FAMILY HEALTH PLAN INSURANCE TPA Ltd.

CHECKLIST FOR SUBMISSION OF DOCUMENTS

Corporate Mobile No.

Emp Name: EMP Id:
Patient Name: E-mail id:
Pt. UHID No.
1. Original detailed discharge summary/Death Summary with sign & stamp of
the hospital.
2. Original Hospital Bill-consolidated and with detail breakup of every
component of the bill with Sign & Stamp of the hospital with pre-printed bill
number.
3. Pre-printed Payment receipt with receipt number for the payment done to
the hospital with sign & stamp of the hospital.
4. If doctor charges are not included in final bill then hospital clarification will
be required.
5. Original investigation reports along with bills & doctor Advice letter.
6. Medicine bills with prescriptions.
7. Positive investigation reports confirming the diagnosis for e.g. for cataract
A-scan report / X-Ray report for fractures etc…
8. In case of surgical packages like Cataract, Maternity, Angioplasty, Hernia etc
– detail breakup of the package. Along with the sticker of the lens/Implant
and the Invoice of the Implant/Lens.
9. Indoor Case papers along with admission notes, daily progress notes &
nursing chart.
10. Medico Legal Certificate from the hospital and First Information report
confirming the cause & situation in case of Road traffic accident and a
certificate from the treating doctor mentioning whether the patient was
under the influence of alcohol at the time of Accident or not.
11. Hospital registration certificate.
12. Obstetric history (GPLA) in the case of maternity claims, which means
that which pregnancy is it, how many no. of living children’s are there before
this pregnancy, was there any case of abortion along with USG report.
13. Cancelled Cheque copy for NEFT of the claim settlement amount.
14. Aadhar Card of the patient.
15. Employee’s PAN card & Aadhar Card.
16. Claim Form – (available on FHPL website www.fhpl.net)
Signature of the employee: Signature of FHPL representative:
Name: Name:
Date: Date:
Note: