The New India Assurance Company Limited 
                    Head Office: 87, M G Road, Fort, Mumbai-400001

HEALTH PLUS MEDICAL EXPENSES POLICY
CLAIM FORM

Issuance of this form does not amount to admission of any liability under the claim on the part of the Insurers.
Please give the following information correctly and completely to enable the Company to process your claim promptly.  
I.	
II.	CLAIM NO.  _____________________________________.

1.	a. Name of the Insured :
              (in whose name policy is issued)
         b. Address of the Insured.

             Phone no.                        Mobile no.                     Email Address
  
2.	Details of the insured person
(In respect of whom claim is made)
a.	Name & relationship to the Insured
b.	Present Completed Age.
c.	Occupation
d.	Residential Address

3.	Policy no.
4.	Nature of disease/illness contracted or injury suffered.
5.	Date on which  injury was sustained/Disease or illness first detected.
6.	a. Name and address of the attending      
              Medical Practitioner
          b. Qualification & Telephone No.
c.	Registration No.
7.	a.  Name & address of the Hospital/Nursing Home/Clinic.
b.	Date of Admission.
c.	Date of Discharge. 

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The New India Assce.Co.Ltd., H.O. Mumbai
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8.	Is this the first year of coverage under
Health Plus Medical Expenses Policy                                  Yes/No
    If no, since when you have been continuously insured under 
    Health Plus Medical Expenses Policy/Mediclaim .  Give details. 
    Of the first policy availed with effect from.

9.	Details of previous claim of the Insured person 
whose claim has been preferred?
a.	Previous claim file reference no. Insurer. 
b.	Policy No. Year 
c.	Hospitalisation period
d.	Diagnosis.
e.	Whether claim settled/repudiated
f.	Amount of claim if settled.  
 
10.	    Are you at present 
             or in respect of whom 
             claim is made is covered under any 
A.	             other similar  type of  scheme like P.A., Cancer 
B.	              Insurance , Mediclaim Policy (Individual/Group), 
C.	              Health Insurance etc.   If so give details.
a.	Name of Insurance Company
b.	Policy no.
c.	Period 
d.	Sum Insured

     11.  Total amount claimed.    Rs.
             Summary : 
a)	Total of Hospital Bills :                                       Rs.
b)	Consultant’s/Surgeon’s/Anesthetist’s Fees:Rs.
c)	Diagnostic Tests :                                              Rs.
d)	Medicines purchased from Chemists:            Rs.   
e)	Emergency Ambulance Expenses :               Rs.
f)	Other expenses not included above :           Rs.

                                            Grand Total :        Rs.

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The New India Assce.Co.Ltd., H.O. Mumbai
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I have incurred medical expenses on the treatment of Disease/Illness/ Accident referred to above. 
In support of the above claim, I enclose following original documents (Please indicate by a tick).

1.	Bills, receipts and Discharge certificate/card from the Hospital giving case history/Admission discharge dates, summary describing the nature of the complaints and its duration, treatment given, advice on discharge .
2.	Hospital  Receipts/ bills, Cash Memos from the Chemist(s) duly  supported by the proper prescription (printed, numbered, stamped receipts)
3.	Receipt and Pathological test reports from a Pathologist supported by the note from the attending Medical Practitioner/Surgeon demanding such Pathological test. All test report for X-Ray, ECG, CT Scan, MRI (Films should not be send unless demanded).
4.	Test Reports and prescriptions relating to First/previous consultations for the same or related illness. 
5.	Surgeon’s certificate stating nature of operation performed and Surgeon’s bill and receipt.
6.	Attending Doctor’s Consultant’s/ Specialist’s/ Anesthetist’s bills and receipt and certificate regarding diagnosis.
7.	Medical certificate issued by the Treating Doctor on the prescribed format by Insurance Company.   
8.	FIR (in case of Accidental injury only) 
      
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.

I also consent and authorise the Insurers to seek medical information from any Hospital/Medical Practitioner who has at any time attended on the Insured.

D.	Dated at:_________________this _____________________Day of ____________2003.

                                                                                 Signature of the Claimant
Important : Incomplete claim form will cause delay in processing of your claim.

The New India Assce.Co.Ltd., H.O. Mumbai

NEW INDIA ASSURANCE CO. LTD.
MEDICAL CERTIFICATE TO BE FILLED IN BY THE ATTENDING DOCTOR WHO TREATED THE PATIENT.

1.	Name of the Patient __________________________ Age_________
2.	Date of Admission __________ Date of Operation_____________      Date of Discharge__________
 3.  Name of the Surgeon/Physician		
    4.  Diagnosis 		
5.	Date of first consultation
  (Prior to Hospitalisation)		
    6.  (a) With what complaints was the  
                patient admitted for:		
  (b) Since when was the patient      
               suffering from the said     
              complaints 		
     7.  Past History of the Patient (if any)
          with the duration of illness.		
     8. Whether the present ailment is a
         complication of Pre-existing              
         disease. 		
     9. Whether the disease/disorder is        
         Congenital in nature.		
    10. Nature of Surgery/treatment 
         given for the present ailment.		
    11. a. Whether Hospital/Nursing
              Home is registered if yes,  
              Regn.No.  		
          b. No. of in-patient beds in the 
              Hospital (including ICU)		
d.	Whether the hospital is having    
      fully equipped Operation    
      Theatre of its own/qualified   
      nurses round the   
      clock/qualified doctors round 
      the Clock? 		

Name and Signature of  the Doctor______________________________
Registration No. ________________   Seal ______________
Date :   _________________________ Place :

ECS Details of the Insured
 
1	Name of the Insured (as appearing in the Bank Account)		
2	Bank Name  		
3	Branch and address		
4	Bank Account No.		
5	Bank Account Type  		
6	IFSC Code		
7	MICR Code