Please return your completed claim form to:

CignaTTK Health Insurance Company Limited

OR Nearest Cigna TTK Branch.
Corporate Office: 401/402, Raheja Titanium, Western Express Highway, Goregaon (East), Mumbai – 400063.
IRDA Registration No. 151
Call (Toll Free): 1-800-10-24462 Visit: www.cignattkinsurance.in E-mail: customercare@cignattk.in
The issue of this Form is not to be taken as an admission of liability
(To be filled in Block Letters) - PART A - To be filled by Insured

CIGNA TTK GLOBAL HEALTH GROUP POLICY

HOSPITALISATION CLAIM FORM - PART A

SECTION A: DETAILS OF PRIMARY INSURED:

a) Policy No.: b) Sl. No. / Certificate No.:

c) Company / TPA ID:

d) Name: S U R N A M E F I R S T N A M E M I D D L E N A M E

e) Address:

City: State: Pin Code:

h) Phone No.:

I) E-mail ID:

SECTION B: DETAILS OF INSURANCE HISTORY:

a) Currently covered by any other Mediclaim / Health Insurance: Yes No

b) Date of Commencement of First Insurance without Break: D D M M Y Y Y Y

c) If yes, Company Name:

Cigna TTK Global Health Group Policy UIN Number: IRDA/NL-HLT/CTTK/P-H/V-I/6/14-15 • Version No.: 1.1/November 2014
Policy No.: Sum Insured (`):

d) Have you been hospitalised in the last four years since inception of the contract? Yes No

Diagnosis:

e) Previously covered by any other Mediclaim / Health Insurance : Yes No

f) If yes, Company Name:

SECTION C: DETAILS OF INSURED PERSON HOSPITALISED:

a) Name: S U R N A M E F I R S T N A M E M I D D L E N A M E

b) Gender: Male Female c) Age: Years Months d) Date of Birth: D D M M Y Y Y Y

e) Relationship to Primary Insured: Self Spouse Child Father Mother Other (Please Specify)

f) Occupation: Service Self Employed Homemaker Student Retired Other (Please Specify)

g) Address:
(If different
from above)

City: State: Pin Code:

h) Phone No.

i) E-mail ID:
SECTION D: DETAILS OF HOSPITALISATION:

a) Name of Hospital where Admitted:

b) Room Category Occupied: Day Care Single Occupancy Twin Sharing

3 or more Beds per Room

c) Hospitalisation due to: Injury Illness Maternity

d) Date of Injury / Date Disease first detected / Date of Delivery: D D M M Y Y Y Y

e) Date of Admission: D D M M Y Y Y Y f) Time: H H : M M

g) Date of Discharge: D D M M Y Y Y Y h) Time: H H : M M

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:

SECTION E: DETAILS OF CLAIM:

a) Details of the Treatment Expenses claimed:

i. Pre-hospitalisation Expenses: `

ii. Hospitalisation Expenses: `

iii. Post-hospitalisation Expenses: `

iv. Health-Check up Cost: `

v. Ambulance Charges: `

vi. Others: `

TOTAL `

vii. Pre-hospitalization Period: Days

viii. Post-hospitalisation Period: Days

b) Claim for Domiciliary Hospitalisation: Yes No

Cigna TTK Global Health Group Policy UIN Number: IRDA/NL-HLT/CTTK/P-H/V-I/6/14-15 • Version No.: 1.1/November 2014
c) Details of Lump Sum / Cash Benefit claimed:

i. Hospital Daily Cash: `

ii. Surgical Cost: `

iii. Critical Illness Benefit: `

iv. Convalescence: `

v. Pre / Post Hospitalisation

Lumpsum Benefit `

vi. Others `

TOTAL `

d) Claim Documents Submitted- Check List:

Claim Form Duly signed Copy of the claim Intimation, if any

Hospital Main Bill Hospital Break-up Bill

Hospital Bill Payment Receipt Hospital Discharge Summary

Pharmacy Bills Operation Theatre Notes

ECG Doctor's request for investigation

Investigation Reports ( Including CT/MRI/USG/HPE) Doctors Prescriptions

Others
SECTION F: DETAILS OF BILLS ENCLOSED:

Sl. No. Bill No. Date Issued By Towards Amount (`)

1. D D M M Y Y Y Y Hospital Main Bill

2. D D M M Y Y Y Y Pre-hospitalisation Bills: Nos.

3. D D M M Y Y Y Y Post-hospitalisation Bills: Nos.

4. D D M M Y Y Y Y Pharmacy Bills

5. D D M M Y Y Y Y

6. D D M M Y Y Y Y

7. D D M M Y Y Y Y

8. D D M M Y Y Y Y

9. D D M M Y Y Y Y

10. D D M M Y Y Y Y

Total Claimed Amount

SECTION G: DETAILS OF PRIMARY INSURED'S BANK ACCOUNT:

a) PAN: b) Account Number:

c) Bank Name and Branch:

d) Cheque / DD Payable Details: e) IFSC Code:

SECTION H: DECLARATION BY THE INSURED:

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 & authorise TPA / insurance company, to seek necessary medical information / documents from any hospital / Medical
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-hospitalisation claim, if any.

Cigna TTK Global Health Group Policy UIN Number: IRDA/NL-HLT/CTTK/P-H/V-I/6/14-15 • Version No.: 1.1/November 2014
Date: D D M M Y Y Y Y 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) SI. No. / Certificate No. Enter the Social Insurance Number or the Certificate As allotted by the Organisation
Number of Social Health Insurance Scheme
c) Company TPA ID No. Enter the TPA ID No License 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 Indicate whether currently covered by another Tick Yes or No
Mediclaim / Health Insurance? Mediclaim / Health Insurance
b) Date of Commencement of Enter the Date of Commencement of First Insurance Use dd-mm-yy format
First Insurance without Break
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 Hospitalised in the Indicate whether Hospitalised in the Last Tick Yes or No
Last Four Years since Inception Four Years of the Contract?
Date Enter the Date of Hospitalisation Use mm-yy format
Diagnosis Enter the Diagnosis Details Open Text
e) Previously covered by any other Indicate whether previously covered by another Tick Yes or No
Mediclaim / Health Insurance? Mediclaim / Health Insurance
f) Company Name Enter the Full Name of the Insurance Company Name of the Organization in full
SECTION C - DETAILS OF INSURED PERSON HOSPITALISED
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
i) E-mail ID Enter E-mail Address of Patient Complete E-mail Address
SECTION D - DETAILS OF HOSPITALISATION

Cigna TTK Global Health Group Policy UIN Number: IRDA/NL-HLT/CTTK/P-H/V-I/6/14-15 • Version No.: 1.1/November 2014
a) Name of Hospital where Admitted Enter the Name of Hospital Name of Hospital in full
b) Room Category Occupied Indicate the Room Category Occupied Tick the right option
c) Hospitalisation due to Indicate Reason of Hospitalisation Tick the right option
d) Date of Injury / Date Disease Enter the Relevant Date Use dd-mm-yy format
First Detected / Date of Delivery
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 Medicine Enter the System of Medicine followed in treating the Patient Open Text
SECTION E - DETAILS OF CLAIM
a) Details of Treatment Expenses Enter the Amount claimed as Treatment Expenses In Rupees (Do not enter paise values)
b) Claim for Domiciliary Hospitalisation Indicate whether Claim is for Domiciliary Hospitalisation Tick Yes or No
c) Details of Lump Sum / Cash Benefit 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 Amounts in Rupees
SECTION G - DETAILS OF PRIMARY INSURED'S 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
d) Cheque / DD Payable Details Enter the Name of the Beneficiary, the Cheque / DD Name of the Individual / Organisation in full
should be made out to
e) 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.
 Please return your completed claim form to:
CignaTTK Health Insurance Company Limited
OR Nearest Cigna TTK Branch.
Corporate Office: 401/402, Raheja Titanium, Western Express Highway, Goregaon (East), Mumbai – 400063.
IRDA Registration No. 151
Call (Toll Free): 1-800-10-24462 Visit: www.cignattkinsurance.in E-mail: customercare@cignattk.in
The issue of this Form is not to be taken as an admission of liability
(To be filled in Block Letters) - PART B - To be filled by Hospital

CIGNA TTK GLOBAL HEALTH GROUP POLICY

HOSPITALISATION CLAIM FORM - PART B

SECTION A: DETAILS OF HOSPITAL

a) Name of the hospital:

b) Hospital ID: c) Type of Hospital: Network Non Network (If non network fill section E)

d) Name of the treating doctor: F I R S T N A M E M I D D L E N A M E S U R N A M E

e) Qualification:

f) Registration No. with State Code: g) Phone No.:

SECTION B: DETAILS OF THE PATIENT ADMITTED

a) Name of the Patient: F I R S T N A M E M I D D L E N A M E S U R N A M E

b) IP Registration Number: c) Gender: Male Female

d) Age: Years Months e) Date of birth: D D M M Y Y Y Y

f) Date of Admission: D D M M Y Y Y Y g) Time: H H : M M

h) Date of Discharge: D D M M Y Y Y Y I) Time: H H : M M

Cigna TTK Global Health Group Policy UIN Number: IRDA/NL-HLT/CTTK/P-H/V-I/6/14-15 • Version No.: 1.1/November 2014
j) Type of Admission: Emergency Planned Day Care Maternity

k) If Maternity i. Date of Delivery: D D M M Y Y Y Y ii. Gravida Status:

l) Status at time of discharge: Discharge to home Discharge to another hospital Deceased

m) Total claimed amount:

SECTION C: DETAILS OF AILMENT DIAGNOSED (PRIMARY)

a) ICD 10 Codes Description

i. Primary Diagnosis:

ii. Additional Diagnosis:

iii. Co-morbidities:

iv. Co-morbidities:

b) ICD 10 PCS Description

i. Procedure 1:

ii. Procedure 2:

iii. Procedure 3:

iv. Details of Procedure:

SECTION C: DETAILS OF AILMENT DIAGNOSED (PRIMARY)

c) Pre-authorization obtained: Yes No d) Pre-authorization No.:

e) If authorization by network hospital not obtained, give reason:

f) Hospitalization due to Injury: Yes No

i. If Yes, 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: Yes No (If Yes, attach reports)

iii. If Medico legal: Yes No iv. Reported to Police: Yes No

v. FIR No.: vi. If not reported to police give reason:

SECTION D: CLAIM DOCUMENTS SUBMITTED - CHECK LIST

Claim Form duly filled and signed Investigation reports

Original Pre-authorization request CT/MR/USG/HPE investigation reports

Copy of the Pre-authorization approval letter Doctor’s reference slip for investigation

Copy of photo ID card of patient verified by hospital ECG

Hospital Discharge summary Pharmacy bills

Operation Theatre notes MLC report & Police FIR

Hospital main bill Original death summary from hospital where applicable

Hospital break-up Bill Any other, please specify

Cigna TTK Global Health Group Policy UIN Number: IRDA/NL-HLT/CTTK/P-H/V-I/6/14-15 • Version No.: 1.1/November 2014
SECTION E: ADDITIONAL DETAILS IN CASE OF NON NETWORK HOSPITAL (ONLY FILL IN CASE OF NON-NETWORK HOSPITAL)

a) Address of
the Hospital

City: State: Pin Code:

b) Phone No. c) Registration No. with State Code:

d) Hospital PAN: e) Number of Inpatient beds:

f) Facilities available in the hospital: i. OT : Yes No ii. ICU : Yes No

iii. Others:

SECTION F: DECLARATION BY THE HOSPITAL:

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.

