National Insurance Company Limited

(Subsidiary of General Insurance Corporation of India)

(Regd Office: 3, Middleston Street, Calcutta – 700 071)

HOSPITALISATION AND DOMICILIARY HOSPITALISATION BENEFIT POLICY

Claim No. C.L .…../…… ……/…… ……/…… ……/…… ……/…… ……………………
Issue of this form does not amount to admission of any liability under the claim on the part of Insurers.
Please give the following information correctly and completely to enable the company to process your claim promptly. If the claim is under personal accident Insurance, Please complete a personal accident claim form.
  1. Name of the Insured ………………………….. For Office Use
(Surname) / Initials Only

  1. 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 : …………………………………
…………………………………
…………………………………
  1. Policy No : .…../…… ……/…… ……/….
4. Nature of Disease / Illness
contracted or injury suffered
5. Date of injury sustained or : …… …… …… …… …… …
Disease / illness first detected : Date / Month/ Year

CLAIM FORM

  1. (a) Name & Address of the

attending Medical Practitioner : …………………………………

: …………………………………

Pin Code…………………………

State / U.Territory……………….

(b) Qualification & Telephone No: …………………………………

(c) Registration No: …………………………………

  1. (a) Name & Address of the

Hospital / Nursing Home / Clinic: …………………………………

: …………………………………

Pin Code…………………………

State / U.Territory……………….

(b) Date of Admission: …… …… …… …… …… …

Date / Month/ Year

(c) Date of Discharge : …… …… …… …… …… …

Date / Month/ Year

  1. If the claim is for Domiciliary

Hospitalisation please indicate :

(a)Date of commencement of

treatment

(b)Date of Completion of:

treatment

(c)Name & Address of

attending Medical Practitioner:

(d)Telephone No:

(e)Registration No:

Date incurred on the treatment of disease / illness / accident referred to above, the expenses as

The details given by me in the schedule of Expenses given overleaf.

In support of the above claim, I enclose the following documents (Please indicate by √ )

  1. Bill Receipt and Discharge Certificate / Card from the Hospital.
  1. Cash Memo from the Hospital / Chemist (s), supported by the proper prescription.
  1. Receipt and Pathological test reports from a Pathologist supported by the note from the attending Medical Practitioner / Surgeon demanding such Pathological tests.
  1. Surgeon’s certificate stating nature of operation performed and surgeon’s bill and receipt.
  1. Attending Doctor’s / Consultant’s / Specialist’s / Anesthetist’s bill and receipt and certificate regarding diagnosis.
  1. In case of Domiciliary Hospitalization, receipt from a qualified nurse who attended the Patient at his / her residence duly supported by a certificate from attending medical practitioner.
  1. Certificate from the attending Medical Practitioner giving reasons for allowing treatment at home.
  1. Certificate from the attending Medical Practitioner / Surgeon that the Patient is fully cured

I hereby warrant the truth of the forgoing 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 of insurance.

Date …………………this ………………day of ………………….2004

Signature of the Claimant

For Office Use

Date of Claim………………………………….

Scheme A / B

Policy NoCategory of Benefits …………………………………Claim No…C.L.

Schedule of Expenses Incurred by the ClaimantFor Office Use Only

Details of expenses claimed under Hospitalization / Amount Amount not (1) – (2) = (3) Balance of benefit Net Payable i.e.,(3)

Domiciliary Hospitalization. (To be supported by Claimed Payable to the credit subject to max 4

Bills / Receipts. Cash Memo etc.,) (1) (2) (3) (4) (5)

BENEFITS : PER PERSON

1. HOSPITALISATION BENEFITS

(I)Per day not exceeding :

a)Room, Board, Nursing

b)Intensive Care, Board, Nursing

Aggregate limit for (a) & (b)

(II)Surgeon, anesthetist, medical practitioner,

Consultant, Specialist.

Anesthesia blood, OT, medicines, drugs

Radiotherapy etc.,

Scheme A / B

Policy NoCategory of Benefits …………………………………Claim No…C.L.

Schedule of Expenses Incurred by the ClaimantFor Office Use Only

Details of expenses claimed under Hospitalization / Amount Amount not (1) – (2) = (3) Balance of benefit Net Payable i.e.,(3)

Domiciliary Hospitalization. (To be supported by Claimed Payable to the credit subject to max 4

Bills / Receipts. Cash Memo etc.,) (1) (2) (3) (4) (5)

  1. DOMICILIARY HOSPITALISATION:

(Non-surgical treatment only)

Medical Practitioners, consultants,

Specialists.

Blood, oxygen, diagnostic material, nursing &

Related expenses.

Total Rs.

Total amount Payable under the claim Rs…………………

Date: Less : Advance on account payment if any Rs…………………

Place: Net amount payable Rs…………………

Signature of the Claimant In case the entire claim is not admissible, reasons there of …………

For Office Use Only

Passed for Payment of Rs………………

Prepared by Checked by Approved by Competent Authority