CLAIM FORM FOR HOSPITALIZATION REIMBURSEMENT BENEFIT

FOR SECURE EARNINGS AND WELLNESS ADVANTAGE PLAN

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)
SECTION A – DETAILS OF PRIMARY INSURED

Policy no:
Company/TPA ID no:
Name:
Address:

City: State:
Pin code: Phone no.:

E-mail ID: ____________________________________________________________________

SECTION B – OTHER INSURANCE HISTORY

Policy No. Company Name Sum Assured Status(active/lapsed/applied/matured) Claim Status

SECTION C- DETAILS OF INSURED PERSON HOSPITALISED

a) Name:
b) Gender: Male Female c) Current Age: d) Date of Birth:
e) Occupation: Service Self-employed Homemaker Student Retired Other
Please specify:
f) Address (if different from above):

City: State:
Pin code: Phone no.:

E-mail ID:_ ____________________________________________________________________

SECTION D- DETAILS OF HOSPITALIZATION

a) Name of the hospital where admitted:

b) Room category occupied: ICU Non ICU
c) Hospitalization due to: Illness Injury Maternity
d) Date of Injury/Date of disease first detected/Date of delivery: D D M M Y Y Y Y
e) Date of admission: D D M M Y Y Y Y f) Time of admission: H H :M M
g) Date of discharge: D D M M Y Y Y Y h) Time of discharge: H H :M M
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
j) System of medicine: Allopathy/Homeopathy/Ayurveda/Unani/Naturopathy

SECTION E- DETAILS OF CLAIM

a) Details of the treatment expenses claimed iv) Claim documents submitted-check

i) Hospitalization period: list:

Days ICU Non ICU Duly filled and signed claim form
Copy of intimation letter, if any
b) Details of lumpsum/cash benefit claimed: Hospital main bill
i) Hospital daily cash Rs. hospital break up bill
ii) Surgical cash Rs. hospital bill payment receipt
iii) Critical illness benefit Rs. Hospital discharge summary
Pharmacy bill
Operation theater notes
Doctor’s request for investigation
Doctor’s prescription
Allinvestigation reports including
ECG,CT, MRI/USG/HPE)
KYC of LA and/or Nominee
(Personalized cancelled cheque,
Passbook/PAN)

SECTION – G DETAILS OF PRIMARY INSURED’S BANK ACCOUNT

a) PAN: b) Account number:

c) Bank name/branch:
d) Payable details: Cheque/DD: e) IFSC code:

SECTION H – 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 voluntarily provide my consent to use my Aadhar to conduct identity check towards KYC compliance by MAX LIFE
INSURANCE
Date: D D M M Y Y Y Y
Place: Signature of 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
b) Company TPA ID no. Enter the TPA ID no.
c) Name Enter the full name of the policyholder <Surname, First name, Middle name>
d) Address Enter the full postal address
SECTION B - DETAILS OF INSURANCE HISTORY
Indicate whether currently covered by
another Mediclaim / Health insurance Yes No

Enter the date of commencement of

first insurance D D M M Y Y Y Y
Enter the full name of the insurance
e) Company name
company
Policy no. Enter the policy number
Enter the total sum insured as per the
Sum insured
policy
SECTION C - DETAILS OF INSURED PERSON HOSPITALIZED
a) Name Enter the full name of the patient
b) Gender Indicate gender of the patient
c) Age Enter completed age of the patient
d) Date of Birth Enter date of birth of patient D D M M Y Y Y Y
e) Occupation Indicate occupation of patient/LA
f) Address Enter the full postal address
g) Phone no Enter the phone number of patient/LA
h) E-mail ID Enter e-mail address of patient/LA
SECTION D - DETAILS OF HOSPITALIZATION
a) Name of Hospital where
Enter the name of hospital
admitted
b) Room category occupied Indicate the room category occupied
c) Hospitalization due to Indicate reason of hospitalization
d) Date of injury/Date of
disease first detected/ Date Enter the relevant date D D M M Y Y Y Y
of delivery
e) Date of admission Enter date of admission D D M M Y Y Y Y
f) Time Enter time of admission H H :M M
g) Date of discharge Enter date of discharge D D M M Y Y Y Y
h) Time Enter time of discharge H H :M M
i) If injury give cause Indicate cause of injury
If medico legal Indicate whether injury is medico legal Yes No
 Indicate whether police report was
Reported to police Yes No
filed
Indicate whether MLC report and
Yes No
police FIR attached
Enter the system of medicine followed
j) System of medicine
in treating the patient
SECTION E – DETAILS OF CLAIM
a) details of treatment Enter the amount claimed as treatment
expenses expenses
c) Details of lump sum/cash Enter the amount claimed as lump
benefit claimed sum/cash benefit
d) Claim documents Indicate which supporting documents
submitted-check list are submitted
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
b) Account number Enter the bank account number
Enter the bank name along with the
c) Bank name and branch
branch
Enter the name of the beneficiary the
d) Cheque/DD payable details
cheque/DD should be made out to
e) IFSC code Enter the IFSC code of the bank branch
 CLAIM FORM FOR HOSPITALIZATION REIMBURSEMENT BENEFIT
FOR SECURE EARNINGS AND WELLNESS ADVANTAGE PLAN
CLAIM FORM – PART B
TO BE FILLED IN BY THE HOSPITAL

