l?

l &***rul l*sura*ce C**tpqrzy Limited

|RDA Reg. l\+. i44 <)*ted 13112120Aq i *r4:1i(L{:0AAN\t42**9PlL19*14{3
We!.F.l$eeqrtr#
C,:lt i,Tt:ll Fre+_l

1800 22 1171 i 18*A XU2 1111

'ttww.tbige*ertsl.i*
CLAIM FORM FOR HEALTH INSURANCE POLICIES OTHER THAN TRAVEL
AND PERSONAL ACCIDENT - PART A
TO BE FILLED IN BYTHE INSURED
The issue of this Form is notto be token os on odmission of liobility

(To be filled in block letters)

o) Policy No: I I l|tt

b) Sl. Nol Certificote No; ttl c) Compqny/ TPA lD No: I I

d) Norne: "ili.jl.tlr,i nl'Ii:1.:l:..Ii i l rl :,1 :,1 ;-

e) Address ttt I

ttt
: i

ltl
City I I

Pin Code: I
Phone No: lll
Emoil lD: I I
I

o) Currently covered by cny other Medicloinr / Heolth lnsuronce:

I t* [ r.r.

b) Dote of commetrcenrent of first lnsuronce without breok: . 1,,,, | ;nl c) lf yes, Compony Nome:

Policy No. I

Sum lnsured (Rs.)

d) Hoveyoubeenhospitolizedinthelost{ouryeorssinceinceptionofthecontroct? [ "* I *" lrlrl:'

Diagnosis;

e) Previously covered by ony other Mediclaim/Heolth insuronce :

[ I *" f) lf yes, Compony Nome: I

"*
,/W/R!i1
.WWhW

o) Nome: :. rl.nlr,i i; i.:l i.i I 5 f

b) Gerrder: Mole
fl Fenrole
[l .) Ag", y"oo[-l-I n,onths
FTI d) Dote of Birth:

e)RelotionshiptoPrimoryinsured:SelfflSpo,,"flchildl-lFotherf-]Motherflotherfl(PleoseSpeci1y)
f) Occupotion: ServiceflSerEmployedl-lHomemol<erl-ls,,a"".flRetiredl-lotherfl(pr"o,eSpecify)

s) Address (if different from obove)

-.i
lttt ll
-rty:l

Pin Code: Phone No: ttlt

E-rnoil lD: I I

€
o
N
a
=
.:
C
.9

Corporote&RegisteredOffice:'Notroj', lOI,20l &30l,Junctionof WesternExpressHighwcy&Andheri -KurloRood,Andheri (Eost),Mumboi -400069.

 o) Nome of Hospitol where Admitted:

b) Room Cotegory occupied: Doy core

t] Singte occuponcy
l-l Iwin shoring
i j 3 or more beds per roo.n
c) Hospitolizotion dueto: lnjury [-l l-l
ltn.r, i-l frlote.nity
f-l d) Dote of lnfury / Dote Diseose first i,JIY
detected ,iDcte of Delivery:
e) Dote of Admission:
r)rime:
g) Dote of Dischorge:
m, |ifl
l) lf lnjury give couse: 5elf intlicled I Rood Troffic Acciderrt
h)rime: l-... I_..l ,
trtr
I l-l Srbr,on.. Abuse / Alcohol Consumption
i. lf Medico legcl:
"*[ *"I
^"I
ii. Reported to police:

iii. MLC Report & Police FIR ottoched:

"*[ NoI
j) System o{ Medicine:
"*[

Detoils of the treatrnent expenses cloimed

Pre-hospitolizotionExpenses: Rs.
I I
ii. Hospitolizotion Expenses: Rs.
Post-hospitclizction Expenses: Rs.
iv. Heolth-Check up Cost: Rs.
v. Arnbulonce Chorges: Rs.
vi. Others (cr:de): Rs.

Totol Rs.
vii. Pre-hospitolizotion period aov,J-T]-l viii. Post-hospitolizotion period: doys
b) Cloim tbr Domiciliory Hospitolizotion:
"*[ r"[ (lf yes, provide detoils in onnexure)
c) Detoils of Lump sum / cosh benefit cloimed:

i. Hospitol Doily Ccsh: Rs

ii. Scrrgicol Cosh: Rs
iii. Criticol lllness Benefit: Rs.
iv Convolescence: Rs.
I
v. Pre/Post hospitolizotion Rs.
Lump surn benefit: vi. Others: Ks.

