OTHER THAN TRAVEL AND PERSONAL ACCIDENT - PART A TO BE FILLED BY THE INSURED ‘The tssue ofthis Form le not 69 be taken ae an admission of liability DETAILS OF PRIMARY INSUREL {To be Filed in block letters) 2) Policy No. T i I [ b) SI. No! Certificate no| [ ¢) Company! TPA ID No} F | 4) Name! s[u[R[N[a[M CLAIM FORM - PART A‘ to ‘CLAIM FORM FOR HEALTH INSURANCE = aly State: | Fin Code| Phone No: Email DETAILS OF INSURANCE HISTORY: 2) Currently covered by any other Mediclaim / Health Insurance: ) Date of commencement of first Insurance without break: [DD] [m[M] [¥[¥[Y|¥ BD tyes.companynane: [_] [ [ Policy No. E I ‘Sum insured (R.) 4) Have you been hospitalized in the last four years since inception ofthe contract@[ Yes JNo Date:[ Mi] mt R g 3 g > ® f i 2 . Diagnosis: €) Previously covered by any other Mediclaim Meath insurance {| Yes | _] No | @ 4 9 g 0 ‘if yes, company name: [| BETAILS OF INSURED PERSON HOSPITALIZED: a) Name! s[ulR[wla[me elilRps|t] [nlalule Lee wlifolo[efe] [xfa[ufe I [ b) Gender Wale] | Femate| 0) Age yoors{ ¥ | ¥ |Months| mt | m] 4) Date of Bith] 0 ©) Relationship to Primary insured: seif{ _] Spouse [chi _ | Father Mother [_ other[ |] (Please specity) 4) Occupation : Servic [Self Employed | |Home Maker |__| Student Other (Please specity) Retired {) Adress: (i iferen from above) I r n 7 L State: [ I Pin Code Phone No: Email ioDETAILS OF HOSPITALIZATION: @) Name of Hospital where Admited v2 pete b) Room Cater occupad: Dey [| Single occupancy [| Twn sharing [_] 3 ormere beds per rom } Hospitalization due o:njuy| —]liness| [Maternity] | ¢) Dee oft Dae Deas it doled IDaleof Dei | |||] ¥ [Y ‘Dat otadnssonf 0 0 |[u] a] [¥ [x] vv ]9 tine [ei [x ][ na ]o) Dae ofDscagef [0 [wm [w][¥] vv [¥] 9 tme[W [i ][ w]e Iiinjury give cause: Senicled| | Road Taf Aciden|_|Substane Abuse iAcool Consumo] | ) Medico legal Yes] |No Il) Reported to Police ii, MLC Report & Police FIR attached[ |Yes|_] No }) System of Medicine DETAILS OF CLAIM: 2) Details ofthe Treatment expenses élaimed 1, Pre -hospitalization expenses Rs, [ I, Hospitalization expenses Rs, ii, Posthospitaizaton expenses Rs | | [| [|_|] Health-check up cost: Rs. ¥. Ambulance Charges: Rs, I | vi Others (code): rs.[-] Tolal Rs, Wi. Pre hospitalization period: days [_] _ wit Post -ospitalzation period: days ) Claim for Domiciliary Hospitalization: ]Yes{ ]No _({tyes, provide detals in annexure) «) Details of Lump sum / cash benefit ca Sa Rs. Ll idee a a vi. Others: Rs. | [ 1 PePutpa Ly un bet Rs, ia I Claim Documents Submitted - Check List: Claim form duly signed Copy ofthe aim intimation, 'eny Hospital Main Bil Hospital Break-up Bill Hospital Bil Payment Reoeiot Doctor's Prescriptions Pharmacy Bil ECG Hospital Discharge Summary Others Operation Theater Notes Doctor's request for investigation bal cna ia DETAILS OF BILLS ENCLOSEL S.No] Bo. * Tsay Twas ‘Amount (3) esi nan Pretcsalon BT Wor Pest epialon Bs Wos Pharrey Bs ae ela ie Sele ele a a DETAILS OF PRIMARY INSURED'S BANK ACCOUNT. apant | [ 2) Account Number eae ‘¢} Bank Name and Branch:| | I ELT] ET d) Cheque / DD Payable deta f H 0 g 2 3 3 3 _ 3 g = ed il, Surgical Cash: Rs. pose oe iv Conlescenc ah 8 : 5 J o g 3 5 ‘9 | i a ‘5 g 0 ®)IFSC Code:DECLARATION BY THE INSURED: . econ one arr Grains yb Sinn sc 8c any onan nb hd ab re sare nope iy er cece Sry tl odo mst Wasre mies a bn he cata tgticats ainsonent al te fase see ease ea Facies Carga ts neces ede roms coset my teal ses freer at hs etnupsene pon egorawron saree {icy sae hae oa ee ren rf apne Rca oti ey pay ca ete enon, § Ee z Date [0 [> [m[M]¥[¥]¥]¥] Place: 2 I Sonate ohernsued GUIDANCE FOR FILLING CLAIM FORM - PART A (To be filled in by the insured) BATABLENENT I ESORPTON omar FS i pa a CoS 2) aN cone: GASSES SES SEMIS [peta pe nomen 9) Gampany TA Do. ere PAID ea ame non Nawe art awe a Gr Sian Peron a has tate pee Tal rk OF SECTIONS DEVAL OF MBURANGEWBTOR? 7 aS TT Tee eran cy sees | Tea yn coer oc rma ant [er eo conor fa PRES amo eee Et ae sar Gay ane tbe rman yh a lg ber Tey au Conn aint Eat lar nna TORS wa Heyes amp apia batter eas [ae nate toes eens Teer One tia ten Tame Dao Eade oa oa 7 ego ore aa a Spanien ee Company Nae ‘En rar Baines COMES Ta teenie Nave Et ala etek ‘Sines Fetrane laser 2) Gen eas Gao a "ie ear Fee 2h = Nano ae on = 0) Restos pian a Tite oto Faber; Bas ay 2 cenesion Teel cospatn tote Tiss rates Fate sea oes as orn pel arse Tras Set Cy Pole ny Phe Ete emer Tras STD code wens ber 9 Ena reat as bt ‘Coma el coe ‘SECTION D-DETALS OF HOGPTALEATION 3) _ Manet espa wir io rhe ane thoi Nese drow Fu 1) Rio clo oree ae ay ao Take on 2) Horton du | eee epee Tia eosin Ba ci iT OS caus Gaeefiear Oa of son Erren earanen Teeaiemiyiemat Tae Erie eran ‘ie ea 9) banda Ere coor se ay me Tee | Biereneaaehage se ie ems Hy gaa [nse sre ty Taf ei onien es od rane reese Tek Yolo Repos Pas at wer poke pT Trak Vr nto TG Roper Poles FR asd inate WLC aa Poa FR he Tea Ysa D_ Sptmetneccere Ex tn hme owed nosing pie’ | Open Tex ‘SECTION E-DETALS OF LANE 2)_tetie cd Yt Epo inet rater gnc ‘ree Go ete pae we Gain fr Daminy epaon ier dian epic ek Ye ts ©) Denis Lin au Ga ta soe Ent ano one ur un a Bae ‘napa Dolan eee) Gain doomons Sttnd Check Tae wih epatg door ies eka enon Te whch bier ancesn i he aneurin noes aw i oar eT ed Ee Beta ot ete Pa one no Ee Barre gS ‘area Crepe aie Energetic aces DODHA | vane ate ha na FSC tae rr FOS no Fah abe aK NST {SECTION H- DECLARATION BY THE SURED ‘Ren cacaraion rly antmetn dt ny mil ace meCLAIM FORM - PART B (ope Fat paket) Sener LU EY THE Homma ‘The lato his Forms not tobe ten san adristen of elify Pete nc thesia peeaorzaton request fon ot PART DETAILS OF HOSPITAL a) Name of the hospital: T [ [ I a) Hospital ID: ) Type of Hospital: Network | Non Network: | | (frst see 1c) Name of the treating doctor:| [s[ulR[N[A| Mle I ® ¢ 8 3 3 g > Telerett) [w[a[ufe wlfofo[ulel [wla[wle [ [ v 4 4 8 2 3 g a €} Quaication: Regtton No. wi Site Cote I a) Phone No, wile feL [alalule T 'b) IP Registration Number: ‘Gender: Male ‘Female dj Age: Years | y | Y | Months | ME} M e}Date ofbith:[ DD |[m[M][¥] ¥] NDateotAdmisson: [> [o] [m[m] [¥[¥]otime:[H [x] [mm 1) Date of Dicharge:{ po ][m [ m] [¥ |v | i Time: [a |) Type of Admission: Emergeney [| Pranned Day Care[ | Materity[] X) if Meter) Dato of Deivery. mM} [¥[¥] i eravica status: Satis atime of dchage: Daca hove| | Dachaye enters |) Total med amount DETAILS OF AILMENT DIAGNOSED (PRIMARY) 4 a 16010 Codes Desorption | 1 Primary Diagnosis — i. Aton Diagnosis: 3. Comores: | ‘x Comat: et ny ». 10D 10-Codes, Description z: z 1 Procedure: 1 ~ 9 i, Procedure: 2 = , 5 Prodi 3 ! \ } } iv Deals of Procedure: ) €)Preautorizao obsined:| |Yes[__| No) PreauborzatonNunber29} Fauhazation by network hosp net cbaned, ie easo: |” 4) Hospitalization due to iriuy[ ]'Yés'[_] No LifYes, ave cause Sefnfcied[ | Road Trafic Accident [ | Substance abso alcool consumption [—] #]Winjry due to substance abuse aloha consimpin, Test conducted to slalsh tis: [ ]res{_] No (tes, atach repos) i. tMedioolega: [| Yes [| No iReporedtoPoice [~] Yes [| No 3 FIR No| I 9 Vi. rot epred ope give reason CLAIM DOCUMENTS SUBMITTED - CHECK LIST Claim Form duly signed el Investigation reports Ofgnal Preauthoraton request CCTIMRUSGIHPE investgaton reports Copy ofthe Pre-aubrizaton approval iter Doctors reference sli fr investigation i ‘Copy of Photo I Card of patent Verified by hospital Eco 8 Hospital Dsoherge summary Pharmacy bils 9 Operation Theatre Notes MLC reports & Pole FIR e [| Hosta man i [| oral deat summary rom testa where sppcsle Hospital break-up bit ‘ay one, pease spect ‘ADDITIONAL DETAILS IN CASE OF NON NETWORK HOSPITAL (ONLY FILL IN CASE OF NON-NETWORK HOSPITAL) a) Adress ofthe Hospital T I | | State: [ “eg io win Si ote I 4) Hospital PAN: | i [ } Number of inpatient beds ‘)Facites avalebleinthehospta oT [| Yes [_ | No juicy Yes [| No ii Ofer : J DECLARATION BY THE HOSPITAL (PLEASE READ VERY CAREFULLY) Wie hereby delre thatthe information furishedin is Cam Fors tro & correct thebestof our inowedge and ble. we have made any {alse or ure stternent, suppression or concglertof any mate fc, urrighto claim uncer is aim shal be fv bee: [b[o|[m]ml[y]x]¥[¥ o a 8 3 3 2 Pin Code [ [| I Phone No: | 2 a 8 ee 3 3 2 > ofthe Hosp Ahoy