HDFC ERGO General Insurance Company Limited

Claim Form

My: jeevika Medisure Micro Insurance

GUIDELINES TO FILL THE FORM

1. Please fill the form in BLOCK LETTERS. Please answer all questions fully and correctly. All details with * are mandatory.
2. Please leave one box blank between two words while writing the ADDRESS.
3. Kindly contact t h e Company’s Office or TPA for any doubts or clarifications on the claim form.
PLEASE USE ONLY ORIGINAL CLAIM FORM. PHOTO COPIES WILL NOT BE ACCEPTED BY THE COMPANY.

CLAIM FORM FOR HEALTH INSURANCE POLICIES OTHER THAN TRAVEL AND PERSONAL ACCIDENT – PART A
TO BE FILLED IN BY THE INSURED
The issue of this Form is not to be taken as an admission of liability

DETAILS OF PRIMARY INSURED:

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

c) Company/ TPA ID No:

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: Phone No: Email ID :

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

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: M M Y Y

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

f) If yes, Company Name

DETAILS OF INSURED PERSON HOSPITALIZED:

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 Y Y months M M d) Date of Birth: D D M M 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: Phone No: E-mail ID:

DETAILS OF HOSPITALIZATION:

a) Name of Hospital where Admitted:

b) Room Category occupied: Day care Single occupancy 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: D D M M Y Y

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

DETAILS OF CLAIM:

a) Details of the treatment expenses claimed

Hospitalization expenses

Total Rs.

HDFC ERGO General Insurance Company Limited. IRDAI Reg. No.146. CIN: U66030MH2007PLC177117. Registered & Corporate Office: 1st
Floor, HDFC House, 165-166 Backbay Reclamation, H. T. Parekh Marg, Churchgate, Mumbai – 400 020. Customer Service Address: D-301, 3rd
Floor, Eastern Business District (Magnet Mall), LBS Marg, Bhandup (West), Mumbai - 400 078. Customer Service No: 022 - 6234 6234 / 0120 -
6234 6234 | care@hdfcergo.com | www.hdfcergo.com. Trade Logo displayed above belongs to HDFC Ltd and ERGO International AG and
used by the Company under license. UIN: Product Name – UIN: my:jeevika Medisure Micro Insurance - IRDA/NL-HLT/L&TGI/P-H/V.I/247/13-14
.
HDFC ERGO General Insurance Company Limited

Claim Form

Document Check List for Hospitalization Claim

Basic Claim Documents

1. Claim Form Duly filled with requisite information and signed by Insured & Hospital
2. Copy of the claim intimation
2. Original Hospital Main Bill
3. Original Hospital Bill break up (Where issued by the Hospital)
3. Original Hospital Bill Payment Receipt
4. Hospital Discharge Card/Summary
4. Original Pharmacy Bill with supporting prescriptions
5. Medical Investigation report: ECG/X-Ray/USG/CT/MRI/Histopathology/pathological and all other medical
investigation report in support of diagnosis as advised by the treating doctor.
5. All Doctor’s consultation note: confirming provisional & final diagnosis/advise for admission/medical
complication/proposed line of treatment/past medical history
6. Original bills and receipts for claiming Ambulance charges(if any)

Pre & post hospitalization Claim documents:

1. Duly filled claim form(s)(If claimed Separately)

2. Pharmacy Bills with supporting prescriptions

3. Medical investigation test reports and payment receipts with doctor’s advice note for such investigations.

4. All Doctor’s consultation note with original bills and receipts for claiming Doctors fees,

By signing the claim form you are authorizing us to collect the following documents from the Hospital.If you have obtained
these documents, then please submit the same

a) Operation Theatre Notes in surgical cases

b) Bar code sticker & Invoice for implants and prosthesis (if used)

c) In case of Accidental Injuries, Medico Legal Certificate and/ or First information Report, where applicable and self
statement giving description of the incident

d) Indoor case papers

Details of Bill Enclosed

Sr.No Bill No Date Issued By Towards Amount (Rs)

1 Hospital Main Bill
2 Pre Hospitalisation Bills--Nos
3 Post Hospitalisation Bills--Nos
4 Pharmacy Bills
5

10

HDFC ERGO General Insurance Company Limited. IRDAI Reg. No.146. CIN: U66030MH2007PLC177117. Registered & Corporate Office: 1st
Floor, HDFC House, 165-166 Backbay Reclamation, H. T. Parekh Marg, Churchgate, Mumbai – 400 020. Customer Service Address: D-301, 3rd
Floor, Eastern Business District (Magnet Mall), LBS Marg, Bhandup (West), Mumbai - 400 078. Customer Service No: 022 - 6234 6234 / 0120 -
6234 6234 | care@hdfcergo.com | www.hdfcergo.com. Trade Logo displayed above belongs to HDFC Ltd and ERGO International AG and
used by the Company under license. UIN: Product Name – UIN: my:jeevika Medisure Micro Insurance - IRDA/NL-HLT/L&TGI/P-H/V.I/247/13-14
.
HDFC ERGO General Insurance Company Limited

