PARAOUNT HEALTH SERVICES & INSURANCE TPA PRIVATE LIITE (IRA License. 006) [formerly known as PARAOUNT HEALTH SERVICES (TPA) PVT.LT] Plot no.a-442, Road -28,.I..C Industrial Area, Wagale Estate, Ram Nagar, Vitthal Rukmani andir, Thane (W), umbai, Pin Code 400 604 Name of Insurer : Policy : Insured Name : Patient Name : PHS I : Employee : obile : Phone (ST) : Name of Corporate: E-ail I : Type of Claim : CLAI OCUENT CHECK LIST ocument Sr. escription Status 1 IRA Claim Form duly signed by the Insured 2 Policy Copy CLAI ACKNOWLEGENT SHEET 3 64VB Compliance Certificate Original Cancelled Cheque copy of Employee/Proposer with the name of the Account 4 Holder Printed on the Cheque Leaf. ain Hospitalisation / Pre-Post 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 the hospital in case of ay Care Treatment / eath Summary in Case of eath Claim a) Copy of the Legal heir certificate, if the claim is for the death of the principle insured. b) Copy of Post ortem Report & eath Certificate (In Accidental eath cases) 7 Original Final Hospital bill with breakup of each Item 8 Original Payment Receipt of ain Hospital bill ( both eposit / Refund) 9 a) Receipt Of Payments made at the Hospital by Credit Card : Please attach the Xerox Copy of the Credit Card Payment Slip as received from the Vendor Original copy of Implant Invoice along with Payment Receipts & Implant Labels / Stickers for Stents/esh/IOL 10 Original bills, original Payment Receipts and investigation / Laboratory Reports Original medicine bills specifying Patient Name and date of purchase along with 11 supporting Prescriptions. 12 Original copy of First Consultation letter and subsequent Prescriptions. In case of / elay Intimation & elay in submission of claim, a letter from insured is 13 required stating reason for the same 14 OTHER OCUENTS Original copy of Obstetric history (Gravida, Para, Living children, Abortions) from a treating doctor. (aternity Claim) b c d e f Original Sonography Report in case of aternity Claim Original A-Scan Report along with IOL Sticker and Tax paid invoice in case of Cataract Claim Copy of the First Information Report (FIR) from Police epartment / Copy of the edico-legal Certificate (LC) in case of Road Traffic Accident (RTA) A medical certificate from a doctor not less qualified than /S confirming the diagnosis of critical illness along with the Investigation reports/other related documents reflecting the critical illness diagnosis. (Critical Illness Cases) In case of claims where the insured has submitted documents to another insurance co. /TPA, he needs to submit attested Photocopies of all the documents along with detailed claim settlement letter from the TPA and any unpaid bills and receipt for the same in originals. Claims Submitted by : Insured / Corporate / Agent / Broker / Insurer / Hopsital Claim Submitted by: obile.
ate of Claim Submission: PHS Executive Name: // HH: Claim Submitted at: PHS -(Location)/ Help esk Signature: Important Points to Remember:- 1. Please mark either or against 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 within 7 Working ays from ate of ischarge from Hospital 4. The above list of documents is indicative. In case of any other document requirement as specified by the Insurance Company, our document recovery team will contact you on receipt of your claim documents by us 5. Please visit us at www.paramounttpa.com to check Online Claim Status or download Paramount obile App 6. ember is advised to keep photocopies of all the papers since Insurer requires all the above documents in original. ocuments once submitted will not returned unless approved & agreed by Insurer 7. Corrections in any documents are not allowed
CLAI FOR - PART A' to 'CLAI FOR FOR HEALTH INSURANCE POLICIES OTHER THAN TRAVEL AN PERSONAL ACCIENT - PART A ETAILS OF PRIAR INSURE: TO BE FILLE B THE INSURE The issue of this Form is not to be taken as an admission of liablity (To be Filled in block letters) a) Policy.: b) Sl. / Certificate no. c) Company/ TPA I : d) Name: S U R N A E F I R S T N A E I L E N A E e) Address: City: State: Pin Code Phone : Email I: ETAILS OF INSURANCE HISTOR: a) Currently covered by any other ediclaim / Health Insurance: es b) ate of commencement of first Insurance without break: c) If yes, company name: Policy. Sum insured () d) Have you been hospitalized in the last four years since inception of the contract? es ate: iagnosis: e) Previously covered by any other ediclaim /Health insurance : : es SECTION A SECTION B f) If yes, company name: ETAILS OF INSURE PERSON HOSPITALIZE: : 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 onths d) ate of Birth e) Relationship to Primary insured: Self Spouse Child Father other Other (Please Specify) f) Occupation ETAILS OF HOSPITALIZATION: : ETAILS OF CLAI: ETAILS OF BILLS ENCLOSE: Sl.. Bill. ate Issued by Towards Amount (Rs) 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. City: Service g) Address (if diffrent from above) : Pin Code Phone : Email I: a) Name of Hospital where Admited: ETAILS OF PRIAR INSURE