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CLAIM FORM - PART A' to 'CLAIM FORM FOR HEALTH INSURANCE POLICIES OTHER THAN TRAVEL AND PERSONAL ACCIDENT - PART A TO BE FILLED BY THE INSURED The issue of this Form is not to be taken as an admission of liablity DETAILS OF PRIMARY INSURED: a) Policy No.: (To be Filled in block letters) SECTION A SECTION B b) Sl. No/ Certificate no. c) Company ...
CLAIM FORM FOR HEALTH INSURANCE POLICIES OTHER THAN TRAVEL AND PERSONAL ACCIDENT - PART A. TO BE FILLED IN BY THE INSURED. The issue of this Form is not to be taken as an admission of liability. (To be filled in BLOCK LETTERS) SECTION A - DETAILS OF PRIMARY INSURED. a) Type of claim Hospitalization Pre Hospitalization. Post Hospitalization.
CLAIM FORM - PART B TO BE FILLED IN BY THE HOSPITAL The issue of this Form is not to be taken as an admission of liability Please include the original preauthorization request form in lieu of PART A. DETAILS OF HOSPITAL.
the insured is taken on this form after Claim Form B is fully filled up by us. Hospital have required infrastructure to fulfill the hospital definition as per IRDA guideline, which is reproduced below:
Document should be only .pdf and size between 0 MB to 15MB! Upload Claim Documents. I will not use the same hospitalization documents to claim at any other. Insurer/TPA or anywhere else. If declarations are found untrue, entire amount shall be recoverable from me (Insured).
authorize TPA / insurance company. to seek necessary medical information / documents from any hospital / Medical practitioner who has attended the person against whom this claim is made. hereby declare that I have included all the receipts for the purpose of this claim & that I will not be making any supplementary claim except
Name of TPA/ Insurance Company : Raksha TPA Pvt. Ltd] Toll free phone number . ... We confirm having read understood and agreed to the Declarations on the reverse of ...
