Claim Form - Part A' To 'Claim Form For Health Insurance Policies Other Than Travel and Personal Accident - Part A
Claim Form - Part A' To 'Claim Form For Health Insurance Policies Other Than Travel and Personal Accident - Part A
Claim Form - Part A' To 'Claim Form For Health Insurance Policies Other Than Travel and Personal Accident - Part A
ACCIDENT - PART A
TO BE FILLED BY THE INSURED
a) Policy No.:
c) Company/ TPA ID No:
U
SECTION A
d) Name:
e) Address:
City:
State:
Pin Code
Phone No:
Email ID:
Yes
No
Date:
Policy No.
Yes
d) Have you been hospitalized in the last four years since inception of the contract?
No
Y
Yes
Diagnosis:
No
SECTION B
a) Name:
b) Gender
Male
Female
Self
f) Occupation
Self Employed
Spouse
Child
Home Maker
Months M
M
D
d) Date of Birth
D
Y
Father
Mother
Other
(Please Specify)
Student
Retired
Other
(Please Specify)
SECTION C
F
Y
c) Age years
City:
State:
Pin Code
Phone No:
Email ID:
DETAILS OF HOSPITALIZATION: :
a) Name of Hospital where Admited:
Day care
Self inflicted
f) Time
g) Date of Discharge: D
Twin sharing
Yes
No
I) If Medico legal
M
Y
M
h) Time:
Yes
No
SECTION D
e) Date of Admission:
I) If injury give cause:
Single occupancy
Maternity
Illness
Injury
j) System of Medicine:
DETAILS OF CLAIM:
a) Details of the Treatment expenses claimed
Rs.
Rs.
Rs.
Rs.
v. Ambulance Charges:
Rs.
Rs.
days
No
SECTION E
Rs.
Total
Rs.
Rs.
Rs.
iv. Convalescence:
Rs.
vi. Others:
Rs.
Total
Rs.
ECG
Doctors request for investigation
Investigation Reports (Including CT
/ MRI / USG / HPE)
Doctors Prescriptions
Others
Sl. No.
Bill No.
Date
Issued by
Towards
Post-hospitalization Bills:
4.
5.
6.
Pharmacy Bills
7.
8.
9.
10.
Amount (Rs)
Nos
Nos
SECTION F
1.
2.
3.
e) IFSC Code:
SECTION G
a) PAN:
Date
Place:
GUIDANCE FOR FILLING CLAIM FORM - PART A (To be filled in by the insured)
DATA ELEMENT
DESCRIPTION
FORMAT
Policy No.
b)
c)
d)
Name
e)
Address
Tick Yes or No
b)
Use dd-mm-yy-forrmat
c)
Company Name
Policy No.
Sum insured
In rupees
Tick Yes or No
Date
Diagnosis
Previously covered by any other Mediclaim / Health
Insurance?
Company Name
Open Text
d)
e)
f)
Tick Yes or No
Name of the organization in full
Name
b)
Gender
c)
Age
d)
Date of Birth
e)
f)
Occupation
g)
Address
h)
Phone No
1)
E-mail ID
b)
c)
Hospitalization due to
d)
e)
Date of admission
f)
Time
g)
Date of discharge
h)
Time
I)
If Medico legal
Tick Yes or No
Reported to Police
Tick Yes or No
Tick Yes or No
System of Medicene
Open Text
j)
b)
Tick Yes or No
c)
d)
PAN
b)
Account Number
c)
c)
c)
IFSC Code
Read declaration carefully and mention date (in dd:mm:yy format), place (open text) and sign.
SECTION H
I hereby declare that the information furnished in the claim form is true & correct to the best of my knowledge and belief. If I have made any false or untrue statement, suppression
or concealent of any material fact with respect to questions asked in relation to this claim, my right to claim reimbrusement 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.
DETAILS OF HOSPITAL
a) Name of the hospital:
e) Qualification:
Non Network :
SECTION A
Network :
c) Type of Hospital:
a) Hospital ID:
e) Date of birth: D
g) Phone No.
b) IP Registration Number:
Emergency
Planned
Discharge to home
g) Time:
Day Care
Female
d) Age: Years
h) Date of Discharge:
i) Date of Delivery:
k) If Maternity
Maternity
Months M
Deceased
SECTION B
Male
c) Gender:
f) Date of Admission:
j) Type of Admission:
a)
ICD 10 PCS
b)
Description
i. Procedure 1:
ii. Procedure 2:
iii. Co-morbidities:
iii. Procedure 3:
iv. Co-morbidities:
Yes
c) Pre-authorization obtained:
No
SECTION C
I. Primary Diagnosis
Description
d) Pre-authorization Number:
No
Self-inflicted
ii) If injury due to substance abuse / alcohol consumption, Test conducted to establish this:
v. FIR No.
Yes
Yes
No
Yes
ii. ICU
Yes
No
ECG
Pharmacy bills
SECTION D
Pin Code:
b) Phone No.
e) Number of inpatient beds
d) Hospital PAN:
i. OT
Yes
No
No
SECTION E
State:
City:
iii. Others:
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.
Place:
SECTION F
Date:
Y
Signature and Seal of the Hospital Authority:
GUIDANCE FOR FILLING CLAIM FORM - PART B (To be filled in by the hospital)
FORMAT
DESCRIPTION
DATA ELEMENT
b)
Hospital ID
c)
Type of Hospital
c)
e)
Qualification
f)
Enter the registration number of the doctor along with the state code
g)
Phone No.
Name of Patient
b)
IP registration Number
c)
Gender
d)
Age
e)
Date of Birth
f)
Date of Admission
g)
Time
Date of Discharge
h)
i)
Time
j)
Type of Admission
Date of Delivery
Gravida Status
k)
l)
M)
If Maternity
b)
ICD 10 Code
Primary Diagnosis
Additional Diagnosis
Co-morbidities
Procedure 1
Procedure 2
Procedure 3
ICD 10 PCS
Details of Procedure
Open text
c)
Pre-authorization obtained
Tick Yes or No
d)
Pre-authorization Number
As allotted by TPA
e)
Open text
f)
Tick Yes or No
Cause
Tick Yes or No
Medico Legal
Reported to Police
Tick Yes or No
Tick Yes or No
FIR No.
Open text
Address
b)
Phone No.
c)
Enter the registration number of the Hospital obtained from local body
like City Corporation / Municipality
d)
Hospital PAN
e)
Digits
f)