S BANK ACCOUNT:: Self Employed b) Room Category occupied: ay care Home aker Student Retired State: Other (Please Specify) Single occupancy Twin sharing 3 or more beds per room c) Hospitalization due to: Injury Illness aternity d) ate of injury / ate isease first detected /ate of elivery: e) ate of Admission: f) Time H H H g) ate of ischarge: h) Time: H H : H I) If injury give cause: Self inflicted Road Traffic Accident ii) Reported to Police a) etails of the Treatment expenses claimed I. Pre -hospitalization expenses iii. Post-hospitalization expenses v. Ambulance Charges: iii. LC Report & Police FIR attached Substance Abuse / Alcohol Consumption es ii. Hospitalization expenses iv. Health-Check up cost: vi. Others (code): j) System of edicine: vii. Pre -hospitalization period: days viii. Post -hospitalization period: days b) Claim for omiciliary Hospitalization: es c) etails of Lump sum / cash benefit claimed: i. Hospital aily cash: iii. Critical Illness benefit: v. Pre/Post hospitalization Lump sum benefit: a) PAN: c) Bank Name and Branch: Total (If yes, provide details in annexure) ii. Surgical Cash: iv. Convalescence: vi. Others: Total b) Account Number: Hospital main Bill Pre-hospitalization Bills: Post-hospitalization Bills: Pharmacy Bills s s I) If edico legal es Claim ocuments Submitted - Check List: Claim form duly signed Copy of the claim intimation, if any Hospital ain Bill Hospital Break-up Bill Hospital Bill Payment Receipt Hospital ischarge Summary Pharmacy Bill Operation Theater tes ECG octor s request for investigation Investigation Reports (Including CT / RI / USG / HPE) octor s Prescriptions Others SECTION C SECTION SECTION E SECTION F SECTION G
ECLARATION B THE INSURE: I hereby declare that the information furnished in the claim form is true & correct to the best of my knowledge and belief. If I have made any false or untrue statement, suppression or concealent of any material fact with respect to questions asked in relation to this claim, my right to claim reimbrusement 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. SECTION H ate Place: Signature of the 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. Enter the policy number As allotted by the Insurance Company b) Sl. / Certificate. Enter the social Insurance number or the certificate number of social health insurance scheme As allotted by the oraganization c) Company TPA I. Enter the TPA I. Licence number as allotted by IRA and printed in TPA documents. d) Name Enter the full name of the policyholder Surname, First name, iddle name e) Address a) Currently covered by any other ediclaim / Health Insurance? Enter the full postal address SECTION B -ETAILS OF INSURANCE HISTOR Indicate whether currently covered by another ediclaim / Health Insurance Include Street, City and Pin code Tick es or b) ate of commencement of first Insurance without break Enter the date of commencement of first Insurance Use dd-mm-yy-forrmat c) Company Name Enter the full name of the Insurance Company Name of the organization in full Policy. Enter the policy number As allotted by the Insurance Company Sum insured d) Have you been Hospitalized in the last four years since Inception of the contract? Enter the total sum insured as per the policy Indicate whether hospitalized in the last four years In rupees Tick es or ate Enter the date of Hospitalization Use mm-yy format iagnosis Enter the diagnosis details Open Text e) Previously covered by any other ediclaim / Health Insurance? Indicate whether previously covered by another mediclaim / Health Insurance Tick es or f) Company Name Enter the full name of the Insurance Company Name of the organization in full SECTION C -ETAILS OF INSURE PERSON HOSPITALIZE a) Name Enter the full name of the patient Surname, First name, iddle name b) Gender Indicate Gender of the patient Tick ale or Female c) Age Enter age of the patient Number of years and months d) ate of Birth Enter ate of Birth of patient e) Relationship to primary Insured Indicate relationship of patient with policyholder, if others, please specify f) Occupation indicate occupation of patient. If others, please specify. g) Address Enter the full postal address Include Street, City and Pin code h) Phone 1) E-mail I Enter the phone number of patient Enter e-mail address of patient SECTION - ETAILS OF HOSPITALIZATION Include ST code with telephone number Complete e-mail address a) Name of Hospital where admited Enter the name of hospital Name of hospital in full b) Room category occupied c) Hospitalization due to d) ate of injury/ate isease first detected / ate of elivery e) ate of admission f) Time g) ate of discharge h) Time I) If injury give cause If edico legal Reported to Police LC Report & Police FIR attached j) System of edicene a) etails of Treatment Expences b) Claim for omiciliary Hospitalization c) etails of Lump sum/ Cash benifit claimed d) Claim documents Submitted-Check List Indicate which bills are enclosed with the amount in rupees a) PAN b) Account Number c) Bank Name and Branch c) Cheque/ payable details 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 system of medicine followed in treating the patient SECTION E - ETAILS OF CLAI Enter the amount claimed as treatment expences 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 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 Use hh-mm- format Use hh-mm- format 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) As allotted by the Income Tax epartment 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
