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ProHealth_ClaimFormA_Apr19.pdf - Please return your...

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ManipalCigna ProHealth Insurance. UIN: CTTHLIP18045V031819 | April 2019 onwardsa. Policy Number:b. Sl. No/Certificate No:c. Company/ TPA ID Nod. Name:e. Address:City:State:Pin Code:b) Date of Commencement of First Insurance without Break:c) If yes, Company Name:d) Have you been hospitalised in the last four years since inception of the contract?e) Previously covered by any other Mediclaim / Health Insurance :f)If yes, Company Name:Diagnosis:YesNoYesNo5easy ways to speed up the claims processSubmit all originaldocuments as per thechecklist within 15days of dischargefrom the hospital.Provide correctand accurate bankdetails withCancelled chequeFor any assistance,please reach out toyour health advisoror connect with ourHealth RelationshipManager.Do not concealor withhold anyinformation withrespect to yourclaim.12345D DM MY Y Y Ya. Name:b. Gender:MaleFemalec. Age:YearsMonthse. Relationship to Primary Insured:SelfSpouseChildFatherMotherOther (Please specify)D DM MY Y Y Yd. Date of BirthPhone No:Email ID:Phone No:Email ID:L A S TN A M EFIRSTN A M EMIDDLEN A M EMANIPALCIGNA PROHEALTH INSURANCE POLICYCLAIM FORM ASECTION I- TO BE COMPLETED BY INSURED PERSON/ CLAIMANTA. DETAILS OF PRIMARY INSURED:B: DETAILS OF INSURANCE HISTORY:a) Currently covered by any Mediclaim / Health Insurance:YesNoPlease return your completed claim form to:ManipalCigna Health Insurance Company Limited(Formerly known as CignaTTK Health Insurance Company Limited)Registered & Corporate Office: 401/402, Raheja Titanium, Western Express Highway, Goregaon (East), Mumbai – 400063.IRDAI Registration No. 151. Call(Toll Free): 1800-102-4462Visit:E-mail:[email protected] |ORNearest ManipalCigna Branch.CIN:U66000MH2012PLC227948The issue of this Form is not to be taken as an admission of liability(To be filled in Block Letters) - PARTA - To be filled by InsuredSum Insured (`):Policy No.:Make sure the formis complete anddon't forget to sign.C.DETAILS OF INSURED PERSON HOSPITALISED:f. Occupation:ServiceSelf EmployedHomemakerStudentRetiredOther (Please specify)g. Address(If different from above):City:State:Pin Code:
ManipalCigna ProHealth Insurance. UIN: CTTHLIP18045V031819 | April 2019 onwardsi. Pre-Hospitalisation Expenses:ii. Hospitalisation Expenses:iii. Post-Hospitalisation Expenses:iv. Health Check up Cost:v. Ambulance Charges:vi. Others:Total:vii. Pre-Hospitalisation Period: Daysviii. Post-Hospitalisation Period: DaysClaim Form Duly SignedCopy of the Claim Intimation, if anyHospital Main BillHospital Break up BillHospital Bill Payment ReceiptHospital Discharge Summaryi. Hospital Daily Cash:ii. Surgical Cash:iii. Critical illness Benefit:iv. Convalescence:v. Pre/Post-HospitalisationLump sum Benefit:vi. Others:Total:Sl. No.Bill No.DateIssued ByTowardsNos.Amount (`)1.

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Term
Two
Professor
ALEX LOFTS
Tags
Social insurance, D M M Y Y Y

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