‘CLAIM FORM @ssi) CCT ieF CLAIM FORM FOR HEALTH INSURANCE POLICIES 'SURARSHA AUR BHAROSA DON (Tobe filed inblock letters) Bie ed 2) Policy No: b)SL.No/ Certificate No: ¢)Company/ TPAD Né )Name: el Address: State: Phone No 2) Currently covered by any other Mediclaim /HeaithInsurance: Yes [__] No| b) Date of commencement of fist Insurance without breab )ifyes, Company Name: Policy No ‘Sum insured (Rs.): ) Have youbeen hospitalized in the last four years since inception ofthe contract? Yes _]No[_Date! Diagnosis: €) Previously covered by any other Mediclaim/Health insurance: Yes [_] No. ‘Vifyes, Company Name: Ghose a) Name: b) Gender: Mate [_]Female| e) Age: years| months d) Date of Birth: ©) Relationship to self spouse [_] chitd [_] Father Primary insured: Mother[”] Other (Please Specify) 1 Occupation: Service[_] SelfEmployed ["] Homemaker [ ] Student [ ] Retired [_] Other (Please Specity) 9) Address: (ifaifferent from above): City: Pin Code: E-mail D: Bien ruc) a) Name of Hospital where Admitted: b)Room Category occupied! Daycare[_] Singleoccupancy [_] Twinsharing[_] 3ormore beds perroom Hospitalization due to: Injury [_] tiness[_] Maternity Dcirar: $81 Genera Instance Company Lind | Corporate & Regtered Ofc Nar 203, ncton of Western Express Haha & Aner Kl Rod fndher aah onbal- 4000 For re das neato trond carton pass ratte Sls Brochure aaley Werte chy tore {Seltngs ae: For 8 Genertinsarnee Crary LsteRDAl ay No Ta ned 1712/2008 |G: Uesooom200PLeIB0S30| Lage dae eng {State Barkot insane 381 Goraral sane Co Ut under eee ° ‘Calle Free) | 1800 22 1111 | 1800 102 1111 [© www.sbigeneralin4d) Date of Injury / Date Disease first detected /Date of Delivery: €)Date of Admission: f)Time: 9) Date of Discharge: hiTime: Dif injury give cause: Selfinflcted] _]Road Traffic Accident[]Substance Abuse / Aleohol Consumption i. if Medico legat Yes[_] No Reported topolice: Yes[_] No MLC Report & Police FIR attached: Yes[_] No Ambulance Charges: Rs. Others (code: Rs. Total: Rs. vi. Pre-hospitalization period: days Vili Post-hospitalization period: days b)Claim for Domiciliary Hospitalization: Yes [_] No[_] (ityes, provide detailsin annexure) €) Details of Lump sum / cash benefit claimed: |. Hospital Dally Cash: Rs. It Surgical Cash: Rs. Critical lines Benefit: Rs. Iv. Convalescence: Rs. \Pre/Post hospitalization Rs. vi, Others: Rs, Lump sum benefit: Claim Documents Submitted- Check List: CClaim Form Duly signed Copy ofthe claim intimation, ifany Hospital Break-up Bill Hospital ill Payment Receipt Hospital Discharge Summary Pharmacy Bill ‘Operation Theatre Notes Ec Doctor's request for investigation Investigation Reports Doctor's Prescriptions Others Including CT/ MRI/ USG / HPE) Elona ‘SINo[BiINo | Date Issued by Towards ‘Amount (Rs) Hospital Main Bil Pre-hospitalzation Bills: Nos Post-hospitalization Bi Pharmacy Bills 10, Gio ee Bank Name: ‘Bank Branch: Bank Account No. MICRNo. Dcirar: $81 Genera Instance Company Lined | Corprate& Regtared Ofc Nar 203, ncton of Western Express Haha & Anche Kila nah ah orbs 4000 For re das nee aos rns and carton pass ratte Sls Brochure aaley Wnts cy tore {Scltngs te: Far 8 GenertinsaraneeCormanyLteRDAl ey No Ta ned 1712/2008 |G UssoooNe0OPLLIB0S40| BlLage deed eng {State Barotac 381 Goraral sane Co Ut under een e ‘Calle Fee) | 1800 22 1111 | 1800 102 1111 [© www.sbigeneralinPuc bat ed {hereby declare that the information furnished in this claim forrn is true & correct to the best of my knowledge and belief. If have made any false or untrue statement, suppression or concealment of any material fact with respect to questions asked in elation to this claim, my right to claim reimbursement shall be forfeited, lalso 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, | hereby declare that | 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, ifany. Date: Signature of the Insured Prace Eten ieee ) DATAELEMENT DESCRIPTION FORMAT ‘SECTION A - DETAILS OF PRIMARY INSURED. a] PolicyNo. Enter the policy number ‘As allottedby the insurance company SI. No/ Certificate No. Enter the social insurance number or the certificate ‘As allottedby the organization ‘o) Company TPAID No. Enter the TPA ID No License number ‘as allotted by IRDA and printedin TPA documents. ‘Name Enter the fullname of the policyholder Sumame