NATIONAL INSURANCE COMPANY LTD.
(a subsidiary of General Insurance Corporation of India)
Regd. Office : 3, MIDDLETON STREET, CALCUTTA – 700 071

HOSPITALISATION AND DOMICILIARY HOSPITALISATION BENEFIT POLICY
CLAIM FORM

Claim No. CL
Issuance 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. If the claim is under Personal Accident Insurance, please complete a Personal
Accident Claim Form.
1. Name of the Insured
(In whose name policy is issued ) (SURNAME) (INITIALS)
2. 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 : ..………………………………………
.………………………………………
……………………………………….
3. Policy No. : ………………………………………..
4. Details of Previous Mediclaim Policies : ……………………………………….
i) Policy No. and Policy Period : ……………………………………….
ii) Policy No. and Policy Period : ……………………………………….
iii) Policy No. and Policy Period : ……………………………………….
(Note : Essential if cost of Health
Check-up is claimed)
5. Nature of Disease / illness contracted
Or injury suffered : ……………………………………….
6. Date of injury sustained or Disease /
Illness first defected : Date Month Year
For Office use only
7.
(a) Name &Address of the attending
Medical Practitioner : ¼¼¼¼¼¼¼¼¼¼¼¼¼¼¼.
(b) Qualification & Telephone No. : ¼¼¼¼¼¼¼¼¼¼¼¼¼¼¼.
(c) Registration No. : ¼¼¼¼¼¼¼¼¼¼¼ ¼¼¼¼.
8.
(a) Name & Address of the Hospital /
Nursing Home / Clinic : ¼¼¼¼¼¼¼¼¼¼¼¼¼¼¼.
Pin Code ¼¼¼¼¼¼¼¼¼¼¼
State /U. Territory ¼¼¼¼¼¼¼..
(b) Date of Admission : ¼¼¼¼¼¼¼¼¼¼¼¼¼¼.
(c) Date of Discharge : ¼¼¼¼¼¼¼¼¼¼¼¼¼¼.
9. If the claim is for Domiciliary
Hospitalisation, Please indicate : ¼¼¼¼¼¼¼¼¼¼¼¼¼¼..
(a) Date of Commencement of treatment :
(b) Date of Completion of treatment : ¼¼¼¼¼¼¼¼¼¼.
(c) Name & Address of attending
Medical Practitioner : ¼¼¼¼¼¼¼¼¼¼¼¼¼¼¼.
(d) Telephone No. : ¼¼¼¼¼¼¼¼¼¼¼¼¼¼¼
(e) Registration No. : ¼¼¼¼¼¼¼¼¼¼¼¼¼¼¼..
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 (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 a pathologist supported by the note from the attending
Medical Practitioner / Surgeon demanding such Pathological Tests.
4. Surgeon’ s certificate Stating nature of operation performed and surgeon’ s bill and receipt.
5. Attending Doctor’ s / Consultant’ s / Speciallist’ s / Aneasthetist’ s bill and receipt and certificate
regarding diagnosis.
6. In case of domiciliary Hospitalisation , receipt from a qualified nurse who atended the patient at his /
her residence duly supported by a certificate from atending Medical Practitioner.
7. Certificate from the attending Medical Practitioner giving reasons for allowing treatment at home.
8. 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 concealments , my right to claim reimbursement of
the said expenses shall be absolutely fortified. I further declare that, in respect of the above treatment, no
benefits are admissible under any other Medical Scheme or Insurance.
Dated ¼¼¼¼¼¼¼¼¼.this ¼¼¼¼¼¼¼day of ¼¼¼¼¼¼¼¼¼.200
Signature of the Claimant
FOR OFFICE USE :
Date of Claim
CLAIM NO. CL
SCHEME A/B
POLICY NO. CATEGORY OF BENEFIT¼¼¼¼¼¼¼
SCHEDULE OF EXPENSES INCURRED
BY THE CLAIMANT
TO BE FILLED IN
BY THE
CLAIMANT
FOR OFFICE USE ONLY
Details of expenses claimed under
Hospitalisation / Domiciliary Hospitalisation
(To be supported by Bills / Receipt , Cash
Memo etc.)
Amount
Claimed
(1)
Amount
Available
(2)
Amount
Payable
(3)
Amount
not
payable
(1-3)
(4)
Balance
benefit to
the credit
(2-3)
(5)
I.
(A) HOSPITALISATION BENEFITS:
(a) Room , Board, Nursing Expenses
For ¼¼days¼¼..@ ..¼.per day
(b) I.C.Unit
For ¼¼.days ¼¼..@¼¼per day
(B) Hospitalisation Benefits other than
Room Board & Nursing expenses &
ICCU (including Pre & Post
Hospitalisation)
1. Surgeon , Anaesthetist, Medical
Practitioner , Consultants , Specialists
fees
2. Anaesthesia , Blood , oxygen , Operation
Theatre charges , Surgical Appliances ,
Medicines & Drugs , Diagnostic,
Materials & X-Ray , Dialysis ,
Chemotherapy , Radiotherapy , cost of
Pacemaker artificial limbs & cost of
Organs and similar other expenses.
II.
DOMICILIARY HOSPITALISATION :
1. Medical Practitioners, Consultants &
Specialists fees for visits etc.
2. Blood , Oxygen , Diagnostic materials ,
X-ray , Employment of qualified Nurses,
Medicines and Drugs and similar
expenses.
III.
COST OF HEALTH CHECK-UP
TOTAL RS.
Date :
Place:
Signature of the Claimant
Checked By : FOR OFFICE USE ONLY
Total amount payable under the cliam Rs¼¼¼¼¼
Less : Advance on account payable, if any Rs. ¼¼¼¼.
Net amount payable Rs. ¼¼¼¼..
Approved By: In case entire claim is not admissible , reasons thereof
Passed for payment of Rs. ¼¼¼¼¼¼¼
COMPETENT AUTHORITY