STAR HEALTH AND ALLIED INSURANCE COMPANY LIMITED

Regd. & Corporate Office: 1, New Tank Street, Valluvar Kottam High Road, Nungambakkam, Chennai - 600 034.
Corporate Olfi@ - Claims Dept. : KRM Center, 6th Floor, No 2 Harington Road, Chstpet, Chennai - 600 031.
v.,;,; *-;,; iil;;;." Toll fr€e Phono No: 1800 425 2255 Toll fce Fax No: 1800 425 5522
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CIN : U66010TN2005F1C055619 Ecal:info@slafiealh.in Website: ww.stafiealfi.if, lRoAl Regn. No:

CLAII\I FOR[4 - PART - A

TO BE FILLED lN BYfHE INSURED The i$ue orlhis Fom is not lo be taken 33 an admission of liability Claim NO.

a) Policy No: b) SI. Nd Cgtilieb tlo:

cI Compony/ TPA lO No:

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i. PFhospalizalioo ExFsS: cl tlebili ol Lurp sm / 6sh benefil clained:
f Clain Fm txy signed
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I Copy otlhc &im iniimtion
ii. HospElEato Expefres: Rs i. HospiH oaily Cash: Rs- X ficailarM.$n El
iir. Pod-hosphlizatd Expons: Rs. ii. Slrgft, Gsh: R5. E ihcgbl BGk{p 8il1
Heollh.Che* Cost iii. Cridol llhssr Eonefl: Rs.
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I hereby declare thal. the information fumished in this claim form is true & corect to the best of my knowledge and belief. lf I have made any false or untrue slatement,
suppresslon or concealment of any matorial fact, my right to daim reimburs6ment shall bs forteited. I also consent E au'thorize TPA / insuranco company, to seek necessary
medical infomation / documents from any hospital / Medical Practitioner who has attended on the person against whom this claim is made. I hereby declare that I have U,
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included all lhe 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. o
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GUIDANCE FOR FILLING CLAIM FORM - PART A (To be fltled ln by the tnrured)
DATA ELEiTENT DESCRIPTION FORMAT
SECTION A. DETAILS OF PRIMARY INSURED
a) Policy No. Enter lhe pollcy number As allotted by the rnsurance company
b) Sl. No/ Certilicate No.
Enter the social insuEnce number s the @rtificate numbor ot
As allotted by the orgEnization
social hoallh insuran@ schomo
c) CompanyTPA lD No. Enter the TPA lD No License number as allotted by IRDA and