Clqim Documents Submitted- Check List:

l-l ctoi* Form Duty signed

I
aow of the cloim intimotion, if ony
il Hospitol Breok-up Bill
I I HosOitol Biil poyment Receipt
1
L--J
| Hospitol Dischorqe Summorv
il Phormocv Bill

L I uperotron theotre Notes

T
T
caa

l Doctor's request for investigotion

u
lnvestigotion Reports
*J-l (lncluding CT/ MRt / USG
Doctor's Prescriptions
Others
i HpE)

IRDA Res. ?4o. 144 l.u;e1! jSii2l20e? C*l i r *ii,

1 I
C Ml4 2,J i),; ? i. -L t 9 t) S 4 b
 W e* ')?l/tt/l/llti;ffii7;;:,u . t

Bonk Nome Bcrnk Bronch I

Bonk Account No IFSC Ccxle I I

MICR No. PAN No. I I

I hereby declore thot the infornrotion furnished in ttris cloim form is true & correct to tlre best of nry knowledge ond belief. lf I hove mcde ony fclse or untrue.
stotentent, suppression or conceolment of ony nroteriol foct with respect to questions osked irr relotion to this cloim, my right to cloirn reintbursement sholl be
forfeited. I olso consent & outhorize TPA,/ insu.or'rce compony. to seek necessory rnedicol inforrnotion I documents from or.ty hospitol/ Medicol Proctitionerwho hos
attended on the person cgoinst whonr this cloirn is mode. I hereby declore thot I hove irrcluded oll the bills / receipts for the purpose of this cloim & thot I wiil not be
nroking ony supplementory cloim except the pre/post-hospitolizotion cloim, if ony.

Dote Signoture of the lnsured

Place: |lllil

DATA ELEMENT DESCRIPTION FORMAT

sEtriio-N A r,,i DErAl Ll PB|I{AW:INIURED

o) Policy No. Enier the policy number As ollotted by tlre insuronce compony

b) Sl. Nol Certificote No. Enter the sociol insurcnce number or the certificote As ollotted by the orgonizotion
number of sociql heolth insuronce scheme
c) Compony TPA lD No. Enter the TPA I D No License number os ollotted by IRDA ond
printed in TPA documents.
d) Nome Enter the full nome of the policyholder Surnome, First nome, Middle nome
e) .Address Enter the full postol oddress lnclude Street, City ond Pin Code

5ECTI6N,,8 t DETAlit$ 0F,ll"lSURANCE HIST,ORY

o) Currently covered by ony other lndicote whether currently covered by or-rother Tick Yes or No
Medicloim / Heolth Insuronce? Medicloim r'Heolth lnsuronce
b) Dote of Commencement of first lnsuronce Enter the dote of commencement of first insuronce Use dd-mm-yy formot
without breok
c) Compony Nome Enter the full nonre of the insuronce compony Norne of the orgonizotion in full
Policy No. Enter the policy number As cllotted by the insurorrce compony

Sum lnsured Enterthe totol sum insured os perthe policy ln rupees

d) Hove you been Hospitolized in the lost lndicote whether hospitolized in the lost four yeors Tick Yes or No
four yecrs since inception of the contrcrct?
Dote Enter the dote of hospiiolizotion Use mnr-yy formot

Diognosis Enter the diognosis detoils Open Text

e) Previously Covered by cny other Mediclaim lndicote whether previously covered by onother Tick Yes or No
lHeolth lnsuronce? Medicloirn I Heolth lnsuronce
f) Cornpcnir Nome Enter tlre full nome of the insuronce compony Nonre of the orgonizotion in full

SrcT{oN e ; DelAtrs:of tEt5-:HREn:,FrttSON ltospitAlrzED tl

o) Nome Enter the full nome of the potient Surnome, First name, Middle nome
b) Gender lndicote Gender of the potient Tick Mole or Femole
c) Age Enter oge of the potient Nunrber of yeors ond months
d) Dcte of Birth Enter Dote of Birth o{ potient Use dd-rnm-yy formot

e) Relotionship to prirnory lnsured lndicote relotionship of potient with policyholder Tick the righi option. lf others, pleose specify.
f) Occupction lndicote occupotion of potient Tick the right option. lf others. pleose specify
g) Address Enter the full postol oddress lnclude Street, City ond Pin Code
h) Phone No Enter the phone number of potient lnclude STD code with telephone number
l) E-mail lD Enter e-moil oddress of potient Complete e-moil oddress

