E-CLAIM DISCLAIMER

Policy No :

Document Type : New Reimb Claim Pre-Post Claim Query Reply

Claim No : (If any)

Policy Holder Name :

Patient Name :

Hospital :

Date of Admission : Date of Discharge

Claimed Amount : No Of Documents

Note: Photos of Radiological Films are to be attached

Disclaimer: I (Policy Holder Name) hereby confirms that hard

copies will be submitted as soon as asked for and that the claim has not been made
elsewhere by me. If declarations are found untrue, the insurance company may recover
the entire amount from me.

NAME :

Sign :

Contact No : Mob : Resi. Office

Place: Date :
 UNDERTAKING FOR CLAIMING REIMBURSEMENT OF <Patient Name>

I , employee of (if applicable) , with Emp ID (if

applicable) covered under policy number with Health India
Insurance TPA Card Number and understand that the current benefit of
Claim processing on scan has been extended as an additional benefit due the current Corona
Outbreak crisis.

I hereby confirm that I am in possession of the claim documents in original pertaining to

<Patient Name> for admission dated of < Hospital Name & Address > and discharge
date , will submit the document in original to Health India Insurance TPA services
private limited once the situation improves / gets normal.

I also confirm that I have not made any claim with any other insurer or organisation for the
claimed reimbursement.

Health India Insurance TPA reserves the right to ask for additional documents and original
documents in advance for certain Scenarios as per the internal claim policy.

Further, I agree to return/refund the claim amount back to the Insurer, if at a later date a
material discrepancy is noticed between the original claim documents versus the scan
documents submitted by me.

Signature
Date: