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Insurance Company:

Service by: MEDI ASSIST INDIA TPA PVT. LTD.


Domiciliary Claim Form
¾ Details of the Insured: *Please Note: Below mentioned columns are mandatory:
*Employee’s Name: *Employee Code: *MAID No:

*Patient’s Name in full: *Complete Residential Address & Contact No.:

*Emergency Contact No.: *E-Mail ID :

¾ Details of the Treatment Expenses :


Name/ Nature of Ailment:

1. Family Doctors Fees: No. of Total Amount


Bills/documents
(a) Doctor/Consultants/Specialist’s Fees (Consultation Notes
Mandatory)
(b) Medicine given by Doctor (Prescription Mandatory)
(c) Medicines brought from Chemists (Prescription Mandatory)
2. Investigation Charges:
(a) Blood Test – (Copy of the Reports Mandatory)
(b) X-Ray – (Copy of the Reports Mandatory)
(c) Others – (Copy of the Reports Mandatory)
3. Dental Treatment : (Doctor Advice, Report, original Bills Mandatory)
Grand Total (1+2+3)

¾ Details of the Insured’s Bank Account (Mandatory details for claim processing)
Name of the Account Holder
Bank Account Number
Bank Name
Bank Branch address
IFSC Code
*Please attach cancelled cheque along with the claim form for ready reference.
Signature of Claimant : Date :

Important Notes/Guidelines to be strictly followed :


1. Name/Nature of illness has to be mentioned in the claim form along with prescription and doctor’s consultation
notes or claim will be rejected.
2. All doctors’ consultation Bills/Chemists Bills/Investigation Bills have to be submitted in original.
3. Copy/Duplicate of claim form to be attached at the end after all other relevant documents are attached.
4. Please use separate claim form for each member i.e. self and spouse.
5. Copies of all the investigation reports have to be enclosed along with the claim form
6. All correspondence should be done at the below mentioned address.
*For further details please contact : Medi Assist India TPA Pvt. Ltd. 1st floor, North Wing, Plot No.7, Excom House,
Saki Vihar Road, Saki Naka, Andheri (E), Mumbai -400 072. Tel: 022-30843800/01/02/03.