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CLAIM FORM - PART A' to 'CLAIM FORM FOR HEALTH INSURANCE POLICIES
OTHER THAN TRAVEL AND PERSONAL ACCIDENT - PART A TO BE FILLED BY
THE INSURED

DETAILS OF PRIMARY INSURED:

Sl. No/
Policy No.: 99000034220400000245 Certificate
no.
Company/ MPHASIS LIMITED
TPA ID No:
Name: D NAGARAJ EmpID: 2555685 MAID: 5106579724
Address:
City: CHENNAI State: TAMIL NADU
Pin Code: 600053 Phone No: 9884873526
Email ID: DUMMY@DUMMY.COM

DETAILS OF INSURANCE HISTORY:

Currently covered by any other Date of commencement of first

Mediclaim / Health Insurance: Yes No Insurance without break:

If yes,
Policy
company MPHASIS LIMITED 99000034220400000245
No.:
name:

Have you been hospitalized in

Sum insured
the last four years since Yes No Date:
(Rs.):
inception of the contract?

Previously covered by any other

Diagnosis: Yes No
Mediclaim /Health insurance:
DETAILS OF INSURED PERSON HOSPITALIZED:

Name: N S ANBHUBHALAGAN Gender: Male Female

1 Date of
Age years:
Birth:
Relationship
to Primary SELF SPOUSE CHILD FATHER MOTHER OTHER(PLEASE SPECIFY)
insured:
SERVICE SELF EMPLOYED HOME MAKER STUDENT RETIRED
Occupation: OTHER(PLEASE SPECIFY)

Address(if
diffrent from
above):
City: CHENNAI State: TAMIL NADU
Pin Code: 600053 Phone No: 9884873526
Email ID: DUMMY@DUMMY.COM

DETAILS OF HOSPITALIZATION:

Name of Hospital ESSVEE HOSPITAL,NO.506, M .T. H. ROAD, AMBATTUR,CHENNAI,TAMIL NADU

where amited:
Room
DAY CARE SINGLE OCCUPANCY TWIN SHARING 3 OR MORE BEDS PER
Category ROOM
occupied:

Hospitalization Date of injury / Date Disease 25-

INJURY ILLNESS MATERNITY
due to: first detected /Date of Delivery: NOV-2023

Date of 25-NOV-2023 Date of 27-NOV-2023

Time: Time:
Admission: Discharge:

If injury give SELF INFLICTED ROAD TRAFFIC ACCIDENT If Medico YES

cause: SUBSTANCE ABUSE / ALCOHOL CONSUMPTION legal: NO

Reported to YES MLC Report & Police FIR System of

YES NO
Police: NO attached: Medicine:
DETAILS OF CLAIM:

Pre -hospitalization
INR Hospitalization expenses INR 14000
expenses
Post-hospitalization
INR Health-Check up cost: INR
expenses
Ambulance Charges: INR Others (code): INR
Pre -hospitalization Post -hospitalization
period: period:

Total: INR 14000

b) Claim for Domiciliary
YES NO (IF YES, PROVIDE DETAILS IN ANNEXURE)
Hospitalization:

c) Details of Lump sum / cash

benefit claimed:
Hospital Daily cash: INR Surgical Cash: INR
Critical Illness benefit: INR Convalescence: INR

Total: INR 14000

Claim Documents Submitted - Check List:
Claim form duly signed Copy of the claim intimation, if any Hospital Main Bill Hospital Break-up
Bill Hospital Bill Payment Receipt
Hospital Discharge Summary Pharmacy Bill Operation Theater Notes ECG
Doctor?s request for investigation Investigation Reports (Including CT/ MRI / USG / HPE) Doctor?s
Prescriptions Others
DETAILS OF BILLS ENCLOSED:
SI No. Bill No. Date Amount (Rs) Remarks

DETAILS OF PRIMARY INSURED?S BANK ACCOUNT:

Account 50100353735927
PAN:
Number:
AMBATTUR GROUND
Bank Name: HDFC BANK Branch: FLOOR411 M T HIGH
ROADAMBATTUR
Cheque / DD HDFC0001290
IFSC Code:
Payable details:

DECLARATION BY THE INSURED: I hereby declare that the information furnished in the claim form is true
& correct to the best of my knowledge and belief. If I have made any false or untrue statement, suppression
or concealent of any material fact with respect to questions asked in relation to this claim, my right to claim
reimbrusement shall be forfeited, I also consent & authorize TPA / Insurance Company, to seek necessary
medical information / documents from any hospital / Medical Practitioner who has attended on the person
against whom this claim is made. I hereby declare that I have included all the bills / receipts for the purpose
of this claim & that I will not be making any supplementary claim except the pre/post-hospitalization claim, if
any.

Date: Place: Signature of the Insured

 GUIDANCE FOR FILLING CLAIM FORM - PART A (To be filled in by the insured)

DATA ELEMENT DESCRIPTION FORMAT

SECTION A - DETAILS OF PRIMARY INSURED
As allotted by the
a) Policy No. Enter the policy number
Insurance Company
Enter the social insurance number
As allotted by the
b) Sl. No/ Certificate No. or the certificate number of social
oraganization
health insurance scheme
Licence number as allotted
c) Company TPA ID No. Enter the TPA ID No. by IRDA and printed in
TPA documents.
Enter the full name of the Surname, First name,
d) Name
policyholder Middle name
Include Street, City and
e) Address Enter the full postal address
Pin code
SECTION B - DETAILS OF INSURANCE HISTORY
Indicate whether currently covered
a) Currently covered by any other
by another Mediclaim / Health Tick Yes or No
Mediclaim / Health Insurance?
Insurance
b) Date of commencement of first Enter the date of commencement
Use dd-mm-yy-forrmat
Insurance without break of first Insurance
Enter the full name of the Name of the organization
c) Company Name
Insurance Company in full
As allotted by the
Policy No. Enter the policy number
Insurance Company
Enter the total sum insured as per
Sum insured In rupees
the policy
d) Have you been Hospitalized in the last Indicate whether hospitalized in the
Tick Yes or No
four years since Inception of the contract? last four years
Date Enter the date of Hospitalization Use mm-yy format
Diagnosis Enter the diagnosis details Open Text
e) Previously covered by any other Indicate whether previously
Mediclaim / Health Tick Yes or No covered by another mediclaim / Tick Yes or No
Insurance? Health Insurance
Enter the full name of the Name of the organization
f) Company Name
Insurance Company in full
SECTION C - DETAILS OF INSURED PERSON HOSPITALIZED
Surname, First name,
a) Name Enter the full name of the patient
Middle name
b) Gender Indicate Gender of the patient Tick Male or Female
Number of years and
c) Age Enter age of the patient
months
d) Date of Birth Enter Date of Birth of patient Use dd-mm-yy format
Indicate relationship of patient with Tick the right option, if
e) Relationship to primary Insured
policyholder others, please specify
Tick the right option. If
f) Occupation indicate occupation of patient
others, please specify.
Include Street, City and
g) Address Enter the full postal address
Pin code
Include STD code with
h) Phone No Enter the phone number of patient
telephone number
1) E-mail ID Enter e-mail address of patient Complete e-mail address
SECTION D - DETAILS OF HOSPITALIZATION
a) Name of Hospital where admited Enter the name of hospital Name of hospital in full

b) Room category occupied
c) Hospitalization due to
d) Date of injury/Date Disease first
detected / Date of Delivery
e) Date of admission
f) Time
g) Date of discharge
h) If injury give cause
If Medico legal
Reported to Police
MLC Report & Police FIR attached
i) System of Medicene
SECTION E - DETAILS OF CLAIM
a) Details of Treatment Expences
b) Claim for Domiciliary Hospitalization
c) Details of Lump sum/ Cash benifit
claimed
d) Claim documents Submitted-Check List
SECTION F - DETAILS OF BILLS ENCLOSED
Indicate which bills are enclosed with the
amount in rupees
SECTION G - DETAILS OF PRIMARY INSURED?s BANK ACCOUNT
Enter the permanent account
a) PAN
number
b) Account Number
c) Bank Name and Branch
d) Cheque/ DD payable details
e) IFSC Code
SECTION H - DECLARATION BY THE INSURED
Read declaration carefully and mention
date (in dd:mm:yy format), place (open
text) and sign.
indicate the room category
Tick the right option
occupied
indicate reason of hospitalization Tick the right option
Enter the relevant date Use dd-mm-yy format
Enter date of admission Use dd-mm-yy format
Enter time of admission Use hh-mm- format
Enter date of discharge Use dd-mm-yy format
indicate cause of injury Tick the right option
indicate whether injury is medico
Tick Yes or No
legal
indicate whether police report was
Tick Yes or No
filed
indicate whether MLC report and
Tick Yes or No
Police FIR attached
Enter the system of medicine
Open Text
followed in treating the patient
Enter the amount claimed as In rupees (Do not enter
treatment expences paise values)
indicate whether claim is for
Tick Yes or No
domiciliary hospitalization
Enter the amount claimed as lump In rupees (Do not enter
sum / cash benefit paise values)
indicate which supporting
Tick the right option
documents are submitted
As allotted by the Income
Tax Department
Enter the Bank account number As allotted by the Bank
Enter the Bank name along with
Name of the Bank in full
the branch
Enter the name of the beneficiary
Name of the individual /
the cheque / DD should be made
organization in full
out to
Enter the IFSC code of the Bank IFSC code of the Bank
branch branch in full
 CLAIM FORM - PART B TO BE FILLED IN BY THE HOSPITAL The issue of this
Form is not to be taken as an admission of liability Please include the original
preauthorization request form in lieu of PART A

