LIC Mediclaim Insurance Policy - Claim Form

 THE NEW INDIA ASSURANCE CO. LTD.,

(Regd & Head Office:_ New India Assurance Bldg., 87, M.G. Road Fort, MUMBAI 400 001)

Underwriting office: DO 120700, New India Centre, 8th Foor, 17- A, Cooperage Road, Mumbai 400 039

LIC Mediclaim Insurance Policy - Claim Form

(Issuance of this form does not assure admission of liability)

1. Name of the employee / Retired employee:__________________________________________

2. Salary Roll No. (S.R. No.):_____________ Cadre:____________________________

3. Email id* :__________________________________; Mobile no*:_________________________

4. Place of working: Place __________ CO/ZO/DO/BO (Code) ______________ ___

5. Residential Address :__________________________________________________

_______________________________________________________________________

6. Name of the Patient :_____________________________________ ____________

7. Relationship with the claimant : _______________________________

8. Nature of illness / accident: _________________________________________________

9. Date of Admission :__________________ Date of Discharge: _______________

10. Total Sum Insured :Rs.________________ Amount claimed :Rs.______________

11. Claim amount received earlier during the current year:____________________________

12. No. of living children as on date______________________

*Please provide the email id, mobile no for receiving information from the TPA about the claim

(For maternity related claims)

I have incurred the above expenses on the treatment of illness / accident referred above, in support of which I

enclose the following documents in original:-

1. Discharge card / Discharge summary from Hospital (Xerox copy attested by Class I officer / OS shall be

accepted)

2. Hospital bills and Receipts, Pathological tests bills and receipts

3. Attending doctors / surgeons / Anaesthetists bills and receipts and certificate stating the diagnosis

4. Cash memos / Chemists Bills duly supported by prescriptions

5. Pathological test reports, X ray reports and attending doctors note requesting for such tests/reports

6. Any other documents related to the claim.

7.

DECLARATION

I hereby warrant the truth of the foregoing particulars in every respect and I agree that if I make any false or

untrue statement, suppression or concealment, my right to re-imbursement shall be absolutely forfeited. I further

declare that, in respect of the above treatment, no benefits are / will be claimed under any other Medical

Insurance.

DATE:

SIGNATURE OF THE EMPLOYEE/RETIRED EMPLOYEE

____________________________________________________________________________________

(TO BE FILLED BY LIC)

We certify that the Person mentioned below is a bonafide employee/ dependent of the employee / retired

employee / spouse of retired employee of LIC of India and the details of insurance coverage are correct as per

our records, as given below:

1. Name of the employee / retired employee:

2. Name of the patient:__________________Relationship with the

employee___________________________

3. Covered with effect from Date: __________________ Compulsory Sum Insured: ________________

4. Total Sum Insured :_______________________________

5. No. of living children (In case of maternity claims) :________________________

SIGNATURE:________________________ DATE:____________________________________

NAME AND DESIGNATION: ____________________________________________________

LIC OFFICE CODE AND SEAL / ADDRESS: