THE ORIENTAL INSURANCE COMPANY LIMITED
Regd. Office : Oriental House, P.B. No. 7037, A-25/27, Asaf Ali Road, New Delhi - 110 002
Universal Health Insurance Claim Form

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 Earning head of the Family
a) Name
b) Covered at S.No. of the policy
c) Residential address
3 Details of Hospitalisation
a) Name of the Insured (In respect of whom
claim is made)
b) Relationship to Earning head of the Family
c) Present completed age.
d) Nature of Disease/illness contracted or
injury sustained.
e) Date of injury sustained or disease/illness first detected.
f) Name and address of the Hospital/Nursing Home.
g) Regd. No. Of the treating Hospital / Nursing Home (in case of non-registered and non- Govt. Hospital, certificate to be obtainedconfirming compliance of policy condition
no. 2.1 (c))
h) Date of Admission.
i) Date of Discharge
j) Details of expenses
SCHEDULE OF HOSPITALISATION EXPENSES
INCURRED
FOR OFFICE USE
Details of expenses claimed for Hospitalisation (to be
supported by Bills, Receipts, Cash Memos alongwith
discharge summary)
Amount
Claimed Rs
Amount
eligible Rs.
Amount
Admissible
Rs
I Hospitalisation
a) Room Board, Nursing Expenses for days
@ Rs per day.
b) Unit charges for days @ Rs. Per day.
II Non- Surgical & Surgical:
a) Surgeon & Anaesthetist fees.
b) Medical Practitioners, Consultants and
specialists fees for consultations No of
visits.
III a) Anesthesia, Blood, Oxygen, Operation
Theatre Charges, Surgical appliances.
b) Diagnostic materials and X-Ray., etc.
c) Dialysis, Chemotherapy, Radiotherapy,
Cost of pacemaker, Artificial Limbs &
Cost of organs and similar expenses.
d) Medicines and Drugs.
i. Supplied by Hospital
ii. Purchased from Chemists.
4 Details of Accident.
a) When did the accident happen (Give date
and exact time.)
b) Where did the accident happen
c) Give full description of the accident, its
cause and injuries sustained.
d) State date, time and place of death.
e) Give names and addresses of two persons
who witnessed the accident.
f) Was the injured person free from infirmity
at the time of accident? If not give
particulars.
g) Was the injured person under the influence
of drugs or alcohol at the time of accident?
h) Name and address of the hospital where
the injured person was treated after the
accident.
(Enclose post-mortem report in case of death
of insured in addition to other documents)
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 made 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.