Letter to Claim from Health Insurance - Template Form

________

FROM:

________
________
Mobile: ________
Email: ________

TO:

The Claims Manager / Grievance Redressal Officer
________
________
IRDAI Registration No.: ________

Re.: Request for reimbursement / settlement of health insurance claim under Policy No. ________

Dear Sir/Madam,

§ 1. Particulars of the Policy and Insured. I, ________, the policyholder / insured under the health insurance policy bearing Policy No. ________ issued by ________ (hereinafter referred to as the "Insurer"), valid from ________ to ________, hereby formally lodge a claim for the reimbursement / settlement of medical expenses lawfully incurred by me, in accordance with the terms and conditions of the said policy.

§ 2. Particulars of the Patient. The medical treatment giving rise to this claim was availed by ________ (relationship to policyholder, if any: ________), whose date of birth is ________ and whose Aadhaar / identity reference is ________.

§ 3. Grounds of the Claim. The said medical expenses were incurred on account of the following diagnosis / medical condition / treatment:

________

§ 4. Particulars of Treatment. The treatment was administered at ________ (Hospital Registration No.: ________) during the period commencing ________ and ending ________, under the care of ________.

§ 5. Enclosures. In compliance with the documentary requirements prescribed under the policy and under the Insurance Regulatory and Development Authority of India (Protection of Policyholders' Interests, Operations and Allied Matters of Insurers) Regulations, 2024, I enclose herewith the following documents in support of this claim:

a. Duly completed and signed Claim Form;

b. Original discharge summary / statement from the treating hospital;

c. Original bills, invoices, receipts and itemised break-up of expenses;

d. Diagnostic / investigation reports and prescriptions;

e. Copy of the policy schedule and proof of identity of the insured;

f. Cancelled cheque / bank details for electronic credit; and

g. Such additional documents as set out below:

________

§ 6. Amount Claimed. In view of the foregoing, I hereby request the Insurer to reimburse / settle the claim amount of Rs. ________ (Rupees ________ only), being the sum lawfully due and payable to me under the terms and conditions of the policy.

§ 7. Mode of Payment. I request that the said amount be remitted to me in the following manner:

________

§ 8. Statutory Timelines. I respectfully draw your attention to the timelines prescribed by the IRDAI, requiring the Insurer to settle or repudiate the claim, and to remit the admitted amount together with applicable interest for any delay, within the periods stipulated under the applicable regulations and the policy terms.

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§ 10. Declaration. I hereby declare that the information furnished above and in the enclosed documents is true, complete and correct to the best of my knowledge and belief, and that nothing material has been concealed or misstated.

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Looking forward to your prompt and favourable response.

Yours faithfully,

________
(Signature of the Policyholder / Insured)
Place: ________
Date: ________