d) Namo Enter the full nams ofthe policyholder Sumame, FiEt name, Middle name
e) Address Enter th€ tull postal address lnclude Street, City and Pin Code
SECTION B - DETAILS OF INSURANCE HISTORY
a) Curehtly covered by any other Mediclaim / Healih lndimte wfiether currBntly coveed by another Mediclaim i
H.alth lnsurance Tlck Yes or No
b) Date of Commencement ot fiGl lnsurance without break Enter the date of commenc€msnt of fiBt insuran@ Use dd{m-yyfomat
c) CompanyNama Enter th6 full name of th6 insurance @mpany Name of the organiation in full
Policy No. Enter the policy numb6r As al,otted by ih6 insurance c
Sum lnsured Enter ths total sum InBUred as par ths pollcy ln rupess
d) Have )rcu been Hospitalizsd in the last 4 yeas lndicate whether hospitalized ir the lasl 4 years Tick Yes or No
Date Enter the date of hospitalization Use mm-yy format
Diagnosis Enter the diagnosis details Open Text
s) P@iously Covered by any other Mediclaim/ Health lndlcate wlrether previously coveEd by another Medic{aim /
Hcalth ln{'rrn.s Tick Yes or No
l) Company Name Enter the full name ofthe insuranca @mpany Name of the organization in tull
SECTION C. DETAILS OF INSURED PERSON HOSPITALIZED
a) Naho Enter the full name ot the patient Sumam6, FiGt name, Middle nahe
b) Gsder lndicate Gender of the patiBnt Tick Male or Female
c) Age Enter age of the patiBnt Number of yoaB and months
d) Oare ofBidh Enter Date of Birth of patient Use dd-mm-yy fomat
e) Relationship to primary lnsured lndicate relationship ot patient with pollcyholder Tick the dght option. lf otheE, please specify.
0 Ocdpation lndiEts occupstion of patient Tick the dght option. ll otheB, please Bpecity,
g) Address Enter the full postal addross lnclude Street. City and Pin Code
h) Phon€ No Entor the phone number of patient lnclud€ STD code with telephone number
i) E-mail lD Enter e-nrail address ot patient Complete e-mail address
$EcnoN D . DETA|LS oF HosptrAltzATtoN
a) Name of Hospil€l where admitted Enter lhe name of hospital Name ot hospital in tull
b) Room €tegory oc@piod lndiHt€ th6 rcom etegory ocapied Tick the dght option
c) Hospitalizalion due to lndl@ts rsason of hospitalization Tick tha right eption
d) Date of lnjury/Date Disease liGt detected/ Date of
Enlsr th8 relevanl date
Delivery Usc dd-mm-yyfomat
e) Oate of admission Enter date ofadmisEion Use dd-mm-yy fomat
0 Time Enter time of admission Use hh:mm format
g) Date of discharge Enter dat€ ot discharge Use dd-mm-yy lomat
h) Time Enter time ofdisdlarge Use hh:mm lormat
i) lflnjurygiv€ cause lndlcate caus6 of injury Tlck lhe dght option
lf Medico legal lndi@te whether injury is m€di@ legal Tick Y$ or No
Reported to Poli@ lndl€te whether police rcport was filed Tlck Yes or No
MLC Report & Police FIR anadred lndicate whethor MLC report and Policc FIR attachcd Tick Yos or No
i) SFlem of Medicine Enter th€ s)6tem of medicino followed in lreatlng the patient Open Text
SECTION E . DETAILS OF CLAIM
a) Oelgils ofTreatment Expenses Entet the amount claimed as keEtment expenses ln rupees (Do not enter paise valuss)
b) Clalm tor Domiciliary H6pltalization lndi€t€ wheth€r claim i6 for domicillary hospitallzation Tlck Y6s or No
c) Details of Lump sum/ cash benelit claimed Entor the amount claimed as lump sum/ cash benefit ln rupees (Do not enter paise wlues)
d) Claim Doements Submitted-Check List lndicate which suppotting documents ar€ Eubmitted Tlck the right option
SECTION F . DETAILS OF BILLS ENCLOSEO
lndicate which bills are enciosed with the amounts in rupees
SECTION G - DETAITS OF PRIMARY INSURED's BANK ACCOUNT

a) PAN Enter the pemanent smunt number As allolted by the lncome Tax department
b) A@rt Number Enter the bank a@ount number As allotted by the bank
c) Bank Name and Branch Enter the bank name along with the branctt Name ot the Bank in full
d) Cheque/ DD payable dctails Enter the name otthe beneliciary the cheque/ DD should be
Name of tte individual/ organizatim in full
e) IFSC Code Enter the IFSC code of the bank branch IFSC code of the b6nk bEnch in full
 STAR HEALTH AND ALLIED INSURANCE COMPANY LIMITED
-/\ Regd. & corpoEte Oflice: 1. New Tank Street, Valluvar Kottam High Road, Nungambakkam, Chennai - 600 034.
Corporats Otti@ - Claims DBpt. : KRM Center, 6ih Floor, No 2 Harington Road, Chetpet, Chennai - 600 031.

