CLAIM FORM - PART A. TO BE FILLED IN BY THE INSURED The issue of this Form is not to be taken as an admission of liability

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1 CLAIM FORM - PART A TO BE FILLED IN BY THE INSURED The ssue of ths Form s not to be tken s n dmsson of lblty (To be flled n block letters) SECTION A - DETAILS OF PRIMARY INSURED Polcy No b Sl. No/Certfcte No: c Compny/TPA ID No d Nme e Address Cty Phone no Stte Eml ID Pncode SECTION B - DETAILS OF INSURANCE HISTORY Currently covered by ny other Medclm/Helth nsurnce Yes No Copes of polces to be ttched b Dte of commencement of frst nsurnce wthout brek c If Yes, Compny Nme Polcy No. Sum Insured d Hve you been hosptlzed n the lst four yers? Yes No Dte Dgnoss e Prevously covered by ny other Medclm/Helth nsurnce Yes No f If yes, Compny Nme SECTION C - DETAILS OF INSURED PERSON HOSPITALISED Nme b Gender Mle Femle c Age Yers Y Y Months M M d Dte of Brth e Reltonshp to Prmry Insured Self Spouse Chld Fther Mother Other (Plese Specfy) f Occupton Servce Self-employed Homemker Student Retred Other (Plese Specfy) g Detls of the tretment expenses clmed Address (f dfferent from bove) h Telephone No Moble No j Cty Eml ID Nme of the Hosptl where dmtted Pre-hosptlston Expenses Post-hosptlston Expenses v Ambulnce Chrges Stte SECTION D - DETAILS OF HOSPITALISATION SECTION E - DETAILS OF CLAIM Hosptlston Expenses v Helth-Check up Cost v Others (code) v Pre-hosptlston Perod dys v Post - hosptlston Perod dys b Clm for Domclry Hosptlzton Yes No (f yes, plese provde detls n nnexure) Totl Pncode b Room Ctegory occuped Dycre Sngle Occupncy Twn Shrng 3 or more beds per room c Hosptllston due to Illness Injury Mternty d Dte of Injury/Dte of dsese frst detected/dte of delvery e Dte of dmsson f Tme H H M M g Dte of dschrge h Tme H H M M If njury, gve cuse Self-Inflcted Rod Trffc Accdent Substnce Abuse Alcohol Consumpton If Medco legl Yes No Reported to polce? Yes No MLC Report, & Polce FIR ttched? Yes No j System of medcne

2 c Detls of Lumpsum/csh beneft clmed: Hosptl Dly Csh Crtcl Illness Beneft v Pre/Post hosptlston lumpsum beneft Clm Documents Submtted - Check Lst: Clm Form duly flled nd sgned Hosptl Mn Bll Hosptl Bll Pyment Recept Phrmcy Bll ECG Investgton Reports (Includng CT, MRI/USG/HPE) Others Surgcl Csh v Convlescence v Others Totl - Copy of clm ntmton Hosptl Brek Up bll Hosptl Dschrge Summry Operton Thetre Notes Doctor s Request for Investgton Doctor s Prescrpton SECTION - F DETAILS OF BILLS ENCLOSED S. No. Bll No. Dte Issued by Towrds Amount () D D M M Y Y Hosptl Mn Bll Pre Hosptlston Blls (.Nos) Post Hosptlston Blls ( Nos) Phrmcy Blls SECTION - G DETAILS OF PRIMARY INSURED S BANK ACCOUNT PAN b Account Number c d Bnk Nme & Brnch Cheque / DD Pyble detls e IFSC Code *plese ttch cncelled cheque pertnng to the sme f MICR No SECTION H - DECLARATION BY THE INSURED I hereby declre tht the nformton furnshed n ths clm form s true & correct to the best of my knowledge nd belef. If I hve mde ny flse or untrue sttement, suppresson or concelment of ny mterl fct, my rght to clm rembursement shll be forfeted. I lso consent & uthorze TPA / nsurnce compny, to seek necessry medcl nformton/documents from ny hosptl/medcl Prcttoner who hs ttended on the person gnst whom ths clm s mde. I hereby declre tht I hve ncluded ll the blls/recepts for the purpose of ths clm & tht I wll not be mkng ny supplementry clm except the pre/post-hosptlzton clm, f ny. Dte: Plce: *plese ttch cncelled cheque pertnng to the sme Sgnture of Insured

3 GUIDANCE FOR FILLING CLAIM FORM - PART A (To be flled n by the nsured) DATA ELEMENT DESCRIPTION FORMAT SECTION A - DETAILS OF PRIMARY INSURED ) Polcy No. b) SI. No/Certfcte No. c) Compny TPA ID No. d) Nme e) Address Enter the polcy number Enter the socl nsurnce number or the certfcte number of socl helth nsurnce scheme Enter the TPA ID No Enter the full nme of the polcyholder Enter the full postl ddress As llotted by the nsurnce compny As llotted by the orgnzton Lcense number s llotted by IRDA nd prnted n TPA documents. Surnme, Frst nme, Mddle nme Include Street, Cty nd Pn Code SECTION B - DETAILS OF INSURANCE HISTORY ) Currently covered by ny other Medclm/ Helth Insurnce? b) Dte of Commencement of frst Insurnce wthout brek c) Compny Nme Polcy No. Sum Insured d) Hve you been Hosptlzed n the lst four yers snce ncepton of the contrct Dte Dgnoss e) Prevously Covered by ny other Medclm/ Helth Insurnce? f) Compny Nme Indcte whether currently covered by nother Medclm/ Helth Insurnce Enter the dte of commencement of frst nsurnce Enter the full nme of the nsurnce compny Enter the polcy number Enter the totl sum nsured s per the polcy Indcte whether hosptlzed n the lst four yers Enter the dte of hosptlzton Enter the dgnoss detls Indcte whether prevously covered by nother Medclm/ Helth Insurnce Enter the full nme of the nsurnce compny Nme of the orgnzton n full As llotted by the nsurnce compny In rupees Use mm-yy formt Open Text Nme of the orgnzton n full SECTION C - DETAILS OF INSURED PERSON HOSPITALIZED ) Nme b) Gender c) Age d) Dte of Brth e) Reltonshp to prmry Insured f) Occupton g) Address h) Phone No ) E-ml ID Enter the full nme of the ptent Indcte Gender of the ptent Enter ge of the ptent Enter Dte of Brth of ptent Indcte reltonshp of ptent wth polcyholder Indcte occupton of ptent Enter the full postl ddress Enter the phone number of ptent Enter e-ml ddress of ptent Surnme, Frst nme, Mddle nme Tck Mle or Femle Number of yers nd months. If others, plese specfy.. If others, plese specfy. Include Street, Cty nd Pn Code Include STD code wth telephone number Complete e-ml ddress SECTION D - DETAILS OF HOSPITALIZATION ) Nme of Hosptl where dmtted b) Room ctegory occuped c) Hosptlzton due to Enter the nme of hosptl Indcte the room ctegory occuped Indcte reson of hosptlzton Nme of hosptl n full d) Dte of Injury/Dte Dsese frst detected/ Dte of Delvery e) Dte of dmsson f) Tme g) Dte of dschrge h) Tme ) If Injury gve cuse If Medco legl Reported to Polce MLC Report & Polce FIR ttched j) System of Medcne Enter the relevnt dte Enter dte of dmsson Enter tme of dmsson Enter dte of dschrge Enter tme of dschrge Indcte cuse of njury Indcte whether njury s medco legl Indcte whether polce report ws fled Indcte whether MLC report nd Polce FIR ttched Enter the system of medcne followed n tretng the ptent Use hh:mm formt Use hh:mm formt Open Text SECTION E - DETAILS OF CLAIM ) Detls of Tretment Expenses b) Clm for Domclry Hosptlzton c) Detls of Lump sum/csh beneft clmed d) Clm Documents Submtted-Check Lst Enter the mount clmed s tretment expenses Indcte whether clm s for domclry hosptlzton Enter the mount clmed s lump sum/csh beneft Indcte whch supportng documents re submtted In rupees (Do not enter pse vlues) In rupees (Do not enter pse vlues) SECTION F - DETAILS OF BILLS ENCLOSED Indcte whch blls re enclosed wth the mounts n rupees

4 DATA ELEMENT DESCRIPTION SECTION G - DETAILS OF PRIMARY INSURED S BANK ACCOUNT ) PAN Enter the permnent ccount number b) Account Number Enter the bnk ccount number c) Bnk Nme nd Brnch Enter the bnk nme long wth the brnch d) Cheque/DD pyble detls Enter the nme of the benefcry the cheque/dd should be mde out to e) IFSC Code Enter the IFSC code of the bnk brnch SECTION H - DECLARATION BY THE INSURED Red declrton crefully nd menton dte (n dd:mm:yy formt), plce (open text) nd sgn. FORMAT As llotted by the Income Tx Deprtment As llotted by the bnk Nme of the Bnk n full Nme of the ndvdul/orgnzton n full IFSC code of the bnk brnch n full

