CLAIM FORM - PART A

TO BE FILLED IN BY THE INSURED

UNITED INDIA INSURANCE COMPANY LIMITED
REGISTERED & HEAD OFFICE: 24, WHITES ROAD, CHENNAI-600014 The issue of theis form is not to be taken as admission of liability
(To be filled in block letters)
DETAILS OF PRIMARY INSURED

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

c) Company/ TPA ID No: SECTION A

d) Name:

SECTION A
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:

c) If yes, company name: Policy No:

SECTION B
Sum Insured (`): 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

a) Name :

b) Gender : Male Female c) Age: years months d) Date of Birth:

e) Relatuionship to Primary Insured: Self Spouse Child Father Mother Other (Please specify)

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

SECTION C
g) Address (if different from above):

City: State:

Pin Code: Phone No: Email 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:

SECTION D
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

a) Details of treatment expenses claimed Claim Documents Submitted- Check List:

i. Pre Hospitalization Expenses ` ii. Hospitalization Expenses ` Claim FormDuly signed

iii. Post Hospitalization Expenses ` iv. Health Check up Cost ` Copy of the claim intimation, if any

v. Ambulance Charges ` vi. Others (code): ` Hospital Main bill

Total ` Hospital Break-up bill

vi. Pre hospitalization period: days vii. Pre hospitalization period: days Hospital Discharge Summary

SECTION E
b) Claim for Domiciliary Hospitalization: Yes No (if yes, provide details in annexure) Pharmacy Bill

c) Details of Lump sum / cash benefit claimed: Operation Theatre Notes

i. Hospital Daily Cash: ` ii. Surgical Cash: ` ECG

iii. Critical Illness Benefit: ` iv. Convalescence: ` Doctor's request for investigation

v. Pre/Post hosp. Lump sum benefit: ` vi. Others: ` Investigation Reports (including CT /
MRI / USG / HPE)
Total ` Doctor's Prescription

Others

DETAILS OF BILLS ENCLOSED

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

1 Hospital Main Bill
2 Pre hospitalisation Bills: ___ Nos
3 Post hospitalisation Bills: ___ Nos
4 Pharmacy Bills:
SECTION F

5
6
7
8
9
10

DETAILS OF PRIMARY INSURED'S BANK ACCOUNT

a) PAN: b) Account Number:

SECTION G

c) Bank Name and Branch

 SECTION G
d) Cheque/ DD Payable details: e) IFSC Code:

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 & 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.

SECTION H
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
Enter the social insurance number or the certificate number of social health
b) SI. No/ Certificate No. As allotted by the organization
insurance scheme
License number as allotted by IRDA and printed in TPA
c) Company TPA ID No. Enter the TPA ID No
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 format
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 4 years since inception of the contract? Indicate whether hospitalized in the last 4 years Tick Yes or No
Date
Enter the date of hospitalization Use mm-yy format
Diagnosis
Enter the diagnosis details 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
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 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 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 made out to Name of the individual/ organization in full
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.
SECTION A
 CLAIM FORM - PART B
TO BE FILLED IN BY THE HOSPITAL
UNITED INDIA INSURANCE COMPANY LIMITED
The issue of theis form is not to be taken as admission of liability
REGISTERED & HEAD OFFICE: 24, WHITES ROAD, CHENNAI-600014
Please include the original preauthorization request form in lieu of PART A
(To be filled in block letters)
DETAILS OF HOSPITAL

a) Name of the Hospital:

c) Hospital ID: c) Type of Hospital: Network Non Network (if non network, fill Section E)

SECTION A
d) Name of the treating doctor:

e) Qualification: f) Registration No. with state code: g) Phone No.

DETAILS OF PATIENT ADMITTED

a) Name of Patient:

b) IP Registration No.: c) Gender : Male Female d) Age: years months e) Date of Birth:

SECTION B
f) Date of Admission: g) Time: : h) Date of Discharge: i) Time: :

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

l) Status at time of discharge: Discharged to home Discharged 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 :

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

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

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 injurydue 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 - CHECKLIST

Claim Form duly signed Investigation reports

Original Pre-authorization request CT/ MRI/ USG/ HPE/ Investigation reports

Copy of the Pre-authorization approval letter Doctor's referance slip

SECTION D
Copy of photo ID card of patient verified by hospital ECG

Hospital discharge summary Pharmacy bills

Oparation Theatre Notes MLC report & Police FIR

Hospital main bill Original death summary from hospital, where applicable

Hospital break-up bill Any other, please specify

DETAILS IN CASE OF NON NETWORK HOSPITAL (ONLY FILL IN CASE OF NON NETWORK HOSPITAL)

a) Address of the hospital:

City: State: SECTION E

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)

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, suppress or concealment of anu material fact, our right to claim under this claim shall be
forfeited.
SECTION F

Date:

Place: Signature of the insured:

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 nospital 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 with the 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 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) Type of Admission
Indicate type of admission of patient Tick the right option
j) 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
k) Status at time of discharge
Indicate status of patient at time of discharge Tick the right option
SECTION C – DETAILS OF AILMENT DIAGNOSED (PRIMARY)
a) ICD 10 Code
Primary Diagnosis
Enter the ICD 10 Code and description of the primary diagnosis Standard Format and Open text
Additional Diagnosis
Enter the ICD 10 Code and description of the additional diagnosis Standard Format and Open text
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 conducted to establish this
Indicate whether test conducted Tick Yes or No
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 along with the state code As allocated by the Medical Council of India
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 INSURED
Read declaration carefully and mention date (in dd:mm:yy format), place (open text) and sign.