Reimbursement Claim Document Checklist
PART A - BASIC CHECKLIST
Duly filled in Claim Form of The New India Assurance Co. Ltd
Original consolidated bill on pre
pre--printed stationery with serial number of hospital, with detail break
break--ups
cost wise and quantity wise as below
below::-
Break--up of laboratory charges:
Break charges: Disposals Medicines, Medicines used in OT, Injections, Professional /
Consultancy charges, Nursing charges, Details of Medical care (if any),Details for equipment charges (if
any), Room rent – break
break--up with number of days .
Original payment receipt (Advance / Final Settlement receipt). receipt). Revenue Stamp on receipts where
payment is above Rs.
Rs.5000
5000//-and stamp & signature of hospital.
hospital.
Xerox copy of hospital registration certificate for current year.
year.
Original Discharge summary/ card in pre pre--printed stationery of hospital duly signed by the consultant
with hospital stamp and registration number of the hospital
Doctor prescription for all investigation reports & medicine bills done outside the hospital
hospital..
Require photo
photo--copy of Indoor case papers (hospitalization for 02 days or prolonged stay), If
hospitalization is for 2 days then declaration from hospital authorities stating time of Admission &
Discharge (24 Hrs.
Hrs. criteria applied.
applied.)
First consultation letter for the presenting complaints
complaints..(if any)
Original tax invoice for any kind of implants
implants..
Photocopy of Medsave ID card, employee ID
Check List
Documents required for Death Cases along with part A
Death summary in pre-printed stationery of hospital signed by the consultant with hospital stamp and
registration number of the hospital & death certificate from municipal corporation .
Attested copy of post postmortem report (in case of death).
Legal heir certificate (in case of death of the main member)
For Maternity Cases along with part A
Original copy of treating doctor certificate regarding obstetric history (Gravida, Para, Living children,
Abortions, Death)
Last done sonography report.
For Accidental Cases along with part A
Attested copy of MLC report (Medico Legal Certificate) & Police FIR .
Original copy of treating doctor's certificate with circumstances and injuries sustained how / when /
where.
Original copy of treating doctor's certificate for any evidence of influence of alcohol / other narcotics
substance during the accident.
