LNeenins India Insurance TPA Ltd. Third Party Administrator in Health Insurance 150 9001:2015 Certified Company ROA Lcence No. 020, POLICY PART-C (Revised) (TO BE FILLED IN BLOCK LETTERS) DETAILS OF THE THIRD. a, Name of TPA/Insurance company: b. Tollfree phone number: Toll Free Fax 4. Name of Hospital i, Address ii, Rohini ID iii, E-mailid ‘TO BE FILLED BY INSURED/PATIEN A. Name ofthe patient: B. Gender: [5 Male (1 Femate (7) Third Gender C. Age: (Years)/(Monthy D._ Date of birth (DMMYYYY) E. Contact Number: . E, Contact Number Of attending relative:~ G. Insured card ID number: ~ H. Policy Number ‘Name of corporate Employee ID: J. Currently do you have any other mediclainvhealth insurance: [7]Yes [2] No ‘Company name: Give details: K; Do you have a family physician: L:Name of the family physician M: Contact Number If any: N: Current Address of Insured patient: (0: Occupation of Insured patient; ~ ‘TO BE FILLED BY TREATING DOCTOR/HOSPITAL Name of the treating doctor: Contact number: [Nature of iliness/Disease with presenting complains Relevant Critical Findings: poeE, Duration ofthe present ailment Days i, Date of first consultation : DDIMMYYYY i, Past history of present ailment ,ffany-— F: Provisional diagnosis: i ICD 10 codes G: Proposed line of treatment i. Medical Management Gy ii, Surgical Management Co iii, Intensive care oo) iv. Investigation c) ¥. —Nomvallopathie treatment oo Hz If vestigation and/or Medical management provide details —-=--———-eee eee i. Route Of Drug Administration 1: 1eSurgical, Name OF Surgery i cD OPCS Code 4 IPosher weatment, provide details K: How did injury occur L: Incase of accident i IsitRTA’ ii, Date of Injury: (OD/MM/YYYY) ii Report police Oye Cine iv. FIRNO — v Injury/disease caused due to substance abuse/Alcohol Consumption [—] Yes [7] No vi, Test conducted to establish this (if yes. Attach report) Yes No M: Incase of Mater Cee Pee Gee ee i. Expected date of delivery(DD/MM/YYYY) (es DETAILS OF PATIENT ADMITTED A. Date of admission (DDIMM/YYYY) B, Time of admission (HH:MM) CC. Is this an emergeney/planned hospitalization event: Emergency (] Planned [—] Mandatory past history of any chronic illness Ityes( Since Month’ Year) i. Diabetes sane ii, Heart disease iii, Hypertension iv. Hyperlipidemias v. Osteoarthritisvi, Asthma/COPD/Bronehitis vii, Cancer viii, Aleohol/Drug abuse ix. Any HiVior STD Related ailment x. Any other ailment, Give details Expected number of days/stay in hospital Days in ICU Room Type Per day room rent Nursing and Service charges + patients diet Expected cost of investigation + diagnostic ICU Charges OT Charges Professional fess surgeon + anesthetist fees + consultation charges: — ‘Medicines consumables + cost of Implants (ifapplicable please specily) Other Hospital expenses if any All-Inclusive package charges if any applicable ‘Sum total expected cost of hospitalization POZ Er ASS Bom DECLARATI (Please read very carefully) We confirm having read understood and agreed to the declarations of this form ‘a, Name OFthe Treating doctor — Qualification ©. Registration Number With State code — Hospital seal Patient/Insured Name and Sign (Must includes Hospital 1D) DECLARATION BY THE PATIENT/REPRESENTATIVE & [agree to allow the hospital to submit all original documents pertaining to hospitalization to the insurer TPA after the discharge. I agree to sign on the inal bill & the discharge summary, before my discharge. »b. Payment to hospital is governed by the terms and condition ofthe policy. In ease the Insurer.P.A is not liable to sett the hospital bill, I undertake to settle the bill as per the tems and condition of the pole. «All non-medical expenses and expenses not relevant to current hospitalization and the amounts over & above the limit authorized by the insurer/T-P.A not governed by the terms and conditions ofthe policy will be paid by meDate: Thereby declare to abide by the terms and conditions of the poliey and if at any time the facts disclosed by ‘me are found to be false or incorreet I forfeit my claim and agree to indemnify the Insurec/T-P.A T agree and understand that T.P.A is in no way warranting the services of the hospital & that the Insurer/T-P.A is in no way guaranteeing that the services provided by the hospital will be of a particular duality or standard Thereby warrant the truth ofthe forgoing particulars in every respect and [agree that if any T have made or shall make any false or untrue statement, suppression or concealment with respect tothe claim, my right to claim reimbursement of the ssid expenses shall be absolutely forfeited. T agree indemnify the hospital against all expenses incurred on my behalf, which are not reimbursed by the Insurer T-P.A. “I/We authorize Insurance company/TPA to contact me/us through mobile/email for any update on this claim” a) Patient’s/Insured’s name: ) Contact Number: ©) email id(optional): 4). Patients/Insured's Signature: Date: HOSPITAL DECLARATION We have no objection to any authorized TPAVInsurance company official verifying documents pertaining to hospitalization. All vali original documents duly countersigned by the insured patient as per the checklist below will be sent to TPA/Insurance company within 7 days ofthe patient's discharge. We agree that T.P.A/Insurance company will not be liable to make the payment in the event of any discrepancy between the facts in this form and discharge summary or other documents. “The patient declaration has been signed by the patient or by his representative in our presence. We agree to provide clarifications for the queries raised regarding this hospitalization and we take the sole responsibility for any delay in offering clarifications ‘We shall abide by the terms and conditions agreed in the MOU. ‘We confirm that no additional amount would be collected from the insured in excess of agreed package rates except costs towards non-admissible amounts (including addtional charges due fo opting higher room rent than eligibilityichoosing separate line of treatment which is not envisaged/considered in package.) ‘We confirm that no recoveries would be made fiom the deposit amount collected from the insured except for costs towards non-admissible amounts (including additional charges due to opting higher room rent than cligibility/choosing separate line of treatment which is not envisagediconsidered in package.) In the events unauthorized recovery of any additional amount from the insured excess of agreed package rates the authorized TPA/Insurance company reserves the right to recover the same fiom us (The network provider) and /r take necessary action, as provided under the MOU or applicable laws. Hospital seal Doctor's Signature Time: