PARAMOUNT HEALTH SERVICES & INSURANCE TPA PRIVATE LIMITED (IRDA License No. 006) [formerly known as PARAMOUNT HEALTH SERVICES (TPA) PVT.
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1 PARAMOUNT HEALTH SERVICES & INSURANCE TPA PRIVATE LIMITE (IRA License No. 006) [formerly known as PARAMOUNT HEALTH SERVICES (TPA) PVT.LT] Plot no.a-442, Road No-28,M.I..C Indurial Area, Wagale Eate, Ram Nagar, Vital Rukmani Mandir, Thane (W), Mumbai, Pin Code Name of Insurer : Policy No : Insured Name : Patient Name : PHS I : Employee No : Mobile No : Phone (ST) : Name of Corporate: I : Type of Claim : CLAIM OCUMENT CHECK LIST ocument Sr. No escription Status 1 IRA Claim Form duly signed by e Insured 2 Policy Copy CLAIM ACKNOWLEGMENT SHEET 3 64VB Compliance Certificate Original Cancelled Cheque copy of Employee/Proposer wi e name of e Account 4 Holder Printed on e Cheque Leaf. Main Hospitalisation / Pre-Po Hospitalisation / OP Claim / eficiency Retrieval / Critical Illness / Cash Benefit Remarks 5 Photo Identity & Address Proof of Insured (In case claim amount is 1 lac & above) 6 Original detailed ischarge Summary / ay care summary from e hospital in case of ay Care Treatment / ea Summary in Case of ea Claim a) Copy of e Legal heir certificate, if e claim is for e dea of e principle insured. b) Copy of Po Mortem Report & ea Certificate (In Accidental ea cases) 7 Original Final Hospital bill wi breakup of each Item 8 Original Payment Receipt of Main Hospital bill ( bo eposit / Refund) 9 a) Receipt Of Payments made at e Hospital by Credit Card : Please attach e Xerox Copy of e Credit Card Payment Slip as received from e Vendor Original copy of Implant Invoice along wi Payment Receipts & Implant Labels / Stickers for Stents/Mesh/IOL 10 Original bills, original Payment Receipts and inveigation / Laboratory Reports Original medicine bills specifying Patient Name and date of purchase along wi 11 supporting Prescriptions. 12 Original copy of Fir Consultation letter and subsequent Prescriptions. In case of No / elay Intimation & elay in submission of claim, a letter from insured is 13 required ating reason for e same 14 OTHER OCUMENTS Original copy of Obetric hiory (Gravida, Para, Living children, Abortions) from a treating doctor. (Maternity Claim) b c d e f Original Sonography Report in case of Maternity Claim Original A-Scan Report along wi IOL Sticker and Tax paid invoice in case of Cataract Claim Copy of e Fir Information Report (FIR) from Police epartment / Copy of e Medico-Legal Certificate (MLC) in case of Road Traffic Accident (RTA) A medical certificate from a doctor not less qualified an M/MS confirming e diagnosis of critical illness along wi e Inveigation reports/oer related documents reflecting e critical illness diagnosis. (Critical Illness Cases) In case of claims where e insured has submitted documents to anoer insurance co. /TPA, he needs to submit atteed Photocopies of all e documents along wi detailed claim settlement letter from e TPA and any unpaid bills and receipt for e same in originals. Claims Submitted by : Insured / Corporate / Agent / Broker / Insurer / Hopsital Claim Submitted by: Mobile No.
2 ate of Claim Submission: PHS Executive Name: /MM/ HH:MM Claim Submitted at: PHS -(Location)/ Help esk Signature: Important Points to Remember:- 1. Please mark eier or again respective check box 2. ate of File Received will be considered as next working day for Claim Files picked up at Help esk 3. Claim Need to be Submitted wiin 7 Working ays from ate of ischarge from Hospital 4. The above li of documents is indicative. In case of any oer document requirement as specified by e Insurance Company, our document recovery team will contact you on receipt of your claim documents by us 5. Please visit us at to check Online Claim Status or download Paramount Mobile App 6. Member is advised to keep photocopies of all e papers since Insurer requires all e above documents in original. ocuments once submitted will not returned unless approved & agreed by Insurer 7. Corrections in any documents are not allowed
3 HFC ERGO General Insurance Company Limited GROUP MEICLAIM INSURANCE Name of Policyholder: Policy No.: INSURE S INFORMATION Certificate No.: (If applicable) Name of Patient: Occupation: Address and phone number: CLAIMANT INFORMATION ate of Bir: M M Present completed age: Relationship to e Policyholder: 1. Nature of sickness/ diseaes/ injury claimed for: Member/ Employee Spouse ependent Child ependent Moer ependent Faer ate on which Injury was suained or disease or illness fir detected: M M ate of fir consultation: M M Name of octor: Address, Phone No. of octor: Qualification of e octor consulted: 2. Have you had any prior treatment for is or related conditions? Name of octor: Address, Phone No. of octor: es No Qualification of e octor: ate: M M 3. Are you making any oer insurance claim as a result of is hospitalization/surgery?: Name of Insurance Company: Policy No.: 4. Was e hospitalization/ surgery a result of an accident? es No es No 5. Place of Accident: ate of Accident: M M 6. etails of hospitalisation: Name of Hospital/ Nursing Home: Address: ate of Admission: 7. CLAIM QUANTUM: M M ate of ischarge: M M ate Nature of expenses incurred Billed By Amount (`) (If space is insufficient, please attach separate li) In support of e above claim, I enclose e following original documents (Please tick) Hospital ischarge Card Bills, Cash Memos, Receipt from Hospitals Cash Memos, Receipts from Pharmacis, Paology and Inveigation Centres Bills, Cash Memos, Receipts from attending octors, Surgeons, Anehetis octor s prescriptions for medicines, paological tes, hospitalisation, surgery, physioerapy Any oer documents. Please specify I/ We e above named, do hereby, to e be of my/our knowledge and belief, warrant e tru of e foregoing atement in every respect, and I/We agree at if I/We have made, or in any furer declaration e Company may require in respect of e said claim, shall make any false or fraudulent atement, or any suppression or concealment e Policy shall be void and all rights to recover ereunder in respect of pa or future claims shall be forfeited. I/We hereby underand, declare, consent and auorise e Company at personal heal details, medical hiory and financial information, as provided to e Company may be utilised for processing e claim made under e Policy. I/We hereby also underand, declare and consent at e Company shall have right to retain and disseminate e same to any service provider for providing services related to insurance. AUTHORISATION I HEREB AUTHORISE on behalf of e patient: (1) Any empl oyer, medical practitioner, hospital, clinic, insurance company, bank, government initution, or oer organisation, initution or person, at has any records or knowledge of e patient and/or who has attended or may hereafter attend e patient to disclose such information to HFC ERGO General Insurance Company; (2) HFC ERGO General Insurance Company or any of its appointed medical examiners or laboratories to perform e necessary medical assessment and tes to evaluate e heal atus of e patient in relation to is claim. This auorisation shall bind e patient s successors and remains valid notwianding dea or incapacity. A photocopy or facsimile copy of is auorisation shall be as valid as e original. Total ate: M M Signature of Patient Regiered & Corporate Office: 1 Floor, Backbay Reclamation, H. T. Parekh Marg, Churchgate, Mumbai Cuomer Service Address: 6 Floor, Leela Business Park, Andheri Kurla Road, Andheri (E), Mumbai Toll-free: (Accessible from India only) Fax: care@hdfcergo.com CIN : U66010MH2002PLC IRA Reg No. 125.
4 This is to certify at e above-mentioned claim lodged by e Insured / Claimant is genuine and e same is recommended for reimbursement. ate: M M Auorised Signatory Name of Attending Physician: Address, Phone No.: I certify at e above named patient, was seen by me on and has been fully cured of e sickness/injury claimed for, which fir incurred on I underand at any person who knowingly and wi intent to defraud or deceive any insurance company files a claim containing any materially false, incomplete or misleading information may be subject to prosecution for insurance fraud. ate: M M SIGNE (Attending Physician) Name of e Policy holder & Seal: ate: M M ATTENING PHSICIAN INFORMATION Regiered & Corporate Office: 1 Floor, Backbay Reclamation, H. T. Parekh Marg, Churchgate, Mumbai Cuomer Service Address: 6 Floor, Leela Business Park, Andheri Kurla Road, Andheri (E), Mumbai Toll-free: (Accessible from India only) Fax: care@hdfcergo.com CIN : U66010MH2002PLC IRA Reg No. 125.
5 HFC ERGO General Insurance Company Limited Consent for Mode of Claim Payment Name of Insured Policy Number Claim Number Beneficiary Name Mode of Payment Cheque Fund Transfer (Please tick for mode of payment) Insured s Name as per Bank Account Bank Account Number (All Fields are Mandatory 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 Mr./ Mrs/ Ms. 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. Signature of Beneficiary Stamp Required in case of Company ate: M M Regiered & Corporate Office: 1 Floor, Backbay Reclamation, H. T. Parekh Marg, Churchgate, Mumbai Cuomer Service Address: 6 Floor, Leela Business Park, Andheri Kurla Road, Andheri (E), Mumbai Toll-free: (Accessible from India only) Fax: care@hdfcergo.com CIN : U66010MH2002PLC IRA Reg No. 125.
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PARAMOUNT HEALTH SERVICES & INSURANCE TPA PRIVATE LIMITED (IRDA License No. 006) [formerly known as PARAMOUNT HEALTH SERVICES (TPA) PVT.
PARAMOUNT HEALTH SERVICES & INSURANCE TPA PRIVATE LIMITED (IRDA License No. 006) [formerly known as PARAMOUNT HEALTH SERVICES (TPA) PVT.LTD] Plot no.a-442, Road No-28,M.I.D.C Industrial Area, Wagale Estate,
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PARAMOUNT HEALTH SERVICES & INSURANCE TPA PRIVATE LIMITED (IRDA License No. 006) [formerly known as PARAMOUNT HEALTH SERVICES (TPA) PVT.
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PARAMOUNT HEALTH SERVICES & INSURANCE TPA PRIVATE LIMITED (IRDA License No. 006) [formerly known as PARAMOUNT HEALTH SERVICES (TPA) PVT.
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