First name, Middle name e)Address Enter the full postal address Include Str t, City and Pin Code ‘SECTION - DETAILS OF INSURANCE HISTORY a] Currently covered by any other Mediclaim / Health Insurance? Indicate whether currently coveredby another Mediclaim /Health Insurance. Tick Yes or No Date of Commencement of frst Insurance without break Enter the date of commencement offirst Use dd-mm-yy format ‘€) Company Name Enter the fullname of the Insurance ‘company ‘Name of the organization in full Policy No. Enter the policy number ‘As allotted by the insurance company ‘Sum Insured Enter the total sum insured {as perthe policy Inrupees: ‘d) Have you been Hospitalizedin the last our years since inception ofthe contract? Indicate whether hospitalizedin the last four years Tick Yes or No Mediclaim /Health Insurance? Medictaim {Health Insurance another Date Enter the date of hospitalization Use mm-yy format Diagnosis Enter the diagnosis details (Open Text €) Previously Covered by any other Indicate whether previously covered by _| Tick Yes or No #) Company Name Enter the fullname of the insurance company. "Name of the organization in Full ‘SECTION C- DETAILS OF INSURED PERSON HOSPITALIZED ‘alName Enter the fullname of the patient Surmame, Firstname, Middle name b)Gender Indicate Gender of the patient Tick Male or Female Age Enter age of the patient ‘Number of years and months ¢) Date of Birth Enter Date of Birth of patient Use dd-mm-yy format e) Relationship to primary Insured Indicate relationship of patient with policyholder Tick the right option, thers, please specify. #) Occupation Indicate occupation of patient Tick the right option. Irothers, please specify. Address: Enter the full postal address Include Street, City and Pin Code Disclimer $81 Genera surance Company Limited | Corporate & Registered Office: "Natral, 301, Junction of Western Express Highway & Andher - Kila Road ‘cher (East, Mumbst-400 08 |For more deal on thee facto, tera, andcondtons lene refer tothe Sale Brochure and Plc Wordnge careful before ancl sl, For Bl General Insrance Company LinitedIRDAI Re, No, 1 ted 5/12/2009 CIN USSOOOMH20099LC390546 | SBI Logo depayed belongs yrdusedbySB\Generalnsurance Co Ls. underieene. ‘Calle Fee) | 1800 22 1111 | 1800 102 1111 [© www.sbigeneralinhh) Phone No Enter the phone number of patient Include STD code with telephone number DE-mallID Enter e-mailaddress of patient ‘Complete e-mail address ‘SECTION D - DETAILS OF HOSPITALIZATION ‘a Name of Hospital where admitted Enter the name of hospital ‘Name of hospitalin full ’b) Room category occupied Indicate the room category occupied Tickthe right option. <] Hospitalization due to Indicate reason of hospitalization Tickthe right option €) Date of njury/Date Disease frst detected/ Date of Delivery Enter the relevant date Use dd-mm-yy format 2) Date of admission Enter date of admission Use dd-mm-yy format Time Enter time ofadmission Usehhimm format a) Date of discharge Enter date of discharge Use dd-mmryy format h)Time Enter time of discharge Usehhimm format D injury give cause Indicate cause of injury Tickthe right option Medico legal Indicate whether injury ismedicolegal___| Tick Yes or No. Reported to Police Indicate whether police report was fled TickYesorNo MLC Report& Police FIR attached Indicate whether MLC reportand Police FiRattached Tick Yes orNo System of Medicine Enter the system of medicine followedin treating the patient (Open Text 'SECTIONE - DETAILS OF CLAIM 12) Detalls of Treatment Expenses Enter the amount claimedas treatment expenses, Th rupees (Do not enter paise values) 'b) Claim for Domiciliary Hospitalization Indicate whether claim is for domiciliary hospitalization, Tick Yes orNo {] Details of Lamp sum/ cash benefit claimed Enter the amount claimed as lump sum/ cash benefit Th rupees (Do not enter paise values) {) Claim Documents Submitted-Check List Indicate which supporting documents aresubmitted Tick the right option SECTION F - DETAILS OF BILLS ENCLOSED Indicate which bls are enclosed with the amounts in rupees ‘SECTION G - DETAILS OF PRIMARY INSURED’S BANK ACCOUNT PAN Enter the permanent account number ‘As allottedby the Income Tax depart- ment ‘by Account Number Enter the bank account number ‘As allottedby the bank ‘e)Bank Name and Branch