HRDD CIRCULAR NO. 723

Transcription

1 Human Resources Development Division (Hospitalisation Cell), Head Office: New Delhi Phone No FAX November 19, 2015 TO ALL OFFICES HRDD CIRCULAR NO. 723 Medical Insurance Scheme for Officers/Employees in lieu of earlier Hospitalisation Scheme under Regulations / Bipartite settlement We refer HRDD Circular No.714 dated vide which it was interalia informed that a new Medical Insurance Scheme for Officers / employees is coming into force w.e.f It was further informed that the operational guidelines of the same shall be circulated separately. Details of the Medical Insurance Scheme were circulated as Annexure/ Schedule-IV of PAD Circular No.271 dated and HRDD Circular No.694 dated However, brief details of the same alongwith operational guidelines containing instructions for seeking reimbursement / availing benefits under the scheme are being circulated herewith as Annexure. All staff members are advised to go through the provisions of the joint note dated for complete details and the operational guidelines very carefully so that the benefits available can be claimed in a proper manner and within the stipulated time. Please note that these are the operational guidelines in brief and detailed guidelines will be circulated after the same are received through IBA/UIIC. (M.C. MADAN) DY. GENERAL MANAGER

2 ANNEXURE BRIEF DETAILS OF MEDICAL INSURANCE SCHEME FOR OFFICERS & WORKMEN STAFF Policy Period to Plan Type Beneficiary Total number of lives covered Group Health Policy (Family Floater) Employee + Spouse + Dependent Children + dependent parents or parent in laws, (Dependent status should be entered and verified in HRMS) All active employees, spouse & dependents Sum insured (Annual cover amount) Cadre Sum insured (Rs.) Officers 4,00,000/- Critical illness Corporate Buffer Clerical & Sub Staff 3,00,000/- In case an employee (self only and not dependents) contracts a critical illness as specified in the scheme, Rs.1,00,000/- shall be paid, as a benefit without any bills, immediately on first detection / diagnosis of the critical illness. Hospitalisation is not required to claim this benefit. Officer/ Employee can claim the benefit by submitting medical certificate, prescription and reports in respect of the illness. In case an individual exhausts the sum insured, the balance will be considered from the Corporate Buffer. However detailed guidelines in this regard shall be circulated separately. Coverages 1(i) Inpatient Hospitalisation expenses (ii) Pre/Post hospitalization expenses covered Pre-hospitalization for 30 days Post Hospitalization for 90 days: 2. Listed Day Care Procedures 3. Domiciliary treatment in respect of specified diseases. Room Rent - Room Rent upto to Rs.5,000/- per day. - ICU charges upto Rs.7,500/- per day. 1 P a g e

3 Ambulance Charges - Ambulance charges upto Rs.1000/- per trip. - Taxi and Auto in actual maximum up to Rs. 750/- per trip Maternity benefits - Normal Delivery : Rs.35,000 - Caesarian Delivery : Rs.50,000 - Complications on Maternity would be covered up to the sum insured plus the Corporate Buffer. New born baby expenses Domiciliary Coverage: Covered under the floater sum insured of the family. Domiciliary treatment shall also be covered under the scheme i.e treatment taken for specified diseases which may or may not require hospitalization as mentioned herein below:- Medical expenses incurred in case of the following diseases which need domiciliary hospitalization/ domiciliary treatment, as may be certified by the recognized hospital authorities and bank s medical officer shall be deemed as hospitalization expenses and reimbursement to the extent of 100%. 2 P a g e Cancer, Leukemia, Thalassemia, Tuberculosis, Paralysis, Cardiac Ailment, Pleurisy, Leprosy, Kidney Ailment, All Seizure disorder, Parkinson s diseases, Psychiatric disorder including schizophrenia and psychotherapy, Diabetes and its complications, hypertension, Asthme, Hepatitis-B, Hepatitis-C, Hemophilia, Myasthenia gravis, Wilson s disease, Ulcerative Colitis, Epidermolysis, bullosa, Venous Thrombosis (not caused by smoking) Aplastic Anaemia, Psoriasis, Third Degree burns, Arthritis, Hypothyroidism, Hyperthyroidism, expenses incurred on radiotherapy and chemotherapy in the treatment of cancer and leukemia, Glaucoma, Tumor, Diphtheria, Malaria, Non-Alcoholic Cirrhosis of Liver, Purpura, Thphoid, Accident of Serious Nature, Cerebral Palsy, Polio, All strokes leading to Paralysis, Hemorrhage caused by accident, all animal/reptile/insect bite or string, chronic pancreatitis, Immuno suppressants, multiple sclerosis/motor neuron disease, status asthamaticus, sequalea of meningitis, osteoporosis, muscular dystrophies, sleep apnea syndrome (not related to obesity), any organ related (chronic) condition, stickle cell disease, systemic lupus erythematous (SLE), any connective tissue disorder, varicose veins, thrombo

4 Congenital internal / external diseases / defects/ anomalies Pre-existing diseases coverage embolism venous thrombosis/venous thrombo embolism(vte), growth disorder, Graves disease, Chronic Pulmonary Disease, Chronic Bronchitis, Physiotherapy and swine flu shall be considered for reimbursement under domiciliary treatment. The cost of medicines, medical reports and visiting charges, in respect of domiciliary treatment shall be reimbursed for the period stated in the Specialist's prescription. If no period is stated, the prescription for the purpose of reimbursement shall be valid for a period not exceeding 90 days. Covered in the policy. Covered in the policy. 3 P a g e

5 OPERATIONAL GUIDELINES TPA CARD i. The scheme is being operationalised by United India Insurance Company through Raksha TPA and all the claims under the scheme are to be processed by the TPA. ii. Each employee and their dependents are to be issued separate TPA ID card containing the photo of the insured. iii. Circle Offices to obtain photographs of all employees and their dependents for the purpose of issuing TPA ID cards. In the meantime the TPA ID card without photograph can be downloaded through website (rakshatpa.com) and / or through mobile app as below iv. For downloading TPA ID Card through website, the employees are advised to follow the path >> visit Raksha TPA web site >> click on IBA >> click PNB. System will ask you to fill the ID card No. where the following is to be filled:- UIC545(Employee PF Number) PNBA eg. If PF number is 70065, the text to be filled shall be UIC PNBA >> click on search button. New screen will appear with all details. If details are correct, click PRINT E-CARD and save the same for records and future reference. For downloading TPA ID card through mobile app, use smart mobile phone for the facility. Download the Mobile App. Raksha TPA, on the application. System will show many options, click on Request E-card and enter the particulars as advised above, then click on search button. New screen will appear with all details. If details are correct, click PRINT E-CARD and save the same for record and future reference. INTIMATION OF CLAIM IN CASE OF ALL HOSPITALISATION (CASHLESS OR OTHERWISE) 4 P a g e i. The reimbursement claims are required to be intimated to Raksha TPA within 24 hours of hospitalization and original documents are to be submitted within 30 days of discharge from the hospital. ii. In case of planned hospitalization, the TPA is to be informed at least two days before hospitalization, but in any case within 24 hours of hospitalization. iii. Intimation has to be sent along with the following particulars:- a. Member ID b. Patient s Name c. Name and address of the Hospital d. Disease / ailment and Treatment given

6 e. Date of admission f. Requested amount iv. Intimation can be sent by the insured / relatives / office where the employee is posted through any of the following methods:- a. Through to Raksha TPA at id helpiba@rakshatpa.com, claimintimation@rakshatpa.com b. Through phone by calling any of the following 24 hours toll free No./Call Center and providing above information a) Delhi b) Delhi c) Mumbai d) Bangalore c. On line Registration by following the undernoted procedure: 1. login to 2. click on claim intimation link 3. Punch in desired details like Member id, date of admission, name of hospital etc. 4. Acknowledgement No. (i.e. your claim no.) shall be reflected, a copy of which may be retained SUBMISSION & PAYMENT OF MEDICAL BILLS (OTHER THAN ON CASHLESS BASIS) i. All claims are to be submitted on the prescribed format of the insurance company. Proforma of the claim form is enclosed. ii. Employees/officers posted within the jurisdiction of Circle Offices shall lodge claim to their Circle Offices. iii. FGM Office Employees/officers shall lodge their Claims iv. to their concerned Circle Offices. Head Office Employees/officers shall lodge their Claims to HRD Division (Hospitalization cell) through their Divisional Heads. v. Circle Offices and HRD Division HO (Hospitalisation Cell) will submit these bills to TPA on daily basis, after keeping proper record. vi. All reimbursements shall be credited in Employees Bank account directly. 5 P a g e

7 PROCEDURE & TIME SCHEDULE FOR SUBMISSION OF MEDICAL CLAIMS HOSPITALISATION CLAIMS - (CASHLESS BASIS) All supporting documents in original, i.e Discharge Card, Medical Prescription, Medicine Bills, related Reports, X-rays, ECG strips, CT scan pictures and other documents relating to the claim must be submitted with the claim form within 30 days from the date of discharge from the hospital. In case of post-hospitalization treatment (limited to 90 days), all claim documents should be submitted within 30 days after completion of such treatment. i. The benefit of cashless hospitalisation facility is available in many hospitals on provider s network. The list of such hospitals can be accessed on PNB Parivar and Raksha TPA s website. ii. Officers/employees are advised to contact TPA counter of the hospital along with TPA ID Card and a Govt. Photo ID proof of the patient for seeking cashless hospitalization claim. iii. On production of ID card, the TPA desk of the hospital shall inform the TPA, the requisite particulars of employee, the patient admitted, reason for hospitalization etc. and seek initial approval of the estimated hospitalization expenses. iv. Some hospitals have a policy of seeking an advance for treatment to start. The same is refundable once the cashless approval is received. v. After treatment, the hospital s TPA desk will submit the bills to the TPA and on receipt of sanction, the patient shall be discharged. Claim amount shall be paid by Insurance Company through TPA directly to the hospital concerned. vi. Any amount not admissible under the scheme and not sanctioned by the TPA shall have to be paid by the officer/ employee to the hospital at the time of discharge of patient. EMERGENCY HOSPITALISATION 6 P a g e vii. In case of post-hospitalisation treatment, all claim documents should be submitted within 30 days after completion of such treatment. In case of an emergency admission to a hospital which is not in PP Network, the officers / employees can approach the TPA for cashless treatment by intimating the Third Party Administrator, call centre number ( , (Delhi), (Mumbai), (Bangalore), mentioning his ID card No and name. The hospital authorities would fax / mail the details of

8 IF HOSPITAL IS NOT IN THE APPROVED LIST OF TPA DOMICILIARY CLAIMS GRIEVANCE REDRESSAL hospitalisation to the Third Party Administrator, who would again revert by fax / mail a confirmation to the hospital to proceed with the claim. Wherever the hospital is not in the approved list of Third Party Administrator, the Third Party Administrator will take necessary action for considering addition of such hospital on their network hospital list in consultation with bank. In an emergency the claim payment would be made to the hospital account and empanelment of the hospital would be considered. Treatment taken from clinics of Specialist Doctors are eligible for reimbursement. The cost of Medicines, Investigations, and consultations, etc. in respect of domiciliary treatment shall be reimbursed for the period stated by the specialist and / or the attending doctor and / or the Bank s Medical Officer. If no period is stated, the prescription, for the purpose of reimbursement shall be valid for a period not exceeding 90 days. All prescriptions for consultations must specify the disease, and should be signed & stamped by the treating doctor. Claims should be submitted on the prescribed format enclosed along with original bills and related prescriptions for consultation. In the event of any grievance relating to the insurance, the insured Person may raise query and grievance in writing to the TPA, through its website link online grievance. The insured person may also submit in writing to the Policy Issuing Office or Grievance Cells at the Regional Office of the United India Insurance on link online complaint 7 P a g e

9 PROFORMA FOR CAPTURING OF DEPENDENT DETAILS Name of employee PF number Branch/office Circle Office SB/CA A/C number IFSC code 1. SELF NAME D.O.B. GENDER 2. DEPENDENTS NAME D.O.B. GENDER RELATION : NAME D.O.B. GENDER RELATION : NAME D.O.B. GENDER RELATION : NAME D.O.B. GENDER RELATION : SIGNATURES OF THE EMPLOYEE SIGNATURES OF THE INCUMBENT INCHARGE The scheme covers Self+Spouse+ dependent children + any two of the dependent parents/parents in law. No age limit for dependents, Dependent will be considered only if his/her monthly income does not exceed Rs Brother and sisters are dependents only if they are physically challenged with 40 % or more disability. Widowed daughter/divorced/separated/daughter/sister including unmarried/ divorced/abandoned or separated from husband/widowed sister and crippled child shall be considered as dependent for the purpose of this policy 8 P a g e

