Rev-08/14
HOSPITAL TREATMENT FORM (To be filled in by the Hospital Authorities) PART ‘B’
The Benefits under this policy are fixed as per Daily Benefit opted by policyholder at proposal stage
and has no relation to actual expenses / free treatment incurred by him before, during or after
Hospitalization. This benefit can be claimed irrespective of any other claim under any policy.
anuMediclaim
If treatment frompolicies.
more than one Hospital, forms from all the Hospitals duly filled in are to be submitted)
(If admission to ICU for more than one spell, details of such different admissions to be given separately)
Name of the patient
Age SEX [Link] No.
Date of Admission in Hospital Time of Admission
Date of Discharge from Hospital Time of Discharge
Date of Admission in ICU Time of Admission in ICU
Date of Discharge from ICU Time of Discharge from ICU
Name of the Attending Doctor/Surgeon Regd. No.
Diagnosis
Whether present ailment/ disease is a complication of
any pre-existing condition that the patient is suffering from?
History of past illness/ ailment/ disease
Diagnosis Duration of illness Past surgeries undergone
If ‘Yes’ please specify the disease/ailment (or) complication of
any previous surgery and the onset of date of the disease
Is the disease /ailment/disorder congenital in nature?
Brief description of the treatment given for present hospitalization
a)Nature of Surgery performed and Duration of surgery
b)Specify the details of Surgery (laser, detailed procedure, any
other modern technical incision)
In case of Accident Cases / RTA, whether
a) Under the influence of Alcohol
b) Medico Legal case
c) FIR lodged
HOSPITAL / DAY CARE CENTRE DETAILS
Name of the Hospital & Address
Hospital Registration No. Registered under (1) Clinical Establishments (Registration & Regulation) Act, 2010I YES / NO
Registered under (2) Enactments specified under Schedule of Section 56(1) of Clinical Establishment Act,2010 ; YES / NO No. of beds:
Registered under any other Act? If YES, pl. specify:
Is the Medical Centre under supervision of registered and qualified medical practitioner: YES /NO
Whether the hospital is having
A fully equipped operation Theatre: YES / NO ICU UNIT: YES / NO
Qualified nurses Round the clock : YES / NO Qualified doctors round the clock: YES / NO
Maintained daily records of patients : YES / NO Are Daily Records accessible to LIC’s authorized personnel : YES / NO
Certificate
A Clear copy of the Health Card / Photo ID This is to certify that Sri/Smt/kum.______________________________
(eg. PAN card / Voter card / Passport / whose ID Card/Photo is pasted as above has undergone
Driving License etc) of the patient hospitalization treatment /surgical procedure as per details given above.
needs to be affixed here and is to be We hereby confirm the particulars of treatment furnished by the
attested by the Principal Insured (PI) and also claimant in the claim form are true.
attested by the Hospital Authorities.
Place:
Date: Signature of the Doctor / Hospital Authorities
with Hospital Seal
To,
____________________________________________________________
____________________________________________________________
I hereby authorize the representatives of the TPA, M/S_______________________________ and Life Insurance Corporation
of India free and unlimited access to seek medical information (Indoor case papers, reports, documents, including
photocopies thereof pertaining to my / my family members’ admission/treatment etc.) from you.
I also hereby authorize the hospital/attending doctor/medical practitioner from whom I/ my family member has sought
medical attention/medical treatment concerning any disease/sickness, ailment or injury to part with the above information
to the TPA/LIC of India or its representatives. Myself/my successors/assigns shall not raise any dispute or litigation on
passing of such information to the TPA or LIC of India or its representatives.
Date & Place Signature of the policyholder/Claimant
