 IRDA member claim form filled by employee (Employee details, dependent details, Hospitalization details & total claimed

ed amount details
with employee's signature)
o Editable Claim form for your reference.
 Patient Govt ID proof copy
 Original cheque leaf of employee with printed account holder name in Cheque leaf (If name is not printed in cheque leaf, Please provide bank account
statement along with cheque leaf)
 Detailed discharge summary (Time of admission, Time of discharge, Course in hospital and etc)
 Hospital final bill
 Breakup of hospital final bill
 Advance payment receipts
 Final payment receipts
 Original lab reports along with doctor advice papers
 Confirmatory lab reports (Eg. Cataract - Ascan report, Maternity - 9th or 8th or 7th month USG scan test report, Etc)
 Copy of Radio therapy charts for regular radio therapy claims
 Copy of Dialysis charts for regular dialysis claims
 Copy of Physio therapy charts for post hospitalization Physio claims
 Copy of Chemo therapy chart for regular chemo therapy claims
 Recently done serum creatinine report for regular dialysis claims
 Original pharmacy bills along with copy of the doctor prescriptions
 Original stent stickers and Stent invoice for those cases where implant involved
 Alcoholic history for road accident/fell down cases
 Self-declaration letter for road accident/fell down cases
 Medico legal certificate / FIR copy for road accident cases
 Indoor case papers (ICP sheets), Drug chart and Temperature chart copies required if medical team requires