UNITED INDIA INSURANCE COMPANY LIMITED
Reg. & Head Office: 24, Whites Road, Chennai - 14

CLAIM FORM FOR HEALTH INSURANCE POLICY 2010

Policy No. Claim No.
Issue 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.
1 a) Name of the Insured (Name in full)
b) Address
c) Occupation
2 Details of Insured Person:
a) Name of the person in respect of whom
the claim is made.
b) Relationship to the Insured
c) Present completed age
d) Occupation
e) Residential address.
3 Details of Hospitalisation:
a) Name of the Insured person (in respect of
whom claim is made)
b) Present completed age
c) Nature of Disease / Illness contracted or
injury sustained
d) Date of injury sustained or disease/ illness
first detected
e) Name and address of the Hospital /
Nursing Home
f) Date of Admission
g) Date of Discharge
h) Details of expenses
a)
b)
c)
d)
e)
f)
g)
h)
SCHEDULE OF HOSPITALISATION EXPENSES
INCURRED
FOR OFFICE USE
Details of expenses claimed for Hospitalisation
( to be supported by Bills, Receipts, Cash Memos
along with discharge summary)
Amount
Claimed Rs
Amount
eligible Rs
Amount
Admissible Rs.
a) Hospitalisation:
a) Room Board, Nursing Expenses for
days
@Rs. per day
b) I.C.U charges for days @
Rs.
per day
b) Non-Surgical & Surgical:
a) Surgeon & Anaesthetist fees
b) Medical Practitioners, Consultants
and specialists fees for
consultations No of visits
c) Nursing expenses
c) a) Anaesthesia, Blood, Oxygen,
Operation Theatre Charges,
Surgical appliances.
b) Diagnostic materials and XRay.,
etc.,
c) Dialysis, Chemotherapy,
Radiotherapy, Cost of peacemaker,
Artificial Limbs & Cost of organs
and similar expenses
d) Medicines and Drugs
i) Supplied by Hospital
ii) Purchased from Chemists
d) Ambulance charges
e) Daily hospital cash
f) Amount of co pay applicable
5 Details of other health insurance policies covering
the above Insured Person
I hereby declare that I have incurred on the treatment of Disease/Illness /Accident referred
above, the expenses as per the details given by me. In support of this claim, I enclose all relevant
bills vouchers and other documents.
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 and I shall rendered myself
liable to any legal action.
Place:
Date: Signature of Insured Person Signature of Insured