THE  NEW  INDIA  ASSURANCE  COMPANY  LIMITED
DIVISIONAL  OFFICE - 712500
 Allied Mount Casa Blanca Building, 2nd Floor, 260 Anna Salai, CHENNAI-600 006.
                   Phone  044-852 2886, 044-852 3347    Fax : 044-858 6565  Email : nia25@vsnl.com

                 THE ISSUE OF THIS FORM IS NOT TO BE TAKEN AS AN ADMISSION OF LIABILITY

FILE No. 48/                               

CLAIM FORM FOR HOSPITALISATION

    1. Citibank Credit Card No..   
       (Under which the premium has been debited)         :

     Policy No. 71250034                                            Certificate No.712500/

 2. Name & Address of the Card holder                                        :
  for correspondence (with telephone no.)
  Email Address

       

    3. Details of the insured person in respect of whom the claim is preferred.
        a)  Name & Age of the insured Person
        
        b)      Relationship to the Cardholder

        c)      His/Her Occupation

    4. Nature of ailment/Diagnosis                                                                       

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

    6. Name and Address of the Hospital/ Nursing home/Clinic
        (where treatment is given)

        Doctor’s Name

    7. a)  Date of Admission                                                 :

        b)  Date of Discharge                                                :

    8.  Have you been insured under any Mediclaim Scheme

         Earlier (held with us or any other insurance co.) If yes

         Xerox Copies of Previous Years’ Policies MUST be enclosed)        

     9.  Have you preferred any claim for the same insured under the
         Mediclaim scheme earlier, if so, give details viz.:

         (a) Previous claim file Ref.No.               :

         (b) Diagnosis                                         :

         (c) Whether settled/repudiated               :

         (d) Amount (if settled)                           :  Rs.

   10. Amount Claimed now under present claim
        (enclose a statement with details of amount claimed)  

   11. I have enclosed the following documents 

1 ATTENDING DOCTOR'S CERTIFICATE AS PER FORMAT GIVEN.   Yes/No
2 CASE HISTORY/ADMISSION-DISCHARGE SUMMARY DESCRIBING THE
      NATURE OF THE COMPLAINTS AND ITS DURATION, TREATMENT
     GIVEN, ADVICE ON DISCHARGE ETC. ISSUED BY THE HOSPITAL.   		Yes/No
3 HOSPITAL RECEIPTS/BILLS/CASH MEMOS IN ORIGINAL (PRINTED,  
     NUMBERED, STAMPED RECEIPT/CREDIT CARD CHARGE-SLIPS)   		Yes/No
4 ALL TEST REPORTS FOR X-RAY, ECG, SCAN, MRI, PATHOLOGY ETC
      (FILMS SHOULD NOT SENT NOW)   		Yes/No
5 TEST REPORTS AND PRESCRIPTIONS RELATING TO FIRST/PREVIOUS
      CONSULTATIONS FOR THE SAME OR RELATED ILLNESS   		Yes/No
6  PRESCRIPTIONS ADVISED BY THE ATTENDING DOCTOR, WITH
      CASH BILLS FOR MEDICINES PURCHASED.   		Yes/No
7  POLICY COPIES FOR CURRENT YEAR AND PREVIOUS YEARS   Yes/No
8

FIR (IN CASE OF ACCIDENTAL INJURY ONLY)/BRIEF DESCRIPTION
        OF THE ACCIDENT.




 Yes/No

 I hereby warrant the truth of the foregoing particulars in every respect and I agree that if I have made or shall make any false or untrue statement, suppression or concealment, my right to claim reimbursement of the said expenses shall be absolutely forfeited.

 I also consent and authorise the insurers to seek medical information from any hospital / medical practitioners who has at any time attended on the insured

 I  hereby declare that I have included all bills/receipts for the purpose of this claim and

 That I will not be making any supplementary claim in respect thereof except the post-Hospitalization claim.

 DATE

 PLACE

                                                                                                      Signature of the Card Member