The Oriental Insurance Company Limited: Hospitalisation and Domiciliary Hospitalisation Benefit Policy Claim Form
The Oriental Insurance Company Limited: Hospitalisation and Domiciliary Hospitalisation Benefit Policy Claim Form
The Oriental Insurance Company Limited: Hospitalisation and Domiciliary Hospitalisation Benefit Policy Claim Form
Regd. Office: “Oriental House”, A-25/27, Asaf Ali Road, New Delhi – 110 002.
Issuing
Office
Claim No.
Insurance of this form does not amount does not admission of any liability under the claim on the part of the
Insurers.
Please give the following information correctly and completely to enable the Company to process your claim
Promptly :
3. Policy No.
c) Registration No. :
I have incurred on the treatment of Disease / illness / Accident referred to above, the expenses as per
the detailsgiven by me in the Schedule of Expenses given overleaf.
In support of the above claim, I enclosed the following documents (please indicate by ✔ )
2. Cash Memos from the Hospital / Chemist (s), supported by the proper prescription.
3. Receipt and Pathological test reports form a Pathologist supported by the note from the attending
Medical Practitioner/ Surgeon demanding such Pathological tests.
4. Surgeon’s certificate stating nature of operation performed and Surgeon’s bill and receipt.
5. Attending Doctor’s / Consultant’s / Specialist’s / Anaesthetist’s bill and receipt and certificate regarding
diagnosis.
6. In case of Domiciliary Hospitalisation , receipt from a qualified nurse who attended the patient at his / her
residence duly supported by a certificate form attending Medical Practitioner.
7. Certificate from the attending Medical Practitioner giving reasons for allowing treatment at home.
8. Certificate form the attending Medical Practitioner / Surgeon that the Patient is fully cured.
I hereby warrant the truth of the foregoing particulars in every respect and 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.
Date of Claim
The Oriental Insurance Company Limited
HOSPITALISATION / DOMICILIARY HOSPTIALISATIO CLAIM SCRUTINY FORM OFFICE: CODE No.
1. (A)
1. (a) Room, Board & Nursing Expenses Per
day, not exceeding (including Boarding
to be provided by the Hospital).
(b) I.C.C. Unit, Board & Nursing Expenses
per day not exceeding.
TOTAL