HDFC ERGO General Insurance Company Limited

Transcription

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 the Insured The issue of this form is not to be taken as an admission of liability a) Policy No.: c) Company/ TPA I No.: d) Name: e) Address: SECTION A ETAILS OF PRIAR INSURE 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 (To be filled in block letters) City: State: Pin Code: a) Currently covered by any other mediclaim health insurance: c) If es, Company Name: Sum Insured (Rs): iagnosis: Phone No.: SECTION B- ETAILS OF INSURANCE HISTOR I: es No b) ate of commencement of fir insurance without break: Policy No.: d) Have you been hospitalized in the la four years since inception of the contract : es No ate: e) Previously covered by any other ediclaim/health insurance: es No f) If es, Company Name: a) Name: SECTION C- ETAILS OF INSURE PERSON HOSPITALISE b) Relationship to primary Insured: Self Spouse Child Father other Other Please Specify: c) ate of Birth: d) Age: e) Address (if different from above) S U R N A E F I R S T N A E I L E N A E f) Gender: ale Female g) Occupation: Service Self employed Homemaker Student Retired Other Please Specify: City: h) Phone No.: i i) obile No.: a) Name of the Hospital where admitted: State: SECTION - ETAILS OF HOSPITALIZATION j) I: b) Room Category occupied: aycare Single Occupancy Twin Sharing 3 or more beds per room Pin Code: c) Hospitalisation 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 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 the treatment expenses claimed i i) Pre-Hospitalization Expenses iii) Po-Hospitalization Expenses v) Ambulance Charges vii) Pre-Hospitalization Period ays For any queries write to us on healthclaims@hdfcergo.com SECTION E- ETAILS OF CLAI ii) Hospitalization Expenses iv) Health-Check up Co vi) Others (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 Allopathic/ Other syems of medicine ii) Surgical Cash iv) Convalescence vi) Others Total ays 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) Others SECTION - F ETAILS OF BILLS ENCLOSE Sr. No. Bill No. ate Issued By Towards Amount (Rs) HFC ERGO General Insurance Company Limited. (Formerly HFC General Insurance Limited from Sept 14, 2016 and L&T General Insurance Company Limited upto Sept 13, 2016). CIN : U66030H2007PLC Regiered & Corporate Office: 1 Floor, HFC House, Backbay Reclamation, H. T. Parekh arg, Churchgate, umbai Cuomer Service Address: -301, 3rd Floor, Eaern Business irict (agnet all), LBS arg, Bhandup (We), umbai For more details on the risk factors, terms and conditions, please read the sales brochure before concluding the sale. Trade Logo of HFC ERGO General Insurance Company Ltd. displayed above belongs to HFC LT and ERGO International AG and used by HFC ERGO General Insurance Company under license. Toll-free: Fax: care@hdfcergo.com UIN: HFHLIP10001V HFTIOP03001V HFPAIP03002V IRAI Reg No

2 a) PAN: b) Account Number: c) Bank Name/ Branch: d) Payable details: Cheque/ : *e) IFSC Code: SECTION G ETAILS OF PRIAR INSURE'S BANK ACCOUNT *f) ICR No.: *Please attach a cancelled cheque pertaining to the same. Note: It is agreed that the Policyholder/Claimant will intimate in writing to HFC ERGO General Insurance Co. Ltd. about any change in bank account details. In an event Insured person bears expenses for treatment please provide account details of Insured Persons in the above format along with proof of incurring such expenses. SECTION H ECLARATION B THE INSURE I hereby declare that the information furnished in this claim form is true & correct to the be of my knowledge and belief. If I have made any false or untrue atement, suppression or concealment of any material fact with respect to queions 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 / edical Practitioner who has attended on the person again 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/po-hospitalization claim, if any. I/We hereby underand, declare, consent and authorise the Company that personal health details, medical hiory and financial information, as provided to the Company may be utilised for processing the claim made under the Policy. I/We hereby also underand, declare and consent that the Company shall have right to retain and disseminate the same to any service provider for providing services related to insurance. ate: Place: Signature of Insured: GUIANCE FOR FILLING CLAI FOR PART A (To be filled in by the insured) ATA ELEENT ESCRIPTION FORAT SECTION A - ETAILS OF PRIAR INSURE a) Policy No. Enter the policy number As allotted by the insurance company b) SI. No/ Certificate No. Enter the social insurance number or the certificate As allotted by the organization number of social health insurance scheme c) Company TPA I No. Enter the TPA I No. License number as allotted by IRA and printed in TPA documents. d) Name Enter the full name of the policyholder Surname, Fir name, iddle name e) Address SECTION B - ETAILS OF INSURANCE HISTOR a) Currently covered by any other ediclaim/ Health Insurance? Indicate whether currently covered by another ediclaim / Health Insurance b) ate of Commencement of fir Insurance without break c) Company Name Policy No. Sum Insured d) Have you been Hospitalized in the la 4 years? ate iagnosis e) Previously Covered by any other ediclaim/ Health Insurance? f) Company Name a) Name b) Gender c) Age d) ate of Birth e) Relationship to primary Insured f) Occupation g) Address h) Phone No i 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 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 Indicate which bills are enclosed with the amounts in rupees Enter the full poal address Enter the date of commencement of fir insurance Enter the full name of the insurance company Enter the policy number Enter the total sum insured as per the policy Indicate whether hospitalized in the la 4 years Enter the date of hospitalization Enter the diagnosis details Indicate whether previously covered by another ediclaim / Health Insurance Enter the full name of the insurance company SECTION C - ETAILS OF INSURE PERSON HOSPITALIZE Enter the full name of the patient Indicate Gender of the patient Enter age of the patient Enter ate of Birth of patient Indicate relationship of patient with policyholder Indicate occupation of patient Enter the full poal address Enter the phone number of patient Enter address of patient SECTION - ETAILS 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 LC report and Police FIR attached Enter the syem of medicine followed in treating the patient SECTION E ETAILS OF CLAI 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 - ETAILS OF BILLS ENCLOSE Include Street, City and Pin Code Name of the organization in full As allotted by the insurance company In rupees Use mm-yy format Open Text Name of the organization in full Surname, Fir name, iddle name Tick ale or Female Number of years and months. If others, please. If others, please Include Street, City and Pin Code Include ST code with telephone number Complete address Name of hospital in full Open Text In rupees (o not enter paise values) In rupees (o not enter paise values) HFC ERGO General Insurance Company Limited. (Formerly HFC General Insurance Limited from Sept 14, 2016 and L&T General Insurance Company Limited upto Sept 13, 2016). CIN : U66030H2007PLC Regiered & Corporate Office: 1 Floor, HFC House, Backbay Reclamation, H. T. Parekh arg, Churchgate, umbai Cuomer Service Address: -301, 3rd Floor, Eaern Business irict (agnet all), LBS arg, Bhandup (We), umbai For more details on the risk factors, terms and conditions, please read the sales brochure before concluding the sale. Trade Logo of HFC ERGO General Insurance Company Ltd. displayed above belongs to HFC LT and ERGO International AG and used by HFC ERGO General Insurance Company under license. Toll-free: Fax: care@hdfcergo.com UIN: HFHLIP10001V HFTIOP03001V HFPAIP03002V IRAI Reg No

3 a) PAN b) Account Number c) Bank Name and Branch GUIANCE FOR FILLING CLAI FOR PART A (To be filled in by the insured) SECTION G - ETAILS OF PRIAR INSURE'S BANK ACCOUNT Enter the permanent account number Enter the bank account number Enter the bank name along with the branch d) Cheque/ payable details Enter the name of the beneficiary the cheque/ should be made out to SECTION H - ECLARATION B THE INSURE 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 e) IFSC Code Enter the IFSC code of the bank branch IFSC code of the bank branch in full HFC ERGO General Insurance Company Limited. (Formerly HFC General Insurance Limited from Sept 14, 2016 and L&T General Insurance Company Limited upto Sept 13, 2016). CIN : U66030H2007PLC Regiered & Corporate Office: 1 Floor, HFC House, Backbay Reclamation, H. T. Parekh arg, Churchgate, umbai Cuomer Service Address: -301, 3rd Floor, Eaern Business irict (agnet all), LBS arg, Bhandup (We), umbai For more details on the risk factors, terms and conditions, please read the sales brochure before concluding the sale. Trade Logo of HFC ERGO General Insurance Company Ltd. displayed above belongs to HFC LT and ERGO International AG and used by HFC ERGO General Insurance Company under license. Toll-free: Fax: care@hdfcergo.com UIN: HFHLIP10001V HFTIOP03001V HFPAIP03002V IRAI Reg No

4 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 this Form is not to be taken as an admission of liability Please include the original preauthorisation reque form in lieu of PART A SECTION A ETAILS OF HOSPITAL (To be filled in block letters) a) Name of the Hospital where treated: b) Hospital I: c) Type of Hospital: Network Non Network (If non network fill section E) d) Name of the 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 with ate Code: g) Phone No: SECTION B ETAILS OF PATIENT AITTE a) Name of the 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 Birth: f) ate of admission: g) Time: H H : h) ate of discharge: i i) Time: H H : j) Type of Admission: Emergency Planned aycare aternity k) If aternity: i i) ate of elivery ii) Gravida Status l) Status at time of discharge: ischarged to Home ischarged to another Hospital eceased 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-authorization obtained: es No d) Pre-authorization Number: e) If authorization 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 ii) If Injury due to Subance abuse/ alcohol consumption, Te Conducted to eablish this: es No No (If yes, attach reports) iii) edico Legal: es No iv) Reported to Police : es No v) FIR No: vi) If not reported to Police give reasons : SECTION CLAI OCUENTS SUBITTE CHECKLIST Claim form duly filled and signed Original Pre authorization Reque Copy of Pre-authorization 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 Inveigation reports CT/RI/USG/HPE inveigation Report octor's reference slip for Inveigation ECG Pharmacy Bills LC Report & Police FIR Original death summary from hospital where applicable Any other, Pl specify a) Address of the Hospital: SECTION E ETAILS IN CASE OF NON NETWORK HOSPITAL City: State: Pin Code: b) Phone No.: c) Regiration no with State Code: d) Hospital PAN: e) No of In-patient Beds: f) Facilities available in Hospital: i i) OT: es No ii) ICU: es No iii)others: SECTION F ECLARATION B HOSPITAL We hereby declare that the information furnished in this Claim Form is true & correct to the 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 this claim shall be forfeited. ate: Place: Signature of Hospital: HFC ERGO General Insurance Company Limited. (Formerly HFC General Insurance Limited from Sept 14, 2016 and L&T General Insurance Company Limited upto Sept 13, 2016). CIN : U66030H2007PLC Regiered & Corporate Office: 1 Floor, HFC House, Backbay Reclamation, H. T. Parekh arg, Churchgate, umbai Cuomer Service Address: -301, 3rd Floor, Eaern Business irict (agnet all), LBS arg, Bhandup (We), umbai For more details on the risk factors, terms and conditions, please read the sales brochure before concluding the sale. Trade Logo of HFC ERGO General Insurance Company Ltd. displayed above belongs to HFC LT and ERGO International AG and used by HFC ERGO General Insurance Company under license. Toll-free: Fax: care@hdfcergo.com UIN: HFHLIP10001V HFTIOP03001V HFPAIP03002V IRAI Reg No

5 a) Name of Hospital b) Hospital I c) Type of Hospital d) Name of treating doctor e) Qualification f) Regiration No. with State Code g) Phone No. a) Name of Patient b) IP Regiration Number c) Gender d) Age e) ate of Admission f) Time g) ate of ischarge h) Time i i) Type of Admission j) If aternity ate of elivery Gravida Status k) Status at time of discharge a) IC 10 Code Primary iagnosis Additional iagnosis Co-morbidities b) IC 10 PCS Procedure 1 Procedure 2 Procedure 3 etails of Procedure c) Present Ailment is a Complication of PE d) Pre-authorization obtained e) Pre-authorization Number f) If authorization by network hospital not obtained, give reason g) Hospitalization due to injury Cause If injury due to subance abuse/alcohol consumption, te conducted to eablish this GUIANCE FOR FILLING CLAI FOR PART B (To be filled in by the hospital) ATA ELEENT ESCRIPTION FORAT SECTION A - ETAILS OF HOSPITAL Enter the name of hospital Enter I number of hospital Indicate whether In network or non network Hospital Enter the name of the treating doctor Enter the qualifications of the treating doctor Enter the regiration number of the doctor along with As allocated by the edical Council of India the ate code Enter the phone number of doctor Include ST code with telephone number SECTION B - ETAILS OF THE PATIENT AITTE Enter the name of hospital Name of hospital in full Enter insurance provider regiration number As allotted by the insurance provider Indicate Gender of the patient Tick ale or Female Enter age of the patient Number of years and months 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 SECTION C ETAILS OF AILENT IAGNOSE (PRIAR) Enter the IC 10 Code and description of the primary diagnosis Enter the IC 10 Code and description of the additional diagnosis Enter the IC 10 Code and description of the co-morbidities Enter the IC 10 PCS and description of the fir procedure Enter the IC 10 PCS and description of the second procedure Enter the IC 10 PCS and description of the third procedure Enter the details of the procedure Indicate whether present ailment is a complication of some pre- exiing disease 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 te conducted edico Legal Indicate whether injury is medico legal Reported To Police Indicate whether police report was filed FIR No. Enter fir information report number As issued by police authorities 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 a) b) Address Phone No. Enter the full poal address Enter the phone number of hospital c) d) Regiration No. PAN Enter the regiration number of patient Enter the permanent account number e) Number of Inpatient Beds Enter the number of inpatient beds f) Facilities available in the hospital Indicate facilities available in the hospital SECTION F - ECLARATION B THE INSURE Read declaration carefully and mention date (in dd:mm:yy format), place (open text) and sign. SECTION G - ECLARATION B THE HOSPITAL Read declaration carefully and mention date (in dd:mm:yy format), place (open text) and sign and amp. Name of hospital in full As allocated by the TPA Name of doctor in full Abbreviations of educational qualifications Use andard format Open text As allotted by TPA Open text Include Street, City and Pin Code Include ST code with telephone number As allocated by the Hospital As allotted by the Income Tax department igits. If others, please HFC ERGO General Insurance Company Limited. (Formerly HFC General Insurance Limited from Sept 14, 2016 and L&T General Insurance Company Limited upto Sept 13, 2016). CIN : U66030H2007PLC Regiered & Corporate Office: 1 Floor, HFC House, Backbay Reclamation, H. T. Parekh arg, Churchgate, umbai Cuomer Service Address: -301, 3rd Floor, Eaern Business irict (agnet all), LBS arg, Bhandup (We), umbai For more details on the risk factors, terms and conditions, please read the sales brochure before concluding the sale. Trade Logo of HFC ERGO General Insurance Company Ltd. displayed above belongs to HFC LT and ERGO International AG and used by HFC ERGO General Insurance Company under license. Toll-free: Fax: care@hdfcergo.com UIN: HFHLIP10001V HFTIOP03001V HFPAIP03002V IRAI Reg No

