Genins Indi* Insur.ance; TPA Ltd.

(For IIIIC / OIC I NIC / I$tA,)

Third Party administrator in Health Insurance
Hospitalisation claim form for Reimbursement
Issuance ofthis form does not amount to admission of any liability under the claim on the part of the
Insurers.
Pls give the following informat ion correctly. A1l the columns are mandatory to fill.
CLAIM CONTROLNO. : Date oflntimation :

1. Nameoflnsured 2.NameofAgent
3. Completepresentaddress

4. TelephoneNo. 5. MobileNo.
6. E mail ID (Insured) Email ID (Agent)
7. PolicyNo.
8. Name ofthe Insured's Bank
9. IFSC Code ofBank A/c No.
I 0. Details of Claimant (Patient)
a. Name of Claimant :

b. Relationship with Insured :

c. PresentAge:
1l . a) Nature ofDiesease/Illness contracted or injury suffered :

b) Date oflnjury orDisease/Illness contracted or injury suffered :

i)When lstdetected:
ii)WhenCured:
iii) Ifnot cured, give completehistory

I 2. Name and address of the hospital/nursing home / clinic admitted to

"--:,
1. Date ofadmission: 2. Date ofDischarge :

13. Total Amount Claimed :

I hereby warrant the truth of foregoing particulars in every respect and I agree that I have made or
shall make any false o.r untrue statement or concealment my right to claim reimbursement of the
expences shali be abdolutely forfeited, I Further declare that in-respect of the above treatment no
benefits are admissible under any other medical scheme or insurance.

Signature oflnsured Signature of Claimant

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CERTIFICATE
(TO BE FTLLED BY THE HOSPITAL / NUR.SING HOME / CLINIC AUTHORITY)

This is to certify that

wasadmittedundermytreatmentform- ut at

and detail information is as unser:

1. Name ofHospitalA{ursing Home
2. Whetherthe same is
-to
registeredwiththe local authority ornot
-
3. ifso, RegistrationNo
4. IfnotRegistered, answerthe following queries :
A. No ofinpatients beds inthe hospitalArlursing Home
' B. Whether you have fully equipped operation theater of your own. Yes / No
C. Whetheryouhave fully qualified Nursing Staff
in your employment round the ciock. YesAtro

5. Date/Time ofAdmission
6. Date I Time ofDischarge
7. History ofpresent illness with duration ofthe presenting complaints:

(a) what is the exact nature of complaint with which patient first presented (seen)

(b) sincehow long he / she has been suffering for the same

8. Pasthistoryofthe disease

9. Name and signature oftreating doctor, with his qualification seal

{
Signature of Doctor.
or
Hospital Authorites
(With Seal of l{ospital)

!.i
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BILL DETAILS
Sr. No. Date Bill No. Amount (in Rs.)

TOTAL Rs.

The Documents To Be Attached With The Claim Form-

l. Original Discharge Card.
2. Photocopy ofintimation given (notrequired forpreposthospitalization claim)
3. Photocopyofregistrationcertificateofhospital.
4. Copy ofvalidphoto idproofofPatient (Aadhar card/PAN card/Passport/Election card).
5. original discharge card/ photocopy of discharge card in case prepost claim.
6. Original hospital bill with all the break ups and original paid receipt.
7. original consultation receipt if any with supporting consultation paper.
8. Original.medicinebills supported withoriginalprescription.
9. Original investigation bills with original prescription original reports and films.
1 0. Stickers in case of implant e.g. cataract- IOL sticker * Invoice.

11. Photocopy of MLC, FIR and alcohol confirmtation certificate from treating Dr. in casb of
accident case
i 2.Xerox copies of current year and all previous year's policy copies.
I 3.Details of previous claim if any for the same patient, with copy of discharge card.
14. If the claim is not subrnitted within 15 days frorn the discharge or iirtimation not Given
within 24 hours frorn the admission, then in both cases, explanation from insured for the
delay with sanction letter frorn divisional manager of United India D.O. to Condone the
delay.
I 5. Blank cancelled cheque leafwith IFSC & MICR code ofyour bank account.
'16. Indoor case papers xerox. (attested with hospital authoriry.)
a