ERICSON INSURANCE TPA PVT. LTD.

11-C, Corporate Park, S.T. Road, Chembur, Mumbai-71

Website: www.ericsontpa.com E mail: care@ericsontpa.com
Tel. No: 022-25280280 Fax No: 022-25270200

Checklist for Reimbursement Claims

Name of the Insured - Gaurav Sharan______ (Date of Birth30/06/1986) Patient Name – Gaurav Sharan
Name of the company – Indian Overseas Bank Employee ID - 59773
Policy No -_____________________________ UHID - _________________ Contact Number- 9108264435 E- Mail ID -akvgaurav@gmail.com

Please put tick mark against the submitted documents:

1. Completely filled Original Claim Form with claimed amount, duly signed by you.
(In case of cashless claim, hospital need to get the same filled & signed from insured)
2. Original Main Hospital bill with Bill Number & break up of all the charges mentioned in the bill.
(Break up of Room rent, Nursing, Pharmacy/Medicines, Investigation charges etc. )
3. Original Discharge summary with Hospital seal & signature of the authorized person.
(Provides details of complaints & treatment given to patient during hospitalisation)
4. Original Death summary.
(In case of death of Patient during Hospital stay).
5. Original Hospital Payment Receipt with receipt number.
(With seal & signature of hospital)
6. Original consultation letters with numbered Payment Receipt.
(For consultation/surgeon charges, follow up charges charged outside the main hospital bill).
7. Hospital registration certificate copy.
(Mentioning hospital Registration No. , Number of beds & validity).
8. Doctor’s registration number with specialisation details.
(On doctor’s letterhead with signature).

9. Original Pharmacy and Investigation bills

(Along with prescriptions & Lab reports).

10. Original prescriptions

(On doctor’s letterhead mentioning duration and dosage for medicines and advice for diagnostic tests).
11. Investigation reports in original/attested from hospital
(Reports for all tests done along with images)
12. Police FIR / Medico Legal Certificate (MLC)
(Mandatory for All Road traffic accidents/poisoning & burns cases-Duly attested by Police with seal)

13. Invoices of the implants or Lenses used for the surgery.

(Surgeries like cataract, angioplasty, knee replacement etc)
14. Cancelled Cheque

15. Implants Stickers in case of Cataract/Joint Replacement, Total Knee/Joint

Replacement.
16. Claims Intimation – Cashless – care @ericsontpa.com

17. Claims Intimation – Reimbursement – iob@ericsontpa.com

NOTE:-

1. Kindly keep a copy of the submitted documents with you for future references.
2. As per Policy Condition, each and every Claim is required to intimated immediately to Insurer/TPA. In case of delayed
intimation, necessary approval from Insurer will be required for processing of the claims. Claim papers are required to be
submitted within 15 days from the date of discharge. For late submission, necessary approval from Insurer will be
required for processing of the claims.
3. Do not forget to collect the acknowledgement copy from our executives for the submitted documents.
4. Claim form, Discharge summary/death summary, final bill with receipt, Hospital registration copy, MLC/FIR, Implant
invoices, supportive investigation reports are the mandatory documents which needs to be submitted in the relevant
claims for faster settlement of claim.
5. Cancelled Cheque to be attached with every claim form. If there are more than 1 claim, then if the Bankers are changed,
the necessary intimation/cancelled cheque should be attached. For Claim above Rs.1,00,000, Electricity Bill/ Telephone
Bill copy is to attached along with Adhar card copy and Pan Card copy.
6. Please note that this is just an indicative checklist & not an exhaustive one, the documents requirement may vary as per
the insurer’s guidelines which will be intimated accordingly.
7. For any assistance please feel free to call our customer care executives on Tel.no. 022-25280280
Toll Free Number 1800 22 2034 Whats App Intimation No. 9167251896