10 DETAILS OF PRIMARY INSURED a) Policy no: UNITED INDIA INSURANCE COMPANY LIMITED REGISTERED & HEAD OFFICE: 24, WHITES ROAD, CHENNAI CLAIM FORM - PART A TO BE FILLED IN BY THE INSURED The issue of theis form is not to be taken as admission of liability b) Sl. No/ Certificate No: (To be filled in block letters) c) Company/ TPA ID No: d) Name: SECTION A e) Address: City: State: SECTION A Pin Code: Phone No: ID: DETAILS OF INSURANCE HISTORY a) Currently covered by any other Mediclaim/ Health Insurance: Yes No b) Date of commencement of first insurance without break: c) If yes, company name: Sum Insured (`): Policy No: d) Have you been hospitalized in the last four years since inception of the contract? Yes No Date: Diagnosis: e) Previously covered by any other Mediclaim/ Health Insurance : Yes No SECTION B f) If yes, Company Name : DETAILS OF INSURED PERSON HOSPITALIZED a) Name : b) Gender : Male Female c) Age: years months d) Date of Birth: e) Relatuionship to Primary Insured: Self Spouse Child Father Mother Other (Please specify) f) Occupation: Service Self Employed Homemaker Student Retired Other (Please specify) g) Address (if different from above): SECTION C City: State: Pin Code: Phone No: ID: DETAILS OF HOSPITALIZATION a) Name of Hospital where Admitted: b) Room category occupied: Day Care Single occupancy Twin sharing 3 or more beds per room c) Hospitalization due to: Injury Illness Maternity d) Date of injury/ Date Disease first detected/ Date of Delivery: e) Date of Admission: f) Time: : g) Date of Discharge: h) Time: : i) If injury, give cause: Self inflicted Road Traffic Accident Substance abuse / Alcohol Consumption i. If Medico Legal: Yes No SECTION D ii. Reported to police: Yes No iii. MLC Report & Police FIR attached: Yes No j) System of medicine: DETAILS OF CLAIM a) Details of treatment expenses claimed Claim Documents Submitted- Check List: i. Pre Hospitalization Expenses ` ii. Hospitalization Expenses ` Claim FormDuly signed iii. Post Hospitalization Expenses ` iv. Health Check up Cost ` Copy of the claim intimation, if any v. Ambulance Charges ` vi. Others (code): ` Hospital Main bill Total ` Hospital Break-up bill vi. Pre hospitalization period: days vii. Pre hospitalization period: days Hospital Discharge Summary b) Claim for Domiciliary Hospitalization: Yes No (if yes, provide details in annexure) Pharmacy Bill c) Details of Lump sum / cash benefit claimed: Operation Theatre Notes SECTION E i. Hospital Daily Cash: ` ii. Surgical Cash: ` ECG iii. Critical Illness Benefit: ` iv. Convalescence: ` Doctor's request for investigation v. Pre/Post hosp. Lump sum benefit: ` vi. Others: ` Investigation Reports (including CT / MRI / USG / HPE) Total ` Doctor's Prescription Others DETAILS OF BILLS ENCLOSED Sl. No. Bill No. Date Issued By Towards 1 Hospital Main Bill Pre hospitalisation Bills: Nos Post hospitalisation Bills: Nos Pharmacy Bills: DETAILS OF PRIMARY INSURED'S BANK ACCOUNT a) PAN: b) Account Number: c) Bank Name and Branch Amount (`) SECTION F SECTION G

11 d) Cheque/ DD Payable details: e) IFSC Code: N G DECLARATION BY THE INSURED I hereby declare that the information furnished in this claim form is true & correct to the best of my knowledge and belief. If I have made any false or untrue statement, suppression or concealment of any material fact with respect to questions asked in relation to this claim, my right to claim reimbursement 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. SECTION H Date: Place: Signature of the insured: a) Policy No. DATA ELEMENT GUIDANCE FOR FILLING CLAIM FORM PART A (To be filled in by the insured) DESCRIPTION SECTION A - DETAILS OF PRIMARY INSURED Enter the policy number FORMAT As allotted by the insurance company Enter the social insurance number or the certificate number of social health b) SI. No/ Certificate No. As allotted by the organization insurance scheme c) Company TPA ID No. Enter the TPA ID No d) Name e) Address Enter the full name of the policyholder Enter the full postal address SECTION B - DETAILS OF INSURANCE HISTORY License number as allotted by IRDA and printed in TPA documents. Surname, First name, Middle name Include Street, City and Pin Code a) Currently covered by any other Mediclaim / Health Insurance? Indicate whether currently covered by another Mediclaim / Health Insurance b) Date of Commencement of first Insurance without break Enter the date of commencement of first insurance c) Company Name Enter the full name 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 per the policy In rupees d) Have you been Hospitalized in the last 4 years since inception of the contract? Indicate whether hospitalized in the last 4 years Date Enter the date of hospitalization Use mm-yy format Diagnosis Enter the diagnosis details Open Text e) Previously Covered by any other Mediclaim/ Health Insurance? Indicate whether previously covered by another Mediclaim / Health Insurance f) Company Name a) Name b) Gender c) Age d) Date of Birth e) Relationship to primary Insured f) Occupation g) Address h) Phone No i) ID a) Name of Hospital where admitted 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) Time i) If Injury give cause If Medico legal Reported to Police MLC Report & Police FIR attached j) System of Medicine a) Details of Treatment Expenses b) Claim for Domiciliary Hospitalization c) Details of Lump sum/ cash benefit claimed d) Claim Documents Submitted-Check List Indicate which bills are enclosed with the amounts in rupees Enter the full name of the insurance company SECTION C - DETAILS OF INSURED PERSON HOSPITALIZED Enter the full name of the patient Indicate Gender of the patient Enter age of the patient Enter Date of Birth of patient Indicate relationship of patient with policyholder Indicate occupation of patient Enter the full postal address Enter the phone number of patient Enter address of patient SECTION D - DETAILS OF HOSPITALIZATION Enter the name of hospital Indicate the room category occupied Indicate reason of hospitalization Enter the relevant date Enter date of admission Enter time of admission Enter date of discharge Enter time of discharge Indicate cause of injury Indicate whether injury is medico legal Indicate whether police report was filed Indicate whether MLC report and Police FIR attached Enter the system of medicine followed in treating the patient SECTION E - DETAILS OF CLAIM Enter the amount claimed as treatment expenses Indicate whether claim is for domiciliary hospitalization Enter the amount claimed as lump sum/ cash benefit Indicate which supporting documents are submitted SECTION F - DETAILS OF BILLS ENCLOSED Name of the organization in full Surname, First name, Middle name Tick Male or Female Number of years and months. If others, please specify.. If others, please specify. Include Street, City and Pin Code Include STD code with telephone number Complete address Name of hospital in full Use hh:mm format Use hh:mm format Open Text In rupees (Do not enter paise values) In rupees (Do not enter paise values) SECTION G - DETAILS OF PRIMARY INSURED S BANK ACCOUNT a) PAN Enter the permanent account number b) Account Number Enter the bank account number c) Bank Name and Branch Enter the bank name along with the branch d) Cheque/ DD payable details Enter the name of the beneficiary the cheque/ DD should be made out to e) IFSC Code Enter the IFSC code of the bank branch SECTION H - DECLARATION BY THE INSURED Read declaration carefully and mention date (in dd:mm:yy format), place (open text) and sign. As allotted by the Income Tax department As allotted by the bank Name of the Bank in full Name of the individual/ organization in full IFSC code of the bank branch in full

