HOSPITAL DECLARATION, Hospital Seal Doctor's, HEALTH INDIA INSURANCE TPA SERVICES PVT. LTD
- DECLARATION BY THE PATIENT / REPRESENTATIVE a
- I agree to allow the hospital to submit all original documents pertaining to hospitalization to the Insurer /T.P.A after the discharge
- I agree to sign on the Final Bill & the Discharge Summary, before my discharge
- B
- Payment to hospital is governed by the terms and conditions of the policy
- In case the lnsurer / TPA is not liable to settle the hospital bill, I undertake to settle the bill as per the terms and conditions of the policy
- C
- All non-medical expenses and expenses not relevant to current hospitalization and the amounts over & above the limit authorized by the Insurer /T.P.A not governed by the terms and conditions of the policy will be paid by me
- D
- I hereby declare to abide by the terms and conditions of the policy and if at any time the facts disclosed by me are found to be false or incorrect I forfeit my claim and agree to indemnify the insurer / T.P.A e
- I agree and understand that T.P.A is in no way warranting the service of the hospital & that the Insurer / TPA is in no way guaranteeing that the services provided by the hospital will be of a particular quality or standard
- F
- I hereby warrant the truth of the forgoing particulars in every respect and I agree that if I have made or shall make any false or untrue statement, suppression or concealment with respect to the claim, my right to claim reimbursement of the said expenses shall be absolutely forfeited
- G
- I agree to indemnify the hospital against all expenses incurred on my behalf, which are not reimbursed by the Insurer / TPA
- H
- I/We authorize Insurance Company / TPA to contact me / us through mobile/email for any update on this claim" a) Patient's / Insured's Name b) Contact number c) e-mail Id (optional) d) Patient's / Insured's Signature:, a
- We have no objection to any authorized TPA / Insurance Company official verifying documents pertaining to hospitalization
- B
- All valid original documents duly countersigned by the insured / patient as per the checklist below will be sent to TPA / lnsurance
- Company within 7 days of the patient's discharge
- C
- We agree that TPA / Insurance Company will not be Iiable to make the payment in the event of any discrepancy between the facts in this form and discharge summary or other documents
- D
- The patient declaration has been signed by the patient or by his representative in our presence
- E
- We agree to provide clarifications for the queries raised regarding this hospitalization and we take the sole responsibility for any delay in offering clarifications
- F
- We will abide by the terms and conditions agreed in the MOU
- G
- We confirm that no additional amount would be collected from the insured in excess of Agreed Package Rates except costs towards non-admissible amounts (including additional charges due to opting higher room rent than eligibility / choosing separate line of treatment which is not envisaged / considered in package)
- H
- We confirm that no recoveries would be made from the deposit amount collected from the lnsured except for costs towards non- admissible amounts (including additional charges due to opting higher room rent than eligibility/choosing separate line of treatment which is not envisaged / considered in package)
- I
- In the event of unauthorized recovery of any additional amount from the Insured in excess of Agreed Package Rates,the authorized
- TPA / Insurance Company reserves the right to recover the same from us (the Network Provider) and,/or take necessary action, as provided under the MOU or applicable laws.
