CLAIM FORM - PART A' to 'CLAIM FORM FOR HEALTH INSURANCE POLICIES OTHER THAN TRAVEL AND PERSONAL ACCIDENT - PART A
TO BE FILLED BY THE INSURED
The issue of this Form is not to be taken as an admission of liablity
DETAILS OF PRIMARY INSURED:
a) Policy No.:
(To be Filled in block letters)
SECTION A SECTION B
b) Sl. No/ Certificate no.
c) Company/ TPA ID No:
e) Address:
DETAILS OF INSURANCE HISTORY:
a) Currently covered by any other Mediclaim / Health Insurance:
b) Date of commencement of first Insurance without break:
c) If yes, company name: Policy No.
Sum insured (Rs.)
d) Have you been hospitalized in the last four years since inception of the contract?
Diagnosis:
e) Previously covered by any other Mediclaim /Health insurance : :
Date:
M M
Y
Y
Y
Y
f) If yes, company name:
DETAILS OF INSURED PERSON HOSPITALIZED: :
DETAILS OF HOSPITALIZATION: :
DETAILS OF CLAIM:
DETAILS OF BILLS ENCLOSED:
Sl. No. Bill No. Date Issued by Towards Amount (Rs)
DETAILS OF PRIMARY INSURED’S BANK ACCOUNT::
SECTION C
SECTION D
SECTION E SECTION F SECTION G
D
Y
M
D
Y
M
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
D
Y
M
D
Y
M
D
Y
M
D
Y
M
D
Y
M
D
Y
M
D
Y
M
D
Y
M
D
Y
M
D
Y
M
D
Y
M
D
Y
M
D
Y
M
D
Y
M
D
Y
M
D
Y
M
D
Y
M
D
Y
M
City: State:
Pin Code Phone No: Email ID:
City: State:
Pin Code Phone No: Email ID:
D D
D D
M M
M M
Y Y
Y Y
Yes No
Yes No
Yes No
d) Name:
S U R N A M E F I R S T N A M E M I D D L E N A M E
a) Name:
S U R N A M E F I R S T N A M E M I D D L E N A M E
b) Gender Male Female c) Age years
M M
Y Y Y Y
Months
d) Date of Birth
e) Relationship to Primary insured:
Self Spouse Child Father Mother Other (Please Specify)
(Please Specify)
Other
RetiredStudentHome MakerSelf EmployedServicef) Occupation
g) Address (if diffrent from above) :
a) Name of Hospital where Admited:
b) Room Category occupied:
Day care
D D
M M
Y Y H H
H H
M H
M H
D D
M M
Y Y Y Y
D D
M M
Y Y
Single occupancy
Twin sharing
3 or more beds per room
c) Hospitalization due to:
Injury
Illness
Maternity
d) Date of injury / Date Disease first detected /Date of Delivery:
e) Date of Admission:
f) Time
g) Date of Discharge:
h) Time:
:
No
Yes
I) If Medico legal
j) System of Medicine:
Substance Abuse / Alcohol Consumption
I) If injury give cause:
Self inflicted
Road Traffic Accident
iii. MLC Report & Police FIR attached
ii) Reported to Police
No
Yes
a) Details of the Treatment expenses claimed
I. Pre -hospitalization expenses
iii. Post-hospitalization expenses
v. Ambulance Charges:
Rs.
Rs.
Rs.
ii. Hospitalization expenses
Rs.
iv. Health-Check up cost:
vi. Others (code):
Rs.
Rs.
Rs.
Total
vii. Pre -hospitalization period:
days
viii. Post -hospitalization period:
days
b) Claim for Domiciliary Hospitalization:
No
Yes
(If yes, provide details in annexure)
c) Details of Lump sum / cash benefit claimed:
i. Hospital Daily cash:
Rs.
Rs.
Rs.
iii. Critical Illness benefit:
v. Pre/Post hospitalization Lump sum benefit:
ii. Surgical Cash:
iv. Convalescence:
vi. Others:
Rs.
Rs.
Rs.
Rs.
Total
Claim Documents Submitted - Check List:
Claim form duly signed
Copy of the claim intimation, if any
Hospital Main Bill
Hospital Break-up Bill
Hospital Bill Payment Receipt
Hospital Discharge Summary
Pharmacy Bill
Operation Theater Notes
ECG
Doctor’s request for investigation
Investigation Reports (Including CT
/ MRI / USG / HPE)
Doctor’s Prescriptions
Others
Hospital main Bill
Pharmacy Bills
Post-hospitalization Bills: Nos
Pre-hospitalization Bills: Nos
a) PAN:
c) Bank Name and Branch:
d) Cheque / DD Payable details:
b) Account Number:
e) IFSC Code:
(IMPORTANT: PLEASE TURN OVER)
DECLARATION BY THE INSURED:
I hereby declare that the information furnished in the claim form is true & correct to the best of my knowledge and belief. If I have made any false or untrue statement, suppression
or concealent of any material fact with respect to questions asked in relation to this claim, my right to claim reimbrusement 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.
Date
Y YD D M M Y Y
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.
Enter the policy number As allotted by the Insurance Company
b) Sl. No/ Certificate No.
Enter the social Insurance number or the certificate number of
As allotted by the oraganization
social health insurance scheme
c) Company TPA ID No.
Enter the TPA ID No.
Licence number as allotted by IRDA and printed
in TPA documents.
d) Name
Enter the full name of the policyholder
Surname, First name, Middle name
Include Street, City and Pin code
Enter the full postal address
e) Address
SECTION B -DETAILS OF INSURANCE HISTORY
a) Currently covered by any other Mediclaim / Health
Insurance?
Indicate whether currently covered by another Mediclaim /
Health Insurance
Tick Yes or No
b) Date of commencement of first Insurance without break Enter the date of commencement of first Insurance Use dd-mm-yy-forrmat
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
In rupees
Enter the total sum insured as per the policySum insured
d) Have you been Hospitalized in the last four years since
Inception of the contract?
Indicate whether hospitalized in the last four years
Tick Yes or No
Date
Enter the date of Hospitalization
Use mm-yy format
Diagnosis Enter the diagnosis details
Open Text
Tick Yes or No
e) Previously covered by any other Mediclaim / Health
Insurance?
Indicate whether previously covered by another mediclaim /
Health Insurance
f) Company Name
Enter the full name of the Insurance Company
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
Include STD code with telephone number
Complete e-mail address
h) Phone No
1) E-mail ID
Enter the phone number of patient
Enter e-mail address of patient
SECTION D - DETAILS OF HOSPITALIZATION
a) Name of Hospital where admited
Enter the name of hospital Name of hospital in full
Tick the right option
Tick the right option
Use dd-mm-yy format
Use dd-mm-yy format
Use hh-mm- format
Use dd-mm-yy format
Use hh-mm- format
Tick the right option
Tick Yes or No
Tick Yes or No
Tick Yes or No
Open Text
b) Room category occupied
c) Hospitalization due to
d) Date of injury/Date Disease first detected / Date of
Delivery
e) Date of admission
f) Time
g) Date of discharge
h) Time
I) If injury give cause
If Medico legal
Reported to Police
MLC Report & Police FIR attached
j) System of Medicene
indicate the room category occupied
indicate reason of hospitalization
Enter the relevant date
Enter date of admission
Enter time of admission
Enter date of discharge
Enter time of discharge
indicate cause of injury
indicate whether injury is medico legal
indicate whether police report was filed
indicate whether MLC report and Police FIR attached
Enter the system of medicine followed in treating the patient
SECTION E - DETAILS OF CLAIM
a) Details of Treatment Expences
b) Claim for Domiciliary Hospitalization
c) Details of Lump sum/ Cash benifit claimed
d) Claim documents Submitted-Check List
Enter the amount claimed as treatment expences
indicate whether claim is for domiciliary hospitalization
Enter the amount claimed as lump sum / cash benefit
indicate which supporting documents are submitted
Tick Yes or No
Tick the right option
In rupees (Do not enter paise values)
In rupees (Do not enter paise values)
SECTION F - DETAILS OF BILLS ENCLOSED
Indicate which bills are enclosed with the amount in rupees
SECTION G - DETAILS OF PRIMARY INSURED’s BANK ACCOUNT
a) PAN
b) Account Number
c) Bank Name and Branch
c) Cheque/ DD payable details
c) IFSC Code
Enter the permanent account number
Enter the Bank account number
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
As allotted by the Income Tax Department
As allotted by the Bank
Name of the Bank in full
Name of the individual / organization in full
IFSC code of the Bank branch in full
SECTION H - DECLARATION BY THE INSURED
Read declaration carefully and mention date (in dd:mm:yy format), place (open text) and sign.
SECTION H
CLAIM FORM - PART B
TO BE FILLED IN BY THE HOSPITAL
The issue of this Form is not to be taken as an admission of liability
Please include the original preauthorization request form in lieu of PART A
(To be Filled in block letters)
DETAILS OF HOSPITAL
a) Name of the hospital:
a) Hospital ID:
c) Name of the treating doctor:
e) Qualification:
DETAILS OF THE PATIENT ADMITTED
c) Type of Hospital:
Network : Non Network : (if non network fill section E)
f) Registration No. with State Code:
g) Phone No.
a) Name of the Patient:
b) IP Registration Number:
c) Gender:
Male Female
d) Age: Years
Months
e) Date of birth:
ii) Gravida Status: :
m) Total claimed amount
h) Date of Discharge:
i) Date of Delivery:
k) If Maternity
Maternity
Day Care
Planned
Emergency
f) Date of Admission:
j) Type of Admission:
I) Status at time of discharge:
Discharge to home
Discharge to another hospital
Deceased
DETAILS OF AILMENT DIAGNOSED (PRIMARY)
a)
ICD 10 Codes
I. Primary Diagnosis
ii. Additional Diagnosis:
iii. Co-morbidities:
iv. Co-morbidities:
vi. If not reported to police give reason:
Description
b)
i. Procedure 1:
ii. Procedure 2:
iii. Procedure 3:
iv. Details of Procedure:
ICD 10 PCS
Description
c) Pre-authorization obtained:
Yes
Yes
Yes
Yes
No
No
No
No
d) Pre-authorization Number:
e) If authorization by network hospital not obtained, give reason:
f) Hospitalization due to injury:
I. If Yes, give cause
Self-inflicted
Road Traffic Accident
Substance abuse / alcohol consumption
iv. Reported to Police
iii. If Medico legal:
(If Yes, attach reports)
ii) If injury due to substance abuse / alcohol consumption, Test conducted to establish this:
v. FIR No.
CLAIM DOCUMENTS SUBMITTED - CHECK LIST
Claim Form duly signed
Original Pre-authorization request
Copy of the Pre-authorization approval letter
Copy of Photo ID Card of patient Verified by hospital
Hospital Discharge summary
Operation Theatre Notes
Hospital main bill
Hospital break-up bill
Investigation reports
CT/MR/USG/HPE investigation reports
Doctor’s reference slip for investigation
ECG
Pharmacy bills
MLC reports & Police FIR
Original death summary from hospital where applicable
Any other, please specify
ADDITIONAL DETAILS IN CASE OF NON NETWORK HOSPITAL (ONLY FILL IN CASE OF NON-NETWORK HOSPITAL)
(PLEASE READ VERY CAREFULLY)
a) Address of the Hospital
d) Hospital PAN:
iii. Others:
DECLARATION BY THE HOSPITAL
We hereby declare that the information furnished in this Claim Form is true & correct to the best of our knowledge and belief. If we have made any false or untrue statement, suppression or concealment of any material fact,
our right to claim under this claim shall be forfeited.
Date:
Place:
Signature and Seal of the Hospital Authority:
SECTION A SECTION B SECTION C
SECTION D
SECTION E SECTION F
Yes No
Yes No
City:
State:
Pin Code:
b) Phone No.
c) Registration No. with State Code:
e) Number of inpatient beds
f) Facilities available in the hospital
i. OT
ii. ICU
Yes No
S U R N A M E F I R S T N A M E M I D D L E N A M E
S U R N A M E F I R S T N A M E M I D D L E N A M E
D D M M Y Y H H M M
Y Y M M
M M
M M
D D
D D
H
M
H
M
Y
Y
D D M M Y Y
D D M M Y Y
Y
Y
g) Time:
GUIDANCE FOR FILLING CLAIM FORM - PART B (To be filled in by the hospital)
DATA ELEMENT
DESCRIPTION
FORMAT
a) Name of the hospital:
b) Hospital ID
c) Type of Hospital
c) Name of treating doctor
SECTION A - DETAILS OF HOSPITAL
e) Qualification
f) Registration No. with State Code
g) Phone No.
Enter the name of hospital
Enter ID number of hospital
Indicate whether in network or non network hospital
Enter the name of the treating doctor
Enter the qualification of the treating doctor
Enter the registration number of the doctor along with the state code
Enter the phone number of doctor
SECTION B - DETAILS OF THE PATIENT ADMITTED
a) Name of Patient
b) IP registration Number
c) Gender
d) Age
e) Date of Birth
f) Date of Admission
g) Time
h) Date of Discharge
i) Time
j) Type of Admission
k) If Maternity
Date of Delivery
Gravida Status
l) Status at time of discharge
M) Total claimed amount
Enter the name of patient
Enter insurance provider registration number
Indicate Gender of the patient
Enter age of the patient
Enter date of birth
Enter date of admission
Enter Time of admission
Enter date of Discharge
Enter time of Discharge
Indicate type of admission of patient
Enter Date of Delivery if maternity
Enter Gravida status if maternity
Indicate status of patient at time of discharge
Indicate the total claimed amount
SECTION C - DETAILS OF AILMENT DIAGNOSED (PRIMARY)
a) ICD 10 Code
Primary Diagnosis
Additional Diagnosis
Co-morbidities
b) ICD 10 PCS
Procedure 1
Procedure 2
Procedure 3
Details of Procedure
c) Pre-authorization obtained
d) Pre-authorization Number
e) If authorization by network hospital not obtained, give reason
f) Hospitalization due to injury
Cause
If injury due to substance abuse/alcohol consumption test
conducted to establish this
Medico Legal
Reported to Police
FIR No.
If not reported to police, give reason
Indicate which supporting documents are submitted
SECTION D - CLAIM DOCUMENTS SUBMITTED-CHECK LIST
SECTION E - DETAILS IN CASE OF NON NETWORK HOSPITAL
a) Address
b) Phone No.
c) Registration No. with State Code
d) Hospital PAN
e) Number of Inpatient beds
f) Facilities available in the hospital
Read declaration carefully and mention date (in dd:mm:yy format), place (open text) and sign. and stamp
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
Enter the ICD 10 Code and description of the first procedure
Enter the ICD 10 Code and description of the second procedure
Enter the ICD 10 Code and description of the third procedure
Enter the details of the procedure
Enter pre-authorization number
Indicate whether pre-authorization obtained
Enter reason for not obtaining pre-authorization number
Indicate if hospitalization is due to injury
Indicate cause of injury
Indicate whether test conducted
Indicate whether injury is medico legal
Indicate whether police report was filed
Enter first information report number
Enter reason for not reporting to police
Enter the full postal address
Enter the phone number of hospital
Enter the permanent account number
Enter the number of inpatient beds
Indicate facilities available in the hospital
SECTION F - DECLARATION BY THE HOSPITAL
Name of the hospital in full
As allocated by the TPA
Tick the right option
Name of doctor in full
Abbreviations of educational qualifications
As allocated by the Medical Council of India
Include STD code with telephone number
Name of patient in full
As allotted by the insurance provider
Tick Male or Female
Number of years and months
Use dd-mm-yy format
Use dd-mm-yy format
Use hh:mm format
Use dd-mm-yy format
Use hh:mm format
Tick the right option
Use dd-mm-yy format
Use standard format
Tick the right option
In rupees (Do not enter paise values)
Include Street, City and Pin Code
Include STD code with telephone number
As allocated by the City Corporation / Municipality
As allocated by the Income Tax Department
Digits
Tick the right option. If others, please specify
Standard Format and Open text
Standard Format and Open text
Standard Format and Open text
Standard Format and Open text
Standard Format and Open text
Standard Format and Open text
Open text
Tick Yes or No
As allotted by TPA
Open text
Tick Yes or No
Tick Yes or No
Tick the right option
Tick Yes or No
Tick Yes or No
As issued by police authrities
Open text
Enter the registration number of the Hospital obtained from local body
like City Corporation / Municipality
