ICS Assure on behalf Care Health Insurance Co Ltd.

Claim of: Mr. Nitul Shah; Claim Number: 92224729

1. What were the complaints presented by you during the admission at Wockhardt
Hospital ?
none

2. Since when are you suffering from the above mentioned problem?
I am suffering the mentioned problem since january

3. Where were you consulting for the same problem before this admission? Kindly
provide a copy of the previous consultation paper and all the previous reports

4. Who referred you to the hospital?

Dr. Ashank Bansal

5. Kindly provide the details

Date and time of admission : 17/01/2022 22.00
Date and time ofdischarge 26/01/2022 18.00
Name of the treating doctor Dr. Ashank Bansal
Name of the Family doctor
Class of accommodation Twin sharing
Total amount offinal bill 415967.49
Mode of payment insurance / credit card
How did you bought the policy
6. What was the explanation given by the Doctor for getting in the hospital?
to get admitted in the hospital and wait for the Dr to come and examine

Date
Place:

Insured's Name:

Insured's signature:

Witness signature:
ICS Assure on behalf Care Health Insurance Co Ltd.
Claim of: Mr. Nitul Shah; Claim Number: 92224729
7. Have you ever hospitalized in past for any complaints, Please provide papers of the
same undergone a surgery for versicose vains in 1st week of janurary of 2022
in the hospital for a day

8. Have you underwent any surgery in past? Kindly provide papers of the same.
undergone a surgery for vericose vains in the 1st week of january of 2022

9. Is the patient included in any other insurance policy/corporate policy, if yes pls
provide the details. yes, max bupa health insurance
policy no. 31193325202101

10.Are you suffering from any of the following ailment?

Ailment Yes/No
no
Ifyes, since when
Simiiar history in the past Months/years
High blood pressure no Months/years
Diabetes no Months/Yyears
Asthma no Months/years
Kidney disease no Months/years
Cancer no Months/years
Congenital illiness no
no
Other (Pl specify) Months/years

11. Who diagnosed you for the above (point no 10) ailment and what treatment were
you taking?

Date
Place

Insured's Name:

Insured's signature

Witness Ignature:
ICS Assure on behalf Care Health
Insurance Co Ltd.
Claim of: Mr. Nitul Shah; Claim Number:
92224729

12.What is the occupation of patient add the below

details related to patient
Name of the organization /institution:
Working since.
Designation:-_ self employment

Address & Contact details:-

13. Kindly provide the occupation/School /College details of the Family members.

Family Members Relation with Patient Occupation

Veer Nitul Shah son college

Vidhi Nitul Shah daughter a educationist and working in

vedantu
Pooja Nitul Shah daughter Civil engineer

14. Have you undergone any master medical health check up in the past ? Kindly
provide the documents.
yes pharma easy health checkup

Date:

Place:

Insured's Name:

Insured's signature:
Witness signature:
ICS Assure on behalf Care Health Insurance Co Ltd.
Claim of: Mr. Nitul Shah; Claim Number: 92224729
15. Kindly mention the habits if any: no

HABITS UNITS PER DAY SINCE WHEN

Smoking
Alcohol

Tobacco chewing

16. Please specify why you choose this hospital?

1. Kindly provide the details of Duodenitis with Auto-immune Hepatitis, when it

was diagnosed and diagnosed by whom and please provide the information of
medicine on which patient is for the same and 1t consultation paper and all
previous OPD paper and Reports ??

it was diagnosed when i was in hospital

diagnosed by Dr. Archit Patel

2. Kindly provide the details of DM, when it was diagnosed and diagnosed by whom
and please provide the information of medicine on which patient is for the same
and 1s consultation paper and all previous OPD paper and Reports ??

Date:

Place:

Insured's Name:

Insured's signature

Witness signature: