HDFC ERGO General Insurance Company Limited

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1 HFC ERGO General Insurance Company Limited CLAI FOR FOR HEALTH INSURANCE POLICIES OTHER THAN TRAVEL AN PERSONAL ACCIENT CLAI FOR PART A To be filled in by e Insured The issue of is form is not to be taken as an admission of liability (To be filled in block letters) SECTION A ETAILS OF PRIAR INSURE a) Policy No.: c) Company/ TPA I No.: d) Name: e) Address: b) Sl. No/ Certificate No.: S U R N A E F I R S T N A E I L E N A E City: State: Pin Code: Phone No.: SECTION B- ETAILS OF INSURANCE HISTOR I: a) Currently covered by any oer mediclaim heal insurance: es No b) ate of commencement of fir insurance wiout break: c) If es, Company Name: e) Sum Insured (Rs): iagnosis: d) Policy No.: f) Have you been hospitalized in e la four years since inception of e contract : es No ate: g) Previously covered by any oer ediclaim/heal insurance: es No h) If es, Company Name: a) Name: b) Gender: e) Relationship to primary Insured: f) Occupation: g) Address (if different from above) SECTION C- ETAILS OF INSURE PERSON HOSPITALISE S U R N A E F I R S T N A E I L E N A E ale Female c) Age: d) ate of Bir: Self Spouse Child Faer oer Oer Please Specify: Service Self employed Homemaker Student Retired Oer Please Specify: City: Pin Code: a) Name of e Hospital where admitted: Phone No.: State: SECTION - ETAILS OF HOSPITALIZATION I: b) Room Category occupied: aycare Single Occupancy Twin Sharing 3 or more beds per room ownloaded from - Broker : Loyal Insurance Brokers Ltd. c) Hospitallisation due to: Illness Injury aternity d) ate of Injury/ ate of disease fir detected/ ate of delivery: e) ate of admission: f) Time: H H : g) ate of discharge: h) Time: H H : I) If injury, give cause: Self Inflicted Road Traffic Accident Subance Abuse Alcohol Consumption i i) If edico legal: es No ii) Reported to police?: es No iii) LC Report, & Police FIR attached? es No j) Syem of medicine: a) etails of e treatment expenses claimed i i) Pre-Hospitalization Expenses iii) Po-Hospitalization Expenses v) Ambulance Charges vii) Pre-Hospitalization Period ays SECTION E- ETAILS OF CLAI ii) Hospitalization Expenses iv) Heal-Check up Co vi) Oers (code) Total viii) Po -Hospitalization Period b) Claim for omiciliary Hospitalization: es No (if yes, please provide details in annexure) c) etails of Lumpsum/ cash benefit claimed: i i) Hospital aily Cash iii) Critical Illness Benefit v) Pre/Po hospitalization Lump sum benefit ii) Surgical Cash iv) Convalescence vi) Oers Total ays SECTION F ETAILS OF BILLS ENCLOSE Claim ocuments Submitted- Check Li: uly filled and signed Claim Form Copy of intimation letter, if any Hospital ain Bill Hospital Break Up bill Hospital Bill Payment Receipt Hospital ischarge Summary Pharmacy Bill Operation Theater Notes ECG octor's Reque for Inveigation octor's Prescription Inveigation Reports ( Including CT, RI/USG/HPE) Oers Sr. No. Bill No. ate Issued By Towards Amount (Rs) Hospital main bill Pre - hospitalization bills - Nos. Po - hospitalization bills - Nos. Pharmacy bills Regiered & Corporate Office: 1 Floor, Backbay Reclamation, H. T. Parekh arg, Churchgate, umbai Cuomer Service Address: 6 Floor, Leela Business Park, Andheri Kurla Road, Andheri (E), umbai Toll-free: Fax: care@hdfcergo.com CIN : U66010H2002PLC IRA Reg No

2 a) PAN: b) Account Number: c) Bank Name/ Branch: SECTION G ETAILS OF PRIAR INSURE'S BANK ACCOUNT d) Payable details: Cheque/ : e) IFSC Code: SECTION H ECLARATION B THE INSURE I hereby declare at e information furnished in is claim form is true & correct to e be of my knowledge and belief. If I have made any false or untrue atement, suppression or concealment of any material fact wi respect to queions asked in relation to is claim, my right to claim reimbursement shall be forfeited. I also consent & auorize TPA / insurance company, to seek necessary medical information / documents from any hospital / edical Practitioner who has attended on e person again whom is claim is made. I hereby declare at I have included all e bills / receipts for e purpose of is claim & at I will not be making any supplementary claim except e pre/po-hospitalization claim, if any. ate: Place: Signature of Insured: GUIANCE FOR FILLING CLAI FOR PART A (To be filled in by e insured) ownloaded from - Broker : Loyal Insurance Brokers Ltd. a) Policy No. b) SI. No/ Certificate No. c) Company TPA I No. d) Name e) Address ATA ELEENT ESCRIPTION FORAT SECTION A - ETAILS OF PRIAR INSURE Enter e policy number As allotted by e insurance company a) Currently covered by any oer ediclaim / Heal Insurance? b) ate of Commencement of fir Insurance wiout break c) Company Name d) Have you been Hospitalized in e la four years since inception of e contract? e) Previously Covered by any oer ediclaim/ Heal Insurance? f) Company Name a) Name b) Gender c) Age d) ate of Bir e) Relationship to primary Insured f) Occupation g) Address h) Phone No I) I a) Name of Hospital where admitted b) Room category occupied c) Hospitalization due to d) ate of Injury/ate isease fir detected/ ate of elivery e) ate of admission f) Time g) ate of discharge h) Time I) If Injury give cause If edico legal Reported to Police LC Report & Police FIR attached j) Syem of edicine a) etails of Treatment Expenses b) Claim for omiciliary Hospitalization c) etails of Lump sum/ cash benefit claimed d) Claim ocuments Submitted-Check Li a) PAN Policy No. Sum Insured ate iagnosis Indicate which bills are enclosed wi e amounts in rupees b) Account Number c) Bank Name and Branch d) Cheque/ payable details e) IFSC Code Enter e social insurance number or e certificate number of social heal insurance scheme Enter e TPA I No. Enter e full name of e policyholder Enter e full poal address SECTION B - ETAILS OF INSURANCE HISTOR Indicate wheer currently covered by anoer ediclaim / Heal Insurance Enter e date of commencement of fir insurance Enter e full name of e insurance company Enter e policy number Enter e total sum insured as per e policy Indicate wheer hospitalized in e la 4 years Enter e date of hospitalization Enter e diagnosis details Indicate wheer previously covered by anoer ediclaim / Heal Insurance Enter e full name of e insurance company SECTION C - ETAILS OF INSURE PERSON HOSPITALIZE Enter e full name of e patient Indicate Gender of e patient Enter age of e patient Enter ate of Bir of patient Indicate relationship of patient wi policyholder Indicate occupation of patient Enter e full poal address Enter e phone number of patient Enter address of patient SECTION - ETAILS OF HOSPITALIZATION Enter e name of hospital Indicate e room category occupied Indicate reason of hospitalization Enter e relevant date Enter date of admission Enter time of admission Enter date of discharge Enter time of discharge Indicate cause of injury Indicate wheer injury is medico legal Indicate wheer police report was filed Indicate wheer LC report and Police FIR attached Enter e syem of medicine followed in treating e patient SECTION E ETAILS OF CLAI Enter e amount claimed as treatment expenses Indicate wheer claim is for domiciliary hospitalization Enter e amount claimed as lump sum/ cash benefit Indicate which supporting documents are submitted SECTION F - ETAILS OF BILLS ENCLOSE Enter e bank account number Enter e bank name along wi e branch Enter e name of e beneficiary e cheque/ should be made out to Enter e IFSC code of e bank branch SECTION H - ECLARATION B THE INSURE As allotted by e organization License number as allotted by IRA and printed in TPA documents. Surname, Fir name, iddle name Include Street, City and Pin Code Tick es or No Name of e organization in full As allotted by e insurance company In rupees Tick es or No Use mm-yy format Open Text Tick es or No Name of e organization in full Surname, Fir name, iddle name Tick ale or Female Number of years and mons. If oers, please. If oers, please Include Street, City and Pin Code Include ST code wi telephone number Complete address Name of hospital in full Tick es or No Tick es or No Tick es or No Open Text In rupees (o not enter paise values) Tick es or No In rupees (o not enter paise values) SECTION G - ETAILS OF PRIAR INSURE'S BANK ACCOUNT Enter e permanent account number As allotted by e Income Tax department As allotted by e bank Name of e Bank in full Name of e individual/ organization in full IFSC code of e bank branch in full Insurance is e subject matter of solicitation Read declaration carefully and mention date (in dd:mm:yy format), place (open text) and sign. Regiered & Corporate Office: 1 Floor, Backbay Reclamation, H. T. Parekh arg, Churchgate, umbai Cuomer Service Address: 6 Floor, Leela Business Park, Andheri Kurla Road, Andheri (E), umbai Toll-free: Fax: care@hdfcergo.com CIN : U66010H2002PLC IRA Reg No

3 HFC ERGO General Insurance Company Limited CLAI FOR FOR HEALTH INSURANCE POLICIES OTHER THAN TRAVEL AN PERSONAL ACCIENT CLAI FOR PART B TO BE FILLE IN B THE HOSPITAL The issue of is Form is not to be taken as an admission of liability Please include e original preauorisation reque form in lieu of PART A SECTION A ETAILS OF HOSPITAL (To be filled in block letters) a) Name of e Hospital where treated: b) Hospital I: c) Type of Hospital: Network Non Network (If non network fill section E) d) Name of e treating octor: S U R N A E F I R S T N A E I L E N A E e) Qualification: f) Regiration No wi ate Code: g) Phone No: SECTION B ETAILS OF PATIENT AITTE a) Name of e patient: S U R N A E F I R S T N A E I L E N A E b) IP Regiration Number: c) Gender: ale Female d) Age: e) ate of Bir: f) ate of admission: g) Time: H H : h) ate of discharge: I) Time: H H : j) Type of Admission: Emergency Planned aycare aternity k) If aternity: I) ate of elivery ii) Gravida Status l) Status at time of discharge: ischarged to Home ischarged to anoer Hospital eceased m) Total Claimed Amount SECTION C ETAILS OF AILENTS IAGNISE (PRIAR) a) IC 10 Codes escription b) IC 10 PCS escription Primary iagnosis Procedure 1 Additional iagnosis Procedure 2 Co-morbidities Procedure 3 Co-morbidities etails of Procedure: c) Pre-auorization obtained: es No d) Pre-auorization Number: e) If auorization by network hospital not obtained, give reason: f) Hospitalization due to Injury: i i) If yes, give cause Self inflicted? Road Traffic Accident Subance Abuse /Alcohol Consumption ownloaded from - Broker : Loyal Insurance Brokers Ltd. ii) If Injury due to Subance abuse/ alcohol consumption, Te Conducted to eablish is: es iii) edico Legal: es No iv) Reported to Police : es No v) FIR No: vi) If not reported to Police give reasons : ate: Place: Claim form duly filled and signed Original Pre auorization Reque Copy of Pre-auorization approval Letter Copy of photo I card of patient verified by Hospital Hospital ischarge Summary Operation Theatre Notes Hospital ain Bill Hospital break up Bill a) Address of e Hospital: City: Pin Code: SECTION CLAI OCUENTS SUBITTE CHECKLIST No Inveigation reports No (If yes, attach reports) CT/RI/USG/HPE inveigation Report octor's reference slip for Inveigation ECG Pharmacy Bills LC Report & Police FIR Original dea summary from hospital where applicable Any oer, Pl specify SECTION E ETAILS IN CASE OF NON NETWORK HOSPITAL b) Phone No.: State: c) Regiration no wi State Code: d) Hospital PAN: e) No of In-patient Beds: f) Facilities available in Hospital: i i) OT: es No ii) ICU: es iii)oers: SECTION F ECLARATION B HOSPITAL We hereby declare at e information furnished in is Claim Form is true & correct to e be of our knowledge and belief. If we have made any false or untrue atement, suppression or concealment of any material fact, our right to claim under is claim shall be forfeited. Signature of Insured: No Regiered & Corporate Office: 1 Floor, Backbay Reclamation, H. T. Parekh arg, Churchgate, umbai Cuomer Service Address: 6 Floor, Leela Business Park, Andheri Kurla Road, Andheri (E), umbai Toll-free: Fax: care@hdfcergo.com CIN : U66010H2002PLC IRA Reg No

4 GUIANCE FOR FILLING CLAI FOR PART B (To be filled in by e hospital) ownloaded from - Broker : Loyal Insurance Brokers Ltd. ATA ELEENT ESCRIPTION FORAT a) Name of Hospital SECTION A - ETAILS OF PRIAR INSURE Enter e name of hospital Name of hospital in full b) Hospital I Enter I number of hospital As allocated by e TPA c) Type of Hospital Indicate wheer In network or non network Hospital d) Name of treating doctor Enter e name of e treating doctor Name of doctor in full e) Qualification Enter e qualifications of e treating doctor Abbreviations of educational qualifications f) Regiration No. wi State Code Enter e regiration number of e doctor along wi As allocated by e edical Council of India e ate code g) Phone No. Enter e phone number of doctor Include ST code wi telephone number SECTION B - ETAILS OF THE PATIENT AITTE a) Name of Patient Enter e name of hospital Name of hospital in full b) IP Regiration Number Enter insurance provider regiration number As allotted by e insurance provider c) Gender Indicate Gender of e patient Tick ale or Female d) Age Enter age of e patient Number of years and mons e) ate of Bir f) ate of Admission g) Time h) ate of ischarge i i) Time j) Type of Admission k) If aternity ate of elivery Gravida Status l) Status at time of discharge m) Total claimed amount a) IC 10 Code Primary iagnosis Additional iagnosis Co-morbidities b) IC 10 PCS Procedure 1 Procedure 2 Procedure 3 etails of Procedure c) Pre-auorization obtained d) Pre-auorization Number e) If auorization by network hospital not obtained, give reason f) Hospitalization due to injury Cause If injury due to subance abuse/alcohol consumption, te conducted to eablish is a) Address b) Phone No. c) Regiration No. wi State Code Enter ate of Bir of patient Enter date of admission Enter time of admission Enter date of discharge Enter time of discharge Indicate type of admission of patient Enter ate of elivery if maternity Enter Gravida atus if maternity Indicate atus of patient at time of discharge Indicate e total claimed amount SECTION C ETAILS OF AILENT IAGNOSE (PRIAR) Enter e IC 10 Code and description of e primary diagnosis Enter e IC 10 Code and description of e additional diagnosis Enter e IC 10 Code and description of e co-morbidities Enter e IC 10 PCS and description of e fir procedure Enter e IC 10 PCS and description of e second procedure Enter e IC 10 PCS and description of e ird procedure Enter e details of e procedure Indicate wheer pre-auorization obtained Enter pre-auorization number Enter reason for not obtaining pre-auorization number Indicate if hospitalization is due to injury Indicate cause of injury Indicate wheer te conducted edico Legal Indicate wheer injury is medico legal Tick es or No Reported To Police Indicate wheer police report was filed Tick es or No FIR No. Enter fir information report number As issued by police auorities If not reported to police, give reason Enter reason for not reporting to police Open Text SECTION CLAI OCUENTS SUBITTE-CHECK LIST Indicate which supporting documents are submitted SECTION E AITIONAL ETAILS IN CASE OF NON NETWORK HOSPITAL Enter e full poal address Enter e phone number of hospital Enter e regiration number of e doctor along wi e ate code d) PAN Enter e permanent account number e) Number of Inpatient Beds Enter e number of inpatient beds f) Facilities available in e hospital Indicate facilities available in e hospital SECTION F - ECLARATION B THE Read declaration carefully and mention date (in dd:mm:yy format), place (open text) and sign. Use andard format In Rupees (o not enter paise values) Open text Tick es or No As allotted by TPA Open text Tick es or No Tick es or No Include Street, City and Pin Code Include ST code wi telephone number As allocated by e edical Council of India As allotted by e Income Tax department igits. If oers, please Regiered & Corporate Office: 1 Floor, Backbay Reclamation, H. T. Parekh arg, Churchgate, umbai Cuomer Service Address: 6 Floor, Leela Business Park, Andheri Kurla Road, Andheri (E), umbai Toll-free: Fax: care@hdfcergo.com CIN : U66010H2002PLC IRA Reg No

5 In-patient Treatment /ay Care Procedures uly filled and signed Claim Form. Photocopy of I card / Photocopy of current year policy. CHECK LIST OF ENCLOSURES FOR SUBISSION OF CLAI Original etailed ischarge Summary wi date of admission & discharge, clinical hiory, pa hiory / procedure details/ ay care summary from e hospital. Original consolidated hospital bill wi break up of each Item, duly signed by e insured. Original payment Receipt of e hospital bill. Fir Consultation letter and subsequent Prescriptions. Original bills, original payment receipts and Reports for inveigation. Original medicine bills and receipts wi corresponding Prescriptions. Original invoice/sticker of implants/bills for Implants (viz. Stent /PHS esh/ IOL etc.) wi original payment receipts Road Traffic Accident In addition to e In-patient Treatment documents: Copy of e Fir Information Report from Police epartment / Copy of e edico-legal Certificate. In Non edico legal cases Treating octor's Certificate giving details of injuries (How, when and where injury suained) In Accidental ea cases Copy of Po ortem Report & ea Certificate (If conducted) For ea Cases In addition to e In-patient Treatment documents: Original ea Summary from e hospital. Copy of e ea certificate from treating doctor or e hospital auority. Copy of e Legal heir certificate, if e claim is for e dea of e principle insured. ownloaded from - Broker : Loyal Insurance Brokers Ltd. Pre and Po-Hospitalization expenses uly filled and signed Claim Form. Photocopy of I card / Photocopy of current year policy. Original edicine bills, original payment receipt wi prescriptions. Original Inveigations bills, original payment receipt wi prescriptions and report. Original Consultation bills, original payment receipt wi prescription. Copy of e ischarge Summary of e main claim. Organ onation/transplantation In addition to e documents of general hospitalization Organ Function te / blood te proving organ failure. Treatment Certificate issued by e Transplant Surgeon of e hospital concerned. Ambulance Benefit uly filled and signed Claim Form. Photocopy of I card / Photocopy of current year policy. Original Bill wi Original Payment Receipt. Treating octor's consultation prescription indicating Emergency Hospitalization. Legal name and any oer names used (Any one of e mentioned documents) Proof of Residence (Any one of e mentioned documents) CUSTOER IENTIFICATION PROCEURE (AS PER KC NORS OF IRA) Please submit e following documents in case of claim amount exceeds 100,000 Passport/ PAN Card/ Voter's Identity Card/ riving License/ Letter from a recognized public auority or public servant verifying e identity and residence of e cuomer Telephone bill/ Bank account atement/ Letter from any recognized public auority/ Electricity bill/ Ration card Regiered & Corporate Office: 1 Floor, Backbay Reclamation, H. T. Parekh arg, Churchgate, umbai Cuomer Service Address: 6 Floor, Leela Business Park, Andheri Kurla Road, Andheri (E), umbai Toll-free: Fax: care@hdfcergo.com CIN : U66010H2002PLC IRA Reg No

6 HFC ERGO General Insurance Company Limited Consent for ode of Claim Payment Name of Insured Policy Number Claim Number Beneficiary Name ode of Payment Cheque Fund Transfer (Please tick for mode of payment) Insured s Name as per Bank Account Bank Account Number (All Fields are andatory in case of Fund Transfer) Branch Name IFSC Code address Attachments In Support of Bank etails (Please tick e type of proof submitted) Cancelled Cheque Bank Passbook Copy eclaration: I r./ rs/ s. undersigned, legal beneficiary of e above claim, declare at all details mentioned in is form are true and I agree to e mode of payment again e particular claim number mentioned above. ownloaded from - Broker : Loyal Insurance Brokers Ltd. Signature of Beneficiary Stamp Required in case of Company ate: Regiered & Corporate Office: 1 Floor, Backbay Reclamation, H. T. Parekh arg, Churchgate, umbai Cuomer Service Address: 6 Floor, Leela Business Park, Andheri Kurla Road, Andheri (E), umbai Toll-free: Fax: care@hdfcergo.com CIN : U66010H2002PLC IRA Reg No. 125.

HDFC ERGO General Insurance Company Limited

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