INSURANCE TPA SERVICES (I) PVT.LT. 6B, Paul ansions, Bishop Lefroy Road, Kolkata 700 020, West Bengal, India ETAILS OF PRIAR INSURE (To be filled in block letters) a) Policy b) Company/ TPA I CLAI FOR FOR EALT INSURANCE POLICIES OTER TAN TRAVEL AN PERSONAL ACCIENT PART A TO BE FILLE IN B TE INSURE The issue of this Form is not to be taken as an admission of liability c) Sl. / Certificate Aadhaar d) Name e) Address S U R N A E F I R S T N A E I L E N A E SE C TION A SECTION B City State Pin Code Phone Email I ETAILS OF INSURANCE ISTOR a) Currently covered by any other ediclaim / ealth Insurance es b) ate of commencement of first Insurance without break c) If yes, company name Policy Sum Insured Rs. Rs. Rs. Rs. Rs. Rs. Rs. d) ave you been hospitalized in the last four years since inception of the contract? es ate iagnosis e) Previously covered by any other ediclaim / ealth insurance c) If yes, company name es ETAILS OF INSURE PERSON OSPITALIZE a) Name S U R N A E F I R S T N A E I L E N A E b) Gender ale Female c) Age years months b) ate of Birth e) Relationship to Primary insured Self Spouse Child Father other Other (Please Specify) SECTION C f) Occupation (Please Specify) Service Self Employed omemaker Student Retired Other Aadhaar. g) Address (if different from above) City State Pin Code Phone Email I ETAILS OF OSPITALIZATION a) Name of ospital where Admitted b) Room Category occupied ay care Single occupancy Twin sharing 3 or more beds per room c) ospitalization due to Injury Illness aternity d) ate of Injury / ate isease first detected /ate of elivery SEC T IO N e) ate of Admission f) Time g) ate of ischarge h) Time i) If Injury give cause Self inflicted Road Traffic Accident Substance Abuse / Alcohol Consumption i) If edico legal es ii) Reported to police es iii) LC Report & Police FIR attached es j) System of edicine 1/7 (IPORTANT PLEASE TURN OVER)
ETAILS OF CLAI a) etails of the treatment expenses claimed i) Pre-hospitalization Expenses Claim Form uly signed ii) ospitalization Expenses iii) Post-hospitalization Expenses iv) ealth-check up Cost Copy of the claim intimation, if any ospital ain Bill v) Ambulance Charges vi) Others (code) Total ospital Break-up Bill ospital Bill Payment Receipt SECTION E vii) Pre-hospitalization period viii) Post-hospitalization period ays ays ospital ischarge Summary Pharmacy Bill b) Claim for omiciliary ospitalization es (If yes, provide details in annexure) Operation Theatre tes c) etails of Lump sum / cash benefit claimed i) ospital aily Cash ECG ii) Surgical Cash octor's request for investigation iii) Critical Illness Benefit iv) Convalescence Investigation Reports (Including CT/ RI / USG / PE) v) Pre/Post hospitalization Lump sum benefit vi) Others octor's Prescriptions Total Others ETAILS OF BILLS ENCLOSE Sl. Bill ate Issued by Towards Amount (Rs) 1. ospital ain Bill 2. 3. 4. 5. 6. 7. 8. 9. 10. Pre-hospitalization Bills s Post-hospitalization Bills s Pharmacy Bills SECTION F SEC T IO N G ETAILS OF PRIAR INSURE S BANK ACCOUNT a) Pan. b) Account. c) Bank Name and Branch d) Cheque/ Payable details e) IFSC Code 2/7 (IPORTANT PLEASE TURN OVER)
ECLARATION B TE INSURE I hereby declare that the information furnished in this claim form is true & correct to the best of my knowledge and belief. If I have made any false or untrue statement, suppression or concealment of any material fact with respect to questions 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 against 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/post-hospitalization claim, if any. S EC TION ate Place Signature of the Insured GUIANCE FOR FILLING CLAI FOR PART A (To be filled in by the insured) a) Policy. b) SI. / Certificate. c) Company TPA I. d) Name e) Address ATA ELEENT a) Currently covered by any other ediclaim / ealth Insurance? b) ate of Commencement of first Insurance without break c) Company Name Policy. Sum Insured d) ave you been ospitalized in the last four years since inception of the contract? ate iagnosis e) Previously Covered by any other ediclaim/ ealth 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. i) E-mail I a) Name of ospital where admitted b) Room category occupied c) ospitalization due to d) ate of Injury/ate isease first detected/ ate of elivery e) ate of admission f) Time ESCRIPTION SECTION A - ETAILS OF PRIAR INSURE Enter the policy number Enter the social insurance number or the certificate number of social health insurance scheme Enter the TPA I Enter the full name of the policyholder Enter the full postal address SECTION B - ETAILS OF INSURANCE ISTOR Indicate whether currently covered by another ediclaim / ealth Insurance Enter the date of commencement of first 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 last four years Enter the date of hospitalization Enter the diagnosis details Indicate whether previously covered by another ediclaim / ealth Insurance Enter the full name of the insurance company SECTION C - ETAILS OF INSURE PERSON OSPITALIZE 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 postal address Enter the phone number of patient Enter e-mail address of patient SECTION C - ETAILS OF INSURE PERSON OSPITALIZE 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 FORAT As allotted by the insurance company As allotted by the organization License number as allotted by IRA and printed in TPA documents Surname, First name, iddle name Include Street, City and Pin Code Tick es or Name of the organization in full As allotted by the insurance company In rupees Tick es or Use mm-yy format Open Text Tick es or Name of the organization in full Surname, First name, iddle name Tick ale or Female Number of years and months. If others, please specify.. If others, please specify. Include Street, City and Pin Code Include ST code with telephone number Complete e-mail address Name of hospital in full Use hhmm format 3/7 (IPORTANT PLEASE TURN OVER)
i) If Injury give cause If edico legal Reported to Police LC Report & Police FIR attached j) System of edicine a) etails of Treatment Expenses b) Claim for omiciliary ospitalization c) etails of Lump sum/ cash benefit claimed d) Claim ocuments Submitted-Check List 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 system 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 Tick es or Tick es or Tick es or Open Text In rupees (o not enter paise values) Tick es or In rupees (o not enter paise values) Indicate which bills are enclosed with the amounts in rupees a) PAN b) Account Number c) Bank Name and Branch d) Cheque/ payable details e) IFSC Code 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 Enter the name of the beneficiary the cheque/ should be made out to Enter the IFSC code of the bank branch SECTION G - ETAILS OF PRIAR INSURE S BANK ACCOUNT 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 IFSC code of the bank branch in full Read declaration carefully and mention date (in ddmmyy format), place (open text) and sign. CLAI FOR - PART B TO BE FILLE IN B TE OSPITAL The issue of this Form is not to be taken as an admission of liability Please include the original preauthorization request from in lieu of PART A ETAILS OF OSPITAL (To be filled in block letters) a) Name of the hospital b) ospital I d) Name of the treating doctor c) Type of hospital Network n Network (if non network fill section E) e) Qualification f) Registration. with State Code SECTION A SEC T IO N B g) Phone. ETAILS OF TE 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 Patient Aadhaar Card no b) IP Registration Number c) Gender ale Female d) Age years months e) ate of Birth f) ate of Admission g) Time h) ate of ischarge i) Time j) Type of Admission Emergency Planned ay Care aternity k) If aternity i) ate of elivery ii) Gravida Status l) Status at time of discharge ischarge to home ischarge to another hospital eceased m) Total claimed amount 4/7 (IPORTANT PLEASE TURN OVER)
SECTION C ETAILS OF AILENT IAGNOSE (PRIAR) a) i) Primary iagnosis IC 10 Codes escription ii) Additional iagnosis iii) Co-morbidities iv) Co-morbidities b) IC 10 PCS escription i) Procedure 1 ii) Procedure 2 iii) Procedure 3 iv) etails of Procedure c) Pre-authorization obtained es d) Pre-authorization Number e) If authorization by network hospital not obtained, give reason f) ospitalization due to injury es i) If es, give cause Self-inflicted Road Traffic Accident Substance abuse / alcohol consumption ii) If injury due to substance abuse / alcohol consumption, Test conducted to establish this es (If es, attach reports) iii) If edico legal es iv) Reported to Police es v) FIR. vi) If not reported to police give reason CLAI OCUENTS SUBITTE - CECK LIST Claim Form duly signed Original Pre-authorization request Copy of the Pre-authorization approval letter Copy of Photo I Card of patient Verified by hospital ospital ischarge summary Operation Theatre tes Investigation reports CT/R/USG/PE Investigation reports octor's reference slip for investigation ECG Pharmacy bills LC reports & Police FIR SECTIO N ospital main bill ospital break-up bill Original death summary from hospital where applicable Any other, please specify 5/7 (IPORTANT PLEASE TURN OVER)