DETAILS OF HOSPITAL:

a) Name of the ESSVEE HOSPITAL,NO.506, M .T. H. ROAD, AMBATTUR,CHENNAI,TAMIL NADU

hospital:

b) Hospital ID: c) Type of

Network Non Network (if non network fill section E)
Hospital:

d) Name of the e)
treating doctor: Qualification:
f) Registration No. g) Phone No.:
with State Code:
DETAILS OF THE PATIENT ADMITTED:

a) Name of the N S ANBHUBHALAGAN

Patient:

b) IP c) Gender:
Male d) Date of
Registration
Female birth:
Number:

e) Date of 25- f) Date of 27-

NOV-2023 Time: NOV-2023 Time:
Admission: Discharge:

g) Type of Emergency Planned Day h) If 1) Date of 2) Gravida

Admission: Care Maternity Maternity: Delivery: Status:

i) Status at time Discharge to home Discharge to j) Total claimed

of discharge: another hospital Deceased amount:
DETAILS OF AILMENT DIAGNOSED (PRIMARY):

a) ICD 10 Codes Description

I. Primary Diagnosis
ii. Additional Diagnosis:
iii. Co-morbidities:
iv. Co-morbidities:
b) ICD 10 Codes Description
i. Procedure 1:
ii. Procedure 2:
iii. Procedure 3:
iv. Details of Procedure

d) Pre-authorization
c) Pre-authorization obtained: Yes No
Number:

e) If authorization by network hospital not

obtained, give reason:

f) Hospitalization
due to injury: Yes No
 i) If Yes, give cause Self-inflicted Road Traffic Accident Substance abuse /
alcohol consumption
ii) If injury due to substance
abuse / alcohol consumption, Yes No (If Yes, attach reports)
Test conducted to establish this:
iii) If Medico legal: Yes No
iv) Reported to Police: Yes No
v) FIR No.:
vi) If not reported to police give
reason:
CLAIM DOCUMENTS SUBMITTED - CHECK LIST:

Claim form duly signed Original Pre-authorization request Copy of the Pre-authorization approval
letter Copy of Photo ID Card of patient Verified by hospital Hospital Discharge summary
Operation Theatre Notes Investigation reports Hospital main bill Hospital break-up bill
CT/MR/USG/HPE investigation reports Doctor?s reference slip for investigation ECG Pharmacy
bills
MLC reports & Police FIR Original death summary from hospital where applicable Any other,
please specify
ADDITIONAL DETAILS IN CASE OF NON NETWORK HOSPITAL (ONLY FILL IN CASE OF
NON-NETWORK HOSPITAL):

ESSVEE HOSPITAL,
a) Address of the NO.506, M .T. H. ROAD,
Hospital AMBATTUR,CHENNAI,
TAMIL NADU,600053
City: CHENNAI State: TAMIL NADU
Pin Code: 600053 Phone No: 9884873526 Registration No.
with State Code:
Number of
Hospital PAN:
inpatient beds
Facilities available in
i. OT YES NO ii. ICU YES NO
the hospital
DECLARATION BY THE HOSPITAL:
We hereby declare that the information furnished in this Claim Form is true & correct to the best of our
knowledge and belief. If we have made any false or untrue statement, suppression or concealment of any
material fact, our right to claim under this claim shall be forfeited.

