(Formerly Religare Health Insurance Company Limited)

Registered Office: 5th Floor, 19 Chawla House, Nehru Place,New Delhi-110019 Corresp. Office: Unit No. 604 - 607, 6th Floor,
Tower C, Unitech Cyber Park, Sector-39, Gurugram -122001 (Haryana) Website: www.careinsurance.com CIN:
U66000DL2007PLC161503 UIN: CHIHLIP22184V062122 IRDAI Registration No. - 148 Page 1
 1. To be filled in by the Insured.
2. The issue of this Form is not to be taken as an admission of liability.
3. To be filled in block letters. Claim Intimation No.:

a) Policy No :

b) SL No./Certificate No : c) Company/TPA ID No:

d) Name :

(Surname) (First Name) (Middle Name)

e) Address :

City :

State : Pin Code :

Phone Number :

Email :

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

b) Date of commencement of first insurance without break : / / (DD/MM/YYYY)

c) If yes, Company Name :

Policy Number : Sum Insured (Rs.)::

d) Have you ever been hospitalized in the last 4 years since inception of the contract? Yes No
• Date : / / (DD/MM/YYYY)
• Diagnosis :

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

f) If yes, Company Name :

Title : Mr. Ms.

:
Name
(First Name) (Middle Name) (Surname)

Gender : M F c) Age : / (YY/MM) d) Date of Birth : / /

e) Relationship with Primary Insured : Self Spouse Child Father Mother

Others (Please
Specify)

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

Address :

: City :

State : Pin Code

Phone Number :

E-mail :

Care Health Insurance Limited (Formerly Religare Health Insurance Company Limited)
Registered Office: 5th Floor, 19 Chawla House, Nehru Place,New Delhi-110019 Corresp. Office: Unit No. 604 - 607, 6th Floor, Tower C, Unitech
Cyber Park, Sector-39, Gurugram -122001 (Haryana) Website: www.careinsurance.com CIN: U66000DL2007PLC161503 UIN:
CHIHLIP22184V062122 IRDAI Registration No. - 148
Page 2
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

b) Date of Injury/Date Disease first detected/Date of Delivery : / / (DD/MM/YYYY)

e) Date of Admission: / / (DD/MM/YYYY) f) Time of Admission : (HH:MM)

g) Date of Discharge: / / (DD/MM/YYYY) h) Time of Discharge: : (HH:MM)

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

i) iii) MLC Report & Police FIR attached: Yes No j) System of Medicine :

a) Details of the treatment expenses claimed

(i) Pre-hospitalization Expenses : Rs. (vi) Others : Rs.

(ii) Hospitalization Expenses : Rs. Total : Rs.

(iii) Post-hospitalization Expenses : Rs. (vii) Pre-hospitalization period : days

(iv) Health Check-up cost : Rs. (viii) Post-hospitalization period : days

(v) Ambulance Charges : Rs.

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 : Rs. (v)Pre/Post hospitalization Lump sum benefit : Rs.

(ii)Surgical Cash : Rs. (vi) Others : Rs.

(iii)Critical Illness Benefit : Rs. Total : Rs.

(iv)Convalescence : Rs.

d) Claim Documents Submitted - Checklist

(i) Claim Form Duly signed : (vii) Pharmacy Bill :

(ii) Copy of the claim intimation, if any : (viii) Operation Theatre Notes :

(iii) Hospital Main Bill : (ix) ECG :

(iv) Hospital Break-up Bill : (x) Doctor's request for investigation :

(v) Hospital Bill Payment Receipt : (xi) I Investigation Reports (Including CT/MRI/USG/HPE) :

(vi) Hospital Discharge Summary : (xii) Doctor's Prescriptions :

(xiii) Others

Care Health Insurance Limited (Formerly Religare Health Insurance Company Limited)
Registered Office: 5th Floor, 19 Chawla House, Nehru Place,New Delhi-110019 Corresp. Office: Unit
No. 604 - 607, 6th Floor, Tower C, Unitech Cyber Park, Sector-39, Gurugram -122001 (Haryana)
Website: www.careinsurance.com CIN: U66000DL2007PLC161503 UIN: CHIHLIP22184V062122
IRDAI Registration No. - 148 Page 3
 S Amount
Bill No. Date Issued by Towards
No. (INR)

