NON-HOSPITAL (OPD) CLAIM FORM

TATA INSTITUTE OF SOCIAL SCIENCESV.N. PURAV MARG, DEONAR, MUMBAI 400 088

THE ORIENTAL INSURANCE COMPANY LIMITED

ANURAG BUSINESS CENTRE202, 2nd floor, W.T.Marg, Next to Amar Theatre

Chembur, Mumbai 400071

GROUP HEALTH INSURANCE POLICY NO. (124291 / 48 / 2016 / 173)

VALIDITY PERIOD : 11/6/2015 to 10/6/2016

Student Name (In CAPITAL LETTERS) : …........................................................................................................................................

Student Bank A/c No. (refer point no. 5 below):...................................................... Name of the Bank: ….............................................

Branch:........................................................................................ IFSC Code No. ….........................................................

Mobile No. FOR OFFICE USE ONLYEmail ID LOT YEAR AND NO. CLAIM NO.

RESIDENTIAL ADDRESS

Insurance Card No (HI ID):

ENROLLMENT NO. AGE (YEAR)

NAME OF PATIENT (IN CAPITAL LETTERS) : PERIOD OF ILLNESS

FROM (DATE) TO (DATE)

NAME OF ILLNESS (IN CAPITAL LETTERS) :

NATURE OF EXPENSES SUB-ITEMTOTAL AMOUNT

INCURRED (in Rs.) R E M A R K S

(A) DOCTOR’S CONSULTATION FEES

1) --------- NO. OF CONSULTATIONS @ Rs…………………..

(B) 1) MEDICINES GIVEN BY DOCTOR

2) INJECTIONS GIVEN BY DOCTOR

3) MEDICINES BOUGHT FROM CHEMISTS

4) INVESTIGATION CHARGES

GRAND TOTAL (Rs.)

I HEREBY DECLARE THAT THE FOREGOING STATEMENTS ARE TRUE IN EVERY RESPECT AND ARE MADE WITHOUT ANY RESERVATION.I ALSO DECLARE THAT I DO NOT GET ANY MEDICAL BENEFITS FOR THE ABOVE ILLNESS FROM ANY OTHER SOURCE.

SIGNATURE OF STUDENT: DATE :

IMPORTANT

1) ALL FIELDS IN THIS FORM ARE MANDATORY.

2) Please send the claim within 30 days from the date of treatment/purchase of medicines.

3) Please attach all Original Prescriptions, Medical Bills, Stamped Payment Receipts from Doctor, Investigation Reports etc. with the claim form.

4) Please ensure that correct Enrollment No. and the Bank details are mentioned, otherwise claim will be rejected.

5) Please provide photocopy of cancelled cheque of your bank account showing student's Name, A/c No., Branch & IFSC code or legible/clear photocopy of first page of passbook mentioning student's Name, A/c No., Branch & IFSC code.