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    Medical Claim Form (English)

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    sujeet.jha.311
    This document is a group medical insurance claim form from Shikhar Insurance Company Ltd. It requests information such as the policy number, patient name, relationship to employee, cause of illness, expenses details with amounts, claimant signature, and notes that an official discharge summary and original payment bills must be submitted. Reimbursement is subject to costs being from a medically authorized doctor and prescribed medicines. The claim form must be submitted within 30 days of medical consultation.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Medical Claim Form (English)

    Uploaded by

    sujeet.jha.311
    114 views1 page
    This document is a group medical insurance claim form from Shikhar Insurance Company Ltd. It requests information such as the policy number, patient name, relationship to employee, cause of illness, expenses details with amounts, claimant signature, and notes that an official discharge summary and original payment bills must be submitted. Reimbursement is subject to costs being from a medically authorized doctor and prescribed medicines. The claim form must be submitted within 30 days of medical consultation.

    Original Description:

    nic bank form

    Original Title

    1563279001_Medical Claim Form(English)

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    This document is a group medical insurance claim form from Shikhar Insurance Company Ltd. It requests information such as the policy number, patient name, relationship to employee, cause of illness, expenses details with amounts, claimant signature, and notes that an official discharge summary and original payment bills must be submitted. Reimbursement is subject to costs being from a medically authorized doctor and prescribed medicines. The claim form must be submitted within 30 days of medical consultation.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    114 views1 page

    Medical Claim Form (English)

    Uploaded by

    sujeet.jha.311
    This document is a group medical insurance claim form from Shikhar Insurance Company Ltd. It requests information such as the policy number, patient name, relationship to employee, cause of illness, expenses details with amounts, claimant signature, and notes that an official discharge summary and original payment bills must be submitted. Reimbursement is subject to costs being from a medically authorized doctor and prescribed medicines. The claim form must be submitted within 30 days of medical consultation.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
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    Shikhar Insurance Company Ltd.

    Head Office: Shikhar Biz Center, Thapathali, Kathamandu,Nepal


    Phone No : 4246101, 4246102 Fax, 977-1-4246103
    E-mail: shikharins@mos.com.np, Web: www.shikharinsurance.com

    GROUP MEDICAL INSURANCE CLAIM FORM

    POLICY NO :

    TABLE OF BENEFIT NO:

    OFFICE NAME: BRANCH :

    ADDRESS: PHONE NO :
    EMPLOYEE'S NAME:
    DESIGNATION :
    STAFF ID NO :
    NAME OF PATIENT : RELATIONSHIP :
    CAUSE OF ILLNESS :
    DATE OF BIRTH:
    (Patient)
    EXPENSES DETAILS
    S.N Particulars Amount (Rs)
    1 Doctor's Fee
    2 Medicine Bills
    3 Pathology Charges
    4 X-Ray Charges
    5 Bed Charge
    6 Surgical Charges
    7 Other Charges
    Total (Figure) NRs:

    Amount in Words: ___________________________________________________

    Official Stamp: Claimant's Signature __________________

    Name: ______________________________

    ______________
    Verified by:

    Note:
    Discharge Summary Should be submitted
    Original copy of payment bills should be submitted.
    Pathological tests is payable if such tests are prescribed by the doctor and the report of test is submitted
    Prescription from medically authorized doctor is to be submitted
    The cost of medicines are payable only if such medicines are prescribed by the doctor so as in the case of extension.
    Consultation fees in local bills not allowed.
    CClaoClaClaiim
    Claim form is to be submitted within 30 days of medical consultation

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