1 Hospital Main Bill

Pre-hospitalization
2
Bills:___Nos
Post-hospitalization
3
Bills:___Nos

4 bills

10

In case of more details, please attach a separate sheet.

a) PAN :

b) Account Number :

c) Bank Name & Branch :

d) Cheque/DD payable details :

e) IFSC Code :

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/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 : / / (DD/MM/YYYY) Signature of the Insured :

Place :

Care Health Insurance Limited (Formerly Religare Health Insurance Company Limited)
Registered Office: 5th Floor, 19 Chawla House, Nehru Place,New Delhi-110019 Corresp. Office: Unit No. 604 - 607, 6th Floor, Tower C,
Unitech Cyber Park, Sector-39, Gurugram -122001 (Haryana) Website: www.careinsurance.com CIN: U66000DL2007PLC161503 UIN:
CHIHLIP22184V062122 IRDAI Registration No. - 148
Page 4
 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
b) SI. No/ Certificate No. As allotted by the organization
social health insurance scheme
License number as allotted by IRDA and
c) Company TPA ID No. Enter the TPA ID No.
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 Indicate whether currently covered by another
Tick Yes or No
Insurance? Mediclaim/Health Insurance
b) Date of Commencement of first Insurance without
Enter the date of commencement of first insurance Use dd-mm-yy format
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 last four years
Indicate whether hospitalized in the last four years Tick Yes or No
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/Health Indicate whether previously covered by another
Tick Yes or No
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
Tick the right option. If others, please
e) Relationship with primary Insured Indicate relationship of patient with policyholder
specify
Tick the right option. If others, please
f) Occupation Indicate occupation of patient
specify
g) Address Enter the full postal address Include Street, City and Pin Code
h) Landline 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
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
Enter the relevant date Use dd-mm-yy format
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
Claim Made for Select the event for which the claim is made Tick Yes or No
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

Care Health Insurance Limited (Formerly Religare Health Insurance Company Limited)
Registered Office: 5th Floor, 19 Chawla House, Nehru Place,New Delhi-110019 Corresp. Office: Unit No. 604 - 607,
6th Floor, Tower C, Unitech Cyber Park, Sector-39, Gurugram -122001 (Haryana) Website: www.careinsurance.com
CIN: U66000DL2007PLC161503 UIN: CHIHLIP22184V062122 IRDAI Registration No. - 148 Page 5
 Data Element Description Format

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.

Care Health Insurance Limited (Formerly Religare Health Insurance Company Limited)
Registered Office: 5th Floor, 19 Chawla House, Nehru Place,New Delhi-110019 Corresp. Office: Unit No. 604 - 607, 6th Floor,
Tower C, Unitech Cyber Park, Sector-39, Gurugram -122001 (Haryana) Website: www.careinsurance.com CIN:
U66000DL2007PLC161503 UIN: CHIHLIP22184V062122 IRDAI Registration No. - 148 Page 6
1. To be filled in by the hospital.
2. The issue of this Form is not to be taken as an admission of liability.
3. Please include the original pre-authorization request form in lieu of PART A.
4. 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
(Surname) (First Name) (Middle Name)
:
e) Qualification
:
f) Registration No. with State Code
:
g) Contact No.

:
a)Name of the Patient:
(Surname) (First Name) (Middle Name)

b) IP Registration No : :

c)Gender : M F d) Age : / (YY/MM) e) Date of Birth : / /

f) Date of Admission : / / (DD/MM/YYYY) g) Time of Admission : (HH:MM)

h) Date of Discharge : / / (DD/MM/YYYY) i) Time of Discharge: : (HH:MM)

j) Type of Admission : Emergency Planned : Day Care Maternity

k) If Maternity,
(i) Date of Delivery / / (DD/MM/YYYY) (ii) Gravida Status :

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

m) Total Claimed Amount :

a) (i) Primary Diagnosis : ICD 10 Code : Description :

(ii) Additional Diagnosis : ICD 10 Code : Description :

(iii) Co-morbidities : ICD 10 Code : Description :

(iv) Co-morbidities : ICD 10 Code : Description :

b) (i) Procedure 1 : ICD 10 Code : Description :

(ii) Procedure 2 : ICD 10 Code : Description :

(iii) Procedure 3 : ICD 10 Code : Description :

(iv) Details of Procedure :
c) Present ailment is a complication of PED : Yes No

If yes, specify detauls :

d) Pre-authorization obtained : Yes No

e) Pre-authorization no. :
f) If authorization by network hospital not obtained, give reason :

Care Health Insurance Limited (Formerly Religare Health Insurance Company Limited)
Registered Office: 5th Floor, 19 Chawla House, Nehru Place,New Delhi-110019 Corresp. Office: Unit No. 604 - 607, 6th Floor, Tower C,
Unitech Cyber Park, Sector-39, Gurugram -122001 (Haryana) Website: www.careinsurance.com CIN: U66000DL2007PLC161503 UIN:
CHIHLIP22184V062122 IRDAI Registration No. - 148 Page 7
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 :

(I) Duly signed Claim Form : (ix) Investigation Report :

(ii) Original Pre-authorization request : (x) CT/ MRI/ USG /HPE investigation reports :

(iii) Copy of Pre-authorization approval letter : (xi) Doctor's reference slip for investigation :

(iv) Copy of photo ID card of patient verified by hospital : (xii) ECG :

(v) Hospital Discharge Summary : (xiii) Pharmacy Bills :

(vi) Operation Theatre notes : (xiv) MLC report & Police FIR :

(vii) Hospital Main Bill : (xv) Original death summary from hospital where applicable :

(viii) Hospital Break-up Bill : (xvi) Any other, please specify :

a) Address of the Hospital :

City :

State : Pin Code :

b) Contact No. : -

c) Registration No. with State Code :

d) Hospital PAN : e) No. of inpatient beds :

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

(iii) Others :

(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 facts, our right to claim under this claim shall be forfeited.
Date : / / (DD/MM/YYYY) Signature & Seal of the Hospital Authority :

Place :

Care Health Insurance Limited (Formerly Religare Health Insurance Company Limited)
Registered Office: 5th Floor, 19 Chawla House, Nehru Place,New Delhi-110019 Corresp. Office: Unit No. 604 - 607, 6th Floor, Tower C,
Unitech Cyber Park, Sector-39, Gurugram -122001 (Haryana) Website: www.careinsurance.com CIN: U66000DL2007PLC161503 UIN:
CHIHLIP22184V062122 IRDAI Registration No. - 148 Page 8
 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 Name of 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
f) Registration No. with State Code As allocated by the Medical Council of India
state Code
g) Contact No. Enter the phone number of doctor Include STD code with telephone number
Section B - Details of 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 Birth of patient 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
Enter the ICD 10 Code and description of the co-
Co-morbidities Standard Format and Open text
morbidities
b) ICD 10 PCS
Procedure 1 Enter the ICD 10 PCS and description of the first procedure Standard Format and Open text
Enter the ICD 10 PCS and description of the second
Procedure 2 Standard Format and Open text
procedure
Enter the ICD 10 PCS and description of the third
Procedure 3 Standard Format and Open text
procedure
Details of Procedure Enter the details of the procedure Open text
c) PED Indicate whether present ailment is a combination of PED Tick Yes or No
If yes, specify details Enter the details of PED Open text
d) Pre-authorization obtained Indicate whether pre-authorization obtained Tick Yes or No
e) Pre-authorization Number Enter pre-authorization number As allotted by TPA
f) If authorization by network hospital not obtained, give
Enter reason for not obtaining pre-authorization number Open text
reason
g) 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
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
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 - Claims Document Submitted Checklist
Indicate which supporting documents are submitted

Care Health Insurance Limited (Formerly Religare Health Insurance Company Limited)
Registered Office: 5th Floor, 19 Chawla House, Nehru Place,New Delhi-110019 Corresp. Office: Unit No. 604 - 607, 6th
Floor, Tower C, Unitech Cyber Park, Sector-39, Gurugram -122001 (Haryana) Website: www.careinsurance.com CIN:
U66000DL2007PLC161503 UIN: CHIHLIP22184V062122 IRDAI Registration No. - 148 Page 9
 Data Element Description Format
Section E - Additional Details in case of Non-Network Hospital
a) Address Enter the full postal address Include Street, City and Pin Code
b) Contact 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 Hospital
Read declaration carefully and mention date (in dd:mm:yy format), place (open text) and sign and stamp

Care Health Insurance Limited (Formerly Religare Health Insurance Company Limited)
Registered Office: 5th Floor, 19 Chawla House, Nehru Place,New Delhi-110019 Corresp. Office: Unit No. 604 - 607, 6th Floor,
Tower C, Unitech Cyber Park, Sector-39, Gurugram -122001 (Haryana) Website: www.careinsurance.com CIN:
U66000DL2007PLC161503 UIN: CHIHLIP22184V062122 IRDAI Registration No. - 148 Page 10
Annexure – I to Claim Form
If a claim is made for any of the following Benefits under ‘Travel Plus’, then kindly tick the appropriate Benefit and fill in the corresponding details:-
Worldwide In-Patient Cover (for emergency) :

Worldwide OPD Cover :

Note: If claiming under ‘Worldwide OPD Cover’, only the relevant fields need to be filled.

Name, address and telephone number of Hospital where treatment was given: ____________________________________________________________
__________________________________________________________________________________________________________________________
Name of treating Medical Practitioner: ____________________________________________________________________________________________
Details of Illness/Injury: ________________________________________________________________________________________________________
Cause of the Illness/Injury: ______________________________________________________________________________________________________
Was the Illness/incident caused/ aggravated due to a pre-existing condition? Please give details: ___________________________________________________
__________________________________________________________________________________________________________________________
Date of onset of Illness (DDMMYYYY):
Nature of treatment: _________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________
Date of treatment (DDMMYYYY): From To

Loss of Passport
Date of loss (DDMMYYYY): Place of loss: ______________________________________________
Detail / Circumstances of loss: _________________________________________________________________________________________________
Total expenses: ___________________________

Loss of Checked-in Baggage

Name of Common Carrier _____________________________________________________________________________________________________
Date of loss (DDMMYYYY): Place of loss: _______________________________________________
Port of disembarkation: _______________________________________________________________________________________________________

Serial no. Details of Loss Amount

Repatriation of Mortal Remains

Cause of death: ______________________________________________________________________________________________________________
Date of death of Insured (DDMMYYYY): Total expenses _____________________
Transportation From: ____________________ To: ________________________Date:

Medical Evacuation
If Medical Evacuation is done, reason for Medical Evacuation: _________________________________________________________________________
Medical Evacuation From: ____________________ To: ________________________ Date:

Serial no. Expense Details Amount

Care Health Insurance Limited (Formerly Religare Health Insurance Company Limited)
Registered Office: 5th Floor, 19 Chawla House, Nehru Place,New Delhi-110019 Corresp. Office: Unit No. 604 - 607, 6th Floor, Tower C,
Unitech Cyber Park, Sector-39, Gurugram -122001 (Haryana) Website: www.careinsurance.com
Page 11
CIN: U66000DL2007PLC161503 UIN: CHIHLIP22184V062122 IRDAI Registration No. - 148
Date

To,
The Medical Suprintendent

Dear Sir,

Re : Authorization in favour of M/s Care Health Insurance Limited and its authorized agents.

I have undergone treatment for

from to in your hospital under Inpatient No. .

I hereby authorise M/s Care Health Insurance Limited and/or its authorised representative to seek any medical information / records from you or
from the Medical Practitioners who has attended on me in connection with the above ailment.

I have no objection in case they seek such information/records in whatsoever regards.

Thanking You,
Yours Faithfully

(Signature of the Claimant)

Address of the Insured -

Care Health Insurance Limited (Formerly Religare Health Insurance Company Limited)
Registered Office: 5th Floor, 19 Chawla House, Nehru Place,New Delhi-110019 Corresp. Office: Unit No. 604 - 607, 6th Floor, Tower C, Unitech
Cyber Park, Sector-39, Gurugram -122001 (Haryana) Website: www.careinsurance.com CIN: U66000DL2007PLC161503 UIN:
CHIHLIP22184V062122 IRDAI Registration No. - 148 Page 12