6 For eath Cases In addition to the In-patient Treatment documents: Original eath Summary from the hospital. Copy of the eath certificate from treating doctor or the hospital authority. Copy of the Legal heir certificate, if the claim is for the death of the principle insured. 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 with prescriptions. Original Inveigations bills, original payment receipt with prescriptions and report. Original Consultation bills, original payment receipt with prescription. Copy of the ischarge Summary of the main claim. Organ onation/transplantation In addition to the documents of general hospitalization Organ Function te / blood te proving organ failure. Treatment Certificate issued by the Transplant Surgeon of the hospital concerned. Ambulance Benefit uly filled and signed Claim Form. Photocopy of I card / Photocopy of current year policy. Original Bill with Original Payment Receipt. Treating octor's consultation prescription indicating Emergency Hospitalization. Legal name and any other names used (Any one of the mentioned documents) Proof of Residence (Any one of the mentioned documents) CHECK LIST OF ENCLOSURES FOR SUBISSION OF CLAI Note: 1. When original bills, receipts, prescriptions, reports and other documents are submitted to the other insurer or to the reimbursement provider, verified photocopies atteed by such other organisation/ provider have to be submitted. 2. If original bills, receipts, prescriptions, reports and other documents are submitted to Us and Insured Person requires same for claiming from other organisation/ provider, then on reque from the Insured Person We will provide atteed copies of the bills and other documents submitted by the Insured Person. 3. Original cancelled cheque with payee name printed on the cheque is required. If name of payee is not printed on the cheque please attach copy of the fir page of bank passbook 4. *Photocopy of Adhar Card /Adhar Card number is mandatory for all claims In-patient Treatment /ay Care Procedures uly filled and signed Claim Form. Photocopy of I card / Photocopy of current year policy. Original etailed ischarge Summary with date of admission & discharge, clinical hiory, pa hiory / procedure details/ ay care summary from the hospital. Original consolidated hospital bill with break up of each Item, duly signed by the insured. Original payment Receipt of the hospital bill. Fir Consultation letter and subsequent Prescriptions. Original bills, original payment receipts and Reports for inveigation. Original medicine bills and receipts with corresponding Prescriptions. Original invoice/sticker of implants/bills for Implants (viz. Stent /PHS esh/ IOL etc.) with original payment receipts Road Traffic Accident In addition to the In-patient Treatment documents: Copy of the Fir Information Report from Police epartment / Copy of the edico-legal Certificate. In Non edico legal cases Treating octor's Certificate giving details of injuries (How, when and where injury suained) In Accidental eath cases Copy of Po ortem Report & eath Certificate (If conducted) CUSTOER IENTIFICATION PROCEURE (AS PER KC NORS OF IRA) Please submit the following documents in case of claim amount exceeds 100,000 Passport/ PAN Card/ Voter's Identity Card/ riving License/ Letter from a recognized public authority or public servant verifying the identity and residence of the cuomer Telephone bill/ Bank account atement/ Letter from any recognized public authority/ Electricity bill/ Ration card HFC ERGO General Insurance Company Limited. (Formerly HFC General Insurance Limited from Sept 14, 2016 and L&T General Insurance Company Limited upto Sept 13, 2016). CIN : U66030H2007PLC Regiered & Corporate Office: 1 Floor, HFC House, Backbay Reclamation, H. T. Parekh arg, Churchgate, umbai Cuomer Service Address: -301, 3rd Floor, Eaern Business irict (agnet all), LBS arg, Bhandup (We), umbai For more details on the risk factors, terms and conditions, please read the sales brochure before concluding the sale. Trade Logo of HFC ERGO General Insurance Company Ltd. displayed above belongs to HFC LT and ERGO International AG and used by HFC ERGO General Insurance Company under license. Toll-free: Fax: care@hdfcergo.com UIN: HFHLIP10001V HFTIOP03001V HFPAIP03002V IRAI Reg No