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For Comparative Insurance Quote: Om Plaza, 430/7, 1st Floor, Sant Nagar, East of Kailash, New Delhi-65
Phone: 011-41324957, 41623784, Mob:+91-8447757651 & 53 Email: ria1@surekhae.com
Health Insurance Claim Procedures
 
(1) Health Insurance Claim Procedure   (2) Protect Your Interest
(3) Claim Form to be Sent to TPA   (4) Circumstances under which claims get Rejected
(5) Claims not Allowed - Some Case Studies   (6) Consumer Forum Cases in Health Insurance (Some Judgments)
3- Claim Form to be Sent to TPA (Specimen of a Claim Form TTK Health Care Services Private Ltd)
7 Jeevan Bheema Nagar Main Road,HALL IIIrd Stage,Bangalore-560 075
Claim Form
(Issuance of this Claim Form is not tantamount to acceptance of Liability by the Insurer)
TTK ID No:
Name & Address of the Insured :
(in whose name policy is issued)
Details of Insured Person:
(in respect of whom claim is made)
Name & relationship of the Insured
  1. Present completed Age 
  2. Occupation
  3. Contact Address
  4. Phone No.
  5. Mobile No.
  6. E-Mail Address
Name of the Insurance Company ..................................
Policy No........................................... Serial No. Of the Schd/ Certificate No. :
AILMENT/ DISEASE/ INJURY :
Date of Injury sustained or disease / illness first detected :
Name of the Hospital :
  1. 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.
  2. Date of commencement of very first insurance for this person with continous insurance coverage.
Have you preferred any claim for the same insured under the mediclaim scheme earlier, if so, give the following details :
  1. Previous claim file ref.no/office 
  2. Diagnosis 
  3. Whether settled/repudiated 
  4. Amount (if settled) 
    Date of Admission 
:
:
:
Rs.
Date of Discharge
TOTAL AMOUNT CLAIMED : Rs.
If the claim is of Domiciliary Hospitalization please indicate
  1. Date of Commencement of the treatment
  2. Date of Completion of treatment
  3. Name & Address of attending Medical Practioner with Telephone No. & Registration No.
Signature of the claimant
I have incurred the below expenses for the treatment of the disease / illness / accident and herewith as per schedule mentioned below: -
Schedule of Expenses incurred by the Claimant 
FOR TTK ONLY
Date Bill No. Description Amount Claimed
         
         
         
         
         
         
         
         
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