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    OPD Claim Form & Checklist

    Uploaded by

    umannam
    This document contains a claim form and checklist for an employee to submit an insurance claim for domiciliary, dental, optical, and health checkup expenses. The form requests information like the employee name and number, claimed amount, contact details, and relationship to the claimant. It also lists the documents needed like bills, prescriptions, identification proofs, and a signed declaration form.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd

    OPD Claim Form & Checklist

    Uploaded by

    umannam
    91 views1 page
    This document contains a claim form and checklist for an employee to submit an insurance claim for domiciliary, dental, optical, and health checkup expenses. The form requests information like the employee name and number, claimed amount, contact details, and relationship to the claimant. It also lists the documents needed like bills, prescriptions, identification proofs, and a signed declaration form.

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    OPD claim form & checklist

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    This document contains a claim form and checklist for an employee to submit an insurance claim for domiciliary, dental, optical, and health checkup expenses. The form requests information like the employee name and number, claimed amount, contact details, and relationship to the claimant. It also lists the documents needed like bills, prescriptions, identification proofs, and a signed declaration form.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    91 views1 page

    OPD Claim Form & Checklist

    Uploaded by

    umannam
    This document contains a claim form and checklist for an employee to submit an insurance claim for domiciliary, dental, optical, and health checkup expenses. The form requests information like the employee name and number, claimed amount, contact details, and relationship to the claimant. It also lists the documents needed like bills, prescriptions, identification proofs, and a signed declaration form.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 1

    OPD claim form & CHECKLIST

    Employee Name:
    Employee No.:

    Claimed Amount:
    Mobile Number :
    Email ID :

    Domiciliary amount Employee work location

    Dental amount Employee relation with claimant

    Optical amount Claimant name :

    Health check
    up amount

    1 Claim Form – Yes/No


    2 Copy of Medi Assist TPA ID Card
    3 Govt. Photo id proof of Insured and Claimant (Copy of Aadhar Card, PAN Card, Voter ID Card etc.)
    4 Please login and update your active salary bank account details in TPA portal and submit supportive
    and sign the declaration form.
    5 All original bills to be submitted with supportive like lab/investigation reports and doctor’s
    advice/prescriptions with dates.
    6 Doctor’s consultation prescription to be mentioned with illness/complaints/diagnosis etc.
    7 All original bills to be submitted with complete itemized and cost wise breakup date wise.

    Points to remember on Claim Submission:

    1) Do not forget to attach the checklist with your claim file and retain all the documents submitted to us including
    POD for the couriered original claim file.
    2) The above list of documents is indicative. In case of any other document required as specified by the insurance
    company, our document recovery Team will send email on receipt of your claim documents.
    3) Please visit Med Assist portal for self-help click here . Please enter your username and password (username is
    MICR<Employee No>) reset password if you are visiting first time.
    4) For more information on claiming process, Please visit the policy
    page: https://microsoft.sharepoint.com/sites/hrw/Pages/MedicalInsurancePolicyOneIndiaIN.aspx

    Date of claim submission. Employee Signature:

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