ETAILS IN CASE OF NON NETWORK OSPITAL (ONL FILL IN CASE OF NON-NETWORK OSPITAL) a) Address City State Pin Code SEC T IO N E S EC TION F b) Phone c) Registration. with State Code d) ospital PAN e) Number of inpatient beds f) Facilities available in the hospital i) OT es ii) ICU es iii) Others ECLARATION B TE OSPITAL (PLEASE REA VER CAREFULL) We hereby declare that the information furnished in this Claim Form is true & correct to the best of our knowledge and belief. If we have made any false or untrue statement, suppression or concealment of any material fact, our right to claim under this claim shall be forfeited. ate Place Signature and Seal of the ospital Authority ATA ELEENT GUIANCE FOR FILLING CLAI FOR - PART B (To be filled in by the hospital) ESCRIPTION SECTION A - ETAILS OF OSPITAL FORAT a) Name of the hospital b) ospital I c) Type of ospital Enter the name of hospital Enter I number of hospital Indicate whether in network or non network hospital Name of the hospital in full As allocated by the TPA d) Name of treating doctor Enter the name of the treating doctor e) Qualification Enter the qualification of the treating doctor f) Registration. with State Code Enter the registration number of the doctor along with the state code g) Phone. Enter the phone number of doctor SECTION B - ETAILS OF TE PATIENT AITTE Name of doctor in full Abbreviations of educational qualifications As allocated by the edical Council of India Include ST code with telephone number a) Name of Patient b) IP registration Number c) Gender d) Age e) ate of Birth f) ate of Admission g) Time h) ate of ischarge i) Time j) Type of Admission k) If aternity i) ate of elivery ii) Gravida Status l) Status at time of discharge m) Total claimed amount Enter the name of patient Enter insurance provider registration number Indicate Gender of the patient Enter age of the patient Enter date of birth Enter date of admission Enter Time of admission Enter date of ischarge Enter time of ischarge Indicate type of admission of patient Enter ate of elivery if maternity Enter Gravida status if maternity Indicate status of patient at time of discharge Indicate the total claimed amount Name of patient in full As allotted by the insurance provider Tick ale or Female Number of years and months Use hhmm format Use hhmm format Use standard format In rupees (o not enter paise values) 6/7 (IPORTANT PLEASE TURN OVER)
a) IC 10 Code Primary iagnosis Additional iagnosis Co-morbidities b) IC 10 PCS Procedure 1 Procedure 2 Procedure 3 etails of Procedure ATA ELEENT c) Pre-authorization obtained d) Pre-authorization Number e) If authorization by network hospital not obtained, give reason f) ospitalization due to injury Cause If injury due to substance abuse/alcohol consumption test conducted to establish this edico Legal Reported to Police FIR. If not reported to police, give reason ESCRIPTION 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 Code and description of the first procedure Enter the IC 10 Code and description of the second procedure Enter the IC 10 Code and description of the third procedure Enter the details of the procedure 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 test conducted Indicate whether injury is medico legal Indicate whether police report was filed Enter first information report number Enter reason for not reporting to police SECTION - CLAI OCUENTS SUBITTE-CECK LIST FORAT Open text Tick es or As allotted by TPA Open text Tick es or Tick es or Tick es or Tick es or As issued by police authrities Open text Indicate which supporting documents are submitted SECTION E - ETAILS IN CASE OF NON NETWORK OSPITAL a) Address b) Phone. c) Registration. with State Code d) ospital PAN e) Number of Inpatient beds f) Facilities available in the hospital Enter the full postal address Enter the phone number of hospital Enter the registration number of the ospital obtained from local body like City Corporation / unicipality Enter the permanent account number Enter the number of inpatient beds Indicate facilities available in the hospital SECTION F - ECLARATION B TE OSPITAL Include Street, City and Pin Code Include ST code with telephone number As allocated by the City Corporation / unicipality As allocated by the Income Tax epartment igits. If others, please specify Read declaration carefully and mention date (in ddmmyy format), place (open text) and sign. and stamp 7/7