ManipalCigna Health Insurance Company Limited
(Formerly known as CignaTTK Health Insurance Company Limited)
Corporate Office: 401/402, Raheja Titanium, Western Express Highway, Goregaon (East),
Mumbai - 400063. IRDAI Registration No. 151. Call (Toll Free): 1800-102-4461
Visit: [Link] E-mail: servicesupport@[Link]
REQUEST FOR REIMBURSEMENT HEALTH MAINTENANCE BENEFIT
(To be filled in block letters)
DETAILS OF HOSPITAL / CLINIC
a. Name of the hospital / Clinic:
i. Address:
ii. Rohini ID:
iii. E-mail ID:
TO BE FILLED BY THE INSURED / PATIENT
a. Proposer Name:
b. Name of the Patient:
c. Gender (Male/ Female/ Third gender):
d. Age Years: Month
e. Date of birth:
f. Contact Number:
g. Insured Card ID Number:
h. Policy Number:
i. Currently do you have any other Mediclaim / Health Insurance: Yes No
Company Name:
Give Details:
j. Do you have a Family Physician: Yes No
k. Name of the Family Physician:
l. Contact Number, if any:
m. Current address of Insured Patient:
n. Occupation of Insured Patient:
TO BE FILLED BY THE TREATING DOCTOR / HOSPITAL
ManipalCigna ProHealth Prime | Claim Form | Health Maintenance Benefit | UIN: MCIHLIP26036V022526 | May 2025
a. Name of the Treating Doctor:
b. Contact Number:
c. Nature of Illness / Disease with Presenting Complaints:
d. Relevant Critical Findings:
e. Duration of the Present Ailment: Days
i. Date of Consultation:
ii. Past History of Present Ailment, if any:
f. Provisional Diagnosis:
i. ICD 10 Code:
DETAILS OF THE PATIENT
a. Date of Consultation:
Mandatory: Past History of any Chronic Illness, if yes since month / year)
Diabetes: mm/yyyy Heart Disease: mm/yyyy
Hypertension: mm/yyyy Hyperlipidemias: mm/yyyy
Osteoarthritis: mm/yyyy Asthma / COPD / Bronchitis: mm/yyyy
Cancer: mm/yyyy Alcohol or Drug Abuse: mm/yyyy
Any HIV or STD / Related Ailments: mm/yyyy
Any other Aliment, give details:
b. Consultation charges:
c. Cost of investigation:
d. Cost of Medicines:
e. Total Claimed amount:
DECLARATION
We confirm having read, understood and agreed to the Declarations portion of this form.
a) Name of the Treating Doctor:
b) Qualification:
c) Registration No. with State Code:
ManipalCigna ProHealth Prime | Claim Form | Health Maintenance Benefit | UIN: MCIHLIP26036V022526 | May 2025
Hospital Seal Patient / Insured
(Must include Hospital ID) Name & Signature
DECLARATION BY THE PATIENT / REPRESENTATIVE
1. I hereby declare that the information furnished in the claim form is true & correct to the best of my knowledge and belief. If I have made any false
or untrue statement, suppression or concealment of any material fact with respect to questions asked in relation to this claim, my right to claim
reimbursement shall be forfeited.
2. I also consent & authorize TPA / Insurance Company, to seek necessary medical information / documents from any hospital / Medical
Practitioner who has attended on the person against whom this claim is made.
3. I hereby declare to abide by the Terms and Conditions of the policy and if at any time the facts disclosed by me are found to be false or incorrect,
I forfeit my claim and agree to indemnify the Insurer / TPA.
4. I hereby warrant the truth of the forgoing particulars in every respect and I agree that if I have made or shall make any false or untrue statement,
suppression or concealment with respect to the claim, my right to claim reimbursement of the said expenses shall be absolutely forfeited.
5. "I/We authorize Insurance Company/TPA to contact me/us through mobile/email for any update on this claim".
a) Patient's / Insured's Name:
b) Contact Number:
I/we hereby give my/our consent to the Company/its authorized representatives to access/download/verify/register/update my/our KYC
documents on/fromthe Central KYC Registry or through any other modes for the purpose of KYC
Patient's / Insured's Signature
Email ID (optional):
Date:
Time:
DOCUMENTS TO BE PROVIDED BY THE INSURED IN SUPPORT OF THE CLAIM
1. Duly filled and signed claim form
2. Outpatient Invoices
3. Treating Doctor Prescription/Consultation papers
4. Investigation reports and bills, if any
5. Medicine bills