IROA Re-rr. |4*. 1,1,1tiuted illl2l2r*9 | Cll'4: l*50\rifita2tii)9?Lc19134b

 581 #e**ral lfiturafic* er:wpany Limtzerj
lilDA Reg. Nr. 144 tltsied 15 17"ft*Aq | *N: ub{tAAA$An?*Agn..C\gO34S
Wl,B!ffgryqrg?
{:11 lToll F r<*.;
x&** 22 1\11 1 180$ t02 111X
CLAIM FORM - PART B w w tu. :;1t i g e n *. r *1. i n

TO BE FILLED IN BYTHE HOSPITAL

The issue of this Form is not to be tqken os on odmission of liobility
Pleose include the originol preauthorizotion request form in lieu of pART A
(To be filled in block letters)

a) Name of the hospital:

b) Hospital lD;

d) Name of the treating doctor:

m c) Type of Hospital: Network [l Non Network I*l (lf non network fill section E)

e) Qualification: f) Registration no with State Code: g) Phone No:

a) Name of lhe patient:

b) lP Registration No:
t-r-rT-rT-r-r] c)Gender:Male
l] remale
I d)Ase:years [T;l uontns [,,_,TI
e) Date of Birth: i; I ii Ir.xl*l :' l :' I i I'r 1) Date of Admissioni ,l l l:l:'l,l,l':' s)Time: IiTl:FT,..]
h) Date of Discharge: ir I ilr l\11 i+l v | :' I -, l't r) Time:
[Tl , l-T:l j1 Type of Admission: Emergency
fl Planned
I Dav CareI Maternity[
Maternity:
k) lf i. Date of Detivery: ii. Gravida Status: [l-I
l) Statusatihetimeofdischarge: Dischargetohonre
I Discharge to another hospitat
l-l Deceased
I *i Torat ctaimed amount l-T-l-T-fT-[l
Description ICD 10 Codes Description

Primary Diagnosis: Procedure 1 :

rT-r-T-T-rTt
ii AdditionalDiasnosis: l-I]-f[_T-T_l ii Procedure 2:
l-f-I_Tl-r-Tt
iii Co-morbidities: nTl-n]] iii Procedure 3: rr-r-r-[T-fl
iv Co-morbidities: rr-r-r.r.-r] iv Details of Procedurel

c) Pre-authorization obtained:
I ves f] uo d) Pre-authorization Number:

e) lf authorization by network hospital not obtained, give reasonr

f) Hospitalization due to tniury: I tr[ *o i) If yes, give cause self-tnflicted

Ll Road Traffic Accident
l-l Substance abuse / aicohol consumption
f-l
ii) lf lnjury due substance abuse/ alcohol consumption, Test c0nducted to establish
this: I Ves [ ruo lrvm,attachrep0rt) iii)tf Medicotegat:[ Ves [ ruo

iv) ReportedtoPolice:
I Ves
[ ruo v. FIB no.

T Claim Form duly signed

T lnvestigation reports

u 0riginal Pre-authorization request

T CT/tulR/USG/HPE investigation rep0rts

u Copy 0l the Pre-auth0rization approval letter

fl
rT
D0ctor's reference slip f0r investigation ECG €
n Copy 0f ph0t0 lD card of patient verified by hospital Pharmacy bills
o
N

n H0spital Discharge summary 0peration Thealre notes MLC report & Police FIB a
o

I Hospital main bill

T 0riginal death summary from h0spital where applicable
t-
c
.9
[' Hospital break-up bill
T Any other, please specify
g
o

& 301, Junction of Western Express Highwoy & Andheri - Kurlc Rood, Andheri (Eost), Murnboi - 4O0
069
o) Address of the Hospitcl:
l||l
ttt
I

Ciqi; tlll|t Stote:

Pin Code: b) Phone No. I I

c)RegistrotionNo.withStoteCode:md)Hospitoloo*.ffi
e) Nr.lnrber of lnpotient beds: [T-n
f) Focilities ovoiloble in the hospitol: i.OTr ,*[N"I ii. lcU : Yes I N.
tr
iii. Others

i/1,#;

conceclment of ony moterisl foct, our right to cloim underthis cloim sholl be forfeited.

oate: fTlT.rTTlTll Place: t--::_ Signature of hospital:

