CLAIM FORM - PART A

TO BE FILLED IN BY THE INSURED

The issue of this Form is not to be taken as an admission of liability
(To be filled in block letters)

DETAILS OF PRIMARY INSURED

a) Policy No. b) SI. No./Certificate No.
c) Company/TPA ID No.
d) Name
e) Address

City
State Pin Code
Ph. No. Email ID

DETAILS OF INSURANCE HISTORY

a) Currently covered by any other Mediclaim/Health Insurance Yes No
b) If yes, Company Name
Policy No. Sum Insured (`)
c) Date of commencement of first Insurance without break DD / MM / YYYY (Copies of Policies to be attached)
d) Have you been hospitalized in the last 4 years? (since inception of the Yes No Date DD / MM / YYYY
contract) Diagnosis
e) Have you been covered by any other Mediclaim/Health Insurance in last 4 years 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 DD / MM / YYYY
e) Relationship to Primary Self Spouse Child Father Mother
insured Other (Please Specify)
f) Occupation Service Self Employee Homemaker Student Retired
Other (Please Specify)
Address (if different
from above)

City
State Pin Code
Ph. 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 of Disease first detected/Date of Delivery DD / M M / YYYY
e) Date of Admission DD / MM / YYYY f) Time HH MM g) Date of Discharge DD / M M / YY Y h) Time HH MM
Y
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
k) Date of Surgery DD / M M / YY Y l) Claim Intimated Yes No
Y
i. Intimated to whom SBU Intermediaries Call Centre Health Claims Team
ii. Intimation No. & date DD / M M / YYYY
iii. If not Intimated, reason?

Page 1 of
 DETAILS OF CLAIM
a) Details of the treatment expenses claimed
i. Pre-hospitalization Expenses ` ii. Hospitalization Expenses `
iii. Post-hospitalization expenses ` iv. Health-Check up Cost `
v. Ambulance Charges ` vi. Others (code) `
vii. Pre-hospitalization period days Total `
viii. Post hospitalization period days
b) Claim for Domiciliary Hospitalization Yes No (If yes, provide details in annexure)
c) Details of Lump sum/cash benefit claimed
i. Hospital Daily Cash ` ii. Surgical Cash `
iii. Critical Illness Benefit ` iv. Convalescence `
v. Pre/Post hospitalization Lump ` vi. Others `
sum benefit
Total `
Claim Documents Submitted - Check List Operation Theatre Notes
Claim Form Duly signed ECG
Copy of the claim intimation Doctor’s request for investigation
Hospital Main Bill Investigation Reports (CT/MRI/USG/HPE)
Hospital Break - up Bill Doctor’s Prescriptions
Hospital Bill Payment Receipt Pre-Hosp. Bills
Hospital Discharge Summary Post-Hosp. Bills
Pharmacy Bill Others

DETAILS OF BILLS ENCLOSED

SI. No. Bill No. Date Issued by Towards (Hospitalization/Pre-hospitalization/ Amount (`)
Post-hospitalization
1 DD / MM / YYYY
2 DD / MM / YYYY
3 DD / MM / YYYY
4 DD / MM / YYYY
5 DD / MM / YYYY
6 DD / MM / YYYY
7 DD / MM / YYYY
8 DD / MM / YYYY
9 DD / MM / YYYY
10 DD / MM / YYYY
Do you want to opt for Automatic Reinstatement of Sum Insured in the event of a claim? If, Yes, applicable premium at short period rates would be
deducted from the claim amount due to you. This reinstated sum will not be available for the same hospitalization. It will be available for treatment

(other thannot
which are certain
case chronic diseases)
of relapse including
within 45 days ofthe
firstsame illness or disease
hospitalization. Please but separate
contact independent
the agent/our case
office of hospitalization
for further details: Yes No

DETAILS OF PRIMARY INSURED’S BANK ACCOUNT (Please submit a cancelled cheque copy for NEFT)
a) PAN b) Account Number
c) Bank Name and Branch
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.

Place: Date: DD/ MM/ YYYY Signature of the Insured

Important:
1. Please submit copy of valid Photo ID.
2. For claimed amount above 1 lac, it is mandatory to submit the KYC (Know your customer) form.

Page 2 of
 Annexure - III

CLAIM FORM - PART B

TO BE FILLED IN BY THE HOSPITAL

The issue of this Form is not to be taken as an admission of liability

(To be filled in block letters)
Please include the original preauthorization request form in lieu of PART 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
e) Qualification f) Registration No. g) Ph No.
with State Code

DETAILS OF THE PATIENT ADMITTED

a) Name of the Patient
b) IP Registration Number c) Gender Male Female d) Age Years Months
e) Date of birth DD / MM / Y YYY f) Date of Admission DD / MM / Y YYY g) Time HH MM
h) Date of Discharge DD / MM / Y YYY i) Time HH MM
j) Type of Admission Emergency Planned Day Care Maternity
k) If Maternity i. Date of Delivery DD / M M / YYYY 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
i. Primary Diagnosis
ii. Additional Diagnosis
iii. Co-morbidities
iv. Co-morbidities
b) ICD 10 Codes Description
i. Procedure 1
ii. Procedure 2
iii. Procedure 3
iv. Details of Procedure
c) Present ailment is a complication of PED? Yes No (If Yes, specify
details)
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 ii. If Injury due to Substance abuse/alcohol (If Yes, attach
Yes No
consumption consumption. Test Conducted to establish this reports)
iii. If Medico legal Yes No iv. Reported to Police Yes No v. FIR No.
vi. If not reported to police give reason

Page 3 of
 CLAIM DOCUMENTS SUBMITTED - CHECK LIST
Claim Form duly signed Operation Theatre notes Doctor’s reference slip for investigation
Original Pre-authorization request Hospital main bill ECG
Copy of the Pre-authorization approval Hospital break-up bill Pharmacy bills
letter
Copy of photo ID card of patient verified Investigation reports MLC report & Police FIR
by hospital
Hospital Discharge summary CT/MR/USG/HPE investigation reports Original death summary from hospital
where applicable
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.
Date of Registration DD / M M / YYYY Expiry date of Registration DD / MM / YYYY
Name of the Registering Authority
d) 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, suppression or concealment of any material fact, our right to claim under this claim shall be forfeited. The
signature of the insured is taken on this form after Claim Form B is fully filled up by us.
Hospital have required infrastructure to fulfill the hospital definition as per IRDA guideline, which is reproduced below:
● Has at least 10 inpatient beds, in those towns having a population of less than 10,00,000 and 15 inpatient beds in all other places
● Has fully qualified nursing staff under its employment round the clock
● Has fully qualified doctor(s) in charge round the clock
● Has a fully equipped operation theatre of its own where surgical procedures are carried out.
● Maintains daily Medical records of patients and will make these accessible to the Company’s authorized personnel.

Place: Date: DD/ MM/ YYYY Signature of Signature and Seal of

Insured/Claimant the Hospital Authority

Page 4 of 4

Clear Form Print Form