ETAILS OF HOSPITAL 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 preauthorization request form in lieu of PART A (To be Filled in block letters) a) Name of the hospital: a) Hospital I: c) Name of the treating doctor: e) Qualification: ETAILS OF THE PATIENT AITTE a) Name of the Patient: c) Type of Hospital: Network : n Network : (if non network fill section E) f) Registration. with State Code: g) Phone. b) IP Registration Number: c) Gender: ale Female d) Age: ears onths e) ate of birth: f) ate of Admission: j) Type of Admission: Emergency Planned ay Care aternity k) If aternity I) Status at time of discharge: ischarge to home ischarge to another hospital eceased ETAILS OF AILENT IAGNOSE (PRIAR) a) IC 10 Codes I. Primary iagnosis ii. Additional iagnosis: iii. Co-morbidities: iv. Co-morbidities: c) Pre-authorization obtained: es e) If authorization by network hospital not obtained, give reason: escription b) vi. If not reported to police give reason: d) Pre-authorization Number: h) ate of ischarge: i) ate of elivery: i. Procedure 1: ii. Procedure 2: iii. Procedure 3: iv. etails of Procedure: m) Total claimed amount IC 10 PCS f) Hospitalization 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: v. FIR. CLAI OCUENTS SUBITTE - CHECK 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 Hospital ischarge summary Operation Theatre tes Hospital main bill Hospital break-up bill AITIONAL ETAILS IN CASE OF NON NETWORK HOSPITAL a) Address of the Hospital d) Hospital PAN: iii. Others: ECLARATION B THE HOSPITAL es (If es, attach reports) Investigation reports iii. If edico legal: CT/R/USG/HPE investigation reports octor s reference slip for investigation ECG Pharmacy bills LC reports & Police FIR es Original death summary from hospital where applicable Any other, please specify (ONL FILL IN CASE OF NON-NETWORK HOSPITAL) ii) Gravida Status: : escription iv. Reported to Police (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: City: S U R N A E F I R S T N A E I L E N A E S U R N A E F I R S T N A E I L E N A E g) Time: H H Pin Code: b) Phone. c) Registration. with State Code: State: e) Number of inpatient beds f) Facilities available in the hospital i. OT es ii. ICU es H H es SECTION A SECTION B SECTION C SECTION SECTION E SECTIO
GUIANCE FOR FILLING CLAI FOR - PART B (To be filled in by the hospital) ATA ELEENT ESCRIPTION FORAT SECTION A - ETAILS OF HOSPITAL a) Name of the hospital: Enter the name of hospital Name of the hospital in full b) Hospital I c) Type of Hospital c) Name of treating doctor e) Qualification f) Registration. with State Code g) Phone. 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 ate of elivery Gravida Status l) Status at time of discharge ) Total claimed amount a) IC 10 Code Primary iagnosis Additional iagnosis Co-morbidities b) IC 10 PCS Procedure 1 Procedure 2 Procedure 3 etails of Procedure c) Pre-authorization obtained d) Pre-authorization Number Enter I number of hospital Indicate whether in network or non network hospital Enter the name of the treating doctor Enter the qualification of the treating doctor Enter the registration number of the doctor along with the state code Enter the phone number of doctor SECTION B - ETAILS OF THE PATIENT AITTE 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 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 As allocated by the TPA Name of doctor in full Abbreviations of educational qualifications As allocated by the edical Council of India Include ST code with telephone number Name of patient in full As allotted by the insurance provider Tick ale or Female Number of years and months Use hh:mm format Use hh:mm format Use standard format In rupees (o not enter paise values) Open text Tick es or As allotted by TPA e) If authorization by network hospital not obtained, give reason Enter reason for not obtaining pre-authorization number Open text f) Hospitalization 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 Indicate which supporting documents are submitted a) Address b) Phone. c) Registration. with State Code d) Hospital PAN e) Number of Inpatient beds f) Facilities available in the hospital 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-CHECK LIST SECTION E - ETAILS IN CASE OF NON NETWORK HOSPITAL Enter the full postal address Enter the phone number of hospital Enter the registration number of the Hospital 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 Tick es or Tick es or Tick es or Tick es or As issued by police authrities Open text 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