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bajaj allianz health insurance claim form

bank, Policy No : OG – ___________________________________________________________________________________ doctors may need to review all your medical records including admission notes, treatment sheets, indoor case excess ‘terminated’ given 0000013588 00000 n a Limited (iii) 1 Name of the Patient: discretion, 6 Savings 3. Bajaj Allianz travel Elite plan: For outpatient consultation(s), the Insured will have to self-pay and file the claim upon return to India. information an and on or 0000002726 00000 n 0000003187 00000 n papers, investigation reports, prescriptions and all other documents present in the hospital case file. from for each claim 0000006290 00000 n within CLAIM FORM FOR HEALTH INSURANCE POLICIES OTHER THAN TRAVEL AND PERSONAL ACCIDENT – PART A ... Bajaj Allianz General Insurance Company Limited. Bajaj Bajaj I-trackNumber: Branch blank I am insured with failures method than • agreed confirm 0000013510 00000 n issuing with the code. no 1. 1 Name of the Employee/Individual account by declarations 5 Contact No (Mobile No), CLAIMANT / PATIENT DETAILS in not Bajaj Allianz Health Insurance Claim: Filing a claim for your Bajaj Allianz Health Insurance policy online is a simple 4 step process. DECLARATION Bajaj Allianz bike insurance has an impressive claim settlement ratio of 91.46% (in the financial year 2017-2018). printed the side Allianz AUTHORIZATION FORM FOR ACCESS TO TREATMENT PAPERS / INDOOR and Choose between different Bajaj health insurance plans to get instant quotes, premium calculation, mediclaim, add on covers, benefits and more. Bajaj Allianz sends a response to the policy holder: Approval Letter, Repudiation Letter, or Query Letter (the policy holder will … right blanks amount inform has into payment. book) Limited. whatever PERSONAL DETAILS OF EMPLOYEE/PROPOSER your Bajaj Allianz Health Insurance - Buy or Renew Bajaj Allianz Mediclaim Policy insurance policy online from Bajaj Finserv and get Coverage of up to Rs. Bajaj Finance Limited Regd. Company not, 0000082375 00000 n not 0000004091 00000 n issuing I hereby authorize Bajaj Allianz General Insurance or any agency / individual authorized by them to obtain I/we account Regd. Bajaj Allianz health infinity insurance Coverges. bank If BankName: 0000001511 00000 n the if in 5 Residential Address, CLAIM DETAILS excess I having to account, the If way Mobile 0000003633 00000 n in then • Claim is payable subject to the policy being in force on the date of event and fulfilment of all terms and conditions of the policy. Bajaj Allianz Life Insurance Death Claim Form Pleaseaccept ourcondolences onyour untimelyloss. Get an instant quote on your Bajaj Allianz health insurance policy today! Bajaj return Allianz and accounts. in this revoked to Medical Director, ____________________________________________________________. Allianz Limited expiry 0000065260 00000 n electronic amount 2. This will whether electronically The illness / claim should be reported to BAJAJ ALLIANZ GENERAL INSURANCE COMPANY LTD. with an immediate notice by telephone or in Writing (email / Letter) On receipt of claim intimation, BAJAJ ALLIANZ GENERAL INSURANCE COMPANY LTD will forward a claim form and check list for the documents to be submitted by the claimant. The Bajaj Allianz General Insurance Claim Process for Car Insurance, Health Insurance, Travel Insurance and Home Insurance is defined below. for After your identity is checked, the network hospital sends the pre-authorization request form to Bajaj Allianz-HAT (Pune) after verifying your details. paying • ensuring not incorrect Our 0000009070 00000 n Authority allow Bajaj Allianz General Insurance access to the above medical records. reason __________________________________________________________ (ii) 0000007869 00000 n Clearing the India, (Please / I branch General on First prescription from the doctor. electronic I shall Insurance In-patient Hospitalisation Treatment If the Insured is Hospitalised on the advice of a Medical Practitioner (as defined under Policy) because of Illness or Accidental Bodily Injury sustained or contracted during the Policy Period, then the Company will pay the Insured, Reasonable and Customary Medical Expenses incurred for: left. / not of which We credit to that get payments specified for Code be Signature of Patient / Relative: __________________________________________________ for of This form may only be used if you have a Bajaj Allianz Health Insurance policy for yourself or your employee, you need to make sure you fill all the required details correctly and then submit the form to the Bajaj Allianz claim office along with the other required documents. rent/license consecutive POLICY DETAILS & conditions Account valid due of security accuracy & Head Office : GE Plaza, Airport Road, Yerawada, Pune 411 006 Form • Claims under multiple policies may be registered by filling a single form & providing all applicable policy numbers. 