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Can you provide me the Hospitalisation and Domiciliary Hospitalisation Benefit Policy Claim Form of New India Assurance Company Limited?

[Vishal Kotkar]

The Hospitalisation and Domiciliary Hospitalisation Benefit Policy Claim Form of New India Assurance Company Limited is as follows:




Few Things that are to be mentioned in the 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 with the Insured :
(b) Present Completed Age :
(c) Occupation :
(d) Residential Address :

3. Policy Number (in Full) :

4. Nature of Disease/Illness contracted or injury sustained :

5. Date on which injury was sustained/Disease
Or illness first detected :

6. (a) Name and Address of the attending :
Medical Practitioner :
Pin Code
State/ U. Territory
(b) Qualification & Telephone No. :
(c) Registration No. :
(d) Name & Address of the Hospital/Nursing
Home / Clinic :

Pin Code
State / U. Territory
(b) Date of Admission :
(c) Date of Discharge :

8. If the Claim is for Domiciliary Hospitalisation,
Please indicate :
(a) Date of Commencement of treatment :
(b) Date of Completion of treatment :
(c) Name & Address of attending Medical :
Practitioner :
Pin Code
State / U. Territory
(d) Telephone No. :
(e) Registration No. :

9. Are you at present covered under any other similar type of scheme like P.A. Cancer Insurance, Mediclaim (Individual or Group), Health Insurance, etc. If Yes. Please give particulars of each

(a) Is this the first year of coverage under Mediclaim Policy? Yes / No.
If no, since when have you been continuously insured under Mediclaim Policy. Give details

(b) (i) Is this the first claim under this policy ? Yes/No
(ii) If no, please quote Previous claim number and details