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,.\-,:,= ?,,--: i ll'.",H... Toll fee Phone No: 1800 425 2255 Toll frse Fax No: 1800 425 5522
CIN : U6601 0TN2005PLC0566,19 EmEi*info@stsrir6lth.h Web6ilE: w.starheahh.in IRDAI Regn. No: 'l 29

TO BE FILLED IN BY THE HOSPITAL

Th. iE*! dthrs Fom E rd b b 6tr illn dhbds dli.thl H.r.! i@d6 h cgill EUhcEb rEU..t h i.lieu dPMT A

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d) N8@ ol tro lreating do.lor:
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0 Regist"alion No. Stale Code:

THE PABEI{T AD]'TflED

a) Nr@ ot Ur Pelient:

b)lPRegiitsationNumb6c- c)Gender: Mao aon", ,*[[ u-nr[] e)Dahoftin: o

f Femah
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r/- ,/- glTire:- i h)D.teof oisderge: r/- ,/- ,[[ Jo
0thl€ofAdilission:
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ilTrDeorMmission: eru,!*ri I fr.*"al I lhyCm. uarunlry , r)fMffiitv i.Ddeorootsry
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DETAILS OF AILTEI{T

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b)

i. ftmary Diagmis: i. ProeduE i:

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lllness: .....

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r:rtRno Ia trItrItrtrtrI vi.rrndopl€dbldicesi**w,

Oaim Fm dult signed I lnwstgatfi rcpona

Gbinal Pc-.ufvialkl requesl t_.. CTrlrRli,SGfi PE hvesligatkn repdls

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P6&lhdizad.n i- Doffi's aafd6nc6 dip for hEsiJalon m
Copy of the epp@al ledcr
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Copy d photo lD erd oi pa'ief,i ufi6d by hct lrl f ECG I
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Hspilal Disdrrge $mmry il Phamcy blls

ope€lion Ih6lE mks T' iJLC mp.( & Pdi@ FIR o

Hospihl roin bill f Oigind dcah su,Wry lM hostihi tllm arplicade

Hospilal brBl({p bill t..... Ary dh6r ple6$ 6ps.ilY

a) MdE$ of lhc Hcp{al:

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c) Reiisfalion No.:

d)pr: ,, ]t it -.ll ]-l|_..]tl]lJ etNunterorrnoariarusll i--1 |)Faciririssewr.breiolhohqrrei: i.or: v* -l ro l__] ii.rcu, v* i_l m [ ]
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DECLARAnoil BYTli€ HOSPr L

our dght to claim unds this daim shall bo fdtoil6d. T16 signatuts of th6 insurcd is taken m his fom ater Claim Fom B is fully lill6d up by us.
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Not to be Faxed / Scanned

GUIDANCE FOR FILLING CLAIU FORM - PART B Oo bc fllled ln bytho hospital)

DATA ELEMENT DESCRIPI1ON FORTAT
SECTION A. DETAILS OF HOSPITAL
a) Name of Hospital Enter the name ol hospital Name o, hospital in full

b) Hospital lD Ehter lD number of hospital As allocated by the TPA

c) Type ofHospital lndicate whether ln network or non network nospital Tick the right option
d) Name of heating doctor Enterthe name ofthe treating doclor Name of doctor in tull

e) Qualitication Enter the qualilications ofthe treating doctor Abbreviations of educational qualifi cations
Enterthe regishation number of the doctor 6long with the state
f) Registration No. with Slate Codo
code
As allocated bythe Mediml Council of lndia
g) Phone No. Enter the phone number ol doctor lnclude STD code with tslephone number
SECTION B - DETAILS OF THE PATIENT ADMITTED
a) Name of Paticnt Enter the name of hospital Name of hospital in full
b) lP Registration Number Enter insurance providor rogistration number As allottod by the insurance provider
c) Gender lndicato Gender ofthe patient Tick Male or Female
d) Age Enter age of the patient Number of years and monhs
e) Date ofAdmission Enter date of admission Use dd-mm.yy format

0 Time Enter time of admission Uss hh:mm fomat

g) Date of Discharge Enter date of discharge Use dd-mm-yy fomat
h) Time Enter time of discharge Us6 hh:mm fomal
i) Tpe of Admission lndimt8 type of admission of patienl Tick the right option
j) ll Matemity
Date of Delivery Enter Date of Delivery if maternity Use dd-mm-yy format
Gravida Status Ent6r Gravida status if maternity Use standard fomat
k) Status at time of discharge lndicate slatus of patienl at time ofdischarge Tick the right option
SECTION C - DETAILS OF AILMENT DIAGNOSED (PRIMARY}
a) ICD 10 Code

Primary Diagnosis
Enter the ICD 10 Code and description ofthe primary
diadnnsiq Slandard Format and Open text
Ent6r the ICD 10 Code and description ot the additional
Additional Diagnosis Standard Fomat and Open ten
diaonosis
Ccmorbidities Enter the ICD 10 Code and descrlption of lhe ccmorbidities Standard Format and Open t€xl
b) lcD 10 Pcs
Pmcedure 1 Enter tho ICD 1 0 PCS and description ofthe first procedure Standard Fomat and Open text
Procedure 2 Enter the ICD 10 PCS and descrlption ofthe second procedure Standard Format and Open text
Procedure 3 Enter the ICD 10 PCS and description ofthe third procedure Standard Fomat and Open text
Details of Procedure Enter the details ofthe pmcedure Open text
lndicate whether presenl ailment is a complication of some pre-
c) Present Ailment is a Complimtion of PED
existinq diseas6
Tick Yes or No

d) PrFauthorizationobtained lndicate wh6th6r pre-authorization obtained Tick Yes or No

e) Pre-authorizetionNumber Enter pre.authorization number As allotted by IPA
0 lf authorization by net$/ork hospital not obtained, givo
Enter reason for not obtaining pre-authorization numbet Open text

g) Hospitalization due to iniury lndicate if hospitalization is due lo injury Tick Yes or No

Cause lndicate cause of inlury Tick the right option
lf injury du€ to substance abus8/alcohol consumption,
lndicate whether test conducted Tick Yes or No
test conducied lo establish this
Medico Legal lndicate whether iniury is medico legal Tick Yes or No
Reported To Police lndicate whether police report was filed Tick Yes or No
FIR No. Enter fir$t infomgtion report number As issued by police aulhorities
lf not reported to police, give rsason Enter reason for not reporting to police Open Tcxt
SECTION D - CTAIM DOCUMENTS SUBMTTTED4HECK LIST
lndicate which suppoding documents are submitted
SECTION E - DETAILS IN CASE OF NOl{ NETWORK HOSPITAL
a) Address Enter the full postal address lncludo Street, Clty and Pin Code
b) Phone No. Enter the phone number of hospitrl lncludo STD code with tolephone number
c) Registration No. Enterth6 rogistration number of patienl As allocated by lhe Hospital
d) PAN Enter the pemanent accounl number As allotled by the lnmme Tax dspartment
e)
f)
Number of lnpatient Beds

Facilities available in lhe hospital

Enter lhe number of inpatient beds

lndicate facilities available in the hospital

Digits

Tick the right option. lf others, please specify

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SECTION F. DECLARATION BY THE HOSPITAL

Read declaBtion carefully and mention date (in dd:mm:yy format), place (open text) and sign and stamp
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 t*r**
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Star Heal$ And Allied lnsurance Company Limited
ReSd and Corporate Office : t, Nex Tan* Street, Valtuvar Kottam Fiigh Road, Nungarnbakkar:T
(hennai * 6OS034. Phime - 044 * 28188800, Telefax * 282SS062
eorporate dlaims Departrnent, 6rh Flo6r- ltBM Centre, No. 2, t{arrir}gton Road, Chetpet,
Chennai - 600 031 Phone - 044 - 4347 8337 . www.starhealth in

for {Eiame.ofttrro }iocpital S Addrcss} 'Date:

Dear Sirs,

ft g AUTIBft }$ATION TO STAR H f ALTH AN DALTISD INSUfi ANCE CO. LI D.,

I have undergone treatment for................-......,...!,.n.....,.,..,.,...."............................................

I herebyauthoriae M/s Stsr Fleafth and Alliad lnsuranee Company Ltd., who is my Health lnsurerto seek any

medicel in{ormotion/r"ecords frcrn you or {rom the Medical Practitioners who have artended on me in

connectionwhh the above ailment and the treatmentgiven.

ln case they seek any such information/records kindly oblige.

Thanking you,

Yours fuithfully,

iSBnat!rre <lf the e laimant)

Addre:s ofthe lnsufed:

tuflent Adrriissinn No: