Optima Restore claim form seek information like policy number, contact details, name of the insured and details regarding the illness for which the claim is to be filed. However, the insured need to be sure of the information provided. In case of any dishonest information provided, the benefits will be forfeited making the policy void. With a ready link to Claim Form at Apollo Munich website, all customers can move ahead with the procedure. Proper reading of form is important before beginning to fill the form.
Take a look at the check list of enclosures to be submitted with the claim form.
Pre- Authorization form is to be filled in case of hospitalization. It is basically a declaration by the patient to make claim for the expenses incurred during the hospitalization. Easy Health Pre- Authorization form will seek information about the patient or the insured person like name of the patient, contact details, age, policy number and card ID number, name of the hospital, nature of illness and other related details. All columns must be closely examined to provide genuine information to the insurer. The form must be duly filled and then must be attached with all the necessary documents to avail the service.
Pre- Authorization form is to be filled in case of hospitalization. It is basically a declaration by the patient to make claim for the expenses incurred during the hospitalization. While seeking health insurance coverage under Optima Restore, the Pre- Authorization form must be filled to avail the policy support. Through this Apollo Munich seek information about the patient or the insured person like name of the patient, contact details, age, policy number and card ID number, name of the hospital, nature of illness and other related details. All columns must be closely examined to provide genuine information to the insurer. The form must be duly filled and then must be attached with all the necessary documents absence of which can lead to complication.
Pre- Authorization form is to be filled in case of hospitalization. It is basically a declaration by the patient to make claim for the expenses incurred during the hospitalization. While seeking health insurance coverage under Optima Plus, the Pre- Authorization form must be filled to avail the policy support. Through this Apollo Munich seek information about the patient or the insured person like name of the patient, contact details, age, policy number and card ID number, name of the hospital, nature of illness and other related details. All columns must be closely examined to provide genuine information to the insurer. The form must be duly filled and attached with all the necessary documents absence of which can lead to complication.
Claim form for Optima Senior is easily available on the website of Apollo Munich. With this provision, the process has been uncomplicated.
The policyholder need to provide basic information like policy number, contact details, name of the insured and details regarding the illness for which the claim is to be filed. However, the insured need to be sure of the information provided. In case of any dishonest information provided, the benefits will be forfeited making the policy void. With a ready link to Claim Form, all customers can move ahead with the procedure. Proper reading of form is important before beginning to fill the form.
You can acquire the claim form for Optima Plus through Apollo Munich Health Insurance website. Here the buyer need to provide basic information like policy number, contact details, name of the policyholder, details of the insured, nature of disease or illness caused, nature of claim and list of enclosures to be attached with the form. The documents provided must be complete and genuine as per the claim. It is to be filled with due care and after proper understanding. Any dishonest information provided can affect the coverage offered by the plan.
With a ready link to Claim Form, all customers can move ahead with the procedure. Proper reading of form is important before beginning to fill the form.
The preauthorization form collects information about the patient, their insurance, treating physician, nature of illness, proposed treatment, hospital admission details, expected costs, and declarations signed by the patient and hospital. It requests the patient's and insured's names, age, contact details, insurance details, current and past medical conditions, primary physician's details, diagnosis, treatment plan, admission date and time, room type, expected fees including room rent, investigations, ICU, surgery, medicines and total estimated costs. The patient and hospital declare that all documents will be provided to the insurer and that non-approved expenses will be paid by the patient.
This document contains certifications and disclosures required for medical billing. It states that the billing information is true and accurate, and that required authorizations and certifications are on file. It covers certifications for third party benefits, private rooms, physician certifications, and signatures authorizing the release of information. It also contains certifications specific to Medicare, Medicaid, TRICARE and other health plans regarding the medical necessity of services and billing other insurances first before submitting claims.
Pre- Authorization form is to be filled in case of hospitalization. It is basically a declaration by the patient to make claim for the expenses incurred during the hospitalization. Easy Health Pre- Authorization form will seek information about the patient or the insured person like name of the patient, contact details, age, policy number and card ID number, name of the hospital, nature of illness and other related details. All columns must be closely examined to provide genuine information to the insurer. The form must be duly filled and then must be attached with all the necessary documents to avail the service.
Pre- Authorization form is to be filled in case of hospitalization. It is basically a declaration by the patient to make claim for the expenses incurred during the hospitalization. While seeking health insurance coverage under Optima Restore, the Pre- Authorization form must be filled to avail the policy support. Through this Apollo Munich seek information about the patient or the insured person like name of the patient, contact details, age, policy number and card ID number, name of the hospital, nature of illness and other related details. All columns must be closely examined to provide genuine information to the insurer. The form must be duly filled and then must be attached with all the necessary documents absence of which can lead to complication.
Pre- Authorization form is to be filled in case of hospitalization. It is basically a declaration by the patient to make claim for the expenses incurred during the hospitalization. While seeking health insurance coverage under Optima Plus, the Pre- Authorization form must be filled to avail the policy support. Through this Apollo Munich seek information about the patient or the insured person like name of the patient, contact details, age, policy number and card ID number, name of the hospital, nature of illness and other related details. All columns must be closely examined to provide genuine information to the insurer. The form must be duly filled and attached with all the necessary documents absence of which can lead to complication.
Claim form for Optima Senior is easily available on the website of Apollo Munich. With this provision, the process has been uncomplicated.
The policyholder need to provide basic information like policy number, contact details, name of the insured and details regarding the illness for which the claim is to be filed. However, the insured need to be sure of the information provided. In case of any dishonest information provided, the benefits will be forfeited making the policy void. With a ready link to Claim Form, all customers can move ahead with the procedure. Proper reading of form is important before beginning to fill the form.
You can acquire the claim form for Optima Plus through Apollo Munich Health Insurance website. Here the buyer need to provide basic information like policy number, contact details, name of the policyholder, details of the insured, nature of disease or illness caused, nature of claim and list of enclosures to be attached with the form. The documents provided must be complete and genuine as per the claim. It is to be filled with due care and after proper understanding. Any dishonest information provided can affect the coverage offered by the plan.
With a ready link to Claim Form, all customers can move ahead with the procedure. Proper reading of form is important before beginning to fill the form.
The preauthorization form collects information about the patient, their insurance, treating physician, nature of illness, proposed treatment, hospital admission details, expected costs, and declarations signed by the patient and hospital. It requests the patient's and insured's names, age, contact details, insurance details, current and past medical conditions, primary physician's details, diagnosis, treatment plan, admission date and time, room type, expected fees including room rent, investigations, ICU, surgery, medicines and total estimated costs. The patient and hospital declare that all documents will be provided to the insurer and that non-approved expenses will be paid by the patient.
This document contains certifications and disclosures required for medical billing. It states that the billing information is true and accurate, and that required authorizations and certifications are on file. It covers certifications for third party benefits, private rooms, physician certifications, and signatures authorizing the release of information. It also contains certifications specific to Medicare, Medicaid, TRICARE and other health plans regarding the medical necessity of services and billing other insurances first before submitting claims.