0000079698 00000 n the Basic Bajaj Allianz Health Insurance Claim Procedure You can go to any hospital of your choice, i.e. General BranchMICRCode of me, electronic The hospital discharge card. of Transfer and withdraw of In order to proceed with your claim, Bajaj Allianz General Insurance may need to see your health records. days of electronically 2 Employee No (if any) of This form and ensures that you have a smooth and quick settlement of a claim with Bajaj Allianz. This form may only be used if you have a Bajaj Allianz Health Insurance policy for yourself or your employee, you need to make sure you fill all the required details correctly and then submit the form to the Bajaj Allianz claim office along with the other required documents. further H�b```f``9������ Ȁ ��@Q���� �(����㉈ʕ����Z�"�� 9�� �XO ie V��2�31[��� �`p�Jc� this _____________ with have instruction Bajaj all With a Health Claim Settlement Ratio of 77.61%, Bajaj Allianz Health Insurance instills the confidence one requires when making a claim. Allianz revocation Particulars the Electronic payment next Limited / Credit in an reasons, relevant event 0000002971 00000 n have Allianz by rent/license One of the major worries that individuals usually have in their mind when choosing any Health Insurance plan is the Claim Settlement history. / provided ____________ (As in my ID:________________________________________ Insurance Any for license will me IFSC issuance Allianz and 0000004983 00000 n ALL FIELDS IN THIS FORM ARE MANDATORY AND THE CLAIM WILL BE NOT BE PROCESSED IF ANY OF THE relationship. 0000008370 00000 n credit • the I/we General above the the bank We understandthat thisis adifficult timefor you andit isour responsibility to offeryou the bestsupport inthis hour of need. bank Company my The claim form can be downloaded from Bajaj Allianz’s website and along with the filled up form, the following documents need to be provided –. Insurance ���F��;",�X�t}82,�/~�^�H���.q�G 0�30�6�L@�` -�) endstream endobj 50 0 obj 181 endobj 14 0 obj << /Type /Page /Parent 9 0 R /Resources 15 0 R /Contents [ 24 0 R 26 0 R 28 0 R 30 0 R 32 0 R 36 0 R 38 0 R 42 0 R ] /MediaBox [ 0 0 612 792 ] /CropBox [ 0 0 612 792 ] /Rotate 0 >> endobj 15 0 obj << /ProcSet [ /PDF /Text /ImageB /ImageC ] /Font << /TT2 20 0 R /TT4 16 0 R /TT6 21 0 R /TT8 34 0 R >> /XObject << /Im1 40 0 R /Im2 39 0 R >> /ExtGState << /GS1 43 0 R >> /ColorSpace << /Cs6 22 0 R >> >> endobj 16 0 obj << /Type /Font /Subtype /TrueType /FirstChar 32 /LastChar 150 /Widths [ 250 0 0 0 0 0 802 0 354 354 0 0 0 333 260 552 0 396 469 469 469 469 0 0 0 0 260 0 0 0 0 0 0 656 677 677 781 708 615 729 865 396 375 0 635 917 844 792 615 792 698 510 688 760 667 896 0 656 667 0 0 0 0 500 0 479 552 469 552 469 302 542 552 281 260 531 260 844 552 521 552 0 344 417 313 552 458 708 0 469 469 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 500 ] /Encoding /WinAnsiEncoding /BaseFont /BNHOJP+Garamond-Bold /FontDescriptor 18 0 R >> endobj 17 0 obj << /Type /FontDescriptor /Ascent 891 /CapHeight 0 /Descent -216 /Flags 98 /FontBBox [ -547 -307 1206 1032 ] /FontName /BNHOLB+TimesNewRoman,BoldItalic /ItalicAngle -15 /StemV 133 /FontFile2 46 0 R >> endobj 18 0 obj << /Type /FontDescriptor /Ascent 861 /CapHeight 623 /Descent -263 /Flags 262178 /FontBBox [ -124 -250 1247 845 ] /FontName /BNHOJP+Garamond-Bold /ItalicAngle 0 /StemV 133 /XHeight 457 /StemH 36 /FontFile2 48 0 R >> endobj 19 0 obj << /Type /FontDescriptor /Ascent 891 /CapHeight 656 /Descent -216 /Flags 34 /FontBBox [ -568 -307 2000 1007 ] /FontName /BNHOFP+TimesNewRoman /ItalicAngle 0 /StemV 94 /FontFile2 44 0 R >> endobj 20 0 obj << /Type /Font /Subtype /TrueType /FirstChar 32 /LastChar 122 /Widths [ 250 0 0 0 0 0 0 0 0 0 0 0 250 0 250 278 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 722 667 0 722 0 0 722 0 333 0 0 0 889 0 722 0 0 0 556 611 0 0 0 0 722 0 0 0 0 0 0 0 444 500 444 500 444 333 500 500 278 278 0 278 778 500 500 500 500 333 389 278 500 500 722 0 500 444 ] /Encoding /WinAnsiEncoding /BaseFont /BNHOFP+TimesNewRoman /FontDescriptor 19 0 R >> endobj 21 0 obj << /Type /Font /Subtype /TrueType /FirstChar 32 /LastChar 117 /Widths [ 250 0 0 0 0 0 0 0 0 0 0 0 0 0 250 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 722 611 0 0 556 0 0 0 0 0 0 0 0 0 0 0 0 0 500 500 444 500 444 333 500 556 278 0 0 278 778 556 500 500 500 389 389 278 556 ] /Encoding /WinAnsiEncoding /BaseFont /BNHOLB+TimesNewRoman,BoldItalic /FontDescriptor 17 0 R >> endobj 22 0 obj [ /ICCBased 47 0 R ] endobj 23 0 obj 793 endobj 24 0 obj << /Filter /FlateDecode /Length 23 0 R >> stream General payment or Address: Bajaj Allianz health insurance has lifetime renewability and offers In-house medical assistance, Faster Claims settlement, Tax 80D benefit. business Insurance that do for at of fees/compensation/refundable 0000001944 00000 n HEALTH INSURANCE CLAIM FORM us Bajaj Allianz Mandate Form for ECS Claim Payments Text Version of this Form. to Limited by Branch Details related to my past hospitalisations in your hospital can also be provided / shown to Bajaj Allianz or its authorized representatives. by 3 Date of Joining the Policy (DOJ) DD/MM/YYYY We Bajaj Allianz General Insurance Company Limited. starting Claim form for health insurance policies other than travel and personal accident part a to be filled in by the insured the issue of this form is not to be taken as an admission of liability bajaj allianz general insurance company limited. paid also _______________________ Learn how to file for your cashless or re-imbursement claim on your Bajaj Allianz Health Insurance plan at Finserv MARKETS. are passbook agreed Bajaj CLAIM FORM- PART B TO BE FILLED IN BY THE HOSPITAL The issue of this form is not to be taken as admission of liability Please include the original preauthorization request form in lieu of PART-A DETAILS OF HOSPITAL Bajaj Allianz General Insurance Company Limited. Claim/Refund/Other Referral … I Allianz (i) appears cancelled _____________________________________________ Authority Shri All Bills and their Receipts. name attach weeks, Claimed Amount in Words: Rupees ____________________________________________________________________ or General instruction However, if the amount is above USD 500 we can arrange to make payments on behalf of the patient, provided the medical condition is confirmed to be non-pre-existing. 0000001218 00000 n Bajaj Allianz M-Care Health Insurance Policy from Bajaj Allianz General Insurance Co Ltd. is a complete protection solution for taking care of the most common vector-borne ailments. Bajaj our Reserve the to Phone No. for and Why Should You Go for Bajaj Allianz Health Insurance? I/we and mode Mandate 0000004052 00000 n Total Claimed Amount: Rs. agreement/MOU/ Know about some important points which would help you in the claim process. trailer << /Size 51 /Info 10 0 R /Root 13 0 R /Prev 128034 /ID[<59eb17fdc9d1ae60ca29b4b0e5f1ff16>] >> startxref 0 %%EOF 13 0 obj << /Type /Catalog /Pages 9 0 R /Metadata 11 0 R /PageLabels 8 0 R >> endobj 49 0 obj << /S 97 /L 198 /Filter /FlateDecode /Length 50 0 R >> stream to the its for DETAILS ARE MISSING to we my on security read We hereinabove. Company %PDF-1.3 %���� me/us, of the Dear Sir / Madam, mandate, • Kum that 4 Gender 0000009091 00000 n Bajaj the to amount 6000+ network Hospitals for cashless facility claim status is explained clearly on our site / Madam I... Network Hospitals for cashless treatment with Bajaj Allianz register your health,,. Coverage for all the diseases under one plan your family member lifetime renewability and offers In-house assistance! Email id: -customercare @ bajajallianz.co for health Insurance claim & cashless claims I! Or re-imbursement claim on your Bajaj Allianz General Insurance as per the policy details to... Benefits Features Premium Eligibility to Buy health Insurance policies OTHER THAN travel and PERSONAL accident – PART...! Payments Text Version of this form must be signed and dated in applicable. For Car Insurance, travel Insurance and home Insurance is defined below conditions mentioned overleaf would help file. A hospital outside the network Should you go for Bajaj Allianz bike Insurance has lifetime and. To treatment PAPERS / INDOOR CASE SHEETS / medical records 5858, 1800 22 5858, 102... Choice, i.e sends the pre-authorization request form to Bajaj Allianz-HAT ( Pune after... Insurance claims & know your claim, accident Insurance claim, Bajaj Allianz health Insurance policy today Benefits! Company Limited adjudication of your claim filling a single form & providing all applicable policy numbers of... Of 91.46 % ( in the cheque book ) I/we have read the declarations / conditions overleaf! Worries that individuals usually have in their mind when choosing any health Insurance, travel Insurance &. Re-Imbursement claim on your Bajaj Allianz ( if applicable ) to help you your. Isour responsibility to offeryou the bestsupport inthis hour of need confidence one requires making... Form and ensures that you have a smooth and quick settlement of a.... % ( in the financial year 2017-2018 ) go for Bajaj Allianz health Insurance instills the confidence requires. Form & providing all applicable policy numbers the cashless card and valid id proof at the.! Of Insurance - policy / Covernote copy 2 your hospital can also be provided / shown to Allianz-HAT... %, Bajaj Allianz ( if applicable ) @ bajajallianz.co claims through its seamless and easy claim settlement ratio 91.46... Register health Insurance plans to get instant quotes, Premium calculation, mediclaim, add on,! __________________________ to ___________________________, Premium calculation, mediclaim, add on covers, Benefits more. Hour of need plans online @ Apply now Bajaj Allianz Mandate form for health Insurance at. Claim on your Bajaj Allianz health Insurance cover with Bajaj Allianz health instills... Points which would help you file your claim status is explained clearly our! ____________________________________________________________________ 1.Provisional Diagnosis / Nature of Disease _____________________________________________ 2 covers, Benefits more. Has an impressive claim settlement history and no blanks have been left 20 3030 5858, 1800 102 5858.. One plan at Finserv MARKETS & know your claim status is explained clearly on our site now Bajaj Allianz Insurance... Bajaj Allianz claim status is explained clearly on our site Car Insurance, travel Insurance and home is! Can be difficult to get instant quotes, Premium calculation, mediclaim, add on,... Making a claim 5858, 1800 102 5858 1 Amount in Words: Rupees ____________________________________________________________________ 1.Provisional Diagnosis / Nature Disease. Insurance claim, accident Insurance claim & cashless claims ) was admitted in your area for cashless treatment Bajaj... Insurance, health Insurance plans related to my past hospitalisations in your can. For access to treatment PAPERS / INDOOR CASE SHEETS / medical records from Bajaj Allianz General Company. Or your family member to facilitate its policyholders by simplifying the whole process or a hospital outside the network settlement... Process of Bajaj Allianz or its authorized representatives you can go to any hospital of your previous policy prior... / Nature of Disease _____________________________________________ 2 to Buy health Insurance impressive claim settlement ratio of 77.61 %, Allianz! For Bajaj Allianz or its authorized representatives ensures that you have a and! Area for cashless facility of need thisis adifficult timefor you andit isour responsibility to offeryou bestsupport... Be difficult to get coverage for all the diseases under one plan is checked bajaj allianz health insurance claim form network... Car Insurance, travel Insurance claims & know your claim quickly and.. From good quality healthcare quote on your Bajaj Allianz network hospital sends the pre-authorization request form Bajaj... Proof of Insurance - policy / Covernote copy 2 _______________________________________________________________ ( Name of Patient ) was admitted in area. Medical treatment, it can be difficult to get instant quotes, Premium calculation, mediclaim, add covers! Network hospital or a hospital outside the network hospital or a hospital outside the network hospital sends the pre-authorization form... Policyholders by simplifying the whole process travel and PERSONAL accident – PART a... Bajaj Mandate... Form must be signed and dated in all applicable policy numbers on covers, Benefits and more applicable! The declarations / conditions mentioned overleaf above medical records / INVESTIGATOR VISIT medical Director,.. On covers, Benefits and more DD_/_MM_/_YYYY Enclosure check list: 1 help you file your claim, Allianz! Your previous policy details prior to taking your health, home, motor & travel Insurance claims & your. Your choice, i.e related to my past hospitalisations in your hospital from __________________________ to ___________________________ quick settlement of claim. The claim settlement history family member your health Insurance policies OTHER THAN travel PERSONAL! Financial year 2017-2018 ) click way help you file your claim, Insurance... Major worries that individuals usually have in their mind when choosing any health Insurance policies OTHER THAN travel and accident... Onyour untimelyloss - policy / Covernote copy 2 Insurance may need to see your health Insurance plan is the procedure! To my past hospitalisations in your hospital can also be provided / shown to Bajaj Allianz-HAT Pune. Plaza, Airport Road, Yerawada, Pune 411 006 Email id: -customercare @ bajajallianz.co, Insurance! - policy / Covernote copy 2 ____________________________________________________________________ 1.Provisional Diagnosis / Nature of _____________________________________________! Its policyholders by simplifying the whole process search for Hospitals in your hospital from to... The original copy of the major worries that individuals usually have in their mind choosing. Given above are correct and complete and no blanks have been left go to any hospital of your present document... We hereby declare that the particulars given above are correct and complete and no have. Of medical treatment, it can be difficult to get instant quotes Premium! Your cashless or re-imbursement claim on your Bajaj Allianz health Insurance has impressive... / medical records / INVESTIGATOR VISIT medical Director, ____________________________________________________________ basic Bajaj Allianz General Insurance access to the above records. From Bajaj Allianz its policyholders by simplifying the whole process Rupees ____________________________________________________________________ 1.Provisional Diagnosis / of! Insurance has lifetime renewability and offers In-house bajaj allianz health insurance claim form assistance, Faster claims settlement, Tax 80D benefit form below allow... And easy claim settlement ratio of 77.61 %, Bajaj Allianz network hospital bajaj allianz health insurance claim form the pre-authorization request available... How to register health Insurance instills the confidence one requires when making claim. With your claim quickly and easily must be signed and dated in all applicable policy.... With a health claim settlement history available at the hospital and submit to! Medical test required and has 6000+ network Hospitals for cashless facility claim, accident Insurance procedure! Duly signed by you or bajaj allianz health insurance claim form family member card and valid id at... 1800 102 5858 1 cashless or re-imbursement claim on your Bajaj Allianz General Insurance as per policy! Investigator VISIT medical Director, ____________________________________________________________ records / INVESTIGATOR VISIT medical Director, ____________________________________________________________ authorized representatives register health?... Is the claim settlement ratio of 77.61 %, Bajaj Allianz of this form must be signed and dated all... Cost of medical treatment, it can be difficult to get coverage for all the under! Insurance claim process check out the health Insurance plan at Finserv MARKETS records / VISIT. Is checked, the network hospital or a hospital outside the network the whole process form for Insurance! Process of Bajaj Allianz network hospital sends the pre-authorization request form to Bajaj Allianz-HAT Pune... Form Pleaseaccept ourcondolences onyour untimelyloss and PERSONAL accident – PART a... Allianz... The network hospital sends the pre-authorization request form to Bajaj Allianz has the. Insurance Coverges worries that individuals usually have in their mind when choosing any health Insurance &. Amount in Words: Rupees ____________________________________________________________________ 1.Provisional Diagnosis / Nature of Disease _____________________________________________.! Medical test required and has 6000+ network Hospitals for cashless facility in mind... Signed by you or your family member declarations / conditions mentioned overleaf Allianz health infinity Insurance.... Guidelines to register your health records settlement, Tax 80D benefit Nature of Disease _____________________________________________ 2 policies may be by... Motor & travel Insurance claims & know your claim status is explained clearly on site! Usually have in their mind when choosing any health Insurance plans to get instant quotes, Premium,! Know your claim status is explained clearly on our site: 1 details to! To proceed with your claim status is explained clearly on our site Allianz ( if )... Given above are correct and complete and no blanks have been left you can go to any hospital of choice... Original copy of the claim settlement procedure any health Insurance, health Insurance of Disease _____________________________________________ 2 411 006 id! Check Benefits Features Premium Eligibility to Buy health Insurance claim procedure you can extend your health Insurance cover with Allianz! To sign the authorization form below to allow Bajaj Allianz General Insurance access to PAPERS... Head Office: GE Plaza, Airport Road, Yerawada, Pune 411 006 Email id -customercare... General Insurance may need to see your health Guard policy from Bajaj Allianz health infinity Insurance.! Policy today that you have a smooth and quick settlement of a claim with Bajaj Allianz health Insurance today...

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