DETAILS OF HOSPITAL

a) Name of 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. with state code:
g) Phone no.:

DETAILS OF THE PATIENT ADMITTED

a) Name of the patient:

b) Registration no.: c) Gender: Male Female
d) Age: Years Months e) Date of birth: D D M M Y Y Y Y
f) Date of admission: D D M M Y Y Y Y g) Time of admission: H H :M M
h) Date of discharge: D D M M Y Y Y Y i) Time of discharge: H H :M M
j) Type of admission emergency: Planned Day care
k) If maternity: i) Date of delivery: D D M M Y Y Y Y ii) Gravida status:
l) Status at time of discharge: Discharge to home Discharge to another hospital Deceased

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.

iv) Co-morbidities iv). Procedure 4.

c) Present ailment is a complication of Pre-existing? YES NO If Yes, specify details

f) 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 reasons
CLAIM DOCUMENTS SUBMITTED. CHECK LIST

Claim form duly signed All Investigation reports including

Copy of photo ID card of patient verified by hospital (CT/MRI/USG/HPE/ECG etc.)

Hospital discharge summary Pharmacy bills

Operation theatre notes KYC of LA/Nominee (personalized cancelled cheque/

passbook, PAN, Aadhar)
Hospital main bill
Hospital break-up bill

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

a) Address of hospital:
b) City: C) State:
d) Pin code: e) Phone no:
f) Registration no: g) PAN:
h) Number of inpatient beds i) Facilities available in the hospital: i) OT: Yes No
ii) ICU: Yes No iii). Others

DECLARATION BY THE INSURED (PLEASE READ VERY CAREFULLY)

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, my right to claim reimbursement shall be forfeited. I also consent &
authorize TPA I insurance company; to seek necessary medical information I documents from any hospital/Medical Practitioner who has attended
on the person against whom this claim is made. I voluntarily provide my consent to use my Aadhar to conduct identity check towards KYC
compliance by MAX LIFE INSURANCE.

Date: D D M M Y Y Y Y
Place: Signature of Insured:

DECLARATION BY THE HOSPITAL

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.

Date: D D M M Y Y Y Y
Place: Signature of Insured:

CHECK LIST OF ENCLOSURES FOR SUBMISSION OF CLAIM

In-patient treatment /day care procedures

Duly filled and signed claim form.
Photocopy of ID card/photocopy of current year policy.
 Copy of detailed discharge summary with date of admission & discharge, clinical history, past history/
procedure details/day care summary from the hospital.
Copy of consolidated hospital bill with break up of each item, duly signed by the insured. Payment receipt of
the hospital bill.
Payment receipt of the hospital bill.
First consultation letter and subsequent prescriptions.
Copy of bills, copy of payment receipts and reports for investigation.
Copy of medicine bills and receipts with corresponding prescriptions.
Copy of invoice/sticker of implants/bills for Implants (viz. Stent/PHS mesh/IOL etc.) with payment receipts

Road traffic accident

In addition to the In-patient treatment documents:
Copy of the First Information Report from police department/copy of the Medico-Legal certificate.

In Non Medico legal cases

Treating doctor’s certificate giving details of injuries (how, when and where injury sustained)

CUSTOMER IDENTIFICATION PROCEDURE (AS PER KYC NORMS OF IRDA)

Please submit the following documents in case of claim amount exceeds Rs. 100,000
Legal name and any other names used (Any one of the Passport/PAN card/voter's identity card/driving license/
mentioned documents) letter from a recognized public authority or public serv-
ant verifying the identity and residence of the customer
Proof of residence (Any one of the mentioned Telephone bill/bank account statement/letter from any
documents) recognized public authority/electricity bill/ration card

NOTE: Please send the documents to TPA office on below address or email the documents to the email id given below:

TPA Name: MD India Health Insurance TPA Pvt. Ltd.

Address: S. No. 46/1, E-space, A-2 Building, 2nd floor, Pune Nagar Road, Vadgaonsheri, Pune 411014.
Email ID: [email protected]
Toll Free No.: 1800 210 6862
Website: www.mdindiaonline.com

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