Reimbursement Claim Form Check List

Please ensure that you submit the following documents as per the check list with in 30 days from the date of
discharge from the hospital in support of your claim.
Employee Name: ____ MAID No: _________________
Employee Code: - Name of the company: _____________________________
E-Mail Id: Contact No: __________________________________
Check List of Documents: Please put a “√” mark in the box Total No. of Enclosures: ________

1. Claim Form duly filled and signed by you.  (Fill the claim amount in Signed Claim Form)
2. Original Main Hospital Bill with break up. 
(Detailed Breakup of various heads like OT Charges, Nursing Charges and Room Rent etc)
3. Original Hospital Payment Receipt with serial number. 
(With seal and signature of the hospital if the main hospital bill does not carry bill number)
4. Original Detailed Discharge Summary from the hospital. 
(Gives the summary of diagnosis, period of admission and treatment in the Hospital)
5. Original Receipts with serial number
(For Consultation/Surgeon charges if charged outside the main hospital bill)
6. Original Investigation bills and reports 
(Along with prescriptions & reports for all tests done along with images)
7. Original Pharmacy bills with original Doctors Prescriptions
(On doctors letterhead mentioning duration and dosage for medicines)
8. Copy of the ID card –Self attested
(Pan Card, Ration card, Passport, Driving License-Election Card –Company ID card etc.,)
9. Original Death Summary in case of a death claims.  (In case of the death of patient during hospital stay)
10. Police FIR/ Medico Legal Certificate (Mandatory for all road traffic accident duly attested by Police)

In Case of Maternity: Letter from treating doctor with Gravida Details (G P L A; No. of Living children)

Declaration: The checklist of documents given herein above and acknowledged here in by or on behalf of
Mediassist does not constitute admissibility of the claim and also does not constitute all the requirements for
processing of the claim for settlement. The claim may also be subjected to medical & commercial scrutiny MA /
Insurer may call for additional information or documents as may be needed for processing the claim. The settlement
of the claim will be subjected to the terms & conditions of the policy. I also consent for the claim to be processed
on the avilable bills/ documents.

Signature of the Insured / Claimant

Frequently asked/raised objections from TPA

Ensure submission of the following supporting documents for processing the claim to avoid any
shortfall/deficiency:

a) Pre numbered Cash Paid receipt

b) Investigation Original Reports
c) Prescription
d) Break up details of Main hospital bill
e) Detailed Discharge Summary

Imp Points to remember:

A. Please retain a copy of all documents submitted to us for further reference

B. Please retain POD copy of the courier for tracking your consignment in case of any delay etc.
C. For implants used in Cataract, Heart Valve Surgeries, CABG,Abdominal Surgeries, Knee replacement
surgeries. Please submit the bill (in case purchased outside) from the vendors for the prosthetic devices
used along with Sticker
D. Please arrange the enclosures as per checklist.