MDINDIA HEALTHCARE SERVICES (TPA) PVT. LTD.

805, Sukhasagar Complex, 8thFloor, Usmanpur, Near Fortune Landmark Hotel,Ashram

Road, Ahmedabad-380 013 (Gujarat).
UAN Voice No. 1860-233-4446. UAN Fax No. 1860-233-4447
E-mail ID: ahmedabad@mdindia.com Website: www.mdindiaonline.com

CLAIM FORM

National Insurance Company The New India Assurance Company

Oriental Insurance Company The United India Insurance Company

1. Current Policy no

2. MDIndia ID No.: MDI5-

3. Corporate Name : Employee Code :

4. Name & Address of the Policy Holder :

5. Name of the Patient:

6. Present Contact Address :

7. Contact No. (Resi. / Office): Mobile No.:

8. Have you preferred any claim for the same Insured under the Mediclaim scheme earlier, if so give details viz

Sr No Particulars Claim 1 Claim 2 Claim 3 Claim 4

(a) Policy Number
(b) Date of Admission
(c) Date of Discharge
(d) Diagnosis
(e) Whether settled / repudiated
(f) Claim Amount (if settled) : Rs.
9. Since when the person covered under the policy without break yrs.

Photocopies of previous year’s policies MUST be enclosed :

10. If the claim is of Domiciliary Hospitalization please indicate

a) Date of Commencement of the treatment

b) Date of Completion of treatment

c) Name & Address of attending Medical Practitioner

d) Contact No. Registration No. Qualification:

11. Details of Expenses incurred by the Claimant

Sr No DATE BILL NO PARTICULARS AMOUNT CLAIMED

GRAND TOTAL:
NOTE: Please attach the sheets if Necessary
In support of the claim, I enclose the following documents
Sr Particulars Yes / No Sr Particulars Yes / No
No Tick No Tick
1 Policy Schedule / Policy Copy 8 Prescriptions*

2 Discharge Card / Summary* 9 Pre Hospitalization Medical Bills*

3 Final Hospital Bill* 10 Post Hospitalization Medical Bills*

4 Surgeon’s Certificate (In all cases of 11 Medical Reports*& MLC / FIR (for
surgery explaining the procedure) accident cases)

5 Attending Doctor’s / Consultant’s / 12 Hospital Payment Receipt*

Specialist’s / Anesthetist’s bill receipt
and certificate regarding diagnosis *

6 Certificate from attending Medical 13 Indoor Case Papers (preferably for

Practitioner giving reasons for all claims above 1 lakh)
allowing treatment at home.*

7 Certificate from attending Medical 14 Previous Policy Copies, if any

Practitioner /Surgeon that the patient
is fully cured.*
* These documents to be submitted as original.

I have incurred the above expenses for the treatment of the disease / illness / accident and herewith as per
schedule mentioned below:

I hereby declare that the above information is true & correct to the best of my knowledge and belief.
If I have made any false, Fraud or untrue statement, suppression or concealment, my right to claim
reimbursement of the expenses shall be forfeited.

I also consent and authorize MDINDIA / Insurance Company to seek medical information from any Hospital
Medical Practitioner who has any time attended on the insured person.

I hereby declare that I have included all bills / receipts for purpose of this claim and that I will not be making any
supplementary claim in respect thereof, except the post Hospitalization claim if any.

Signature of Policy Holder

 MEDICLAIM MEDICAL REPORT (MMR)

CERTIFICATE FROM ATTENDING DOCTOR OF CLAIMANT FROM THE NURSING HOME/HOSPITAL

1. Name of Patient:

2. Age: DOB: Sex: M F

/ /

3. Are you a family doctor of patient?:- Yes/ No Since: yrs.

4. Who referred the case to you?

5. When did the patient approach you for the first time in connection with present disease suffered?

Date of First Consultation:

6. Details of previous history of disease / surgery (if any) of patient?

7. Is the patient suffering from Diabetes, Hypertension (Blood Pressure), Kidney problems, Cancer, T.B., Heart
Problem and AIDS or other disease?
 If yes (Since how long he or she may be suffering from the same.):

9. Present disease suffered (Diagnosis):

10. Duration of present disease suffered (i.e. since how long he or she may be suffering from present disease
before approaching you) :

11. Is the present disease suffered connected to previous disease or Diabetes, Hypertension (Blood Pressure),

Surgery or other existing disease? :

12. Is disease suffered Acute or Chronic? :

13. Whether the disease is caused due to any congenital defects (Yes/No)?

14. Whether the patient had any complications during or after pregnancy (Yes/No)?
15. Whether the disease/injury is caused directly or indirectly due to the use of alcohol or drugs (Yes/No):

16. Could the patient have been aware the illness or disease of which treatment is being taken now? If yes since

when? (Approx. period of illness):

Date when the illness / injury was sustained:

17. Is the disease suffered requires hospitalization? : Yes / No

a) Nature of treatment given : Operative / I.V.Fluid / Injection / Oral Treatment /Other Parenteral Treatment

b) Indoor case no. of the patient Hospital / Nursing home:

18. Date of Admission : Time of admission:

19. Date of Discharge : Time of discharge:

20. Is your hospital registered with local authority? If yes, please attach photocopy of certificate

Registration Number of Hospital:

21. No. of total beds in your Nursing Home / Hospital:

22. Other comments you would like to make (if any) connected to present disease suffered by the patient:

23. "Whether the patient is fully cured or not?" Yes / No

Certified that the details furnished above are true to the best of my knowledge and as per the records available
at this hospital.

Doctor’s Name: Qualification:

Registration No: Contact No:

Date: DOB: / /
Signature of Attending Doctor

(With rubber stamp and registration no. of your Nursing Home / Hospital)

Name of Policy Holder:

Date: / /
Signature of Policy Holder
 Mandate Form for Electronic Clearance System
Policy Number

MDID / EMP Number

Claim Number

Policy Holder Name

Telephone Number Email ID

Name of Account Holder

Name of Bank
Branch Name

Branch Address

Type of Account:

Account Number Cancelled Cheque Y N

MICR Code IFSC Code

Declaration:-

1. I hereby declare that the information furnished in this ECS Form is true & correct to the best of my knowledge &
belief. If I have made any false or untrue statement, suppression or concealment of any material fact, my right to claim
reimbursement shall be forfeited.
2. I agree that I shall not hold TPA/Insurance Company responsible for delay or non-receipt of the payment for any
reason whatsoever after issue of the instructions for payment by Insurer/TPA based on the above.
3. As per the revised RBI guidelines, Canceled cheque should have pre-printed name of account holder.

Date:
Place: Signature of the Policy Holder

SAMPLE CHEQUE FORMAT

Note: Claims Number / Policy number / MDID number to be mentioned on cancel cheque and Please enclose
the cancelled cheque of your bank account for our record; your banker should be a participant of NEFT/RTGS Facility.