DATA ELEMENT DESCRIPTION FORMAT

SEGT,ION.A: trETAtl5 OF HOSPTTAL

o) Nome of Hospitcl Enter the nome of hospitol Nome of hospitol in full

b) Hospitol lD Enter lD number of hospitol As ollocoted by the TPA
c) Type of Hospitcl lndicote whether ln network or non network hospitol Tick the right option
d) Nome o{treoting doctor Enter the nome of the treoting doctor Nome of doctor in full

e) Quolificotion Enter the quolificotions of the treoting doctor Abbreviotions of educotionol quolificotions
f) Registrotion No. with State Code Enter the registrotion nurnber of tire doctor olong As ollocoted by the Medicol Council of lndio
with the stcte code
g) Phone No. Errter ttre phone nurnber of doctor lnclude STD code with telephone number

,,,SEGIION B*,DETA}LSAFTHE PATIEHTAtsMIl'+En .

a) Ncme of Pctient Enter the name o{ hospitol Nome of hospitcrl in full

b) lP Registrotion Number Enter insuronce provider registrotion nurnber As ollotted by the insuronce provider

c) Gender lndicote Gender of the potient Tick Mole or Femole

d) ASe Enter oge of the potient Nurnber of yeors ond months
e) Dote of Birth Enter dote of odmission Use dd-mrn-yy formot

f) Dote of Admission Enter dote of odmission Use dd-mm-yy formot

g) Time Enter time of odn.rission Use hh:mm formot

h) Dote of Dischorge Enter dote of dischorge Use dd-nrm-y,v formot

l) Time Enter tinre of dischorge Use hh:mm formot

i) Type of Admission lndicote type of odmission of potient llck the right option
k) lf Moternity
Dote of Delivery Enter Dote of Delivery if rnoternity Use dd-mnr-1y {ormot

Grovido Stotus Enter Grovido stqtus if moternity Use stondord formot

l) Stotus ot time of dischcrge lndicote stotus of pctient ot t;me of discharge Tick the right option
m) Totol cloimed cnrount lndicote the totol cloimed smount ln rupees (Do rrot enter poise volues)

, .E€fl0lrl C *'DETAILS3F,,AILMEHT DIASNOSEDdFRIMAR$ ,,

o) ICD l0Code
Primory Diognosis Enter the ICD l 0 Code ond description of the Stondord Fornrot orrd Open text
prirnory diognosis
Additionol Diognosis Enter tlre ICD I 0 Code ond description of the Stondord Formqt ond Open text
odditioncl diognosis
Co-morbidities Enter the ICD 1 0 Code ond description of Stondord Formot ond Open text
the co-morbidities

iRDa l?eg. I'i<t. i4r+ 4,.:to<1 11/1212**9 | tlli: i,)h/t9}CttttiSAC9?Li:l7C54A

 Reimbursement Check List

claim arel
The documents that you need to submit for a hospitalization reimbursement

o Duly filled & signed claim form

o Original discharge card/day care summary/discharge summary with
complete treatment details'
o Original hospital final bill with stamp of hospital'
o Complete itemized billbreakup of the hospitalbill'
o Original & Proper pre- numbered payment receipts'
o All original medicine bills with relevant prescriptions
o X-ray in case of
All original investigation reports (Test report) and x-1dy films if available'-
accident.
o IOL sticker and invoice/purchase order of lens or implant required in-case of surgery' -
o MLC/FIR copy in cases of accident.
o For one-day hospitalization, please ensure that time of admission and
time of discharge is
mentioned on the discharge summary'
o complete obstetric history in case of maternity claim with usG.
o Registration certificate of hospital in case occupancy is less than 15 bedded
(specially applicable

in town cities).
C
o lndoor case papers( Depending on case to case)
o Govt. Photo id with address proof of claimant'
o name of policy holder' lf
Original Cancelled cheque with printed name of account holder, in the
with cancelled
name is not mentioned on cheque then passbook copy or statement along
cheque.

Pre and Post Hospitalization procedure:

frp.r*r i*urr"d ,p-to th. p*'rd of 60 days after discharge relevant to the hospitalization that can be
period of '
considered under the post hospitalization expenses; accordingly expenses
incurred up-to the
pre hospitalization expenses'
30 days prior to the hospitalization that can be considered under the
* The documents that required in post-hospitalization or pre-hospitalization claim are:
1. Copy of the discharge summary of the corresponding hospitalization.
2. All relevant doctors' prescriptions for investigations and medication'
3. All original bills for investigations done with the respective original
reports'
4. All original bills for medicines supported by relevant prescriptions'

Note: Documents are required subject to treatment. Please coordinate with

concern relationship manager in case of any clarification or query.

Thank You