 Duly filled HDFC ERGO claim form - Claim form is available on the Intranet.

Please mention the

patient’s HDFC ERGO ID No. and your Employee Code/ADP ID on the claim form correctly.

 Original Discharge Summary/Card - It should be compulsorily on the hospital letterhead with

the hospital address seal and signaturegiving information about the Patient, History about the ailment,
Provisional and Final Diagnosis, Date and Time of Admission, Date and Time of Discharge, Investigations
done, Treatment rendered, condition of the patient at the time of discharge, advice on post-discharge and
follow-up etc. GPLA (gravid) status (in maternity case)

 Original final bill- It should be compulsorily on the hospital letterhead with the hospital address
seal and signaturementioningthe details under different headings like Room Charges, Nursing Charges,
Professional Fees, Medicine Charges, Investigation charges etc.

 Payment Receipts-Payment Receipts for the Final bill with the hospital address seal and signature
mentioning that the amount billed has been completely settled/paid by the patient to the hospital.

 Breakup of bills - Complete break up of consumables and surgical materials used at the time
of surgery and the Break-up of the Hospital Final Bill showing the charges for different types of
Investigations, medicines used, consumables, Charges towards OT, Professional charges etc.

 Lab/Investigation Reports - All the lab/investigation reports in original with the prescriptions
and bills mentioning the findings of investigations done.

 Pharmacy Bills-Pharmacy/Medicine bills with doctor’s prescriptions.

 OPD Consultation Papers-1st Consultation Papers/Out Patient Consultation Papers fromthe

hospital.

 Number of beds in Hospital and Hospital Registration Number - Letter from the hospital
mentioning the total number of beds in the hospital/ICU and the hospital Registration number on the
hospital letterhead with the hospital address seal and signature.

 ECS form and Cancelled Cheque for NEFT- ECS Form and Original Cancelled Cheque with
printed name or bank statement should be attested by bank have to be submitted for settlement of
claims.
 Photo ID proof and Address proof- Employees are requested to submit a proof of identity and
proof of address of both the employee as well as the patient for reimbursementclaims above 1 Lakh.

 Other relevant documents as given below:

i) IOL (Intra-Cular Lens) sticker in case of Cataract.

ii) X-Ray films/reports in case of dental treatments. If films are not available then the print out of
observations on the hospital letterhead with hospital address seal and signature mentioning the
patient’s name and other details.
iii) In-Patient Department Papers/In Door Case Papers (ICP). This requirement is raised if the
papers submitted are not sufficient to arrive at the conclusion whether the claim is admissible or
not.

 In case of Injury/Accidents, the following additional documents have to be

submitted:

i) Circumstances leading to Injuryand effect of alcoholshould be mentioned by the Doctor on

the hospital letterhead with the hospital address seal and signature.
ii) Pre-operative X-Ray Reports.
iii) Medical Legal Certificate (MLC) from the hospital with the hospital addresses seal and
signature in case of accidental claims along with Original FIR (If filed) from the Police
Authorities. If it is a Non-MLC case then a letter mentioning the same.

PRE AND POST HOSPITALIZATION CLAIM:

Time span which would be covered under the Pre & Post Hospitalization Expenses:
-          Pre Hospitalization Cover Clause - 30 days prior to hospitalization
-          Post Hospitalization Cover Clause - 60 days following hospitalization
 Reimbursement Claim Form, ECS Mandate & cancelled cheque with employee’s name printed on it.
 Copy of the discharge summary of the corresponding hospitalization.
 All relevant doctors’ prescriptions for investigations and medication.
 All bills for investigations done with the respective reports.
 All bills for medicines supported by relevant prescriptions.

Please do not submit the documents directly to HDFC ERGO office. Please submit all the above
mandatory documents only to the below person within 15 days after the discharge. Employees are
requested to keep a copy of all the documents before submitting.