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While undergoing any planned treatment the insured can inform his/ her respective insurer in advance. Like other plans of Apollo Munich, Optima Senior is also available with this provision. The insured can fill the claim intimation form and claim the coverage for better facilities. This form will seek information about self, the illness that the person is suffering from and the treatment against which the claim is filed. This will intimate the insurance company well in advance about the treatment insured will be going for thereby providing him/ her the right support. The insured need to provide information about the diagnosis to be done, expected treatment expenses, address, date of birth and contact details. The claim settlement will depend on the information and documents provided by the insured. Also, the claimant must submit the claim intimation form as soon as possible, in order to allow the insurance company work over it. Complete submission of the required documents is extremely important.
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10th Floor, Building No. 10, Tower B, DLF City Phase II, DLF Cyber City, Gurgaon-122002
Claim Intimation Form
E-mail : [email protected] ToLL FrEE : 1800-102-0333 www.apollomunichinsurance.com
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1. Apollo Munich Health Card Number :
2. Policy Number :
3. Name of Policyholder : (in whose name policy is issued)
First Name :
Last Name :
4. Name of person admitted :
First Name :
Last Name :
5. Date of Birth / Age : (DD__ __ /MM __ __/YYYY __ __ __ __ ) __________________Years
6. Address :
7. Date of loss / Treatment / Event / Admission :
8. Unique ID of Provider, If any :
9. Provider Name :
10. Provider address in case of non network :
11. Provisional Diagnosis :
12. Treatment Planned :
13. Estimated Expenses : Rs.
14. Estimated length of stay (if it is an inpatient treatment) :
_________________ Days
15. Contact details, if changed :
16. Intimating Persons :
17. Admitting Doctor details :
Date :
Place : Signature of person suffering injury or legally authorized representative
City : State : Pin Code :
City : State : Pin Code :
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