12 UNITED INDIA INSURANCE COMPANY LIMITED REGISTERED & HEAD OFFICE: 24, WHITES ROAD, CHENNAI DETAILS OF HOSPITAL a) Name of the Hospital: CLAIM FORM - PART B TO BE FILLED IN BY THE HOSPITAL The issue of theis form is not to be taken as admission of liability Please include the original preauthorization request form in lieu of PART A (To be filled in block letters) c) Hospital ID: c) Type of Hospital: Network Non Network (if non network, fill Section E) d) Name of the treating doctor: e) Qualification: f) Registration No. with state code: g) Phone No. SECTION A DETAILS OF PATIENT ADMITTED a) Name of Patient: b) IP Registration No.: c) Gender : Male Female d) Age: years months e) Date of Birth: f) Date of Admission: g) Time: : h) Date of Discharge: i) Time: : j) Type of Admission: Emergency Planned Day Care Maternity k) If Maternity: i. Date of Delivery: ii. Gravida Status: SECTION B l) Status at time of discharge: Discharged to home Discharged to another hospital Deceased m) Total claimed amount DETAILS OF AILMENT DIAGNOSED (PRIMARY) a) ICD 10 Codes Description b) ICD 10 PCS Description i. Primary Diagnosis : i. Procedure 1 : ii. Additional Diagnosis : ii. Procedure 2 : iii. Co-morbidities : iii. Procedure 3 : iv. Co-morbidities : iv. Details of Procedure : SECTION C c) Pre authorization obtained: Yes No d) Pre-authorization 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 injurydue to Substance abuse / alcohol consumption, Test Conducted to establish this: Yes No (if yes, attach reports) 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 - CHECKLIST Claim Form duly signed Original Pre-authorization request Investigation reports CT/ MRI/ USG/ HPE/ Investigation reports Copy of the Pre-authorization approval letter Copy of photo ID card of patient verified by hospital Hospital discharge summary Doctor's referance slip ECG Pharmacy bills SECTION D Oparation Theatre Notes Hospital main bill Hospital break-up bill MLC report & Police FIR Original death summary from hospital, where applicable Any other, please specify DETAILS IN CASE OF NON NETWORK HOSPITAL (ONLY FILL IN CASE OF NON NETWORK HOSPITAL) a) Address of the hospital: City: Pin Code: b) Phone No: c) Registration No. with State Code: State: SECTION E d) Hospital PAN e) Number of inpatient beds f) Facilities available in the hospital: i. OT: Yes No ii. ICU: Yes No iii. Others: DECLARATION BY THE HOSPITAL (Please read very carefully) 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, suppress or concealment of anu material fact, our right to claim under this claim shall be forfeited. Date: SECTION F Place: Signature of the insured: DATA ELEMENT a) Name of Hospital b) Hospital ID c) Type of Hospital d) Name of treating doctor e) Qualification f) Registration No. with State Code g) Phone No. a) Name of Patient GUIDANCE FOR FILLING CLAIM FORM PART B (To be filled in by the hospital) DESCRIPTION SECTION A - DETAILS OF HOSPITAL Enter the name of hospital Enter ID number of hospital Indicate whether In network or non network nospital Enter the name of the treating doctor Enter the qualifications of the treating doctor Enter the registration number of the doctor along with the state code Enter the phone number of doctor SECTION B DETAILS OF THE PATIENT ADMITTED Enter the name of hospital FORMAT Name of hospital in full As allocated by the TPA Name of doctor in full Abbreviations of educational qualifications As allocated by the Medical Council of India Include STD code with telephone number Name of hospital in full

13 b) IP Registration Number c) Gender d) Age e) Date of Admission f) Time g) Date of Discharge h) Time i) Type of Admission j) If Maternity Date of Delivery Gravida Status k) Status at time of discharge a) ICD 10 Code Primary Diagnosis Additional Diagnosis Co-morbidities b) ICD 10 PCS Procedure 1 Procedure 2 Procedure 3 Details of Procedure c) Pre-authorization obtained d) Pre-authorization Number e) If authorization by network hospital not obtained, give reason f) Hospitalization due to injury Cause If injury due to substance abuse/alcohol consumption, test conducted to establish this Medico Legal Reported To Police FIR No. If not reported to police, give reason Indicate which supporting documents are submitted 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 Enter insurance provider registration number Indicate Gender of the patient Enter age of the patient Enter date of admission Enter time of admission Enter date of discharge Enter time of discharge Indicate type of admission of patient Enter Date of Delivery if maternity Enter Gravida status if maternity Indicate status of patient at time of discharge SECTION C DETAILS OF AILMENT DIAGNOSED (PRIMARY) Enter the ICD 10 Code and description of the primary diagnosis Enter the ICD 10 Code and description of the additional diagnosis Enter the ICD 10 Code and description of the co-morbidities Enter the ICD 10 PCS and description of the first procedure Enter the ICD 10 PCS and description of the second procedure Enter the ICD 10 PCS and description of the third procedure Enter the details of the procedure Indicate whether pre-authorization obtained Enter pre-authorization number Enter reason for not obtaining pre-authorization number Indicate if hospitalization is due to injury Indicate cause of injury Indicate whether test conducted Indicate whether injury is medico legal Indicate whether police report was filed Enter first information report number Enter reason for not reporting to police SECTION D CLAIM DOCUMENTS SUBMITTED-CHECK LIST SECTION E DETAILS IN CASE OF NON NETWORK HOSPITAL Enter the full postal address Enter the phone number of hospital Enter the registration number of the doctor along with the state code Enter the permanent account number Enter the number of inpatient beds Indicate facilities available in the hospital SECTION F - DECLARATION BY THE INSURED As allotted by the insurance provider Tick Male or Female Number of years and months Use hh:mm format Use hh:mm format Use standard format Standard Format and Open text Standard Format and Open text Standard Format and Open text Standard Format and Open text Standard Format and Open text Standard Format and Open text Open text As allotted by TPA Open text As issued by police authorities Open Text Include Street, City and Pin Code Include STD code with telephone number As allocated by the Medical Council of India As allotted by the Income Tax department Digits. If others, please specify Read declaration carefully and mention date (in dd:mm:yy format), place (open text) and sign.