HDFC ERGO General Insurance Company Limited
OPD CLAIM FORM (Outpatient Treatment Cover Claim Form)
(Please answer all questions in detail)
Policy Details
Policy Number __________________________________ Policy Start Date _______________________ Policy End date ______________________
Group Corporate name (In case of corporate/ Group policy) ________________________________________________________________________
HDFC ERGO ID Number (as mentioned on Health Card) __________________________________________________________________________
Personal Details of the Employee / Proposer
Employee / Insured name ____________________________________________________________________________________________________
Employee Number (In case of corporate/ Group policy) _____________________________________________________________________________
Email ID ______________________________________________________________________________ Date of Joining D D M M Y Y Y Y
Occupation _______________________________________________________________ Contact No. _____________________________________
Residence address _________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
Patient Details
Name of the Patient ________________________________________________________________________________________________________
Relationship to the Employee / Proposer [Self/ Spouse / Child / Parent / others (please specify)] ____________________________________________
Date of Birth D D M M Y Y Y Y Age Yrs Gender Male Female
Nature of illness/disease contracted or injury suffered ____________________________________________________________________________
Name & address of the attending Doctor ______________________________________________________________________________________
Treatment Commencement Date D D M M Y Y Y Y Treatment End Date D D M M Y Y Y Y
Claim Details
Amount Claimed
Consulting Doctor's Fees Rs. Other Doctors Fees Rs.
Pharmacy/Medicine Charges Rs. Other Medicine/ Pharmacy Charges Rs.
Investigation Charges Rs. Other Investigation Charges Rs.
Others (Kindly Specify) Rs. Any other Expenses Rs.
Total Claimed Amount Rs.
Document Check List (Please tick P
wherever applicable)
In Support of the above claim, I enclose following Documents Original Photocopy
Bills/Receipt/Cash Memos in original for medicines etc.(name of patient along with date)
Most recent medical prescription in support of the above
Receipts and Pathological test reports in original from a Pathological Lab supported by the note
from the treating doctor/ Surgeon advising such pathological test
Attending doctors/consultant's/specialist's bill/receipt and certificate regarding
diagnosis, whichever is prescribed along with doctors registration number (compulsory).
Declaration
I hereby agree, affirm and declare that:
a) The statements/information given/stated by me/us in this claim form is true, correct and complete to the best of my information, knowledge and belief.
b) No material information which is relevant to the processing of the claim or which in any manner has a bearing on the claim, has been withheld or not
disclosed.
c) If I have given/made any false or fraudulent statement/information or suppressed or concealed or in any manner failed to disclose material information,
the policy shall be void and I shall not be entitled to all/any rights to recover there under in respect of any or all claims, past, present or future.
d) The receipt of this claim form/other supporting/related documents, may not constitute an agreement by the Company of the claim and the company
reserve the right to process or reject or require further/additional information in respect of the claim.
e) I also consent and authorize the Insurer and its representative to seek medical information from any hospital/medical practitioner who has any time
attended on the insured person.
f) I confirm that the expenses for which claim is being lodged have been incurred in respect of the insured.
Date: D D M M Y Y Y Y
Signature of Claimant
The issue or acceptance of this form is not to be construed as admission of liability on the part of the Company
Corresponding Off : 6th Floor, MBC Tower, Old No. 90, New No. 199, Luz Church Road, Mylapore, Chennai - 4. Toll free no.: 1860 2000 700 | Fax: 1860 2000 600 | Email: healthclaims@hdfcergo.com
Corporate Office : 6th Floor, Leela Business Park, Andheri-Kurla Road Andheri (East), Mumbai 400 059.
