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: a) Currently covered by any oer mediclaim heal insurance: c) If es, Company Name: Sum Insured (Rs): iagnosis: Phone No.: SECTION B- ETAILS OF INSURANCE HISTOR Email I: es No b) ate of commencement of fir insurance wiout break: Policy No.: d) Have you been hospitalized in e la four years since inception of e contract : es No ate: e) Previously covered by any oer ediclaim/heal 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 Faer oer Oer Please Specify: c) ate of Bir: 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 Oer Please Specify: City: h) Phone No.: i i) obile No.: a) Name of e Hospital where admitted: State: SECTION - ETAILS OF HOSPITALIZATION j) Email 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 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) 1. 2. 3. 4. Allopaic/ Oer syems of medicine Regiered & Corporate Office: 1 Floor, 165-166 Backbay Reclamation, H. T. Parekh arg, Churchgate, umbai 400 020. Cuomer Service Address: 6 Floor, Leela Business Park, Andheri Kurla Road, Andheri (E), umbai 400 059. Toll-free: 1800 2 700 700 (Accessible from India only) Fax: 91 22 66383699 care@hdfcergo.com www.hdfcergo.com CIN : U66010H2002PLC134869 IRA Reg No. 125. 1
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 e same. Note: It is agreed at e 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 e above format along wi proof of incurring such expenses. 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) ATA ELEENT ESCRIPTION FORAT SECTION A - ETAILS OF PRIAR INSURE a) Policy No. Enter e policy number As allotted by e insurance company b) SI. No/ Certificate No. Enter e social insurance number or e certificate As allotted by e organization number of social heal insurance scheme c) Company TPA I No. Enter e TPA I No. License number as allotted by IRA and printed in TPA documents. d) Name Enter e full name of e policyholder Surname, Fir name, iddle name e) Address SECTION B - ETAILS OF INSURANCE HISTOR a) Currently covered by any oer ediclaim/ Heal Insurance? Indicate wheer currently covered by anoer ediclaim / Heal Insurance b) ate of Commencement of fir Insurance wiout break c) Company Name Policy No. Sum Insured d) Have you been Hospitalized in e la 4 years? ate iagnosis 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) E-mail 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 wi e amounts in rupees Enter e full poal address 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 e-mail 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 Include Street, City and Pin Code Name of e organization in full As allotted by e insurance company In rupees Use mm-yy format Open Text 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 e-mail address Name of hospital in full Open Text In rupees (o not enter paise values) In rupees (o not enter paise values) Insurance is e subject matter of solicitation Regiered & Corporate Office: 1 Floor, 165-166 Backbay Reclamation, H. T. Parekh arg, Churchgate, umbai 400 020. Cuomer Service Address: 6 Floor, Leela Business Park, Andheri Kurla Road, Andheri (E), umbai 400 059. Toll-free: 1800 2 700 700 (Accessible from India only) Fax: 91 22 66383699 care@hdfcergo.com www.hdfcergo.com CIN : U66010H2002PLC134869 IRA Reg No. 125. 2
a) PAN b) Account Number c) Bank Name and Branch GUIANCE FOR FILLING CLAI FOR PART A (To be filled in by e insured) SECTION G - ETAILS OF PRIAR INSURE'S BANK ACCOUNT Enter e permanent account number Enter e bank account number Enter e bank name along wi e branch d) Cheque/ payable details Enter e name of e beneficiary e 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 e Income Tax department As allotted by e bank Name of e Bank in full Name of e individual/ organization in full e) IFSC Code Enter e IFSC code of e bank branch IFSC code of e bank branch in full Regiered & Corporate Office: 1 Floor, 165-166 Backbay Reclamation, H. T. Parekh arg, Churchgate, umbai 400 020. Cuomer Service Address: 6 Floor, Leela Business Park, Andheri Kurla Road, Andheri (E), umbai 400 059. Toll-free: 1800 2 700 700 (Accessible from India only) Fax: 91 22 66383699 care@hdfcergo.com www.hdfcergo.com CIN : U66010H2002PLC134869 IRA Reg No. 125. 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 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 anoer 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-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 ii) If Injury due to Subance abuse/ alcohol consumption, Te Conducted to eablish is: es No iii) edico Legal: es No iv) Reported to Police : es No v) FIR No: vi) If not reported to Police give reasons : No (If yes, attach reports) SECTION CLAI OCUENTS SUBITTE CHECKLIST 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 Inveigation 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 a) Address of e Hospital: SECTION E ETAILS IN CASE OF NON NETWORK HOSPITAL City: State: Pin Code: b) Phone No.: 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 No 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. ate: Place: Signature and seal of e Hospital Auority Regiered & Corporate Office: 1 Floor, 165-166 Backbay Reclamation, H. T. Parekh arg, Churchgate, umbai 400 020. Cuomer Service Address: 6 Floor, Leela Business Park, Andheri Kurla Road, Andheri (E), umbai 400 059. Toll-free: 1800 2 700 700 (Accessible from India only) Fax: 91 22 66383699 care@hdfcergo.com www.hdfcergo.com CIN : U66010H2002PLC134869 IRA Reg No. 125. 4
a) Name of Hospital b) Hospital I c) Type of Hospital d) Name of treating doctor e) Qualification f) Regiration No. wi 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-auorization obtained e) Pre-auorization Number f) If auorization 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 is GUIANCE FOR FILLING CLAI FOR PART B (To be filled in by e hospital) ATA ELEENT ESCRIPTION FORAT SECTION A - ETAILS OF HOSPITAL Enter e name of hospital Enter I number of hospital Indicate wheer In network or non network Hospital Enter e name of e treating doctor Enter e qualifications of e treating doctor Enter e regiration number of e doctor along wi As allocated by e edical Council of India e ate code Enter e phone number of doctor Include ST code wi telephone number SECTION B - ETAILS OF THE PATIENT AITTE Enter e name of hospital Name of hospital in full Enter insurance provider regiration number As allotted by e insurance provider Indicate Gender of e patient Tick ale or Female Enter age of e patient Number of years and mons 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 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 present ailment is a complication of some pre- exiing disease 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 Reported To Police Indicate wheer police report was filed 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 a) b) Address Phone No. Enter e full poal address Enter e phone number of hospital c) d) Regiration No. PAN Enter e regiration number of patient 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 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 e 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 wi telephone number As allocated by e Hospital As allotted by e Income Tax department igits. If oers, please Regiered & Corporate Office: 1 Floor, 165-166 Backbay Reclamation, H. T. Parekh arg, Churchgate, umbai 400 020. Cuomer Service Address: 6 Floor, Leela Business Park, Andheri Kurla Road, Andheri (E), umbai 400 059. Toll-free: 1800 2 700 700 (Accessible from India only) Fax: 91 22 66383699 care@hdfcergo.com www.hdfcergo.com CIN : U66010H2002PLC134869 IRA Reg No. 125. 5
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. 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. CHECK LIST OF ENCLOSURES FOR SUBISSION OF CLAI Note: 1. When original bills, receipts, prescriptions, reports and oer documents are submitted to e oer insurer or to e reimbursement provider, verified photocopies atteed by such oer organisation/ provider have to be submitted. 2. If original bills, receipts, prescriptions, reports and oer documents are submitted to Us and Insured Person requires same for claiming from oer organisation/ provider, en on reque from e Insured Person We will provide atteed copies of e bills and oer documents submitted by e Insured Person. 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 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) 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, 165-166 Backbay Reclamation, H. T. Parekh arg, Churchgate, umbai 400 020. Cuomer Service Address: 6 Floor, Leela Business Park, Andheri Kurla Road, Andheri (E), umbai 400 059. Toll-free: 1800 2 700 700 (Accessible from India only) Fax: 91 22 66383699 care@hdfcergo.com www.hdfcergo.com CIN : U66010H2002PLC134869 IRA Reg No. 125. 6