Apollo Munich claim procedure is easy to understand with information provided in simple and uncomplicated wordings. Insure Health claim form is easily available on the website of the company. The form is to filled while filing the claim for insured illness.
The form seeks basic information like policy number, contact details, name of the insured and details regarding the illness for which the claim is to be filed. However, the insured need to be sure of the information provided. Details provided must be correct and complete to receive the listed benefits. In case of any dishonest information provided, the benefits will be forfeited making the policy void. With a ready link to Claim Form on the website, all customers can move ahead with the procedure.
This document contains a health insurance claim form for Royal Sundaram Alliance Insurance Company. It requests information about the policyholder, patient, illness details, hospitalization details, other insurance policies, previous claims history, and authorization to obtain medical records. The attending physician section collects medical information about the patient's condition, treatment, and certification of the details provided.
The document provides an overview of the UB-04 form which replaced the UB-92 form and was mandated for use in May 2007, it describes the various form locators that make up the UB-04 including those for patient information, billing information, diagnosis codes, and provider information. The presentation aims to educate Medicare Part A providers on properly completing the UB-04 form.
The document summarizes a court order from the High Court of Judicature at Bombay granting temporary bail to Dr. P.V. Varavara Rao for 4 weeks. Key details include:
- Dr. Rao was seeking bail in a case registered in Gadchiroli for various offenses.
- He had been recently released on bail in another case by the Principal Seat of the court on medical grounds.
- Considering Dr. Rao's health condition, the court granted him temporary bail for 4 weeks on the same terms and conditions as the previous bail order.
- The bail order lists several conditions for Dr. Rao including reporting to police every 2 weeks, not
Meghalaya high court bail to juvenile orderZahidManiyar
1. The petitioner filed a revision petition challenging the order of the Juvenile Justice Board rejecting bail for a child in conflict with the law accused of rape.
2. The court analyzed Section 12 of the Juvenile Justice Act which states that bail must be granted to a child unless there are clear reasons they may face danger or their release would defeat justice.
3. The court found that the Board did not properly consider Section 12 or the welfare of the child in line with the objectives of the Juvenile Justice Act. The bail order was set aside and the matter remitted back to the Board.
The court issued several directions to the jail authorities at Tihar prison in Delhi regarding facilities for inmates during the COVID-19 pandemic. It ordered that tele-calling facilities be extended to prepaid numbers if the number and recipient are verified. Daily calls of up to 5 minutes were permitted for inmates in isolation or recovering from COVID-19. The court also directed that the 136 eligible inmates aged 45+ be vaccinated by May 31 and that vaccines for the 279 inmates aged 18-44 be requested within 48 hours. Further, e-mulaqaats (video calls) of 30 minutes per week were allowed for all inmates.
Telangana hc may 26 testing of dead bodiessabrangsabrang
This document is a High Court order from the State of Telangana summarizing 5 writ petitions related to COVID-19. The petitions address issues such as lack of quarantine for international passengers arriving in Telangana, insufficient protective equipment for medical workers, failure to test deceased individuals for COVID-19, and inadequate testing and resources in rural areas. The court heard arguments from petitioners and government representatives on these matters concerning public health and rights during the pandemic.
This document summarizes a court case regarding the procurement of Remdesivir injections during the COVID-19 pandemic. It discusses a criminal application filed by relatives of COVID patients seeking to intervene in the case on behalf of a Member of Parliament who helped procure injections. The court rejects their application, finding that they are not necessary to determine if the MP's actions followed legal procedures. The court examines documents from the District Collector regarding the approved purchase of 1700 injections through legal channels, which differ from claims about injections transported via private plane. The legality of the procurement methods is still under investigation.
20211201 bombay hc bail to sudha bharadwajsabrangsabrang
1. The applicant Sudha Bharadwaj filed a bail application challenging the orders passed by Additional Sessions Judge K.D. Vadane on November 26, 2018 extending her detention and February 21, 2019 taking cognizance of offenses.
2. The applicant argued that Judge Vadane lacked jurisdiction as he was not designated as a Special Judge under the NIA Act to try offenses investigated by the NIA. Only Special Courts constituted by the state government had jurisdiction in such cases.
3. Therefore, the applicant claimed the detention extension and cognizance orders passed by the judge without jurisdiction were null and void, and that she was entitled to default bail.
This document provides guidelines and an application form for provisional registration with the Malaysian Medical Council. [1] It outlines the requirements to practice medicine in Malaysia including submitting the application prior to practice and [2] outlines that provisional registration allows newly qualified practitioners to undertake clinical training needed for full registration. [3] It details the eligibility requirements to apply for provisional registration and the documents that must be submitted with the application form.
Delhi hc shifa ur rehman judgment may 7ZahidManiyar
This document is a court judgment regarding a petition filed by Shifa-ur-Rehman, President of the Alumni Association of Jamia Milia Islamia, who was arrested in connection with an FIR related to the 2020 Delhi riots. The petition challenges an order extending the period of investigation and the petitioner's detention. The court heard arguments from both sides on issues such as whether the petitioner was denied the right to consult his lawyer and whether the reasons provided for extension were sufficient. The court considered the matter in light of relevant sections of the UAPA and precedents.
The court heard arguments from counsel for the petitioner Jenny Roweena and the two respondents, the State of Maharashtra and NIA, regarding the medical report of the petitioner's husband Dr. Hany Babu Tharayil. While the petitioner's counsel argued that the report suggested he still required critical care and should be allowed house arrest, the NIA objected stating the report said he was ready for discharge. The court then requested the hospital to further examine the patient and provide an updated report by June 14th. It also allowed the interim order to continue and permitted family visits as per hospital protocol until the next hearing date of June 15th.
1) The court heard from petitioner 1, who submitted that she converted to Islam of her own free will and married petitioner 2 without force. She stated she faces threats to her life from respondents 6 and 7 due to her marriage.
2) Petitioner 1 provided documents showing she is of legal age to marry. She asked the court to protect her life and that of her husband based on constitutional guarantees.
3) The court directed respondents 1-5, including police, to ensure the petitioners' safety and are not harassed by respondents 6 and 7, and to allow them to live married without interference.
- The document is an affidavit filed on behalf of Respondents 2 and 3 (State of Uttar Pradesh) in response to a writ petition filed in the Supreme Court of India regarding the arrest of Siddique Kappan.
- It summarizes the key facts of Kappan's arrest for allegedly attempting to disturb law and order in Hathras under the guise of journalism, and asserts that due process was followed.
- The affidavit denies allegations made in the writ petition, provides details on informing Kappan's family and access to lawyers, and argues the petition is not maintainable.
The Supreme Court of India heard a writ petition filed by Yash Pal Singh, whose son was killed in an alleged encounter by police officers in 2002. The court noted that the case has been pending since then, and the police officers involved have not been properly investigated or prosecuted despite court orders. The court criticized the laxity of the state in defending its police officers. It directed the state of Uttar Pradesh to deposit Rs. 7 lakhs as interim costs to the petitioner, as he has been denied justice for 19 years. The matter was listed for further hearing on October 20th.
