Claim Forms

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Insurance claim forms

Doctor’s statement

Crisis cover claim - Cancer, Heart & Musculoskeletal

Doctor's Statement Cancer 

Doctor's Statement Heart Related Conditions

Doctor’s Statement Bone, Joint, Muscle and Connective Tissue Related Conditions

  • Cancer

  • Early Stage Cancer (Prostate/Thyroid/

  • Bladder/CLL/Melanoma)

  • Carcinoma-in-situ (Breast/ Cervix Uteri/ Uterus/ Ovary/ Fallopian Tube/ Vagina)

  • Mastectomy For Carcinoma-In-Situ Breast

  • Prostatectomy For Stage 1 Prostate Cancer

  • Hysterectomy (surgical Uterus Removal)

  • Salpingectomy (surgical Fallopian Tube Removal)

  • Oopherectomy (surgical Ovary(ies) Removal)

  • Partial Colectomy/Gastrectomy with End-to-end Anastomosis

  • Cystectomy For Carcinoma-In-Situ Urinary Bladder/ Papillary Carcinoma Of The Bladder

     

  •  Coronary Artery Disease Requiring Surgery/ By-Pass Surgery
  • Other Serious Coronary Artery Disease

  • Angioplasty & Other Invasive Treatments

  • Keyhole Coronary By-Pass Surgery

  • Minimally Invasive Direct Coronary Artery Bypass Grafting (MIDCAB)

  • Enhanced External Counterpulsation Procedure

  • Transmyocardial Laser Therapy

  • Heart Attack/ Acute Myocardial Infarction

  • Heart Valve Replacement/ Surgery

  • Percutaneous Heart Valve Surgery

  • Surgery of AortaMinimally invasive surgery to Aorta

  • Large Asymptomatic Aortic Aneurysm/ Dissection

  • (Hypertrophic) Cardiomyopathy

  • Pericardiectomy (with Surgery)

  • Insertion of Pacemaker

  • Insertion of Cardiac Defibrillator

  • Infective Endocarditis (Early/Late)

  • Eisenmenger's Syndrome (Early/Late)

     

  • Paralysis/ Paralysis of Limbs/Loss of Use of One Limb
  • Loss Of Limbs/Fingers

  • Surgical Reattachment Of Amputated Limb

  • Loss Of A Single Hand/ Foot By Amputation

  • Limb Amputation Due To Type 2 Diabetic Complications

  • Muscular Dystrophy (Moderate / Severe)

  • Rheumatoid Arthritis (Moderate / Severe / Chronic)

  • Joint Replacement Due to Severe Osteoarthritis

  • Total Knee/ Hip Replacement

  • Osteoporotic Fracture Requiring Surgery

  • Osteoporotic Fracture Of The Hip/ Vertebra

  • Osteogenesis Imperfecta

  • Poliomyelitis (Moderate / Severe)

  • Progressive Scleroderma (Early / Late)

  • Progressive Scleroderma With CREST Syndrome

  • Major Burns/ Third Degree Burns

  • Mild/ Moderately Severe Burns

  • Grafting Due To Burn

 

Crisis cover claim - Kidney, Liver, Lung, Gastrointestinal, Brain & Nerve

Doctor's Statement Kidney, Liver, Lung & Gastrointestinal Related Conditions

Doctor's Statement Brain and Nerve Related Conditions

  • End Stage Kidney Failure
  • Chronic Severe Renal Impairment

  • Severe Diabetic Nephropathy resulting in Kidney Failure

  • Systemic Lupus Erythematosus (SLE) with with Lupus Nephritis or Severe Kidney Complications

  • Medulla Cystic Disease

  • Nephrectomy/ Removal of one Kidney

  • End Stage Liver Failure

  • Fulminant Viral Hepatitis

  • Cirrhosis of the Liver

  • Autoimmune Hepatitis (Early / Chronic)

  • Partial Hepatectomy

  • Portal Vein Thrombosis

  • End Stage Lung Disease

  • Primary Pulmonary Arterial Hypertension

  • Surgical Removal of the Lungs (whole lung or lobes)

  • Status Asthmaticus

  • Surgical Insertion of a Vena-cava Filter

  • Heart Failure due to Chronic Lung Disease

  • Acute Necrotizing / Chronic Relapsing Pancreatitis

  • Biliary Tract Reconstruction Surgery

  • Chronic Primary Sclerosing Cholangitis

  • Chronic Crohn's Disease

  • Chronic Ulcerative Colitis

  • Adrenalectomy For Adrenal Adenoma

  • Chronic Adrenal Insufficiency

  • Apallic Syndrome

  • Akinetic Mutism / Locked In Syndrome

  • Encephalitis (With Recovery)

  • Meningitis (With Recovery / Reversible Neurological Deficits)

  • Tuberculous Myelitis / Meningeal Tuberculosis

  • Brain (Aneurysm) Surgery

  • Surgical Removal Of Pituitary Tumour

  • Insertion of Cerebral Shunt

  • Insertion of Ventriculoperitoneal Shunt

  • Endovascular Treatment of Cerebral AVM

  • Craniotomy for Treatment of Aneurysm/ AVM

  • Benign Brain Tumour

  • Surgical Excision of a Spinal Meningioma

  • Surgery for Drug Resistant (Severe) Epilepsy

  • Major Head Trauma (Mild / Severe)

  • Cervical Spinal Cord Injury (Accident)

  • Head Trauma (Accident) Requiring Re-constructive Surgery / Open Craniotomy

  • Surgical Repair of Depressed Skull Fracture

  • Motor Neuron Disease (Early / Severe)

  • Peripheral Neuropathy

  • Myasthenia Gravis (Less Severe / Severe)

  • Spinal Cord Disease/Injury Cause Bowel & Bladder Dysfunction

  • Multiple Sclerosis (Early / Severe)

  • Guillain-Barre Syndrome

  • Parkinson's Disease (Early / Moderate / Severe)

  • Progressive Supranuclear Palsy (Early / Late)

  • Diagnosis of Alzheimer's Disease or Dementia

  • Alzheimer's Disease or Dementia (Moderate / Severe)

  • Stroke

  • Stroke Treatment By Carotid Angioplasty & Stent

  • Carotid Artery Surgery

  • Surgery For Subdural Haematoma Due To Accident

  • Coma

 

Crisis cover claim - Eyes, Ear & Others

 

Doctor's Statement Eyes and Ears Related Conditions

Doctor's Statement Other Illnesses

  • Blindness/ Loss of Sight (Both Eyes)

  • Corneal Transplant

  • Loss of Sight in One Eye

  • Bilateral Severe Low Vision

  • Deafness/ Loss of Hearing

  • Cochlea Implant

  • Bilateral Severe Hearing Loss

  • Surgical Drainage for Cavernous Sinus Thrombosis

  • HIV Infection due to Blood Transfusion / Organ Transplant

  • HIV Infection due to Assault

  • Full Blown AIDS

  • Occupationally Acquired HIV / Hepatitis B or C Infection

  • Aplastic Anaemia (Acute or Chronic)

  • Myelodysplastic Syndrome or Myelofibrosis

  • Loss of Independent Existence

  • Loss of Speech

  • Tracheostomy

  • Facial Reconstructive Surgery

  • Type 2 Diabetic Retinopathy

  • Limb Amputation due to Type 2 Diabetic Complications

  • Major Organ Transplant or Bone Marrow Transplant

  • Pending Major Organ Transplant

  • Small Bowel Transplant

  • Terminal Illness