HOSPITALIZATION/ DOMICILIARY TREATMENT
MEDICAL CLAIM FORM
Click to view procedures of lodging claim
1. Insured:
Policy No:
Period of Insurance:
   
2. Item No./ Serial No.:
Name of the member:
Age:
Address:
Sex:
       
3. If injured in an accident
Date & time of accident:
Place of accident:
Details of the cause:
Injury sustained:
Name and address of doctor who attended:
4. Details of illness:
5. Medical attendant/s
Name and address of Doctor/s attending member:
6. Is there any Personal Accident Policy purchased for the members?
7.
Details of Claims:
Please fill up the items under which benefits are claimed in respect of the above accident illness/ giving amount claimed and enclosing Original receipt, bills, prescription and the certificate completed by Doctor/s giving the medical attention in respect of which a claim is made.
Benefits Particulars Amount claimed(NRs.)
A.
 Doctor's fee
B.
 Medicines and drugs prescribed
C.
 Suegeon's and Anesthetist's fees and charges for operating theatre
D.
 Pathologist fees
E.
 Electrical treatment fees (X-Ray, ECG, Endoscopy, Ultrasound, C.T. Scan)
F.
 Room and Nurshing expenses
G.
 Accupunture and physiotherapy treatment
H.
 Plaster/ Bandage charges and materials
I.
 Eye and Oral treatment
J.
 Others, if any as per policy
We declare that our member has suffered the above described injuries/illness and that to the best of our knowledge and belief the foregoing particulars are in every respect true.

We also declare that there is no other insurance of other source to cover the items claimed.
Date
 
 
 
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