Signature and Seal of the

Date: Place: Hospital Authority:

GUIDANCE FOR FILLING CLAIM FORM - PART B (To be filled in by the hospital)

DATA ELEMENT DESCRIPTION FORMAT

SECTION A - DETAILS OF HOSPITAL
Name of the hospital in
a) Name of the hospital: Enter the name of hospital
full
As allocated by the
b) Hospital ID Enter ID number of hospital
TPA
c) Type of Hospital Enter the name of the treating doctor Name of doctor in full
Abbreviations of
Enter the qualification of the treating
e) Qualification educational
doctor
qualifications
As allocated by the
Enter the registration number of the
f) Registration No. with State Code Medical Council of
doctor along with the state code
 India
Include STD code with
g) Phone No. Enter the phone number of doctor
telephone number
SECTION B - DETAILS OF THE PATIENT ADMITTED
a) Name of Patient Enter the name of patient Name of patient in full
Enter insurance provider registration As allotted by the
b) IP registration Number
number insurance provider
c) Gender Indicate Gender of the patient Tick Male or Female
Number of years and
d) Age Enter age of the patient
months
e) Date of Birth Enter date of birth Use dd-mm-yy format
f) Date of Admission Enter date of admission Use dd-mm-yy format
g) Time Enter Time of admission Use hh:mm format
h) Date of Discharge Enter date of Discharge Use dd-mm-yy format
i) Time Enter time of Discharge Use hh:mm format
j) Type of Admission Indicate type of admission of patient Tick the right option
k) If Maternity
i) Date of Delivery Enter Date of Delivery if maternity Use dd-mm-yy format
ii) Gravida Status Enter Gravida status if maternity Use standard format
Indicate status of patient at time of
l) Status at time of discharge Tick the right option
discharge
In rupees (Do not enter
M) Total claimed amount Indicate the total claimed amount
paise values)
SECTION C - DETAILS OF AILMENT DIAGNOSED (PRIMARY)
a) ICD 10 Code
b) Gender Indicate Gender of the patient Tick Male or Female
Enter the ICD 10 Code and description Standard Format and
Primary Diagnosis
of the primary diagnosis Open text
Enter the ICD 10 Code and description Standard Format and
Additional Diagnosis
of the additional diagnosis Open text
Enter the ICD 10 Code and description Standard Format and
Co-morbidities
of the Co-morbidities Open text
b) ICD 10 PCS
Enter the ICD 10 Code and description Standard Format and
Procedure 1
of the first procedure Open text
Enter the ICD 10 Code and description Standard Format and
Procedure 2
of the second procedure Open text
Enter the ICD 10 Code and description Standard Format and
Procedure 3
of the third procedure Open text
Details of Procedure Enter the details of the procedure Open text
Indicate whether pre-authorization
c) Pre-authorization obtained Tick Yes or No
obtained
d) Pre-authorization Number Enter pre-authorization number As allotted by TPA
e) If authorization by network hospital not Enter reason for not obtaining pre-
Open text
obtained, give reason authorization number
Indicate if hospitalization is due to
f) Hospitalization due to injury Tick Yes or No
injury
Cause Indicate cause of injury Tick the right option
If injury due to substance abuse/alcohol
consumption test conducted to establish Indicate whether test conducted Tick Yes or No
this
Medico Legal Indicate whether injury is medico legal Tick Yes or No
Reported to Police
FIR No.
If not reported to police, give reason
SECTION D - CLAIM DOCUMENTS SUBMITTED-CHECK LIST
Indicate which supporting documents are
submitted
SECTION E - DETAILS IN CASE OF NON NETWORK HOSPITAL
a) Address
b) Phone No.
c) Registration No. with State Code
d) Hospital PAN
e) Number of Inpatient beds
f) Facilities available in the hospital
SECTION F - DECLARATION BY THE HOSPITAL
Read declaration carefully and mention
date (in dd:mm:yy format), place (open
text) and sign. and stamp
DECLARATION:
Date
Date of Submission
Indicate whether police report was filed Tick Yes or Not
As issued by police
Enter first information report number
authrities
Enter reason for not reporting to police Open text
Include Street, City
Enter the full postal address
and Pin Code
Include STD code with
Enter the phone number of hospital
telephone number
Enter the registration number of the As allocated by the
Hospital obtained from local body like City Corporation /
City Corporation / Municipality Municipality
As allocated by the
Enter the permanent account number Income Tax
Department
Enter the number of inpatient beds Digits
Indicate facilities available in the Tick the right option. If
hospital others, please specify
Employee Signature
Generated On :- 27 Nov 2023