This document is a deed of settlement between Chan Chee Seng and Tan Gaik Suan, who are getting divorced. It outlines agreements regarding child custody, maintenance payments, division of property including a vehicle and bank accounts, costs of the divorce proceedings, and a statement that this settlement represents the final agreement between the parties. The wife will have primary custody of their minor child, and the husband will have visitation rights and pay monthly maintenance.
1. This document summarizes a court case involving a writ petition filed by two lesbian petitioners (S. Sushma and U. Seema Agarval) seeking police protection from their parents.
2. The petitioners had fled from Madurai to Chennai to escape pressure and opposition from their parents regarding their lesbian relationship. Their parents had filed missing person reports with the police.
3. The court held in-camera hearings and counseling sessions with the petitioners and their parents to better understand the situation. It was found that the petitioners were clear about their relationship, while the parents were concerned about societal stigma and their daughters' safety.
The Supreme Court of India heard a suo moto writ petition regarding problems faced by migrant workers during the COVID-19 pandemic.
The Court noted submissions from petitioners regarding inadequate distribution of dry rations, cooked food and cash transfers to migrant workers. States provided details of steps taken to help migrant workers, including transportation, food and registration processes.
The Court emphasized the need to complete registration of unorganized workers under new social security laws to help workers access welfare schemes. It directed the central government to file an affidavit with details on developing a national database for registration of all unorganized workers across states. The Court also stressed the need to effectively monitor welfare schemes to ensure benefits reach beneficiaries.
The court heard a bail application for 7 Bangladeshi nationals who were arrested for violating laws during the COVID-19 pandemic. The court granted interim bail to 5 applicants and held the 6th applicant's request pending extension of their expired visa. Strict conditions were imposed, including adherence to visa terms and regular reporting. The Ministry of External Affairs was directed to facilitate the applicants' participation in their trial and discuss their cases with Bangladesh to possibly decide the matter without trial.
(1) This document is a claim form for a health insurance policy. It requests information to process an insurance claim for hospitalization.
(2) The form requests details about the insured's policy and medical history. It also seeks information on the hospitalized person, including their diagnosis, treatment details, and bills.
(3) The insured is asked to provide bank account details for claim reimbursement and declare that the information provided is true before signing the form.
This document contains a request for cashless hospitalization for a medical insurance policy. It includes forms for the insured/patient, treating doctor, and hospital to fill out with details of the hospitalization such as:
- Patient information like name, age, policy details
- Doctor and hospital details
- Diagnosis and treatment details
- Expected costs for room rent, investigations, surgery, medicines, etc.
- Past medical history and comorbidities
- Declarations to be signed by patient, doctor and hospital regarding terms and conditions.
To claim insurance coverage under Maxima health plan, the insured need to fill the respective claim form. The form seek basic information like policy number, contact details, name of the insured and details regarding the illness for which the claim is to be filed. However, the insured need to be sure of the information provided. In case of any dishonest information provided, the benefits will be forfeited making the policy void. With a ready link to Claim Form at Apollo Munich website, all customers can move ahead with the procedure. Proper reading of form is important before beginning to fill the form.
Take a look at the check list of enclosures to be submitted with the claim form.
Apollo Munich claim procedure is easy to understand with information provided in simple and uncomplicated wordings. Insure Health claim form is easily available on the website of the company. The form is to filled while filing the claim for insured illness.
The form seeks basic information like policy number, contact details, name of the insured and details regarding the illness for which the claim is to be filed. However, the insured need to be sure of the information provided. Details provided must be correct and complete to receive the listed benefits. In case of any dishonest information provided, the benefits will be forfeited making the policy void. With a ready link to Claim Form on the website, all customers can move ahead with the procedure.
This document contains a health insurance claim form for Royal Sundaram Alliance Insurance Company. It requests information about the policyholder, patient, illness details, hospitalization details, other insurance policies, previous claims history, and authorization to obtain medical records. The attending physician section collects medical information about the patient's condition, treatment, and certification of the details provided.
The document provides an overview of the UB-04 form which replaced the UB-92 form and was mandated for use in May 2007, it describes the various form locators that make up the UB-04 including those for patient information, billing information, diagnosis codes, and provider information. The presentation aims to educate Medicare Part A providers on properly completing the UB-04 form.
The document summarizes a court order from the High Court of Judicature at Bombay granting temporary bail to Dr. P.V. Varavara Rao for 4 weeks. Key details include:
- Dr. Rao was seeking bail in a case registered in Gadchiroli for various offenses.
- He had been recently released on bail in another case by the Principal Seat of the court on medical grounds.
- Considering Dr. Rao's health condition, the court granted him temporary bail for 4 weeks on the same terms and conditions as the previous bail order.
- The bail order lists several conditions for Dr. Rao including reporting to police every 2 weeks, not
Meghalaya high court bail to juvenile orderZahidManiyar
1. The petitioner filed a revision petition challenging the order of the Juvenile Justice Board rejecting bail for a child in conflict with the law accused of rape.
2. The court analyzed Section 12 of the Juvenile Justice Act which states that bail must be granted to a child unless there are clear reasons they may face danger or their release would defeat justice.
3. The court found that the Board did not properly consider Section 12 or the welfare of the child in line with the objectives of the Juvenile Justice Act. The bail order was set aside and the matter remitted back to the Board.
The court issued several directions to the jail authorities at Tihar prison in Delhi regarding facilities for inmates during the COVID-19 pandemic. It ordered that tele-calling facilities be extended to prepaid numbers if the number and recipient are verified. Daily calls of up to 5 minutes were permitted for inmates in isolation or recovering from COVID-19. The court also directed that the 136 eligible inmates aged 45+ be vaccinated by May 31 and that vaccines for the 279 inmates aged 18-44 be requested within 48 hours. Further, e-mulaqaats (video calls) of 30 minutes per week were allowed for all inmates.
Telangana hc may 26 testing of dead bodiessabrangsabrang
This document is a High Court order from the State of Telangana summarizing 5 writ petitions related to COVID-19. The petitions address issues such as lack of quarantine for international passengers arriving in Telangana, insufficient protective equipment for medical workers, failure to test deceased individuals for COVID-19, and inadequate testing and resources in rural areas. The court heard arguments from petitioners and government representatives on these matters concerning public health and rights during the pandemic.
This document summarizes a court case regarding the procurement of Remdesivir injections during the COVID-19 pandemic. It discusses a criminal application filed by relatives of COVID patients seeking to intervene in the case on behalf of a Member of Parliament who helped procure injections. The court rejects their application, finding that they are not necessary to determine if the MP's actions followed legal procedures. The court examines documents from the District Collector regarding the approved purchase of 1700 injections through legal channels, which differ from claims about injections transported via private plane. The legality of the procurement methods is still under investigation.
20211201 bombay hc bail to sudha bharadwajsabrangsabrang
1. The applicant Sudha Bharadwaj filed a bail application challenging the orders passed by Additional Sessions Judge K.D. Vadane on November 26, 2018 extending her detention and February 21, 2019 taking cognizance of offenses.
2. The applicant argued that Judge Vadane lacked jurisdiction as he was not designated as a Special Judge under the NIA Act to try offenses investigated by the NIA. Only Special Courts constituted by the state government had jurisdiction in such cases.
3. Therefore, the applicant claimed the detention extension and cognizance orders passed by the judge without jurisdiction were null and void, and that she was entitled to default bail.
This document provides guidelines and an application form for provisional registration with the Malaysian Medical Council. [1] It outlines the requirements to practice medicine in Malaysia including submitting the application prior to practice and [2] outlines that provisional registration allows newly qualified practitioners to undertake clinical training needed for full registration. [3] It details the eligibility requirements to apply for provisional registration and the documents that must be submitted with the application form.
Delhi hc shifa ur rehman judgment may 7ZahidManiyar
This document is a court judgment regarding a petition filed by Shifa-ur-Rehman, President of the Alumni Association of Jamia Milia Islamia, who was arrested in connection with an FIR related to the 2020 Delhi riots. The petition challenges an order extending the period of investigation and the petitioner's detention. The court heard arguments from both sides on issues such as whether the petitioner was denied the right to consult his lawyer and whether the reasons provided for extension were sufficient. The court considered the matter in light of relevant sections of the UAPA and precedents.
The court heard arguments from counsel for the petitioner Jenny Roweena and the two respondents, the State of Maharashtra and NIA, regarding the medical report of the petitioner's husband Dr. Hany Babu Tharayil. While the petitioner's counsel argued that the report suggested he still required critical care and should be allowed house arrest, the NIA objected stating the report said he was ready for discharge. The court then requested the hospital to further examine the patient and provide an updated report by June 14th. It also allowed the interim order to continue and permitted family visits as per hospital protocol until the next hearing date of June 15th.
1) The court heard from petitioner 1, who submitted that she converted to Islam of her own free will and married petitioner 2 without force. She stated she faces threats to her life from respondents 6 and 7 due to her marriage.
2) Petitioner 1 provided documents showing she is of legal age to marry. She asked the court to protect her life and that of her husband based on constitutional guarantees.
3) The court directed respondents 1-5, including police, to ensure the petitioners' safety and are not harassed by respondents 6 and 7, and to allow them to live married without interference.
- The document is an affidavit filed on behalf of Respondents 2 and 3 (State of Uttar Pradesh) in response to a writ petition filed in the Supreme Court of India regarding the arrest of Siddique Kappan.
- It summarizes the key facts of Kappan's arrest for allegedly attempting to disturb law and order in Hathras under the guise of journalism, and asserts that due process was followed.
- The affidavit denies allegations made in the writ petition, provides details on informing Kappan's family and access to lawyers, and argues the petition is not maintainable.
The Supreme Court of India heard a writ petition filed by Yash Pal Singh, whose son was killed in an alleged encounter by police officers in 2002. The court noted that the case has been pending since then, and the police officers involved have not been properly investigated or prosecuted despite court orders. The court criticized the laxity of the state in defending its police officers. It directed the state of Uttar Pradesh to deposit Rs. 7 lakhs as interim costs to the petitioner, as he has been denied justice for 19 years. The matter was listed for further hearing on October 20th.
This document is a deed of settlement between Chan Chee Seng and Tan Gaik Suan, who are getting divorced. It outlines agreements regarding child custody, maintenance payments, division of property including a vehicle and bank accounts, costs of the divorce proceedings, and a statement that this settlement represents the final agreement between the parties. The wife will have primary custody of their minor child, and the husband will have visitation rights and pay monthly maintenance.
1. This document summarizes a court case involving a writ petition filed by two lesbian petitioners (S. Sushma and U. Seema Agarval) seeking police protection from their parents.
2. The petitioners had fled from Madurai to Chennai to escape pressure and opposition from their parents regarding their lesbian relationship. Their parents had filed missing person reports with the police.
3. The court held in-camera hearings and counseling sessions with the petitioners and their parents to better understand the situation. It was found that the petitioners were clear about their relationship, while the parents were concerned about societal stigma and their daughters' safety.
The Supreme Court of India heard a suo moto writ petition regarding problems faced by migrant workers during the COVID-19 pandemic.
The Court noted submissions from petitioners regarding inadequate distribution of dry rations, cooked food and cash transfers to migrant workers. States provided details of steps taken to help migrant workers, including transportation, food and registration processes.
The Court emphasized the need to complete registration of unorganized workers under new social security laws to help workers access welfare schemes. It directed the central government to file an affidavit with details on developing a national database for registration of all unorganized workers across states. The Court also stressed the need to effectively monitor welfare schemes to ensure benefits reach beneficiaries.
The court heard a bail application for 7 Bangladeshi nationals who were arrested for violating laws during the COVID-19 pandemic. The court granted interim bail to 5 applicants and held the 6th applicant's request pending extension of their expired visa. Strict conditions were imposed, including adherence to visa terms and regular reporting. The Ministry of External Affairs was directed to facilitate the applicants' participation in their trial and discuss their cases with Bangladesh to possibly decide the matter without trial.
(1) This document is a claim form for a health insurance policy. It requests information to process an insurance claim for hospitalization.
(2) The form requests details about the insured's policy and medical history. It also seeks information on the hospitalized person, including their diagnosis, treatment details, and bills.
(3) The insured is asked to provide bank account details for claim reimbursement and declare that the information provided is true before signing the form.
This document contains a request for cashless hospitalization for a medical insurance policy. It includes forms for the insured/patient, treating doctor, and hospital to fill out with details of the hospitalization such as:
- Patient information like name, age, policy details
- Doctor and hospital details
- Diagnosis and treatment details
- Expected costs for room rent, investigations, surgery, medicines, etc.
- Past medical history and comorbidities
- Declarations to be signed by patient, doctor and hospital regarding terms and conditions.
To claim insurance coverage under Maxima health plan, the insured need to fill the respective claim form. The form seek basic information like policy number, contact details, name of the insured and details regarding the illness for which the claim is to be filed. However, the insured need to be sure of the information provided. In case of any dishonest information provided, the benefits will be forfeited making the policy void. With a ready link to Claim Form at Apollo Munich website, all customers can move ahead with the procedure. Proper reading of form is important before beginning to fill the form.
Take a look at the check list of enclosures to be submitted with the claim form.
Claim intimation form seek information from the insured individual about self, illness he/ she is suffering from and kind of treatment against which the claim is filed. Apollo Munich explains the procedure to be followed while filing claim for coverage under Maxima health plan. The form is to be filled to intimate the insurer about the treatment to be availed and the related expenditure. It includes information about the policyholder, the diagnosis to be done, expected treatment expenses, address, date of birth and contact details. The claim settlement will depend on the information and documents provided by the insured. Also, the claimant must submit the claim intimation form as soon as possible, in order to allow the insurance company to work over it.
Complete submission of the required documents is extremely important. It will affect the kind of coverage offered by the insurer.