Claim Form

DETAILS OF POLICY HOLDER’S BANK ACCOUNT

a. PAN No.:
b. Account Number:
c. Bank Name and Branch:
d. Cheque / DD Payable d e t a i l s :
e. IFSC Code:

Enclose cancelled cheque of policy holder for NEFT payment

Please note, NEFT would depend on location and bank of the insured. Alternatively cheque will be issued. Please note providing cheque details/cancelled cheque does not indicate
a d m i s s i o n o f liability. The same would be applicable if the claim is tenable as per the terms and condition of the Policy

REASON FOR DELAY/NO INTIMATION

If claim i s not intimated or intimated beyond stipulated time given in the Policy, provide reason for the same
...................................................................................................................................................................................................................
If the claim is submitted beyond stipulated time period given in the Policy document, provided reason for the same
.....................................................................................................................................................................................................................

DECLARATION BY THE INSURED/CLAIMANT:

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 / 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-hospitalization claim, if any.

Date: D D M M 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 number As allotted by the organization
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 Mediclaim / Indicate whether currently covered by another Mediclaim / Tick Yes or No
Health insurance? Health Insurance

b) Date of Commencement of first Insurance Enter the date of commencement of first insurance Use dd-mm-yy format
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 Hospitalized in the last four Indicate whether hospitalized in the last four years Tick Yes or No
years since inception of the contract?

Date Enter the date of hospitalization Use mm-yy format

Diagnosis Enter the diagnosis details Open Text

e) Previously Covered by any other Mediclaim/ Indicate whether previously covered by another Mediclaim / Tick Yes or No
Health insurance? 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 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.

HDFC ERGO General Insurance Company Limited. IRDAI Reg. No.146. CIN: U66030MH2007PLC177117. Registered & Corporate Office: 1st
Floor, HDFC House, 165-166 Backbay Reclamation, H. T. Parekh Marg, Churchgate, Mumbai – 400 020. Customer Service Address: D-301, 3rd
Floor, Eastern Business District (Magnet Mall), LBS Marg, Bhandup (West), Mumbai - 400 078. Customer Service No: 022 - 6234 6234 / 0120 -
6234 6234 | care@hdfcergo.com | www.hdfcergo.com. Trade Logo displayed above belongs to HDFC Ltd and ERGO International AG and
used by the Company under license. UIN: Product Name – UIN: my:jeevika Medisure Micro Insurance - IRDA/NL-HLT/L&TGI/P-H/V.I/247/13-14
.
HDFC ERGO General Insurance Company Limited

Claim Form

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 HOSPITALIZATION

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) Hospitalization due to Indicate reason of hospitalization Tick the right option

d) Date of Injury/Date Disease first detected/ Date Enter the relevant date Use dd-mm-yy format
of
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 Hospitalization Indicate whether claim is for domiciliary hospitalization 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 should be Name of the individual/ organization in full
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.

HDFC ERGO General Insurance Company Limited. IRDAI Reg. No.146. CIN: U66030MH2007PLC177117. Registered & Corporate Office: 1st
Floor, HDFC House, 165-166 Backbay Reclamation, H. T. Parekh Marg, Churchgate, Mumbai – 400 020. Customer Service Address: D-301, 3rd
Floor, Eastern Business District (Magnet Mall), LBS Marg, Bhandup (West), Mumbai - 400 078. Customer Service No: 022 - 6234 6234 / 0120 -
6234 6234 | care@hdfcergo.com | www.hdfcergo.com. Trade Logo displayed above belongs to HDFC Ltd and ERGO International AG and
used by the Company under license. UIN: Product Name – UIN: my:jeevika Medisure Micro Insurance - IRDA/NL-HLT/L&TGI/P-H/V.I/247/13-14
.
HDFC ERGO General Insurance Company Limited

Claim Form

CLAIM FORM-PART B
To be filled in by the Hospital
The issue of this form is not taken as an admission of liability

(To be filled in block letters)

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

DETAILS OF THE PATIENT ADMITTED

a) Name of the Patient: 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) IP Registration Number: c) Gender: Male Female d) Age: Years Y Y Months M M e) Date of birth: D D M M Y Y

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

j) Type of Admission: Emergency Planned Day Care Maternity k) If Maternity i. Date of Delivery: D D M M Y Y ii. Gravida Status:

l) Status at time of discharge: Discharge to home Discharge to another hospital Deceased m) Total claimed amount

DETAILS OF AILMENT DIAGNOSED (PRIMARY)

a) ICD 10 Codes Description b) ICD 10 PCS Description

i. Primary Diagnosis: i. Procedure 1:

ii. Additional Diagnosis: ii. Procedure 2:

iii. Co-morbidities: iii. Procedure 3:

iv. Co-morbidities: iv. Details of Procedure:

d) Pre-authorization obtained: Yes No e) Pre-authorization Number:

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

g) 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:

CLAIM DOCUMENTS SUBMITTED - CHECK LIST

Claim Form duly 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

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 :

DECLARATION BY THE HOSPITAL (PLEASE READ VERY CAREFULLY)

HDFC ERGO General Insurance Company Limited. IRDAI Reg. No.146. CIN: U66030MH2007PLC177117. Registered & Corporate Office: 1st
Floor, HDFC House, 165-166 Backbay Reclamation, H. T. Parekh Marg, Churchgate, Mumbai – 400 020. Customer Service Address: D-301,
3rd Floor, Eastern Business District (Magnet Mall), LBS Marg, Bhandup (West), Mumbai - 400 078. Customer Service No: 022 - 6234 6234
/ 0120 - 6234 6234 | care@hdfcergo.com | www.hdfcergo.com. Trade Logo displayed above belongs to HDFC Ltd and ERGO
International AG and used by the Company under license. UIN: Product Name – UIN: my:jeevika Medisure Micro Insurance - IRDA/NL-HLT/L&TGI/P-
H/V.I/247/13-14
.
HDFC ERGO General Insurance Company Limited

Claim Form

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

Place: Signature and Seal of the Hospital Authority:

HDFC ERGO General Insurance Company Limited. IRDAI Reg. No.146. CIN: U66030MH2007PLC177117. Registered & Corporate Office: 1st
Floor, HDFC House, 165-166 Backbay Reclamation, H. T. Parekh Marg, Churchgate, Mumbai – 400 020. Customer Service Address: D-301,
3rd Floor, Eastern Business District (Magnet Mall), LBS Marg, Bhandup (West), Mumbai - 400 078. Customer Service No: 022 - 6234 6234
/ 0120 - 6234 6234 | care@hdfcergo.com | www.hdfcergo.com. Trade Logo displayed above belongs to HDFC Ltd and ERGO
International AG and used by the Company under license. UIN: Product Name – UIN: my:jeevika Medisure Micro Insurance - IRDA/NL-HLT/L&TGI/P-
H/V.I/247/13-14
.
HDFC ERGO General Insurance Company Limited

Claim Form

GUIDANCE FOR FILLING CLAIM FORM – PART B (To be filled in by the hospital)
DATA ELEMENT DESCRIPTION FORM
AT
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
Enter the registration number of the doctor along with the state code
f) Registration No. with State Code As allocated by the Medical Council of India
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
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
Enter the ICD 10 Code and description of the primary
Primary Diagnosis Standard Format and Open text
diagnosis
Enter the ICD 10 Code and description of the additional
Additional Diagnosis Standard Format and Open text
diagnosis
Co-morbidities Enter the ICD 10 Code and description of the co-morbidities Standard Format and Open text
b) ICD 10 PCS
Procedure 1 Enter the ICD 10 PCS and description of the first procedure Standard Format and Open text
Procedure 2 Enter the ICD 10 PCS and description of the second procedure Standard Format and Open text
Procedure 3 Enter the ICD 10 PCS and description of the third procedure Standard Format and Open text
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 not obtained, give reason
Enter reason for not obtaining pre-authorization number Open text

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/alcohol consumption, test
Indicate whether test conducted Tick Yes or No
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

HDFC ERGO General Insurance Company Limited. IRDAI Reg. No.146. CIN: U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor, HDFC
House, 165-166 Backbay Reclamation, H. T. Parekh Marg, Churchgate, Mumbai – 400 020. Customer Service Address: D-301, 3rd Floor, Eastern
Business District (Magnet Mall), LBS Marg, Bhandup (West), Mumbai - 400 078. Customer Service No: 022 - 6234 6234 / 0120 - 6234 6234 |
care@hdfcergo.com | www.hdfcergo.com. Trade Logo displayed above belongs to HDFC Ltd and ERGO International AG and used by the Company
under license. UIN: Product Name – UIN: my:jeevika Medisure Micro Insurance - IRDA/NL-HLT/L&TGI/P-H/V.I/247/13-14
.
HDFC ERGO General Insurance Company Limited

Claim Form

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

HDFC ERGO General Insurance Company Limited. IRDAI Reg. No.146. CIN: U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor, HDFC
House, 165-166 Backbay Reclamation, H. T. Parekh Marg, Churchgate, Mumbai – 400 020. Customer Service Address: D-301, 3rd Floor, Eastern
Business District (Magnet Mall), LBS Marg, Bhandup (West), Mumbai - 400 078. Customer Service No: 022 - 6234 6234 / 0120 - 6234 6234 |
care@hdfcergo.com | www.hdfcergo.com. Trade Logo displayed above belongs to HDFC Ltd and ERGO International AG and used by the Company
under license. UIN: Product Name – UIN: my:jeevika Medisure Micro Insurance - IRDA/NL-HLT/L&TGI/P-H/V.I/247/13-14
.