United India Insurance medical reimbursement claim form



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When you or your family member discharge from hospital and there is no cashless procedure available in the hospitals, you need better to go medical reimbursement for your hospital bills. Its very useful to get returns of your funds, while you submitting bills you need to follow below things.

You are responsible for submission of accurate claims for your reimbursement, you need to submit your accurate hospitals bills.You need to submit the bills between you joined and discharged the hospital. This reimbursement policy is intended to ensure that you are reimbursed based on the code or codes that correctly describe the health care services provided. Centers for Medicare and Medicaid Services (CMS) or other coding guidelines. References to CPT or other sources are for definitional purposes only and do not imply any right to reimbursement.

Before you submit the reimbursement claim form please remember to check below things:


Original Claim Form duly signed by you.
[Fill the claim amt in Signed Claim Form ]

medical reimbursement claim form
medical reimbursement claim form
Original Main Hospital bill with Bill Number & break up,
(With detailed break up of various heads like Room Rent/OT charges/Nursing etc).

Original Discharge summary
(Gives the summary of diagnosis and treatment in hospital)

Original Death summary
(Only in case of death of Patient during Hospital stay).

Original Hospital Payment Receipt with receipt number
(With seal & signature of hospital) (if main bill does not carry a bill number).

Original Payment Receipt with receipt number
(For consultation/surgeon charges if charged outside the main hospital bill).

Hospital registration number
(Registration No. & Number of beds, on hospital letterhead with signature).

Doctor’s registration number
(On doctor’s letterhead with signature).

Original Pharmacy and Investigation bills
(Along with prescriptions & Lab reports).

Original prescriptions
(On doctor’s letterhead mentioning duration and dosage for medicines and advice for diagnostic tests).
Investigation reports in original/attested from hospital
(Reports for all tests done along with images)

Police FIR / Medico Legal Certificate (MLC)
(Mandatory for All Road traffic accidents-Duly attested by Police with)ls

for more details United India Insurance medical reimbursement claim form please click Here

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