Universal Sompo General insurance Co. Ltd.
(A joint venture between Allahabad Bank, Sompo Japan Insurance Inc., Indian Overseas Bank, Karnataka Bank and Dabur Investments)
Regd. Office: Unit 401, 4th Floor, Sangam Complex,127, Andheri Kurla Road, Andheri(East) Mumbai 400059

IOB Retirees Health Claim Form

Name of the Insurance Company: Universal Sompo General insurance Co. Ltd.
Address of the Policy issuing Office : # 554‐555, “B” Wing , 5th Floor, Capitale Towers , AnnaSalai, Teynampet, Chennai – 600 018.
EMSL’s ID No. :
1. Name of the Insured (In whose name policy is issued):
2. Details of the insured Person (In respect of whom claim is made):
(a) Name & relationship to the insured :
(b) Present completed age: Phone No.:
(c) Occupation: *Mobile No.:
(d) Residential address:
* (e) E‐Mail – I.D.
3. Bank Details of the Insured/Claimant (in whose name policy is issued): Mandatory Details
(a) Name of the Account holder
(b) Remas No: (b) Branch Name:
(c) IFSC Code: (e) IOB Pension A/c Number:
(f) Re‐enter Account Number: (g) Account Type (saving/current)
(h) Bank Address (i) Copy of cancelled cheque leaf
4. Nature of Disease/illness contracted or injury suffered:
5. Date of injury sustained or Disease/ illness first detected:
6. (a) Name & Address of the Hospital/ Nursing Home/Clinic:
(b) Date of Admission:
(c) Date of Discharge:
7. (a) Name and Address of the attending Medical Practitioner :
(b) Qualification: Telephone No.:
(c) Registration No.: Total Beds in Hospital: Regd. No of Hospital:
8. Have you been insured under any Mediclaim Scheme earlier with us or any other Insurance Co Copies of previous year’s Insurance policies must be enclosed
9. Date of Commencement of very first insurance for this insured:
Person with continuous Insurance Cover
10. If the claim is for Domiciliary Hospitalization:
Please indicate
(a) Date of Commencement of treatment:
(b) Date of Completion of treatment:
(c) Name & Address of attending Medical Practitioner
11. Total Amount Claimed: Rs.
I have incurred on the treatment of disease/illness/accident referred to above the expenses as per the details given by me in the Schedule of Expenses given overleaf.
In support of the above claim, I enclose the following documents:
Claim Form Duly Signed: Yes/No Pre Hospitalization bills ___ Nos. Yes/No
EMSL Pre‐Authorization Certificate: Yes /No Post Hospitalization bills ___ Nos. Yes/No
Claim Intimation Letter Yes/No Hospital Payment receipt Yes/No
Discharge Summary Yes/No Hospitalization Bill Yes/No
Medicines Bills with Dr’s prescription Yes/No Surgeon’s surgery certificate Yes/No
Operation Theater / Pharmacy Bills Yes/No Surgeon/Consultant’s bills Yes/No
Investigation reports with Dr’s prescription Yes/No
MRI ___ Nos. Yes/No ECG ___Nos. Yes/No
CT scan ___ Nos. Yes/No X‐Ray ___Nos. Yes/No
US scan ___ Nos. Yes/No Other’s (If any) Yes/No
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.
Dated: Signature of the Claimant
Schedule of Expenses Incurred
Sr. No. Date of the Bill Bill No Name of the Hospital/Lab/Medical Shop Amount
Consent Form
From:
Patient’s Name and address:
To:
Whomsoever it may concern: (hospital/doctor)
Sir,
I here by authorize EMeditek
(TPA) Services Limited representatives free and unlimited access to seek medical information (Indoor case papers, reports, documents, including photocopies thereof / pertaining my, admission / treatment) from any hospital / medical practitioner from which or whom I have at any time sought or shall seek medical attention concerning any disease/ sickness, ailment or injury, which affects my physical or mental health.
Yours faithfully,
Signature of the Patient EMeditek
Customer Care: 0124 – 4466 6666
CHENNAI OFFICE ADDRESS : New No.169, Old No.76, 3rd Floor, TTK Road , Alwarpet,
Chennai