CLAIM FORM FOR HEALTH INSURANCE POLICIES OTHER THAN TRAVEL AND PERSONAL ACCIDENT PART A

TO BE FILLED IN BY THE INSURED

The issue of this Form is not to be taken as an admission of liability

Name of Insurance Company: _______________________________________________________

(To be filled in block letters)

DETAILS OF PRIMARY INSURED:

a) Policy No:

b) Sl. No/ Certificate No:

c) Company/ TPA ID No:

S

SECTION A

d) Name :

e) Address :

City:

State:

Pin Code:

Phone No:

Email ID :

DETAILS OF INSURANCE HISTORY:

Yes

No

b) Date of commencement of first Insurance without break:

c) If yes, company name:

Date:

Policy No.

Sum Insured (Rs.)

d) Have you been hospitalized in the last four years since inception of the contract?

Diagnosis:

Yes

No

e) Previously covered by any other Mediclaim / Health insurance :

Yes

No

SECTION B

a) Currently covered by any other Mediclaim / Health Insurance:

f) If yes, Company Name

DETAILS OF INSURED PERSON HOSPITALIZED:
S

a) Name:
b) Gender:

Male

Female

c) Age: years Y

Self

Spouse

f) Occupation:

Self Employed

Child

Homemaker

months M M

d) Date of Birth:

M
M M

Father

Mother

Other

(Please Specify)

Student

Retired

Other

(Please Specify)

SECTION C

e) Relationship to Primary insured:

Service

g) Address (if different from above):

City:

State:

Pin Code:

Phone No:

E-mail ID:

DETAILS OF HOSPITALIZATION:
a) Name of Hospital where Admitted:
Day care

c) Hospitalization due to:

Injury

e) Date of Admission:

i) If Injury give cause:

Self inflicted

ii. Reported to police:

Illness

Yes

Maternity
Y

3 or more beds per room

d) Date of Injury / Date Disease first detected /Date of Delivery:

f) Time:

Road Traffic Accident

No

Twin sharing

Single occupancy

g) Date of Discharge: D

Substance Abuse / Alcohol Consumption

iii. MLC Report & Police FIR attached:

Yes

No

i. If Medico legal:

D
Y

M M

h) Time:

Yes

No

SECTION D

b) Room Category occupied:

j) System of Medicine:

DETAILS OF CLAIM:
a) Details of the treatment expenses claimed

Claim Documents Submitted- Check List:

i. Pre-hospitalization Expenses:

Rs.

ii. Hospitalization Expenses:

Rs.

Claim Form Duly signed

iii. Post-hospitalization Expenses:

Rs.

iv. Health-Check up Cost:

Rs.

Copy of the claim intimation, if any

v. Ambulance Charges:

Rs.

vi. Others (code):

Rs.

Hospital Main Bill

Total
vii. Pre-hospitalization period:

days

viii. Post-hospitalization period:

b) Claim for Domiciliary Hospitalization:

Yes

No

Rs.
days

(If yes, provide details in annexure)

Hospital Bill Payment Receipt

Hospital Discharge Summary
Pharmacy Bill

c) Details of Lump sum / cash benefit claimed:

Operation Theatre Notes

i. Hospital Daily Cash:

Rs.

ii. Surgical Cash:

Rs.

iii. Critical Illness Benefit:

Rs.

iv. Convalescence:

Rs.

vi. Others:

Rs.

Total

Rs.

v. Pre/Post hospitalization Lump sum benefit: Rs.

SECTION E

Hospital Break-up Bill

ECG
Doctor's request for investigation
Investigation Reports (Including CT
/ MRI / USG / HPE)
Doctor's Prescriptions
Others

DETAILS OF BILLS ENCLOSED:

Sl. No

Bill No

Issued by

Date
D

3.
4.

5.
6.

7.
8.

9.
10

Towards
Hospital Main Bill
Pre-hospitalization Bills:
Post-hospitalization Bills:
Pharmacy Bills

Amount (Rs)

SECTION F

1.
2.

Nos
Nos

DETAILS OF PRIMARY INSURED'S BANK ACCOUNT:

d) Cheque/ DD Payable details:

SECTION G

a) PAN:
c) Bank Name and Branch:

b) Account Number:

e) IFSC Code:

(IMPORTANT: PLEASE TURN OVER)

DECLARATION BY THE INSURED:

Date: D

Place:

Signature of the Insured

GUIDANCE FOR FILLING CLAIM FORM PART A (To be filled in by the insured)
DATA ELEMENT

DESCRIPTION

FORMAT

SECTION A - DETAILS OF PRIMARY INSURED

a)

Policy No.

b)

SI. No/ Certificate No.

c)

Company TPA ID No.

Enter the TPA ID No

d)

Name

Enter the full name of the policyholder

License number as allotted by IRDA and printed

in TPA documents.
Surname, First name, Middle name

e)

Address

Enter the full postal address

Include Street, City and Pin Code

a)

Enter the policy number

Enter the social insurance number or the certificate number of
social health insurance scheme

SECTION B - DETAILS OF INSURANCE HISTORY

Indicate whether currently covered by another Mediclaim /
Health Insurance
Enter the date of commencement of first insurance

As allotted by the insurance company

As allotted by the organization

b)

Currently covered by any other Mediclaim / Health

Insurance?
Date of Commencement of first Insurance without break

c)

Company Name

Enter the full name of the insurance company

Name of the organization in full

Policy No.

Enter the policy number

As allotted by the insurance company

Sum Insured
Have you been Hospitalized in the last four years since
inception of the contract?
Date

Enter the total sum insured as per the policy

In rupees

Indicate whether hospitalized in the last four years

Tick Yes or No

Enter the date of hospitalization

Use mm-yy format

Diagnosis
Previously Covered by any other Mediclaim/ Health
Insurance?
Company Name

Enter the diagnosis details

Indicate whether previously covered by another Mediclaim /
Health Insurance
Enter the full name of the insurance company

Open Text

d)

e)
f)

Tick Yes or No
Use dd-mm-yy format

Tick Yes or No
Name of the organization in full

SECTION C - DETAILS OF INSURED PERSON HOSPITALIZED

a)

Name

Enter the full name of the patient

Surname, First name, Middle name

b)

Gender

Indicate Gender of the patient

Tick Male or Female

c)

Age

Enter age of the patient

Number of years and months

d)

Date of Birth

Enter Date of Birth of patient

Use dd-mm-yy format

e)

Relationship to primary Insured

Indicate relationship of patient with policyholder

Tick the right option. If others, please specify.

f)

Occupation

Indicate occupation of patient

Tick the right option. If others, please specify.

g)

Address

Enter the full postal address

Include Street, City and Pin Code

h)

Phone No

Enter the phone number of patient

Include STD code with telephone number

i)

E-mail ID

Enter e-mail address of patient

Complete e-mail address

SECTION D - DETAILS OF HOSPITALIZATION

a)

Name of Hospital where admitted

Enter the name of hospital

Name of hospital in full

b)

Room category occupied

Indicate the room category occupied

Tick the right option

c)
d)

Indicate reason of hospitalization

Tick the right option

Enter the relevant date

Use dd-mm-yy format

e)

Hospitalization due to
Date of Injury/Date Disease first detected/ Date of
Delivery
Date of admission

Enter date of admission

Use dd-mm-yy format

f)

Time

Enter time of admission

Use hh:mm format

g)

Date of discharge

Enter date of discharge

Use dd-mm-yy format

h)

Time

Enter time of discharge

Use hh:mm format

i)

If Injury give cause

Indicate cause of injury

Tick the right option

If Medico legal

Indicate whether injury is medico legal

Tick Yes or No

Reported to Police

Indicate whether police report was filed

Tick Yes or No

MLC Report & Police FIR attached

Indicate whether MLC report and Police FIR attached

Tick Yes or No

System of Medicine

Enter the system of medicine followed in treating the patient

Open Text

j)

SECTION E - DETAILS OF CLAIM

a)

Details of Treatment Expenses

Enter the amount claimed as treatment expenses

In rupees (Do not enter paise values)

b)

Claim for Domiciliary Hospitalization

Indicate whether claim is for domiciliary hospitalization

Tick Yes or No

c)

Details of Lump sum/ cash benefit claimed

Enter the amount claimed as lump sum/ cash benefit

In rupees (Do not enter paise values)

d)

Claim Documents Submitted-Check List

Indicate which supporting documents are submitted

Tick the right option

SECTION F - DETAILS OF BILLS ENCLOSED

Indicate which bills are enclosed with the amounts in rupees
SECTION G - DETAILS OF PRIMARY INSUREDS BANK ACCOUNT
a)

PAN

Enter the permanent account number

As allotted by the Income Tax department

b)

Account Number

Enter the bank account number

As allotted by the bank

c)

Bank Name and Branch

Name of the Bank in full

d)

Cheque/ DD payable details

e)

IFSC Code

Enter the bank name along with the branch

Enter the name of the beneficiary the cheque/ DD should be
made out to
Enter the IFSC code of the bank branch
SECTION H - DECLARATION BY THE INSURED

Read declaration carefully and mention date (in dd:mm:yy format), place (open text) and sign.

Name of the individual/ organization in full

IFSC code of the bank branch in full

SECTION H

I hereby declare that the information furnished in this claim form is true & correct to the best of my knowledge and belief. If I have made any false or untrue statement,
suppression or concealment of any material fact with respect to questions asked in relation to this claim, my right to claim reimbursement shall be forfeited. I also consent &
authorize TPA / insurance company, to seek necessary medical information / documents from any hospital / Medical Practitioner who has attended on the person against
whom this claim is made. I hereby declare that I have included all the bills / receipts for the purpose of this claim & that I will not be making any supplementary claim except
the pre/post-hospitalization claim, if any.

