CLAIM FORM

(Issuance of this form does not amount to admission of any liability under the claim on the part of the insurance.)

Name of the Insurance Company:

EMSLs ID No.:

Policy No.:

1. Name of the Insured (In whose name policy is issued):

2. Details of the insured Person (In respect of whom claim is made):
(a) Name:

(b) Gender:

(d) Relationship Status:

(c) Present completed age:

(e) Occupation:

(h)Phone No.:

(i)Mobile No.:

(f) E-Mail ID:

City:

(g) Residential address:

State:
Pin Code:
3. Nature of Disease/illness contracted or injury suffered:
4. Date of injury sustained or Disease/illness frist detected:
5. (a) Name & Address of the Hospital/ Nursing Home/ Clinic:
(b) Date of Admission D D / M M / Y Y
6. (a) Name of the attending Medical Practitioner:
(b) Address:
City:
State:
Pin Code:

(c) Date of Discharge

D D

/ MM/ Y Y

(c) Qualification:
(d) Telephone No.:
(e) Registration No.:

7. Have you been insured under any Mediclaim Scheme earlier:

(Whether with us or any other Insurance Co.) If yes, photo
Copies of previous years Insurance policies must be enclosed
8. Date of Commencement of very first insurance for this insured:
Person with continuous Insurance Cover
9. If the claim is for Domiciliary Hospitalization:
Please idicate
D D
(a) Date of Commencement of treatment:
(c) Name of attending Medical Practitioner
(d) Address
City:

/ MM/ Y Y

(b) Date of Completion of treatment:

State:

D D

/ MM/ Y Y

Pin Code:

10. Total Amount Claimed: Rs.

I have incurred on the treatment of disease/illness/accident referred to above the expenses as per the details given by me in the Schedule of
Expenses given overleaf.
In support of the above claim, I enclose the following documents:
Name of Documents

Yes No

Name of Documents

Yes No
Nos.

Claim Form Duly Signed:

X-Ray

Claim Intimation Letter

Medicines Bills with Drs prescription

Photo ID Proof

Operation Theater / Pharmacy Bills

Discharge Summary

Surgeons surgery certificate

Hospitalization Bill

Surgeon/Consultants bills

Hospital Payment receipt

ECG

Nos.

Investigation reports with Drs prescription

Pre Hospitalization bill

Nos.

MRI

Nos.

Post Hospitalization bill

Nos.

CT scan

Nos.

Others (If any)

Nos.

US scan

Nos.

I hereby warrant the truth of the foregoing particulars in every respect and I agree that if I have made or shall make any false or untrue statement, suppression
or concealment, my right to claim reimbursement of the said expenses shall be absolutely forfeited. I further declare that, in respect of the above treatment,
no benefits are admissible under any other Medical Scheme or Insurance.

Signature of the Insured/Patient

Dated: D D / M M / Y Y

Sr. No.

Date of the Bill

Bill No.

Schedule of expenses Incurred

Name of the Hospital/Lab/Medical Shop

Amount

NEFT DETAILS
Bank Details of the Insured/Claimant (in whose name policy is issued)
(a) Bank Name:

(b) Branch Name:

(c) IFSC Code:

(e) Account Number:

(f) Re-enter Account Number:

(f) Name as appearing in Bank Account:

DECLARATION
I / We hereby declare that the particulars given above are correct and complete and no blanks have been left. If the transaction is delayed or not effected at all for
reason of incomplete or incorrect information I / we would not hold E-Meditek (TPA) Services Limited responsible.
I / We further undertake to refund, at any time, any excess amount whether demanded by E-Meditek (TPA) Services Limited or not, which has been credited to my
account [due to any reason] by E-Meditek (TPA) Services Limited, in excess of (i) the amount due to me, or (ii) Claim/Refund/ Any other payment.
I / We agree that the payment will be endeavoured to be credited starting from the date of next payment cycle and unless the Mandate is revoked by me/us issuance
of relevant credit instruction for electronic payment from E-Meditek (TPA) Services Limited into the aforesaid account will be valid discharge to E-Meditek (TPA) Services
Limited for having paid (i) the amount due to me, or (ii) Claim/Refund/ Any other payment.
I / We further confirm that we understand this mode as a method of payment introduced by Reserve Bank of India, which provides us an option to receive the amount
and or to collect our payments by electronic payment mode directly through my/our bank accounts.
I / We further confirm that I/we understand, E-Meditek (TPA) Services Limited, shall make electronic payment to my account by issuing the Payment instruction
electronically through its banker to the Clearing Authority and the Clearing Authority would ensure credit to my/our specified bank account provided hereinabove.
I / We further undertake to inform E-Meditek (TPA) Services Limited with an advance notice of 15 days, to withdraw from this mode of electronic payment.
I / We further confirm that E-Meditek (TPA) Services Limited will have, at its sole discretion, the right to return back to the option of paying to me/us by way of cheque
if there are more than 2 consecutive failures in remittances for no fault on the side of E-Meditek (TPA) Services Limited.
After E-Meditek (TPA) Services Limited issuing the Payment instruction electronically through its banker, for whatever reasons, if I/we do not get the credit to my/our
account, then same shall neither constitute the default in (i) Payment of amount requested by me, or (ii) Payment of amount due to me/us, or (iii) Payment of claim/
Refund/Any other payment by E-Meditek (TPA) Services Limited nor constitute default of any terms and conditions of any Claim/Refund/Other contract with me/us.

Date: DD / MM / YY

Signature of Proposer

[Please note that As per government directions all claim payments are to be made only by NEFT
(Electronic Transfer)]

(Kindly attach the copy of cancelled Cheque in this Box)

Consent Form
From:
Patients Name and address:

To:
Whomsoever it may concern: (Hospital/Doctor)

Sir/Mam,
I here by authorize E-Meditek (TPA) Services Limited representatives free and unlimited access to seek medical information (Indoor case
papers, reports, documents, including photocopies thereof / pertaining my, admission / treatment) from any hospital / medical practitioner
from which or whom I have at any time sought or shall seek medical attention concerning any disease/ sickness, ailment or injury, which
affects my physical or mental health.
Yours faithfully,

Signature of the Insured/Patient