Claim intimation form seek information from the insured individual about self, illness he/ she is suffering from and kind of treatment against which the claim is filed. Apollo Munich explains the procedure to be followed while filing claim under Optima Plus coverage. The form is to be filled to intimate the insurer about the treatment to be availed and the related expenditure. It includes information about the policyholder, the diagnosis to be done, expected treatment expenses, address, date of birth and contact details. The claim settlement will depend on the information and documents provided by the insured. Also, the claimant must submit the claim intimation form as soon as possible, in order to allow the insurance company work over it.
Complete submission of the required documents is extremely important. It will affect the kind of coverage offered by the insurer.
This document provides guidance for filling out an insurance claim form. It outlines the various sections of the form, including details of the insured and hospitalization, diagnosis and treatment details, documents required, and declarations. Key sections include insured details, hospital and doctor information, diagnosis and treatment codes, pre-authorization, documents submitted, and declarations by insured and hospital.
While undergoing any planned treatment the insured can inform his/ her respective insurer in advance. Like other plans of Apollo Munich, Optima Senior is also available with this provision. The insured can fill the claim intimation form and claim the coverage for better facilities. This form will seek information about self, the illness that the person is suffering from and the treatment against which the claim is filed. This will intimate the insurance company well in advance about the treatment insured will be going for thereby providing him/ her the right support.
The insured need to provide information about the diagnosis to be done, expected treatment expenses, address, date of birth and contact details. The claim settlement will depend on the information and documents provided by the insured. Also, the claimant must submit the claim intimation form as soon as possible, in order to allow the insurance company work over it. Complete submission of the required documents is extremely important.
Life insurance is a contract between you and the life insurance company (the insurer), which provides you (the assured) or your beneficiary for whose benefit the policy is taken with a pre-determined amount on the happening of a particular event contingent on the duration of human life
Health plus claim intimation form is for Health Insurance Policies (HCB & MSB Claims).Form must be completed & signed by Policy Holder / Principal Insured only and submitted to the TPA.
1. The document appears to be an insurance claim form for hospitalization expenses from ICICI Lombard Health Care.
2. It requests information about the insured person, the nature of their illness/injury, dates of admission and discharge, treatment details and expenses.
3. The form must be filled out by both the insured and the treating doctor/hospital. Supporting documents like bills, reports, and age/identity proof must be provided.
Health plus claim is a part of life insurance. Issuance of this form does not amount to admission of any liability under the claim on the part of the insurers.
This document is a claim form for hospitalization expenses under a health insurance policy with Life Insurance Corporation of India.
The 4-page form requests information about the policyholder, insured member, hospitalization details including dates and hospitals, attending doctors, treatment details, expenses incurred and documents being submitted.
It includes declarations by the policyholder/claimant authorizing access to medical information and confirming inclusion of all relevant documents and bills. The final page is for discharge of the claim and selection of payment method as NEFT/RTGS or demand draft along with bank account details.
This document contains instructions and templates for Public Information Officers regarding their duties and responsibilities under the Right to Information Act 2005.
It provides guidance on properly forwarding RTI applications and appeals to the relevant authorities. It also includes templates for rejecting applications if the requests are vague or non-specific, transferring applications to other departments as needed, notifying third parties about disclosed information, and collecting additional fees from applicants.
The document advises PIOs to handle requests courteously and within statutory timeframes, while protecting privacy and following legal exemptions. It also outlines best practices for PIOs and APIOs to assist applicants and maintain updated records to facilitate information disclosure.
1. This document appears to be a bill submitted by Tie-up Hospital to ESIC (Employee State Insurance Corporation) for reimbursement for medical services provided.
2. It includes details of a cataract surgery performed on a patient named Vallavan R., including diagnosis, treatment provided, costs claimed, and certifications that cashless treatment was provided according to the agreement between the hospital and ESIC.
3. The total amount claimed is Rs. 15,175 and various forms are included as required documentation for the bill to be processed by ESIC, such as discharge records, referral documents, and patient satisfaction certification.
This document provides information about making an insurance claim for residential property damage through CGU Insurance. It outlines the claims process, including that CGU will contact the claimant about the claim, may inspect damage before authorizing repairs, and may appoint a loss adjuster. It advises claimants not to authorize repairs themselves and to provide documentation like receipts or photos to support the claim. Disputes can be resolved through CGU or referred to the Financial Ombudsman Service. The second page is a claims report form for claimants to provide details of the damaged property, tenants, costs, and other relevant information to support their claim.
Claim intimation form seek information from the insured individual about self, illness he/ she is suffering from and kind of treatment against which the claim is filed. Apollo Munich explains the procedure to be followed while filing claim under Optima Restore coverage. The form is to be filled to intimate the insurer about the treatment to be availed and the related expenditure. It includes information about the policy holder, the diagnosis to be done, expected treatment expenses, address, date of birth and contact details. The claim settlement will depend on the information and documents provided by the insured. Also, the claimant must submit the claim intimation form as soon as possible, in order to allow the insurance company to work over it.
Complete submission of the required documents is extremely important. It will affect the kind of coverage offered by the insurer.
This document appears to be a health insurance claim form containing patient and provider information. It includes identifying information for the patient such as name, address, date of birth, and insurance information. It also lists the medical services provided to the patient such as dates of service, diagnosis codes, procedure codes, charges and payment amounts. At the bottom it includes identifying and contact information for the billing provider.
This document summarizes information related to resolving liens from the Pennsylvania Department of Public Welfare (DPW). It discusses DPW's responsibilities to provide notice when a claim is beginning and being settled. It provides details on what to include in notice letters to DPW. It also discusses strategies for disputing medical expenses claimed by DPW, such as only including related treatment in settlement demands. Ethics rules on expediting litigation and client confidentiality are reviewed. Options for special needs trusts are presented for clients requiring long-term care.
This document is an insurance proposal form for an OptimaRestore health insurance plan. It requests information from the applicant such as personal details, plan details, details of individuals to be insured, nominee details, existing insurance policies, medical history, lifestyle details, and payment details. The document outlines general exclusions of the policy such as a 30-day waiting period for pre-existing diseases and exclusions for war-related events, criminal acts, suicide, and hazardous activities.
In simple and uncomplicated policy wordings, the customer information sheet of Optima Restore provide all policy details. It help the policy buyer or the policyholder to get familiar with what he/ she is covered for, the benefits offered by the plan, exclusions, renewal benefits, information about renewal benefits, renewal conditions and the claim procedure. Conditions related to cashless access must also be studied in detail. With no hidden clause Apollo Munich help you understand the policy coverage with genuine information to make the process transparent and simple for the customers. As per the policy variant the benefits offered will differ, thus it require a close study.
The information must be read in accordance to the policy document and policy brochures to obtain a clear idea about the related terms and conditions.
To assist insured people with uncomplicated health insurance services, Apollo Munich explains claim procedure in simple language and clear guidelines. Giving all information about the procedure for reimbursement for medical expenses, procedure to avail cashless facility and intimation details. Optima Restore offers unique coverage through easy to follow claim procedure. It is advised to be clear about the process of claim as it will affect the kind of services received. Optima Restore claim procedure form gives access to information about the steps to be followed.