Annexure - III
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Annexure - III

GUIDANCE FOR FILLING CLAIM FORM PART B (To be filled in by the hospital)
DATA ELEMENT

DESCRIPTION

FORMAT

SECTION A - DETAILS OF HOSPITAL

a)

Name of Hospital

Enter the name of hospital

Name of hospital in full

b)

Hospital ID

Enter ID number of hospital

As allocated by the TPA

c)

Type of Hospital

Indicate whether In network or non network nospital

Tick the right option

d)

Name of treating doctor

Enter the name of the treating doctor

Name of doctor in full

e)

Qualification

Abbreviations of educational qualifications

f)

Registration No. with State Code

g)

Phone No.

Enter the qualifications of the treating doctor

Enter the registration number of the doctor along with the state
code
Enter the phone number of doctor

As allocated by the Medical Council of India

Include STD code with telephone number

SECTION B DETAILS OF THE PATIENT ADMITTED

a)

Name of Patient

Enter the name of hospital

Name of hospital in full

b)

IP Registration Number

Enter insurance provider registration number

As allotted by the insurance provider

c)

Gender

Indicate Gender of the patient

Tick Male or Female

d)

Age

Enter age of the patient

Number of years and months

e)

Date of Admission

Enter date of admission

Use dd-mm-yy format

f)

Time

Enter time of admission

Use hh:mm format

g)

Date of Discharge

Enter date of discharge

Use dd-mm-yy format

h)

Time

Enter time of discharge

Use hh:mm format

i)

Type of Admission

Indicate type of admission of patient

Tick the right option

j)

If Maternity
Date of Delivery

Enter Date of Delivery if maternity

Use dd-mm-yy format

Gravida Status

Enter Gravida status if maternity

Use standard format

Status at time of discharge

Indicate status of patient at time of discharge

Tick the right option

k)

SECTION C DETAILS OF AILMENT DIAGNOSED (PRIMARY)

a)

ICD 10 Code
Enter the ICD 10 Code and description of the primary
diagnosis
Enter the ICD 10 Code and description of the additional
diagnosis
Enter the ICD 10 Code and description of the co-morbidities

Primary Diagnosis
Additional Diagnosis
Co-morbidities
b)

Standard Format and Open text

Standard Format and Open text
Standard Format and Open text

ICD 10 PCS
Procedure 1

Enter the ICD 10 PCS and description of the first procedure

Standard Format and Open text

Procedure 2

Enter the ICD 10 PCS and description of the second procedure

Standard Format and Open text

Procedure 3

Enter the ICD 10 PCS and description of the third procedure

Standard Format and Open text

Details of Procedure

Enter the details of the procedure

Indicate whether present ailment is a complication of some preexisting disease
Indicate whether pre-authorization obtained

Open text

c)

Present Ailment is a Complication of PED

d)

Pre-authorization obtained

e)
f)

Pre-authorization Number
If authorization by network hospital not obtained, give
reason
Hospitalization due to injury

Enter pre-authorization number

As allotted by TPA

Enter reason for not obtaining pre-authorization number

Open text

Indicate if hospitalization is due to injury

Tick Yes or No

Cause
If injury due to substance abuse/alcohol consumption,
test conducted to establish this
Medico Legal

Indicate cause of injury

Tick the right option

Indicate whether test conducted

Tick Yes or No

Indicate whether injury is medico legal

Tick Yes or No

Reported To Police

Indicate whether police report was filed

Tick Yes or No

FIR No.

Enter first information report number

As issued by police authorities

If not reported to police, give reason

Enter reason for not reporting to police

Open Text

g)

Tick Yes or No
Tick Yes or No

SECTION D CLAIM DOCUMENTS SUBMITTED-CHECK LIST

Indicate which supporting documents are submitted
SECTION E DETAILS IN CASE OF NON NETWORK HOSPITAL
a)

Address

Enter the full postal address

Include Street, City and Pin Code

b)

Phone No.

Enter the phone number of hospital

Include STD code with telephone number

c)

Registration No.

Enter the registration number of patient

As allocated by the Hospital

d)

PAN

Enter the permanent account number

As allotted by the Income Tax department

e)

Number of Inpatient Beds

Enter the number of inpatient beds

Digits

f)

Facilities available in the hospital

Indicate facilities available in the hospital

Tick the right option. If others, please specify

SECTION F - DECLARATION BY THE INSURED

Read declaration carefully and mention date (in dd:mm:yy format), place (open text) and sign.
SECTION G - DECLARATION BY THE HOSPITAL
Read declaration carefully and mention date (in dd:mm:yy format), place (open text) and sign and stamp