5 CLAIM FORM - PART B TO BE FILLED IN BY THE HOSPITAL The ssue of ths Form s not to be tken s n dmsson of lblty Plese nclude the orgnl preuthorzton request form n leu of PART A (To be flled n block letters) SECTION A - DETAILS OF HOSPITAL Nme of the Hosptl b Hosptl ID c Type of Hosptl Network Non Network (If non network fll form secton E) d Nme of the tretng Doctor e Qulfcton f Regstrton No wth stte Code g Phone No: SECTION B - DETAILS OF PATIENT ADMITTED Nme of the ptent b IP Regstrton Number c Gender Mle Femle d Age Yers Y Y Months M M e Dte of Brth f Dte of Admsson g Tme of Admsson H H M M h Dte of Dschrge Tme of Dschrge H H M M j Type of Admsson Emergency Plnned Dycre Mternty k If Mternty Dte of Delvery Grvd Sttus l Sttus t tme of dschrge Dschrged to Home Dschrged to nother Hosptl Decesed SECTION C - DETAILS OF AILMENTS DIAGNOSED (PRIMARY) ICD 10 Code Descrpton b ICD 10 PCS Descrpton Prmry Dgnoss Addtonl Dgnoss Co-morbdtes c Present lment s complcton of PED? Yes No If Yes, specfy detls Clm form duly flled nd sgned Orgnl pre uthorzton request Copy of pre-uthorzton pprovl letter Copy of photo d crd of ptent verfed by hosptl Hosptl dschrge summry Operton thetre notes Hosptl mn bll Hosptl brek up bll Address of the Hosptl Cty SECTION D - CLAIM DOCUMENTS SUBMITTED - CHECKLIST Investgton reports CT/MRI/USG/HPE nvestgton report Doctor s reference slp for nvestgton ECG Phrmcy blls MLC report & polce FIR Orgnl deth summry from hosptl where pplcble Any other, plese specfy SECTION E - DETAILS IN CASE OF NON NETWORK HOSPITAL (Only fll n cse of Non Network Hosptl) b Phone No: c Regstrton no wth Stte Code d Hosptl PAN e No of In-ptent Beds f Fcltes vlble n Hosptl OT Yes No ICU Yes No Others Stte Detls of Procedure 1 Detls of Procedure 2 Detls of Procedure 3 d Pre-uthorzton obtned Yes No e Pre-uthorzton Number f If uthorzton by network hosptl not obtned, gve reson g Hosptlston due to Injury Yes No If yes, gve cuse Self nflcted? Yes No Rod Trffc Accdent Yes No Substnce Abuse/Alcohol Consumpton Yes No If Injury due to Substnce buse/lcohol consumpton, Test Conducted to estblsh ths: Yes No (If yes, ttch reports) If Medco Legl Yes No v Reported to Polce Yes No v FIR No v If not reported to Polce gve resons v Detls of Procedure Pncode

6 (PLEASE READ VERY CAREFULLY) SECTION F - DECLARATION BY THE INSURED I hereby declre tht the nformton furnshed n ths clm form s true & correct to the best of my knowledge nd belef. If I hve mde ny flse or untrue sttement, suppresson or concelment of ny mterl fct, my rght to clm rembursement shll be forfeted. I lso consent & uthorze TPA/nsurnce compny, to seek necessry medcl nformton/documents from ny hosptl/medcl Prcttoner who hs ttended on the person gnst whom ths clm s mde. I hereby declre tht I hve ncluded ll the blls/recept for the purpose of ths clm & tht I wll not be mkng ny supplementry clm expect the pre/post hosptlzton clm, f ny, Dte: Plce: Sgnture of the Insured (PLEASE READ VERY CAREFULLY) SECTION G - DECLARATION BY HOSPITAL We hereby declre tht the nformton furnshed n ths Clm Form s true & correct to the best of our knowledge nd belef. If we hve mde ny flse or untrue sttement, suppresson or concelment of ny mterl fct, our rght to clm under ths clm shll be forfeted. The sgnture of the nsured s tken on ths form fter clm form B s fully flled up by us. Dte: Plce: Tretng Doctor Sgnture nd sel of the Hosptl Authorty

7 GUIDANCE FOR FILLING CLAIM FORM - PART B (To be flled n by the hosptl) DATA ELEMENT DESCRIPTION FORMAT SECTION A - DETAILS OF HOSPITAL ) Nme of Hosptl b) Hosptl ID c) Type of Hosptl d) Nme of tretng doctor e) Qulfcton f) Regstrton No. wth Stte Code g) Phone No. ) Nme of Ptent b) IP Regstrton Number c) Gender d) Age e) Dte of Brth e) Dte of Admsson f) Tme g) Dte of Dschrge h) Tme ) Type of Admsson j) If Mternty Dte of Delvery Grvd Sttus k) Sttus t tme of dschrge l) Totl clmed mount ) ICD 10 Code Prmry Dgnoss Addtonl Dgnoss Co-morbdtes b) ICD 10 PCS Procedure 1 Procedure 2 Procedure 3 Detls of Procedure c) Present Alment s Complcton of PED d) Pre-uthorzton obtned e) Pre-uthorzton Number f) If uthorzton by network hosptl not obtned, gve reson g) Hosptlzton due to njury Cuse If njury due to substnce buse/lcohol Enter the nme of hosptl Enter ID number of hosptl Indcte whether In network or non network Hosptl Enter the nme of the tretng doctor Enter the qulfctons of the tretng doctor Enter the regstrton number of the doctor long wth the stte code Enter the phone number of doctor SECTION B - DETAILS OF THE PATIENT ADMITTED Enter the nme of hosptl Enter nsurnce provder regstrton number Indcte Gender of the ptent Enter ge of the ptent Enter dte of dmsson Enter tme of dmsson Enter dte of dschrge Enter tme of dschrge Indcte type of dmsson of ptent Enter Dte of Delvery f mternty Enter Grvd sttus f mternty Indcte sttus of ptent t tme of dschrge Indcte the totl clmed mount SECTION C - DETAILS OF AILMENT DIAGNOSED (PRIMARY) Enter the ICD 10 Code nd descrpton of the prmry dgnoss Enter the ICD 10 Code nd descrpton of the ddtonl dgnoss Enter the ICD 10 Code nd descrpton of the co-morbdtes Enter the ICD 10 PCS nd descrpton of the frst procedure Enter the ICD 10 PCS nd descrpton of the second procedure Enter the ICD 10 PCS nd descrpton of the thrd procedure Enter the detls of the procedure Indcte whether present lment s complcton of some pre- exstng dsese Indcte whether pre-uthorzton obtned Enter pre-uthorzton number Enter reson for not obtnng pre-uthorzton number Indcte f hosptlzton s due to njury Indcte cuse of njury Indcte whether test conducted consumpton, test conducted to estblsh ths Medco Legl Indcte whether njury s medco legl Reported To Polce Indcte whether polce report ws fled FIR No. Enter frst nformton report number If not reported to polce, gve reson Enter reson for not reportng to polce SECTION D - CLAIM DOCUMENTS SUBMITTED-CHECK LIST Indcte whch supportng documents re submtted Nme of hosptl n full As llocted by the TPA Nme of doctor n full Abbrevtons of eductonl qulfctons As llocted by the Medcl Councl of Ind Include STD code wth telephone number Nme of hosptl n full As llotted by the nsurnce provder Tck Mle or Femle Number of yers nd months Use hh:mm formt Use hh:mm formt Use stndrd formt In rupees (do not enter pse vlues) Open text As llotted by TPA Open text As ssued by polce uthortes Open Text

8 DATA ELEMENT DESCRIPTION SECTION E - DETAILS IN CASE OF NON NETWORK HOSPITAL ) Address Enter the full postl ddress b) Phone No. Enter the phone number of hosptl c) Regstrton No. wth Stte Code Enter the regstrton number of ptent d) Hosptl PAN Enter the permnent ccount number e) Number of Inptent Beds Enter the number of nptent beds f) Fcltes vlble n the hosptl Indcte fcltes vlble n the hosptl SECTION F - DECLARATION BY THE INSURED Red declrton crefully nd menton dte (n dd:mm:yy formt), plce (open text) nd sgn. SECTION G - DECLARATION BY THE HOSPITAL Red declrton crefully nd menton dte (n dd:mm:yy formt), plce (open text) nd sgn nd stmp. FORMAT Include Street, Cty nd Pn Code Include STD code wth telephone number As llocted by the Hosptl As llotted by the Income Tx deprtment Dgts. If others, plese specfy

CLAIM FORM - PART A. TO BE FILLED IN BY THE INSURED The issue of this Form is not to be taken as an admission of liability

CLAIM FORM - PART A. TO BE FILLED IN BY THE INSURED The issue of this Form is not to be taken as an admission of liability CLAIM FORM - PART A TO BE FILLED IN BY THE INSURED The ssue of ths Form s not to be tken s n dmsson of lblty SECTION A - DETAILS OF PRIMARY INSURED c d e Polcy No Compny/TPA ID No Nme Address b Sl. No/Certfcte