I understand that the issuance of this form is not to be construed as an admission of liability by Future Generali India Insurance Co. Ltd. (FGIICL).
The information provided herein, and the corresponding documents, are true and correct, and if FGIICL finds any such information to be incorrect or false, this claim shall stand forfeited. FGIICL, and persons authorized by FGIICL, are authorized to access and obtain all hospitalization records and documents pertaining to this claim and those related to any previous hospitalization of the patient named in this claim.
The amount admitted by FGIICL, against this claim, be remitted to the bank account mentioned by me and such remittance, by FGIICL, shall act as full and final discharge of the liability of FGIICL against this claim. I will not hold FGIICL accountable for any delay or non-credit or credit to a different account, owing to feeding of incorrect or incomplete information by me. In case of change in the bank account, I will advise FGIICL, in writing with appropriate details for updating its records.
I confirm that all the hospitalization records shall be uploaded, hereon, and the originals shall be retained by me for one (1) year from the date of uploading. I also, confirm that the originals shall not be used for filing a claim with any other insurer. If FGIICL learns of such consequent filing, FGIICL shall be entitled to recover the admitted amount from me and inform such other insurers for appropriate action.
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