To enjoy hassle free and uncomplicated claim process, it is advised to keep copies of documents submitted to the Third Party Administrator and also don’t forget to quote your policy number or member ID.
Optima Restore is the recently launched Unbelievable plan by Apollo Munich. The product is available in affordable sum insured options ranging from 3 lakhs to 15 lakhs. It is available for individual as well as family coverage. Optima Restore comes equipped with unique healthcare benefits like Restore benefit- that automatically reinstates entire sum insured if exhausted in the policy year and Multiplier benefit- that offers 50% no claim bonus going maximum up to 100%. Besides the basic coverage features, the policy weaves along another list of unique healthcare benefits. With no sub-limit, lifelong renewal and tax benefit, Optima Restore entitle the insured to family discount of 10% and an additional discount of 7.5% as per the policy terms.
Enjoy unique health insurance coverage with first of its kind plan- Optima Restore.
In simple and uncomplicated policy wordings, the customer information sheet provide all policy details. Information regarding Optima Senior coverage is explained in uncomplictade language by Apollo Munich. It help the policyholder to get familiar with what he/ she is covered for, the benefits offered by the plan, exclusions, renewal benefits, information about renewal benefits, renewal conditions and the claim procedure. Conditions related to cashless access must also be studied in detail. With no hidden clause, it provide genuine information to make the process transparent and simple for the individual. As per the policy variant the benefits offered will differ, thus it require a close study.
The information must be read in accordance to the policy document and policy brochures to obtain a clear idea about the related terms and conditions.
Proposal form is meant to seek accurate information about the proposer and his/ her life. Proposal form for Optima Senior is easily accessible through the website of Apollo Munich. It requires the details like name, address, plan details, nominee details and about the life of the proposer. The form is to be filled by the proposer and the information provided should be authentic.
Information about any pre- existing illness if any and the lifestyle of the individual is to be provided by the policyholder. Along with the proposal form, the proposer need to attach certain crucial documents like ID proof, residence proof, age proof, renewal notice with claim details and photocopies of other documents like previous policies and endorsements. The form is to be duly filled and attached with all necessary documents (information regarding documents to be attached is clearly mentioned in the form).
Optima Senior is a plan exclusively designed for senior citizens by Apollo Munich Health Insurance. This wonderful plan is power packed with amazing benefits to guarantee best healthcare to people of age 61 years or above. With no additional loading, the plan ensures best coverage during retirement years. Optima Senior is available in cover options of 2 lakhs, 3 lakhs and 5 lakhs. It is possible to acquire lifelong coverage under this plan along with an access to e-opinion for listed critical illnesses. With an option of higher sum insured one can enjoy several benefits with comprehensive coverage.
Tax Benefit and discount offer makes the plan affordable for all income groups.
This document provides the prospectus for the OptimaSENIOR health insurance plan. It outlines the plan's suitability, schedule of benefits, salient features and benefits, exclusions, and waiting periods. Key details include:
- The plan covers medical expenses for inpatient treatment, pre-hospitalization, post-hospitalization care, day care procedures, and more.
- It has benefits like e-opinion and ambulance coverage up to specified limits.
- Several medical conditions and treatments have waiting periods of up to 36 months.
- Exclusions include cosmetic treatments, substance abuse, experimental treatments, and pre-existing conditions (among others).
- The basic sum insured ranges from Rs. 200,000
Claim intimation form seek information from the insured individual about self, illness he/ she is suffering from and kind of treatment against which the claim is filed. Apollo Munich explains the procedure to be followed while filing the claim. The form is to be filled to intimate the insurer about the treatment to be availed and the related expenditure. It includes information about the policyholder, the diagnosis to be done, expected treatment expenses, address, date of birth and contact details. The claim settlement will depend on the information and documents provided by the insured. Also, the claimant must submit the claim intimation form as soon as possible, in order to allow the insurance company work over it.
Complete submission of the required documents is extremely important. It will affect the kind of coverage offered by the insurer.
At times the policyholder need to get some changes in the details provided while buying the policy. Also the person might want to change the plan. To allow people do that, Apollo Munich provides the respective link on its website. The insured need to fill the Change Request Form in order to avail the provision. The individual need to provide the detail about the change. He/ she can opt from the categories of change in the plan, change in address, change in sum insured, member addition/ deletion and others. Thereafter, the form will seek further related information and details so as to exercise the required change. Along with these details, the individual need to provide name of witness, address and contact details.
Proposal form is meant to seek accurate information about the proposer and his/ her life. Apollo Munich website gives you ready access to the proposal form of Optima Plus- a unique top-up plan for people. The form is to be filled in by the proposer. The buyer needs to provide details like name, address, plan details, nominee details, occupation and income details and other medical and lifestyle information. Here, the insured need to make sure that information provided is genuine. It is important to claim all the committed benefits by the insurance company. With policy declaration and warranty information, it demystifies the understanding with clear details.
Along with the proposal form, the proposer need to attach certain crucial documents like ID proof, residence proof, age proof and income proof. Read all the related instructions about the documents to be attached.
In simple and uncomplicated policy wordings, this link provide all policy details about Optima Plus. It help policy buyers to get familiar with what he/ she is covered for, the benefits offered by the plan, exclusions, renewal benefits, claim procedure and other related terms of the policy. To help people understand all crucial features easily, Apollo Munich website provide link for policy wording form. The link will familiarize you with information about waiting period, schedule of benefits and similar other features that must be read well before making payment.
However, the information must be read in accordance to the policy document and policy brochures to obtain a clear idea about the related terms and conditions.
To assist insured people with uncomplicated health insurance services, claim procedure is explained in simple language by Apollo Munich. Giving all information about the procedure for reimbursement, this document help you get familiar with all the related terms and conditions. Obtain all claim procedure information about Optima Plus through link available on website. It explains the procedure to be followed in different circumstances. With the help of the information displayed, you can obtain information about the precautions to be exercised in terms of policy document for future references and claim purposes.
To enjoy hassle free and uncomplicated claim process, it is advised to keep copies of documents submitted to the Third Party Administrator and also don’t forget to quote your policy number or member ID.
Proposal form is meant to seek accurate information about the proposer and his/ her life. Proposal form for Maxima is easily accessible through the website of Apollo Munich. It requires the details like name, address, plan details, nominee details and about the life of the proposer. The form is to be filled by the proposer according to the instructions provided in the form. Make sure that the information provided is genuine.
The form is to be closely studied by the proposer and must be filled with due attention. Along with the proposal form, the proposer need to attach certain crucial documents like ID proof, residence proof, age proof, renewal notice with claim details and photocopies of other documents like previous policies and endorsements. The form is to be duly filled and attached with all necessary documents (information regarding documents to be attached is clearly mentioned in the form).
In simple and uncomplicated policy wordings, the customer information sheet of Maxima provide all policy details. It help the policy buyer or the policyholder to get familiar with what he/ she is covered for, the benefits offered by the plan, exclusions, renewal benefits, information about renewal benefits, renewal conditions and the claim procedure. Conditions related to cashless access must also be studied in detail. With no hidden clause Apollo Munich help you understand the policy coverage with genuine information to make the process transparent and simple for the customers. As per the policy variant the benefits offered will differ, thus it require a close study.
The information must be read in accordance to the policy document and policy brochures to obtain a clear idea about the related terms and conditions.
To assist insured people with uncomplicated health insurance services, Apollo Munich explains claim procedure in simple language and clear guidelines. The form provides information in uncomplicated guidelines. The policyholder can read all about the claim procedure to be followed while seeking outpatient and inpatient benefits. The procedure for reimbursement of medical expenses incurred, procedure to avail cashless facility and intimation details must be understood before paying for any plan. It is advised to be clear about the process of claim as it will affect the kind of services offered.
To enjoy hassle free and uncomplicated claim process, it is advised to keep copies of documents submitted to the Third Party Administrator and also don’t forget to quote your policy number or member ID.
Maxima is a plan that takes care of your everyday health needs. It is an easy to buy plan that covers expenses incurred in the form of Doctors’ consultations, Pharmacy bills, Diagnostic tests, Dental treatment, Optical services and Annual health check-up. Maxima health plan by Apollo Munich offers comprehensive coverage while taking care of little illnesses too. Along with wide inpatient coverage, Maxima also offer benefits with unique outpatient coverage. With additional critical illness coverage and provision of lifelong renewal, the plan makes insurance coverage feasible at affordable premium rates. Get self as well as your family members insured under this easy to understand plan and enjoy a stress free health future.
1) This document outlines the benefits provided by an Individual Personal Accident Standard policy. The policy provides insurance coverage for accidental death, permanent total or partial disability, and other related costs like transportation of remains, education funds for dependents, etc. subject to specified terms and conditions.
2) The policy pays a percentage of the sum insured for permanent total or partial disabilities. It also provides a weekly benefit for temporary total disability, reimbursement of medical expenses, and other additional benefits like family transportation in case of certain claims.
3) The policy contains standard exclusions for pre-existing conditions, suicide, HIV/AIDS, war, pregnancy, congenital anomalies, non-allopathic treatments, and criminal acts.
Proposal form is meant to seek accurate information about the proposer and his/ her life. Easy Travel proposal form is easily accessible through the website of the company. It requires the details like name, address, contact details, plan details, nominee details and about the life of the proposer. The form is to be filled by the proposer and the information provided should be authentic. It help the insurer, Apollo Munich to provide customers required information.
Policy proposal form seek information about any pre- existing illness if any and the life style of the individual. Along with the proposal form, the proposer need to attach certain crucial documents like ID prooof, residence proof, age proof, renewal notice with claim details and photocopies of other documents like previous policies and endorsements. The form is to be duly filled and attached with all necessary documents (information regarding documents to be attached is clearly mentioned in the form).
Proposal form is meant to seek accurate information about the proposer and his/ her life. Easy Health proposal form is easily accessible through the website of the company. It requires the details like name, address, plan details, nominee details and about the life of the proposer. The form is to be filled by the proposer and the information provided should be authentic.
The form is to be closely studied by the proposer and must be filled with due attention. It seek information about any pre- existing illness if any and the life style of the individual. Along with the proposal form, the proposer need to attach certain crucial documents like ID prooof, residence proof, age proof, renewal notice with claim details and photocopies of other documents like previous policies and endorsements. The form is to be duly filled and attached with all necessary documents (information regarding documents to be attached is clearly mentioned in the form).
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1. Optima Restore
Claim Form 10th Floor, Building No. 10, Tower B, DLF City Phase II, DLF Cyber City, Gurgaon-122002
PART A
TO BE FILLED IN BY THE INSURED
The issue of this Form is not to be taken as an admission of liability
1. Policy No. : 2. Sl. No/ Certificate No. : 3. Company/ TPA ID No :
4. Name & Address of the Policyholder :
5. Details of the Insured Person Hospitalised :
a) Name :
b) Relationship : c) Date of Birth : d) Age/Years :
e) Address :
f) Gender: Male / Female g) Occupation :
h) Telephone No : i) Mobile No :
j) E-mail ID, if any :
6. Hospitallisation due to Illness / Injury / Maternity : Details :
a) Date of Injury sustained/ Disease first detected / LMP :
b) If injury, how it occurred :
c) If injury, whether Medico legal : Yes / No d) If MLC, whether reported to police? Yes / No
e) System of medicine : Allopathic / Other systems of medicine
7. Insurance History :
a) Date of commencement of first Insurance for the person (without break) :
b) Are you presently covered with any other Mediclaim / Health Insurance? : Yes / No
c) If Yes, give details - Company / Policy Number / Sum Insured (copies of policies to be attached) :
8. Name of the Hospital where admitted :
9. Room Category occupied : Day care / Single occupancy / Twin sharing / 3 or more
10. Past Hospitalisation History :
a) Have you been hospitalised in the last 4 years? : Yes / No
b) If Yes, Diagnosis :
c) Month and Year :
11. Is claim is for Domiciliary Hospitalisation? : Yes / No (If Yes, provide details in annexure)
12. Policyholder’s Bank Account particulars :
Payable details: Cheque / DD / NEFT * Payable to :
Bank Name : Bank Branch :
Bank Account Number : IFSC Code :
MICR No. : Policyholder’s PAN :
Note: It is agreed that the Policyholder/ Claimant will intimate in writing to Apollo Munich about any change in bank account details.
*Please attach a cancelled cheque pertaining to the same account.
13. Details of the treatment expenses claimed :
a) Pre-hospitalisation Expenses : Rs. b) Hospitalisation Expenses : Rs.
c) Post-hospitalisation Expenses : Rs. d) Health check-up Cost : Rs.
e) Ambulance Charges : Rs. f ) Others (code) : Rs.
13A. Details of Lumpsum / cash benefit claimed :
a) Hospital Daily Cash : Rs. b) Surgical Cash : Rs.
c) Critical Illness Benefit : d) Convalescence :
e) Pre / Post hospitalisation lumpsum benefit :
f) Others :
14. Details of bills enclosed :
Sl. No. Bill No. Date Issued by Towards Amount
(If there is insufficient space to provide additional relevant information, whether as requested or otherwise, please attach extra sheet duly signed.)