Date: D D M M Y Y Y Y
Place: Signature and Seal of the Hospital Authority:
GUIDANCE FOR FILLING CLAIM FORM - PART B (To be filled in by the hospital)

DATA ELEMENT DESCRIPTION FORMAT

SECTION A - DETAILS OF HOSPITAL

a) Name of Hospital Enter the name of hospital Name of hospital in full

b) Hospital ID Enter ID number of hospital As allocated by the TPA

c) Type of Hospital Indicate whether In network or non-network hospital Tick the right option

d) Name of treating doctor Enter the name of the treating doctor Name of doctor in full

e) Qualification Enter the qualifications of the treating doctor Abbreviations of educational qualifications

f) Registration No. with State Code Enter the registration number of the doctor along As allocated by the Medical Council of India
with the state code

g) Phone No. Enter the phone number of doctor Include STD code with telephone number

SECTION B - DETAILS OF THE PATIENT ADMITTED

a) Name of Patient Enter the name of hospital Name of hospital in full

b) IP Registration Number Enter insurance provider registration number As allotted by the insurance provider

c) Gender Indicate Gender of the patient Tick Male or Female

d) Age Enter age of the patient Number of years and months

e) Date of Birth Enter date of admission Use dd-mm-yy format

f) Date of Admission Enter date of admission Use dd-mm-yy format

g) Time Enter time of admission Use hh:mm format

h) Date of Discharge Enter date of discharge Use dd-mm-yy format

i) Time Enter time of discharge Use hh:mm format

j) Type of Admission Indicate type of admission of patient Tick the right option

k) If Maternity

Date of Delivery Enter Date of Delivery if maternity Use dd-mm-yy format

Cigna TTK Global Health Group Policy UIN Number: IRDA/NL-HLT/CTTK/P-H/V-I/6/14-15 • Version No.: 1.1/November 2014
Gravida Status Enter Gravida status if maternity Use standard format

l) Status at time of discharge Indicate status of patient at time of discharge Tick the right option

m) Total claimed amount Indicate the total claimed amount In rupees (Do not enter paise values)

SECTION C - DETAILS OF AILMENT DIAGNOSED (PRIMARY)

a) ICD 10 Code

Primary Diagnosis Enter the ICD 10 Code and description of the Standard Format and Open text
primary diagnosis

Additional Diagnosis Enter the ICD 10 Code and description of the Standard Format and Open text
additional diagnosis

Co-morbidities Enter the ICD 10 Code and description of the Standard Format and Open text
co-morbidities

b) ICD 10 PCS

Procedure 1 Enter the ICD 10 PCS and description of the Standard Format and Open text
first procedure

Procedure 2 Enter the ICD 10 PCS and description of the Standard Format and Open text
second procedure

Procedure 3 Enter the ICD 10 PCS and description of the Standard Format and Open text
third procedure

Details of Procedure Enter the details of the procedure Open text

c) Pre-authorization obtained Indicate whether pre-authorization obtained Tick Yes or No

d) Pre-authorization Number Enter pre-authorization number As allotted by TPA

e) If authorization by network hospital Enter reason for not obtaining pre-authorization Open text
not obtained, give reason number

f) Hospitalization due to injury Indicate if hospitalization is due to injury Tick Yes or No

Cause Indicate cause of injury Tick the right option

If injury due to substance abuse/ Indicate whether test conducted Tick Yes or No
alcohol consumption, test conducted
to establish this

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

FIR No. Enter first information report number As issued by police authorities

If not reported to police, give reason Enter reason for not reporting to police Open Text

SECTION D - CLAIM DOCUMENTS SUBMITTED-CHECK LIST

Indicate which supporting documents are submitted

SECTION E - DETAILS IN CASE OF NON NETWORK HOSPITAL

a) Address Enter the full postal address Include Street, City and Pin Code

b) Phone No. Enter the phone number of hospital Include STD code with telephone number

c) Registration No. with State Code Enter the registration number of the doctor As allocated by the Medical Council of India
along with the state code

d) Hospital PAN Enter the permanent account number As allotted by the Income Tax department

e) Number of Inpatient beds Enter the number of inpatient beds Digits

f) Facilities available in the hospital Indicate facilities available in the hospital Tick the right option. If others,
please specify

SECTION F - DECLARATION BY THE HOSPITAL

Read declaration carefully and mention date (in dd:mm:yy format), place (open text) and sign and stamp

Cigna TTK Global Health Group Policy UIN Number: IRDA/NL-HLT/CTTK/P-H/V-I/6/14-15 • Version No.: 1.1/November 2014