Enter the bank name along with the branch ‘Name of the Bank in full ‘dh Cheque/DD payable details Enter the name of the beneficiary the cheque/ DD should be made out to Name of the individual/ organizationin full e)IFSC Code. Enter the IFSC code of the bankbranch IFSC code of the bank branch in full ‘SECTION H - DECLARATION BY THE INSUREI D Read declaration carefully and mention date (in dd:mrnyy format), place (open text) and sign. Disclaimer: $81 Genera surance Company Limited! Corporate & Registered Office: "Nara. 301, Junction of Western Express Highway & Angher~ Kura Road ‘Andheri, Mumba 40004 |For more detalonth ir factor, tems, andconton, please refer tothe Sales Brochure and Ply Wording careful before ancl sl, For Bl General Insrance Company LinitedIRDAI Re, No, 1 ted 5/12/2009 CIN USSOOOMH20099LC390546 | SBI Logo depayed belongs ‘oState ankofindsandusedby SBI Generalinurance Co, Ls. under ance ‘Calle Fee) | 1800 22 1111 | 1800 102 1111 [© www.sbigeneralinCLAIMFORM PART B: ‘TOBE FILLED INBY THE HOSPITAL, ‘The issue of this Formis not to be taken as an admission of lability Please include the original preauthorization request formin lieu of PART A (Tobe filed in block letters) ee sone Sioa ua) {) Name of the patient: istration no with State Code; DvP Registration No Teender Mele |] Female Sele amen PEPE Date of Admission Time: Date of Discharge Te ype of cision: Emergency [-] Paned[] Daycare[_] maternity WF Moterity 1 Date ofDetvery 1 Grave tt I Status at thetime ofascharge:Dischargetohome [] _ Dishergetoanotherhosptal [_] Deceased mn) Totaleemedamount Pence) 1CD10Codes | Description ICD 10 Codes | Descriptio ee eee oe {Adio Dagnosis Procedure 2: Wico-morbides FC | 5 J itrocna 1 Conor Iv Deals of Procedure €)re-authorization obtained Yes] _] No €)re-authorization Number: €) authorization by network hoeptalnotobained, gv reason: f)Hospitalization due tonjury. |_]¥es[|_]No il Yes. give cause Self-Inflicted| ] Road Trafic Accident |] Substance abuse/ alcohol consumption, I if Injury due Substance abuse/ alcohol consumption, Test Conducted to establish this: Yes{_]No[_] lifes, attach report) IfMedicoLegal- Yes Ht Q Iv)Reported to Police Yes |_| No| MIFIR No. vilifnot reported to police give reason Bee ne akan Claim Form duly signed Investigation reports (Original Pre-authorization request (CT/MR/USG/HPE investigation reports Copy of the Pre-authorization approvalletter Doctors reference slip torinvestigation ECG Copy of photo ID card of patient verified by hospital Pharmacy bils Hospital Discharge summary Operation Theatre notes MLCreport & Police FIR Hospital mein bill ‘Original death summary from hospital where applicable Hospital break-up bill ‘Any other please specify Dcirar: $81 Genera Instance Company Lind | Corporate & Regtered Ofc Nar 203, ncton of Western Express Haha & Aner Kila Rod nah ah orbs 4000 For re das nee aos rns and carton pass ratte Sls Brochure aaley Wnts cy tore {Scltngs te: Far 8 GenertinsaraneeCormanyLteRDAl ey No Ta ned 1712/2008 |G UssoooNe0OPLLIB0S40| BlLage deed eng {Scie ano ndnondvsndby Sb\Gonrnmraee Got under ioose. ° ‘Calle Fee) | 1800 22 1111 | 1800 102 1111 [© www.sbigeneralinEIU cance ona een enneneeae) a) Address of the Hospital: City Stat Pin Code: }Phone No, ) Registration No. with State Code <) Hospital PAN: e) Number of Inpatient beds: ‘)Faciltiesavalableinthehospitat: iJ OT: Yes|_] No[_] i.tcU:Yes [_] No| Others F. DECLARATION BY THE HOSPITAL (PLEASE READ VERY CAREFULLY) We hereby declare that the information furnished ‘Claim Formis true & correct to the best of our knowledge and belief. 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. Date: Signature of hospit CI een een DATAELEMENT, DESCRIPTION FORMAT ‘SECTION A DETAILS OF HOSPITAL ‘alName of Hospital Enter the name of hospital Name of hospitalin ful by Hospital ID Enter ID number of hospital ‘As allocated by the TPA ‘el Type of Hospital Indicate whether In network or non network hospital Tickthe right option Name of treating doctor Enter the name ofthe treating doctor Name of doctorin ful ‘e) Qualification Enter the qualifications of the treating doctor “Abbreviations of educational qualifications, 1) Registration No. with State Code Enter the registration number of the doctor along with the state code ‘As allocated by the Medical Councllof India ‘a) Phone No. Enter the phone number of doctor Include STD code with telephone number ‘SECTION B- DETAILS OF THE PATIENT ADMITTED ‘alName of Patient Enter the name of hospital Name of hospitalin full D)IP Registration Number Enterinsurance providerregistration | Asallotted by the insurance provider number ‘1Gender Indicate Gender of the patient, “Tick Male or Female Age Enter age of the patient ‘Number of years andrmonths e)Date of bith Enter date of admission Use dc-mm-yy format 1) Date of Admission Enter date of admission Use dd-mm-yy format ‘ah Time Enter time of admission Usehhmm format hh) Date of Discharge Enter date of discharge Use dd-mm-yy format Time: Enter time of discharge Use hhimm format i) Type of Admission Indicate type of admissionofpatient__| Tickthe right option KJIF Maternity Date of Delivery Enter Date of Delivery frmaternity Use deh man yy format Gravida Status, Enter Gravida status if maternity Use standard format Status at time of discharge Indicate status of patient at time of __| Ticktheright option discharge m) Total claimed amount Indicate the total claimed amount Tnrupees (Do not enter paise values) Dcirar: $81 Genera Instance Company Lind | Corporate & Regtered Ofc Nar 203, ncton of Western Express Haha & Aner Kila Rod nah ah orbs 4000 For re das nee aos rns and carton pass ratte Sls Brochure aaley Wnts cy tore {Scltngs te: Far 8 GenertinsaraneeCormanyLteRDAl ey No Ta ned 1712/2008 |G UssoooNe0OPLLIB0S40| BlLage deed eng {State Barotac 381 Goraral sane Co Ut under een ° ‘Calle Fee) | 1800 22 1111 | 1800 102 1111 [© www.sbigeneralin‘SECTION C- DETAILS OF AILMENT DIAGNOSED (PRIMARY) alICD 10 Code Enter the ICD 10 Code and description of the primary diagnosis, ‘Standard Format and Open text ‘Additional Diagnosis Enter the ICD 10 Code and description of the additional diagnosis ‘Standard Format and Open text ‘Co-morbidities Enter the ICD 10 Code and description of the co-morbiaities ‘Standard Format and Open text DATAELEMENT DESCRIPTION FORMAT )ICD 10 PCS. Procedure 1 Enter the ICD 10 PCS and description of | Standard Format and Open text the first procedure Procedure 2 Enter the ICD 10PCS and description of | Standard Format and Open text the second procedure Procedures Enter the ICD 10PCS and description of | Standard Format and Open text the third procedure Details of Procedure Enter the details of the procedure Open text €]Pre-authorization obtained Indicate whether pre-authorization Tick Yes or No obtained <)Pre-authorization Number Enter pre-authorization number Asallottedby TPA @)iF authorization by network hospital rot Enter reason for not obtaining pre-authorizationnnumber Open text, ) Hospitalization due to injury Indicate fhospitalization is due toinjury Tick Yes orNo Cause Indicate cause of injury Tick the right option, ‘SECTION /D- CLAIM DOCUMENTS SUBMITTED-CHECK LIST. Indicate which supporting documents are submitted SECTION E - DETAILS IN CASE OF NON NETWORK HOSPITAL al Address: Enter the full postal address Include Street, City and Pin Code b)Phone No. Enter thephonenumber ofhospital__| Include STD code with telephone number ) Registration No, with State Code Enter the registration number of the doctor along with the state code ‘As allocated by the Medical Council of India ‘@) Hospital PAN, Enter the permanent account number | Asallotted by the Income Tax department ‘e) Number of Inpatient beds Enter the number ofinpatient beds Digits 4) Feclties avalable in the hospital Indicate facities avalable in the hospital Tick the right option. others, please specify ‘SECTION D- CLAIM DOCUMENTS SUBMITTED-CHECK LIST Read declaration carefully and mention date (in dd:mrnyy format), place (open textJand signand stamp Disclaimer: $81 Genera surance Company Limited! Corporate & Registered Office: "Nara. 301, Junction of Western Express Highway & Angher~ Kura Road ‘Andheri, Mumba 40008 |For more detail onthe irk ator ters andcontion, pleas refer tothe Sales Brochure and Poley Wording careful befor ancl sl, For Bl General Insrance Company LinitedIRDAI Re, No, 1 ted 5/12/2009 CIN USSOOOMH20099LC390546 | SBI Logo depayed belongs to State ark of indi andusedby SBI Geneallurance ‘§ Call (Tol Free} | 1800 22 1111 | 1800 102 1111 Jo www.sbigeneralin