VARISTHA Mediclaim for Senior Citizens

Claim Form (Section I only)

1. Name and address of the Insured

2. Details of the Insured Person:
(in respect of whom claim is made)

(a) Name and relationship to the insured:

(b) Completed age at present:

(c) Occupation:

(d) Residential address:

3. Policy No.

4. Nature of disease / illness contracted or
Injury suffered:

5. Date of injury sustained or disease illness first detected:

6. ( a ) Name and address of the Medical practitioner:

( b ) Qualification & Telephone No.

( c ) Registration No.

7. ( a ) Name and address of the Hospital/ Nursing Home/Clinic:

( b ) Date and time of admission:

( c ) Date and time of Discharge:

I have incurred on the treatment of disease / illness / accident referred to above, the expense as per the details given by me in the Schedule of Expense 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.

2. Cash Memos from the Hospital / Chemist (s), supported by the proper Prescription.

3. Receipt and Pathological test reports from Pathologist supported by the note from the attending Medical Practitioner / Surgeon demanding such Pathological test.

4. Surgeon’s Certificate stating nature of operation performed and Surgeon’s Bill and receipt.

5. Attending Doctor’s / Consultant’s / Anaesthetist’s bill and receipt and certificate regarding diagnosis.

6. Certificate from the attending Medical Practitioner / Surgeon that the Patient is fully cured.

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.

Place :

Date :
Signature of the Claimant

Date of Claim:

Policy No………………………………. Claim No

SCHEDULE OF EXPENSES INCURRED BY THE CLAIMANT
Details of expenses claimed under Hospitalisation / Domiciliary Hospitalisation (To be supported by Bills / Receipts, Cash Memo etc.) Amount
Claimed
(1) Amount Payable
(2)
(a) Room, Board, Nursing Expenses
For………Days.………..

(b) I.C. Unit
For ……..Days…………

(c) Surgeon and Anaesthesist Fees

(d) Anaesthesia, Blood, Oxygen, Operation Theatre, Surgical Appliance.

(e) Diagnostic Material & X-Ray

(f) Medical Practitioners, Consultants and Specialist’s Fees for Visits / Consultations.

(g) Medicines and Drugs:

(i) Supplied by Hospital

(ii) Purchased from chemists

N.B. For claims under Section II, Standard Claim Form of our Critical Illness Policy will be used.