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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 ...
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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.
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CLAIM FORM - PART B. DETAILS OF HOSPITAL. 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.
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Main Claim - (Hospitalization Claim) This is reimbursements of your medical expenses incurred during hospital. admission. The admission should be for a planned medical treatment or a medical emergency. Pre Post - Expenses incurred for tests & diagnostics leading to treatment before 30 days and after 60 days of.
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..
Medi Assist allows you to submit your reimbursement claim online. Watch this video to learn more about online claim submission. Track Claims in real-time. Medi Assist allows you to track your claim in real-time, anytime and from anywhere – just click the Claims tile to check your claim status.
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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 ...
