Toll Free No: 180011142 callcenter@medsave.in ESAVE HEALTHCARE (TPA) LIITE F- 701, Lado Sarai, ehrauli New elhi 110030 Web: www.medsave.in CHECKLIST OF ENCLOSURES FOR SUBISSION OF CLAI [Please tick the appropriate [ ] box] Name of the claimant:. Employee Code: CAR No:.. Policy No: No of Enclosures:.. ate Of Submission:... GENERAL 1. uly filled & Signed claim form by insured [ ] 2. Photo copy of E Card/ health Card [ ] 3. Photo copy of I Card * [ ] 4. Original copy of consolidated bill of hospital with breakup [ ] 5. Original copy of receipt of payment [ ] 6. All original prescription for bill attached [ ] 7. All original investigation /pathological/reports along with films/c. [ ] 8. Original discharge summary of hospital duly Signed by the treating doctor with hospital Seal and registration number. [ ] 9. Original invoice of implants (viz Stents/ PHS mesh /IOL etc) [ ] 10. First consultation letter for the presenting Complaints. [ ] 11. Pre/Post hospitalization bills/receipts/ reports in original pertaining to the incidence for which hospitalization has happened [ ] 12. Original prescription/doctors notes of previous treatment for the presenting complaints [ ] 13. Cancelled cheque along with IFSC details or a copy of the pass book and NEFT form [ ] FOR EATH CASES 1. Attested copy of death summary of the hospital duly signed by the treating doctor with hospital seal and registration number [ ] 2. Attested copy of death certificate from competent authorities [ ] 3. Legal Heir certificate/ letter from the underwriting office to settle the claim in the name of nominee/ dependents [ ] FOR ATERNIT CASE 1. Original copy of treating doctor s certificate regarding obstetric history (Gravida, Para, Living Children, Abortions, eath) [ ] FOR RTA 1. Attested copy of LC Report [ ] 2. Attested Copy of FIR [ ] 3. Original copy of treating doctor s certificate with circumstances and injuries sustained due to RTA [ ] 4. Original copy of Treating doctors certificate for any evidence of influence of Alcohol/ other Narcotics substance during the accident [ ] Checklist of Enclosures for submission of claim
Toll Free No: 180011142 callcenter@medsave.in *Photo Copy of I Card: Any Govt. Issued I card (PAN card, Passport Copy, AAHAR card, Voter Id proof etc) In case of new born babies the identity proof of the mother and the hospital authorization letter/ischarge Card/unicipal Birth Certificate (if available) In case of children- School Identity Card along with Guardian s I proof Under Taking: I / We hereby confirm that the above mentioned documents in support of the claimed amount have been submitted in full and final. No other documents would be submitted on a later date, that will alter and enhance the claim value. ate : Signature Place:. Name:. Address: City:.. Pin:.. obile No:. E mail: isclaimer: We acknowledge receipt of your claim and confirm that it has been registered with us on the basis of above documents. However the above acknowledgement does not guarantee settlement/ payment of claimed amount. This claim will be subject to pass through medical and commercial scrutiny, which may call for additional document that needs to be submitted within the stipulated time frame on intimation. ate: Name of Claimant Signature For edsave Place: Checklist of Enclosures for submission of claim
ediassist a) Policy No.: c) Company/ TPA I (A I) No: R REIBURSEENT CLAI FOR TO BE FILLE B THE INSURE The issue of this Form is not to be taken as an admission of liability ETAIS OF PRIAR INSURE: b) Sl.No/ Certificate no. (To be Filled in block letters) )Name: S U R N A E F I R S T N A E I L E N A E e) Address: City: Pin Code Phone No: Email I: a) Currently covered by any other ediclaim /Health Insurance: es No c) If yes, company name: Policy No. b) Claim for omiciliary Hospitalization: es No State: ETAILS OF INSURANCE HISTOR: b) ate of commencement of first Insurance without break: Sum insured () d) Have you been hospitalized in the last four years since inception of the contract? es No ate: iagnosis: e) Previously covered by any other ediclaim / Health insurance:: es