CLAIM FORM - PART A' to 'CLAIM FORM FOR HEALTH INSURANCE POLICIES OTHER THAN TRAVEL AND PERSONAL ACCIDENT

TO BE FILLED BY THE INSURED
(To be Filled in block letters)
The issue of this Form is not to be taken as an admission of liablity


DETAILS OF PRIMARY INSURED:
SECTION A
a) Policy No.: b) Sl. No/ Certificate no.
c) Company/ TPA ID No:
d) Name:        
e) Address:    
                      
             City:    State:
             Pin Code:       Phone No.:  Email ID:



DETAILS OF INSURANCE HISTORY:
SECTION B
a) Currently covered by any other Mediclaim / Health Insurance: Yes No
b) Date of commencement of first Insurance without break:        
c) If yes, company name:            Policy No.
           Sum insured (Rs.):    
d) Have you been hospitalized in the last four years since inception of the contract? Yes No          Date:      
       Diagnosis:            
e) Previously covered by any other Mediclaim /Health insurance : :Yes No
f) If yes, company name:      



DETAILS OF INSURED PERSON HOSPITALIZED: :
SECTION C
d) Name:        
b) Gender            Male Female           c) Age years        Months        d) Date of Birth          
e) Relationship to Primary insured:    Self   Spouce   Child   Father     Mother   Other    (Please Specify)  
f) Occupation        Service   Self Employed   Home Maker   Student   Retired   Other    (Please Specify)  
g) Address (if diffrent from above) :
                      
             City:    State:
             Pin Code:       Phone No.:      Email ID:



DETAILS OF HOSPITALIZATION: :
SECTION D
a) Name of Hospital where Admited:   
b) Room Category occupied:       Day Care  Single Occupency  Twin sharing      3 or more beds per room 
c) Hospitalization due to:       Injury   Illness   Maternity        
d) Date of injury / Date Disease first detected /Date of Delivery:          
e) Date of Admission:                f) Time                
g) Date of Discharge::                h) Time           
I) If injury give cause:       Self inflicted   Road Traffic Accident   Substance Abuse / Alcohol Consumption       
       i) If Medico legal         Yes No
       ii) Reported to Police   Yes No      
       iii) MLC Report & Police FIR attached    Yes No      
j) System of Medicine:   





DETAILS OF CLAIM:
SECTION E
a) Details of the Treatment expenses claimed                                                                                                                                                        Claim Documents Submitted - Check List:
i. Pre -hospitalization expenses        Rs.       ii. Hospitalization expenses        Rs.         Claim form duly signed
iii. Post-hospitalization expenses      Rs.       iv. Health-Check up cost:           Rs.         Copy of the claim intimation, if any
v. Ambulance Charges:                      Rs.      vi. Others (code):          Rs.         Hospital Main Bill
                                                                                                                               Total                           Rs.         Hospital Break-up Bill
vii. Pre -hospitalization period:     Days                                viii. Post -hospitalization period:      Days                     Hospital Bill Payment Receipt
b) Claim for Domiciliary Hospitalization:   Yes No          (If yes, provide details in annexure)                                                         Hospital Discharge Summary
c) Details of Lump sum / cash benefit claimed:                                                                                                                                             Pharmacy Bill
i. Hospital Daily cash:                       Rs.       ii. Surgical Cash:                         Rs.         Operation Theater Notes
iii. Critical Illness benefit:                Rs.       iv. Convalescence:                        Rs.         ECG
v. Pre/Post hospitalization Lump sum benefit        Rs.    vi. Others:   Rs.         Doctor’s request for investigation
                                                                                                                        Total                                   Rs.         Investigation Reports
(Including CT/ MRI/ USG / HPE)
                                                                                                                                                                                                                         Doctors Prescriptions
                                                                                                                                                                                                                         Others

DETAILS OF BILLS ENCLOSED:
SECTION F

Sl.No. Bill No. Date Issued By Towards Amount(Rs)
1. Hospital main Bill
2. Pre-hospitalization Bills: Nos
3. Post-hospitalization Bills: Nos
4. Pharmacy Bills
5.
6.
7.
8.
9.
10.


DETAILS OF PRIMARY INSUREDS BANK ACCOUNT::
SECTION G
a) PAN:                           b) Account Number:    
c) Bank Name:   
        Branch         
d) Cheque / DD Payable details:          
e) IFSC Code: 


DECLARATION BY THE INSURED:
SECTION H 
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 / Medical Practitioner who has attended on the person against 
whomthis 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.
Date:                 Place:       Signature of the Insured:    
GUIDANCE FOR FILLING CLAIM FORM - PART A (To be filled in by the insured)
DATA ELEMENT DESCRIPTION FORMAT
SECTION A - DETAILS OF PRIMARY INSURED
a) Policy No. Enter the policy number As allotted by the Insurance Company
b) Sl. No/ Certificate No. sEoncteiarl thheea sltohc iinasl uInrasunrcaen scceh neummeber or the certificate number of As allotted by the oraganization
c) Company TPA ID No. Enter the TPA ID No. Licence number as allotted by IRDA and printed in TPA documents.
d) Name Enter the full name of the policyholder Surname, First name, Middle name
e) Address Enter the full postal address Include Street, City and Pin code
SECTION B -DETAILS OF INSURANCE HISTORY
a) Currently covered by any other Mediclaim / Health Insurance? Indicate whether currently covered by another Mediclaim / Health Insurance Tick Yes or No
b) Date 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 Yes or No
    Date & Diagnosis Enter the date of Hospitalization & Enter the diagnosis details Use mm-yy format & Open Text
e) Previously covered by any other Mediclaim / Health Insurance? Indicate whether previously covered by another mediclaim /Health Insurance Tick Yes or No
f) Company Name Enter the full name of the Insurance Company Name of the organization in full
SECTION C -DETAILS OF INSURED PERSON HOSPITALIZED
a) Name Enter the full name of the patient Surname, First name, Middle name
b) Gender Indicate Gender of the patient Tick Male or Female
c) Age Enter age of the patient Number of years and months
d) Date of Birth Enter Date 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 STD code with telephone number
1) E-mail ID Enter e-mail address of patient Complete e-mail address
SECTION D - DETAILS 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) Date of injury/Date Disease first detected / Date of Delivery Enter the relevant date Use dd-mm-yy format
e) Date of admission Enter date of admission Use dd-mm-yy format
f) Time Enter time of admission Use hh-mm- format
g) Date 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 Medico legal indicate whether injury is medico legal Tick Yes or No
    Reported to Police indicate whether police report was filed Tick Yes or No
    MLC Report & Police FIR attached indicate whether MLC report and Police FIR attached Tick Yes or No
j) System of Medicene Enter the system of medicine followed in treating the patient Open Text
SECTION E - DETAILS OF CLAIM
a) Details of Treatment Expences Enter the amount claimed as treatment expences In rupees (Do not enter paise values)
b) Claim for Domiciliary Hospitalization indicate whether claim is for domiciliary hospitalization Tick Yes or No
c) Details of Lump sum/ Cash benifit claimed Enter the amount claimed as lump sum / cash benefit In rupees (Do not enter paise values)
d) Claim documents Submitted-Check List indicate which supporting documents are submitted Tick the right option
SECTION F - DETAILS OF BILLS ENCLOSED
Indicate which bills are enclosed with the amount in rupees
SECTION G - DETAILS OF PRIMARY INSUREDs BANK ACCOUNT
a) PAN Enter the permanent account number As allotted by the Income Tax Department
b) Account Number Enter the Bank account number As allotted by the Bank
c) Bank Name and Branch Enter the Bank name along with the branch Name of the Bank in full
c) Cheque/ DD payable details Enter the name of the beneficiary the cheque / DD 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
SECTION H - DECLARATION BY THE INSURED          (Read declaration carefully and mention date (in dd:mm:yy format), place (open text) and sign.)