CLAIM FORM - E-Meditek TPA

Name of the Insurance Company: 

EMSL’s ID No.: 

1. Name of the Insured (In whose name policy is issued): 

2. Details of the insured Person (In respect of whom claim is made): 

(a) Name: (b) Gender: (d) Relationship Status: 

(c) Present completed age: (e) Occupation: (h)Phone No.: 

(i)Mobile No.: (f) E-Mail – ID: 

(g) Residential address: City: 

State: 

Pin Code: 

3. Nature of Disease/illness contracted or injury suffered: 

4. Date of injury sustained or Disease/illness frist detected: 

5. (a) Name & Address of the Hospital/ Nursing Home/ Clinic: 

(b) Date of Admission D D / M M / Y Y (c) Date of Discharge D D / M M / Y Y 

6. (a) Name of the attending Medical Practitioner: 

(b) Address: (c) Qualification: 

City: (d) Telephone No.: 

State: Pin Code: (e) Registration No.: 

7. Have you been insured under any Mediclaim Scheme earlier: 

(Whether with us or any other Insurance Co.) If yes, photo 

Copies of previous year’s Insurance policies must be enclosed 

8. Date of Commencement of very first insurance for this insured: 

Person with continuous Insurance Cover 

9. If the claim is for Domiciliary Hospitalization: 

Please idicate 

(a) Date of Commencement of treatment: D D / M M / Y Y (b) Date of Completion of treatment: D D / M M / Y Y 

(c) Name of attending Medical Practitioner 

(d) Address 

City: State: Pin Code: 

10. Total Amount Claimed: Rs. 

I have incurred on the treatment of disease/illness/accident referred to above the expenses as per the details given by me in the Schedule of 

Expenses given overleaf. 

In support of the above claim, I enclose the following documents: 

Name of Documents Yes No Name of Documents Yes No 

Claim Form Duly Signed: X-Ray Nos. 

Claim Intimation Letter Medicines Bills with Dr’s prescription 

Photo ID Proof Operation Theater / Pharmacy Bills 

Discharge Summary Surgeon’s surgery certificate 

Hospitalization Bill Surgeon/Consultant’s bills 

Hospital Payment receipt ECG Nos. 

Investigation reports with Dr’s prescription Pre Hospitalization bill Nos. 

MRI Nos. Post Hospitalization bill Nos. 

CT scan Nos. Other’s (If any) Nos. 

US scan Nos. 

Dated: D D / M M / Y Y 

CLAIM FORM 

(Issuance of this form does not amount to admission of any liability under the claim on the part of the insurance.) 

Policy 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 further declare that, in respect of the above treatment, 

no benefits are admissible under any other Medical Scheme or Insurance. 

Signature of the Insured/Patient

Sr. No. 

Date of the Bill 

Bill No. 

Bank Details of the Insured/Claimant (in whose name policy is issued) 

Schedule of expenses Incurred 

Name of the Hospital/Lab/Medical Shop 

NEFT DETAILS 

(a) Bank Name: (b) Branch Name: 

(c) IFSC Code: (e) Account Number: 

(f) Re-enter Account Number: (f) Name as appearing in Bank Account: 

DECLARATION 

Amount 

• I / We hereby declare that the particulars given above are correct and complete and no blanks have been left. If the transaction is delayed or not effected at all for 

reason of incomplete or incorrect information I / we would not hold E-Meditek (TPA) Services Limited responsible. 

• I / We further undertake to refund, at any time, any excess amount whether demanded by E-Meditek (TPA) Services Limited or not, which has been credited to my 

account [due to any reason] by E-Meditek (TPA) Services Limited, in excess of (i) the amount due to me, or (ii) Claim/Refund/ Any other payment. 

• I / We agree that the payment will be endeavoured to be credited starting from the date of next payment cycle and unless the Mandate is revoked by me/us issuance 

of relevant credit instruction for electronic payment from E-Meditek (TPA) Services Limited into the aforesaid account will be valid discharge to E-Meditek (TPA) Services 

Limited for having paid (i) the amount due to me, or (ii) Claim/Refund/ Any other payment. 

• I / We further confirm that we understand this mode as a method of payment introduced by Reserve Bank of India, which provides us an option to receive the amount 

and or to collect our payments by electronic payment mode directly through my/our bank accounts. 

• I / We further confirm that I/we understand, E-Meditek (TPA) Services Limited, shall make electronic payment to my account by issuing the Payment instruction 

electronically through its banker to the Clearing Authority and the Clearing Authority would ensure credit to my/our specified bank account provided hereinabove. 

• I / We further undertake to inform E-Meditek (TPA) Services Limited with an advance notice of 15 days, to withdraw from this mode of electronic payment. 

• I / We further confirm that E-Meditek (TPA) Services Limited will have, at its sole discretion, the right to return back to the option of paying to me/us by way of cheque 

if there are more than 2 consecutive failures in remittances for no fault on the side of E-Meditek (TPA) Services Limited. 

• After E-Meditek (TPA) Services Limited issuing the Payment instruction electronically through its banker, for whatever reasons, if I/we do not get the credit to my/our 

account, then same shall neither constitute the default in (i) Payment of amount requested by me, or (ii) Payment of amount due to me/us, or (iii) Payment of claim/ 

Refund/Any other payment by E-Meditek (TPA) Services Limited nor constitute default of any terms and conditions of any Claim/Refund/Other contract with me/us. 

Date: DD / MM / YY 

Signature of Proposer 

[Please note that As per government directions all claim payments are to be made only by NEFT 

(Electronic Transfer)] 

(Kindly attach the copy of cancelled Cheque in this Box)

From: 

Patient’s Name and address: 

To: 

Whomsoever it may concern: (Hospital/Doctor) 

Consent Form 

Sir/Mam, 

I here by authorize E-Meditek (TPA) Services Limited representatives free and unlimited access to seek medical information (Indoor case 

papers, reports, documents, including photocopies thereof / pertaining my, admission / treatment) from any hospital / medical practitioner 

from which or whom I have at any time sought or shall seek medical attention concerning any disease/ sickness, ailment or injury, which 

affects my physical or mental health. 

Yours faithfully, 

Signature of the Insured/Patient

CLAIM FORM - E-Meditek TPA

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