No 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 Service Self Employed Home aker Student Retired Other (Please Specify) g) Address (if different from above): City: Pin Code Phone No: EmailI : a) Name of Hospital where Admited: ETAILS OF HOSPITALIZATION: b) Room Category occupied: aycare Single occupancy Twin sharing 3ormorebedsperroom c) Hospitalization due to: Injury Illness aternity d)ate of injury /ate isease first detected /ate of elivery: d) 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 Substance Abuse/Alcohol Consumption I) If edico legal es No ii) Reported to Police iiii. L C Report &Police FIR attached es No j)system of edicine: a) etails of the Treatment expenses claimed I. Pre-hospitalization expenses iii. Post-hospitalization expenses iv. Ambulance Charges: ETAILS OF CLAI: ii. Hospitalization expenses v. Health Check up cost: vi. Others(code): Total State: 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 vii. Pre-hospitalization period: days viii.post-hospitalization period: days Hospital ischarge Summary c) etails of Lump sum/ cash benefit claimed: i. Hospital aily cash: (If yes, provide details in annexure) ii. Surgical Cash: Pharmacy Bill OperationTheater Notes iii. Critical Illness benefit: iv. Convalescence: octor s request for investigation Investigation Reports (Including CT v. Pre /Post hospitalization Lump sum benefit:: vi. Others: Total /RI/USG/HPE) octor s Prescriptions Others Sl.No. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. a) PAN: BillNo. c) Bank Name and Branch: ate Issuedby ETAILS OF BILLS ENCLOSE: Towards ETAILS OF PRIAR INSURE S BANK ACCOUNT: b)account Number: Hospital main Bill Pre-hospitalization Bills: Post-hospitalization Bills: Pharmacy Bills Nos Nos ECG Amount (Rs) SECTIONA SECTIONB SECTIONC SECTION SECTIONE SECTIONF SECTIONG d) Cheque/ Payable details: e) IFSC Code: ANTI-ONE LAUNERING REQUIREENT (For claim more than or equal to 1 Lakh - One ocument each from (1) and (2)) 1. Proposer s Identification (a) Passport (b) PAN Card (c) Voter s I Card (d) riving License (e) AAHAR Card 2. Proposer s Address (a) Current Telephone /obile Bill (b) Current Bank Passbook (c) Electricity Bill (d) Ration Card (e) Valid Rent Lease Agreement (IPORTANT: PLEASE TURNOVER)
ECLARATION BTHE 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. SECTIONH. ate Place: Signature of the Insured GUIANCEFOR FILLING CLAI FOR - PARTA(To be filled in by the insured) ATA ELEENT ESCRIPTION FORAT SECTION A- ETAILS OF PRIARINSURE a) Policy No. Enter the policy number As allotted by the Insurance Company b) Sl. No/ Certificate No. Entert he social Insurance number or the certificate number of social health insurance scheme As allotted y the oraganization c) Company TPAI No. Enter the TPAI No. 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 Enter the full postal address Include Street, City and Pin code a) Currently covered by any other ediclaim / Health Insurance? SECTION B -ETAILS OF INSURANCEHISTOR Indicate whether currently covered by another ediclaim /Health Insurance Tick es or No 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 No. Enter the policy number As allotted by the Insurance Company Sum insured Enter the total sum insured as per the policy In rupees d) Have you been Hospitalized in the last four years since Inception of the contract? Indicate whether hospitalized in the last four years Tick es or No 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 No f) Company Name Enter the full name of the Insurance Company Name of the organization in full SECTION C -ETAILS OF INSUREPERSON 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 Use dd-mm-yy format e) Relationship to primary Insured Indicate relationship of patient with policyholder Tick the right option if others,please specify f) Occupation indicate occupation of patient Tick the right option. If others please specify. g) Address Enter the full postal address Include Street, City and Pin code h) Phone No Enter the phone number of patient Include ST code with 1) E-mail I Enter e-mail address of patient Complete e-mail address SECTION - ETAILS OF HOSPITALIZATION a) Name of Hospital where admited Enter the name of hospital Name of hospital in full b) Room category occupied indicate the room category occupied Tick the right option c) Hospitalization due to indicate reason of hospitalization Tick the right option d) ate of injury/ ate isease first detected / ate of elivery Enter the relevant date Use dd-mm-yy format e) ate of admission Enter date of admission Use dd-mm-yy format f) Time Enter time of admission Use hh-mm- format g) ate of discharge Enter date of discharge Use dd-mm-yy format h) Time Enter time of discharge Use hh-mm- format I) If injury give cause indicate cause of injury Tick the right option If edico legal indicate whether injuryis medico legal Tick es or No Reported to Police indicate whether police report was filed Tick es or No LC Report& Police FIR attached indicate whether LC report and Police FIR attached Tick es or No j) System of edicene Enter the system of medicine followed in treating the patient Open Text SECTION E - ETAILS OF CLAI a) etails of Treatment Expences Enter the amount claimed as treatment expences In rupees (o not enter paise values) b) Claim for omiciliary Hospitalization indicate whether claim is for domiciliary hospitalization Tick es or No c) etails of Lump sum/ Cash benifit claimed Enter the amount claimed as lump sum / cash benefit In rupees (o not enter paise values) d) Claim documents Submitted-Check List indicate which supporting documents are submitted Tick the right option Indicate which bills are enclosed with the amount in rupees SECTION F - ETAILS OF BILLS ENCLOSE SECTION G - ETAILS OF PRIAR IN SURE s BANKACCOUNT a) PAN Enter the permanent account number As allotted by the Income Tax epartment b) Account Number Enter the Bank account number As allotted by the Bank c) Bank Name and Branch Entert he Bank name along with the branch Name of the Bank in full c) Cheque/ payable details Enter the name of the beneficiary the cheque / should be made out to Name of the individual / organization in full c) IFSC Code Enter the IFSC code of the Bank branch IFSC code of the Bank branch in full Read declaration carefully and mention date (in dd:mm:yy format), place (open text) and sign. SECTION H - ECLARATIONBTHE INSURE
NEFT Format To edsave Healthcare (TPA) Limited F-701A, Lado Sarai, ehrauli, New elhi Sirs, I / We furnish below details of my /our bank account to be used for effecting payments due to us by NEFT / RTGS: Registration for NEFT / RTGS Payments Name Category (Please select one) Policyholder / Intermediary / Surveyor / Advocate / Investigator / Panel octor / ealer / Landlord / Vendor Policy Number (Policyholders only) Claim number, if any, provided (Policyholders only) Agency / Broker Code (for Agents / Brokers / Corporate Agents / Bancassurance only) Permanent Address Address for Communication BANK ACCOUNT ETAILS FOR NEFT / RTGS PAENTS IFSC Code * Bank Name Bank Branch Name Bank Branch Address ICR Code (9 igit number) Full Bank Account No. (for NEFT) * * Please attach a copy of a cancelled cheque leaf. Verify the details with your bank before submitting. I wish to receive alerts from the Company on processing of payments to my account through SS and / or Email obile Phone No. (for SS alert) Email I (for mail notification) (please write in BLOCK letters) I/We hereby declare that the particulars given above are correct and express my/our willingness to receive credit of payments though the mode indicated above. Notwithstanding my/our choice of mode edsave Healthcare (TPA) Ltd reserves the right to issue a cheque / credit the account in the mode that they may deem fit. I/We would not hold edsave Healthcare (TPA) Ltd responsible, if the transaction is delayed or not effected at all or credited to an incorrect account for reasons of incomplete /incorrect information. Signature of Applicant Place: ate For Office Use: Reference No: Bank etails verified by: etails captured in System on: etails captured in System verified And found correct: Signature of Officer Name & esignation ate: