Quick Claim Assessment Form

1. Full Name *

2. Mobile Number *

3. Email ID *

4. City & State *

5. Insurance Company * -- Select Insurance Company -- Star Health Insurance HDFC Ergo Health Insurance ICICI Lombard General Insurance Niva Bupa Health Insurance Care Health Insurance National Insurance Company New India Assurance Oriental Insurance Company United India Insurance Bajaj Allianz General Insurance Tata AIG General Insurance Reliance General Insurance SBI General Insurance Manipal Cigna Health Insurance Aditya Birla Health Insurance Future General insurance Other ACKO Insurance

Please specify your Insurance Company

6. Type of Policy *
Individual Corporate

7. Policy Number

8. Claim Number

9. Claim Type *
Cashless Reimbursement

10. What is the current status of your claim? *
Claim Rejected Partially Approved Cashless Denied Claim Pending Query Raised Investigation

11. Claim Amount (Approx.) *

12. Amount Rejected / Disputed

13. What reason has the insurer given for rejecting or reducing your claim? *

14. Have you already approached the insurance company's Grievance Officer?
Yes No

15. What assistance are you looking for?
Claim Review Reconsideration Grievance Support Ombudsman Guidance Not Sure

Submit for Assessment