15. For details of Claim Documents to be submitted, please refer CHECK LIST.
Date : Signature of the Policyholder / Claimant :
1
2. Optima Restore
Claim Form 10th Floor, Building No. 10, Tower B, DLF City Phase II, DLF Cyber City, Gurgaon-122002
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 preauthorisation request form in lieu of PART A
1. Name of the Hospital where treated :
2. Hospital ID : 3. Type of Hospital : Network / Non-Network
4. In case of non network , please provide below details :
a) Address of the Hospital with Pin Code :
b) Telephone No : c) Registration No :
d) Number of Inpatient beds : e) PAN :
f) Other Facilities available in the hospital :
OT : Yes / No
i) ii) ICU : Yes / No iii) Others :
5. Details of the patient admitted :
a) Name of the patient :
b) IP Registration Number : c) Gender: Male / Female d) Age :
e) Date of Admission (DD/MM/YYYY) : f) Time of Admission :
g) Date of Discharge (DD/MM/YYYY) : h) Time of Discharge :
6. Ailment Diagnosed (Primary) :
a) ICD 10 Code :
Primary Diagnosis :
Additional Diagnosis :
Co-morbidities :
b) Details of Procedure/s done :
c) ICD 10 PCS :
Procedure 1 :
Procedure 2 :
Procedure 3 :
7. a) Type of Admission : Emergency / Planned / Day-care / Maternity
b) Date of delivery, if maternity (DD/MM/YYYY) : c) Gravida Status :
8. Is the treatment for an injury? If Yes, give details
a) Was it self inflicted? : Yes / No b) Whether RTA : Yes / No
c) If MLC, whether notified to police : Yes / No d) MLC / FIR No :
e) If MLC not notified, give reasons :
9. Was the Injury/ disease caused due to Substance abuse / Alcohol consumption : Yes / No
a) If Yes, whether any test was conducted to establish this? : Yes / No If Yes, please attach Report.
10. Whether the present ailment is a complication of any illness suffered in the past : Yes / No
If Yes, specify details :
11. Whether Pre-authorisation obtained : Yes / No
a) If Yes, Pre Auth Number :
b) If authorisation by network hospital not obtained, give reason :
12. Details of the Treating Doctor :
a) Name of the Treating Doctor:
b) Registration No with state code :
c) Mobile No. : d) Qualification :
13. For details of Claim Documents to be submitted, please refer CHECK LIST.
DECLARATION BY THE INSURED
I hereby declare that the information furnished in this Claim Form is true & correct to the best of my knowledge and belief. If I have made any false or untrue statement, suppression
or concealment of any material fact, my right to claim reimbursement shall be forfeited.
I also consent & authorise TPA / Insurance Company., to seek necessary medical information / documents from any hospital / Medical Practitioner/ Insurer who has attended on the
person against whom this claim is made.
I hereby declare that I have included all the Bills / receipts for the purpose of this claim & that I will not be making any supplementary claim except the Pre/Post – hospitalisation
claim, if any.
DECLARATION BY THE HOSPITAL
We hereby declare that the information furnished in this Claim Form is true & correct to the best of our knowledge and belief. If we have made any false or untrue statement,
suppression or concealment of any material fact, our right to claim under this claim shall be forfeited.
Signature of the Insured : Seal & Signature of the Hospital Authority :
Date : Date :
2
3. Optima Restore
Claim Form 10th Floor, Building No. 10, Tower B, DLF City Phase II, DLF Cyber City, Gurgaon-122002
PART C
For Office Use Only (Refer IRDA / TAC Master for codes wherever applicable)
1. TPA Code : 2. Insurer Code :
3. Product Code : 4. Policy Number :
5. Policy Start Date : 6. Policy End Date :
7. Sum Insured : 8. Bonus Sum Insured Accrued, if any :
9. Master Claim ID :
10. Diagnosis Code :
Primary Diagnosis :
Additional Diagnosis :
Co-morbidities :
11. Procedure Code :
Procedure 1 :
Procedure 2 :
Procedure 3 :
12. Details of Claim Paid :
A) Indemnity Benefit :
a) Room & Nursing Charges :
b) ICU Charges :
c) OT Charges :
d) Medicine & Consumable Charges :
e) Professional Fees’ Charges :
f) Investigation Charges :
g) Ambulance Charges :
h) Miscellaneous Charges :
B) Fixed / Lumpsum Benefit :
a) Hospital Daily Cash :
b) Surgical Cash :
c) Critical Illness Benefit :
d) Convalescence :
e) Pre / Post hospitalisation lumpsum benefit :
Others :
f)
13. Total Claim Paid :
14. Total Rejected Amount :
15. Reason for Rejection of Claim :
16. Reason for Reduction of Claim :
17. Whether claim paid was for PED :
18. If Yes, PED Code :
19. Whether claim paid under alternate medicine : Yes / No
20. Amount of co-payment / deductible applicable :
21. Corporate Buffer Utilised, if any :
22. Date of Payment (DD/MM/YYYY) :
23. Payment Reference Number :
24. Date of Claim Intimation (DD/MM/YYYY) :
25. Date of receipt of complete claim documents (DD/MM/YYYY) :
Duly filled and signed Claim Form.
3
4. Optima Restore
Claim Form 10th Floor, Building No. 10, Tower B, DLF City Phase II, DLF Cyber City, Gurgaon-122002
Check List of Enclosures for Submission of Claim
In-patient Treatment /Day Care Procedures Organ Donation/Transplantation
In addition to the documents of general hospitalization
q Duly filled and signed Claim Form. q Organ Function test / blood test proving organ failure.
q Photocopy of ID card / Photocopy of current year policy. q Treatment Certificate issued by the Transplant Surgeon of the hospital
concerned.
q Original Detailed Discharge Summary / Day care summary from the
hospital.
Ambulance Benefit
q Original consolidated hospital bill with break up of each Item, duly q Duly filled and signed Claim Form.
signed by the insured.
q Photocopy of ID card / Photocopy of current year policy.
q Original payment Receipt of the hospital bill. q Original Bill with Original Payment Receipt.
q First Consultation letter and subsequent Prescriptions. q Treating Doctor’s consultation prescription indicating Emergency
Hospitalization.
q Original bills, original payment receipts and Reports for investigation.
q Original medicine bills and receipts with corresponding Prescriptions. Pre and Post-hospitalisation expenses
q Duly filled and signed Claim Form.
q Original invoice/bills for Implants (viz. Stent /PHS Mesh / IOL etc.) with q Photocopy of ID card / Photocopy of current year policy.
original payment receipts.
q Original Medicine bills, original payment receipt with prescriptions.
q Original Investigations bills, original payment receipt with prescriptions
Road Traffic Accident and report.
In addition to the In-patient Treatment documents: q Original Consultation bills, original payment receipt with prescription.
q Copy of the First Information Report from Police Department / Copy of q Copy of the Discharge Summary of the main claim.
the Medico-Legal Certificate.
For Death Cases
In Non Medico legal cases
In addition to the In-patient Treatment documents:
q Treating Doctor’s Certificate giving details of injuries (How, when and q Original Death Summary from the hospital.
where injury sustained) q Copy of the Death certificate from treating doctor or the hospital
In Accidental Death cases authority.
q Copy of the Legal heir certificate, if the claim is for the death of the
q Copy of Post Mortem Report & Death Certificate principle insured.
Customer Identification Procedure (as per KYC norms of IRDA)
Please submit the following documents in case of claim amount exceeds Rs. 100,000
Legal name and any other names used Passport/ PAN Card/ Voter’s Identity Card/ Driving License/ Letter from a recognized public authority or public
(Any one of the mentioned documents) servant verifying the identity and residence of the customer
Proof of Residence Telephone bill/ Bank account statement/ Letter from any recognized public authority/ Electricity bill/ Ration card
(Any one of the mentioned documents)
AMHI/PR/H/0018/0063/102010/P
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