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Claim Form - MDIndia Healthcare Services

Claim Form - MDIndia Healthcare Services

Claim Form - MDIndia Healthcare

MDINDIA HEALTHCARE SERVICES (TPA) PVT. LTD. S. No. – 46/1, E-space, A Wing, 3rd Floor, Pune Nagar Road, VadgaonSheri, Pune - 411014 (Maharashtra) UAN Voice : 1860-233-4446 UAN Fax: 1860-233-4447 Email: customercare@mdindia.com - Website: www.mdindiaonline.com CLAIM FORM National Insurance Company The New India Assurance Company Oriental Insurance Company The United India Insurance Company 1. Current Policy no. :- 2. MDIndia ID No.: MDI5- ___________________________________ 3. Corporate Name :____________________________________ Employee Code : __________________ 4. Name & Address of the Policy Holder:____________________________________________________ ___________________________________________________________________________________ 5. Name of the Patient: __________________________________________________________________ 6. Present Contact Address: ______________________________________________________________ 7. Contact No. (Resi. / Office): _______________________ Mobile No.: __________________________ 8. Have you preferred any claim for the same Insured under the Mediclaim scheme earlier, if so give details viz Sr. No. Particulars Claim 1 Claim 2 Claim 3 Claim 4 (a) Policy Number (b) Date of Admission (c) Date of Discharge (d) Diagnosis (e) Whether settled / repudiated (f) Claim Amount (if settled) : Rs. 9. Since when the person covered under the policy without break _________ yrs. Xerox copies of previous year’s policies MUST be enclosed: 10. If the claim is of Domiciliary Hospitalization please indicate a) Date of Commencement of the treatment______________________________________ b) Date of Completion of treatment _____________________________________ c) Name & Address of attending Medical Practitioner

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MDINDIA HEALTHCARE SERVICES (TPA) PVT. LTD.
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Pune Claim Form - MDIndia Healthcare Services
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MDINDIA HEALTHCARE SERVICES (TPA) PVT. LTD.
MDINDIA HEALTHCARE SERVICES (TPA) PVT. LTD.
MDINDIA HEALTHCARE SERVICES (TPA) PVT. LTD.
MDINDIA HEALTHCARE SERVICES (TPA) PVT. LTD.
MDINDIA HEALTHCARE SERVICES (TPA) PVT. LTD.
MDINDIA HEALTHCARE SERVICES (TPA) PVT. LTD.
MDINDIA HEALTHCARE SERVICES (TPA) PVT. LTD.
MDINDIA HEALTHCARE SERVICES (TPA) PVT. LTD.
MDINDIA HEALTHCARE SERVICES (TPA) PVT. LTD.
MDINDIA HEALTHCARE SERVICES (TPA) PVT. LTD.
MDINDIA HEALTHCARE SERVICES (TPA) PVT. LTD.