PARAMOUNT HEALTH SERVICES & INSURANCE TPA PRIVATE LIMITED (IRDA License No.

006)

[formerly known as PARAMOUNT HEALTH SERVICES (TPA) PVT.LTD]

Plot no.A-442, Road No-28,M.I.D.0 Industrial Area, Wagale Estate, Ram Nagar, Vitthal Rukmani Mandir, Thane (W), Mumbai, Pin Code — 400 604

CLAIM ACKNOWLEDGMENT SHEET

Name of Insurer : PHS ID :
Insured Name : Employee No :
Patient Name : Mobile No :
Policy No : Phone (STD) :
Name of Corporate:
Type of Claim (To Main Hospitalisation / Pre-Post Hospitalisation / OPD Claim / Deficiency Retrieval / Critical Illness / Cash Benefit E-Mail ID of
primary insured :
be ticked) :
CLAIM DOCUMENT CHECK LIST
Sr. No Description Document Remarks
Status(Y/N)
IRDA Claim Form duly signed by the Insured & Hospital
1
Part-A: Duly signed by the insured with Claimed amount ,Mobile number & Email ID along with PHS ID

Part-B: Duly signed and stamped by hospital

Declaration form duly signed & stamped by the hospital in case treatment taken is under PPN/GIPSA hospitals.
1.a Policy Declaration Form duly signed by the Insured & Hospital hospitals.
2 In case of No Intimation / Delay Intimation & Delay in submission of claim, a letter from insured is required stating
reason for the same.

3 Original Cancelled Cheque Leaf of Employee/Proposer with the Name of the AccountHolder Printed on the Cheque
Leaf.

4 ID Proof of Employee / Primary Insured- Any of one (Passport,Voter ID, Driving License, Or any Government
Approved ID ) . If Claim is above 1 lakh- PAN is mandatory with address Proof
5 ID Proof of Patient- Any of one (Passport,Voter ID, Driving License, Or any Government Approved ID )

6 Original detailed Discharge Summary as per IRDA Format / Day care summary from the hospital (in case of Day Care
Treatment) / Death Summary (in Case of Death Claim)

6.a Copy of the Legal heir certificate (if the claim is for the death of the principle insured)

6.b Copy of Post Mortem Report & Death Certificate (In Accidental Death cases)

7 Policy Copy ( if individual policy)

8 64VB Compliance Certificate ( If individual policy)
9 Original Final Hospital bill with cost wise breakup of each Item
10 Original Payment Receipt of Main Hospital bill ( both Deposit / Refund)
10.a Receipt Of Payments made at the Hospital by Credit Card : Please attach the Xerox Copy of the Credit Card Payment
Slip as received from the Vendor

11 Original copy of Implant Invoice along with Payment Receipts & Implant Labels / Stickers for Stents/ Mesh/ IOL

12 Original bills, original Payment Receipts and investigation / Laboratory Reports

13 Original medicine bills specifying Patient Name and date of purchase along with supporting Prescriptions.

14 Original copy of First Consultation letter and subsequent Prescriptions.

15 Hospital Registration certificate issued by Competent authority as per Indian nursing council Act 1947 (If hospital not
falls in GIPSA/PPN )
16 OTHER DOCUMENTS
16.a Original copy of Obstetric history (Gravida, Para, Living children, Abortions) from treating doctor. (Maternity Claim)

16.b Original Sonography Report in case of Maternity Claim

16.c Original A-Scan Report along with IOL Sticker and Tax paid invoice in case of Cataract
Claim

16.d Copy of the First Information Report (FIR) from Police Department / Copy of the Medico-Legal Certificate (MLC) in
case of Road Traffic Accident (RTA)
A medical certificate from a doctor not less qualified than MD/MS confirming the diagnosis of critical illness along
16.e
with the Investigation reports/Other related documents reflecting the critical illness diagnosis. (Critical Illness
Cases)
In case of claims where the insured has submitted documents to another insurance cofTPA, he needs to submit
16.f
attested Photocopies of all the documents along with detailed claim settlement letter from the TPA and any unpaid bills
and receipt for the same in originals.
Claims Submitted by : Insured / Corporate / Agent / Broker / Insurer / Hospital
Claim Submitted by: Mobile No.

Date of Claim DD /MM/YYYY HH:MM PHS Executive

Submission: Name:
,
Claim Submitted at: PHS - (Location) / Help Des! Signature:

Important Points to Remember:-

1. Please mark either V or x against respective check box
2. Date of File Received will be considered as next working day for Claim Files picked up at Help Desk
3. Claim Need to be Submitted within 7 Working Days from Date of Discharge from Hospital
4. The above list of documents is indicative. In case of any other document requirement as specified by the Insurance Company, our document recovery team will contact you on receipt
of your claim documents by us
5. Please visit us at www.paramounttpa.com to check Online Claim Status or download Paramount Mobile App
6. Member is advised to keep photocopies of all the papers since Insurer requires all the above documents in original. Documents once submitted will not returned unless approved &
agreed by Insurer
7. Corrections in any documents are not allowed, otherwise it will not be entertained during adjudication.
 IFFCO-TOKIO General Insurance Company Limited
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 / ___
MM / ______
YYYY
e) Date of Admission DD / ___
___ MM / ______
YYYY f) Time HH MM g) Date of Discharge DD / ___
___ MM / ______
YYYY h) Time 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 iii. MLC Report & Police FIR attached Yes No
j) System of Medicine
k) Date of Surgery DD / ___
___ MM / ______
YYYY l) Claim Intimated Yes No
i. Intimated to whom SBU Intermediaries Call Centre Health Claims Team
ii. Intimation No. & date DD / ___
___ MM / ______
YYYY
iii. If not Intimated, reason?

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 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 than certain chronic diseases) including the same illness or disease but separate independent case of hospitalization
which are not case of relapse within 45 days of first hospitalization. Please contact the agent/our office 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.
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 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 / ______
YYYY f) Date of Admission DD / ___
___ MM / ______
YYYY g) Time HH MM
h) Date of Discharge ___
DD / ___
MM / ______
YYYY i) Time 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 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

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 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 / ___
MM / ______
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:
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Place: Date: ___/___/______

DD MM YYYY Signature of Signature and Seal of
Insured/Claimant the Hospital Authority

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 POLICY DECLARATION FORM

Date:…………………….
Name of the Hospital :……………………………………………………………………………………………………………………………….
Address:…………………………………………………………………………………………………………………………………………………….
PATIENT NAME (BLOCK LETTERS):…………………………………………………………………… AGE/SEX :……………………….
Mobile No of Patient:…..........................
Date of Admission:………………………………………….. Date of Discharge:……………………………………………

Undertaking by the Patient regarding Heath Insurance Policy

(स्वास्थ्य बीमा पॉलिसी के संबंध में रोगी द्वारा शपथ-पत्र))

I declare that I do not have any health insurance policy.

( मैं घोषणा (खु लासा) करता हूं कक मेरे पास कोई भी स्वास्थ्य बीमा पॉकलसी नहीूं है।

Signature: ………………………………………… (हस्ताक्षर)

Name of the Patient/Patient’s attendant (मरीज का नाम)

I declare that I have health insurance policy.

(मैं घोषणा (खु लासा) करता हूं कक मेरे पास एक स्वास्थ्य बीमा पॉकलसी है।

Signature: ………………………………………… (हस्ताक्षर)

Name of the Patient/Patient’s attendant (मरीज का नाम)

Based on patient undertaking hospital declare that patient: (रोगी के उपक्रम के आधार पर हम उस रोगी की घोषणा करते हैं)

 Does not have insurance coverage hence we will bill the patient as per our rack rates. We may or may not
consider discount for all such undertakings. (स्वास्थ्य बीमा कवरे ज नही ूं है इसकलए हम मरीज को अपनी रै क दरोूं के अनुसार कबल
दें गे। हम ऐसे सभी उपक्रमोूं के कलए छूट पर कवचार कर भी सकते हैं और नही ूं भी।)

 Patient has health insurance coverage but out of own free will is opting for reimbursement/ cash paying
mode. . As insured is already covered under TPA servicing for which we are network provider, hence we
agree to bill this patient as per PHS or insurer agreed rate list (whichever is less). The benefit of discount as
per MOU will also be given to this patient. (रोगी के पास स्वास्थ्य बीमा कवरे ज है लेककन वह अपनी मजी से रीइूूंबससमेंट/नकद
भुगतान मोड का कवकल्प चुन रहा है । . चूूँकक बीकमत व्यक्ति पहले से ही टीपीए सकविकसूंग के अूंतगित कवर है कजसके कलए हम नेटवकि प्रदाता हैं ,
इसकलए हम इस मरीज को पीएचएस या बीमाकताि द्वारा सहमत दर सूची (जो भी कम हो) के अनुसार कबल दे ने के कलए सहमत हैं । एमओयू के
अनुसार छूट का लाभ भी इस मरीज को कदया जायेगा.)

Signature: …………………………………………

Name of the Hospital Representative & Hospital Seal