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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/ TPA ID No: e) Address: DETAILS OF INSURANCE HISTORY: a) Currently covered by any other Mediclaim / Health Insurance: b) Date of commencement of first ...
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.
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.
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).
CLAIM FORM - PART B. (To be filled in BLOCK LETTERS) 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. SECTION A - DETAILS OF HOSPITAL. Name of the Hospital. Hospital ID. Type of Hospital . Network.
We confirm having read understood and agreed to the Declarations on the reverse of this form a) Name of treating doctor: (PLEASE READ VERY CAREFULLY) Patient / Insured Name & Si ature: Si ature of treatin doctor Hospital Seal (Must include Hospital ID)
Access to electronic resources at Raksha Health Insurance TPA Pvt.Ltd. is restricted to employees, insurance companies, customers, hospitals, or individuals authorized by Raksha Health Insurance TPA Pvt.Ltd..
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
Raksha Health Insurance TPA Pvt. Ltd. ISO 9001:2008 & 27001:2013 Certified Company . 0129-3501420. Faridabad ,Haryana. ... Register; Search Provider. PPN List(GIPSA Co.s) Provider Network; Labs; Career; Downloads . Claim Form(Insured) Claim Form(Hospital) Cashless Request Form; IRDAI Annual Report 18; IRDAI Annual Report 19; Checklist; Claim/Cashless Procedure; Language . English; Hindi; Claim Form (To be filled by Insured) MemberId : Policy Number : Patient Name : Email Id :
Raksha TPA Pvt Ltd provides a checklist of documents required for submitting an insurance claim, including a completed claim form, member ID or policy number, policy copies, discharge summaries, bills, reports, and proofs of identity and address if the claimed amount is over Rs. 100,000.
