Reimbursement Claim Form - Medi Buddy

1 Reimbursement Claim FORM TO BE FILLED BY THE INSUREDThe issue of this Form is not to be taken as an admission of liablityDETAILS OF PRIMARY INSURED:a) Policy No.:(To be Filled in block letters)SECTION ASECTION Bb) Sl. No/ Certificate ) Company / TPA ID (MA ID)No:e) Address:DETAILS OF INSURANCE HISTORY:a) Currently covered by any other Mediclaim / Health Insurance:b) Date of commencement of first Insurance without break:c) If yes, company name:Policy insured (Rs.)d) Have you been hospitalized in the last four years since inception of the contract?Diagnosis:e) Previously covered by any other Mediclaim /Health insurance : :Date:MMYYYYf) If yes, company name:DETAILS OF INSURED PERSON HOSPITALIZED: DETAILS OF HOSPITALIZATION: DETAILS OF Claim :DETAILS OF BILLS ENCLOSED:Sl. byTowardsAmount (Rs)DETAILS OF PRIMARY INSURED S BANK ACCOUNT:SECTION CSECTION DSECTION ESECTION FSECTION GSECTION :State:Pin CodePhone No:Email ID:City:State:Pin CodePhone No:Email ID:DDDDMMMMYYYYYesNoYesNoYesNod) Name:SURNAMEFIRST NAMEMI DDLENAMEa) Name:SURNAMEFIRST NAMEMIDDLENAMEb) GenderMaleFemalec) Age yearsMMYYYYM onthsd) Date of Birthe) Relationship to Primary insured:SelfSpouseChildFatherMotherOther (Please Specify)(Please Specify)OtherRetiredStudentHome MakerSelf EmployedServicef) Occupationg) Address (if diffrent from above) :a) Name of Hospital where Admited:b) Room Category occupied:Day careDDMMYYHHHHMHMHDDMMYYYYDDMMYYS ingle occupancyTwin sharing3 or more beds per roomc) Hospitalization due to:InjuryIllnessMaternityd) Date of injury / Date Disease first detected /Date of Delivery:e) Date of Admission:f) Timeg) Date of Discharge:h) Time.

2 NoYesI) If Medico legalj) System of Medicine:Substance Abuse / Alcohol ConsumptionI) If injury give cause: Self inflictedRoad Traffic Accidentiii. MLC Report & Police FIR attachedii) Reported to PoliceNoYesa) Details of the Treatment expenses claimedI. Pre -hospitalization expenses iii. Post-hospitalization expenses v. Ambulance Hospitalization expenses Health-Check up cost:vi. Others (code) Pre -hospitalization period:daysviii. Post -hospitalization period:daysb) Claim for Domiciliary Hospitalization:NoYes(If yes, provide details in annexure)c) Details of Lump sum / cash benefit claimed:i. Hospital Daily cash: Critical Illness benefit:v. Pre/Post hospitalization Lump sum benefit:ii. Surgical Cash:iv. Convalescence:vi. Documents Submitted - Check List: Claim form duly signedCopy of the Claim intimation, if anyHospital Main BillHospital Break-up BillHospital Bill Payment ReceiptHospital Discharge SummaryPharmacy BillOperation Theater NotesECGD octor s request for investigationInvestigation Reports (Including CT/ MRI / USG / HPE)Doctor s PrescriptionsOthersHospital main BillPharmacy BillsPost-hospitalization Bills: NosPre-hospitalization Bills: Nosa) PAN:c) Bank Name and Branch:d) Cheque / DD Payable details:b) Account Number:e) IFSC Code:(IMPORTANT: PLEASE TURN OVER) medi AssistRDECLARATION BY THE INSURED:DateYYDDMMYYP lace:Signature of the InsuredI hereby declare that the information furnished in the Claim form is true & correct to the best of my knowledge and belief.

3 If I have made any false or untrue statement, suppression or concealent of any materialfact 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 FOR FILLING Claim FORM - PART A (To be filled in by the insured)DATA ELEMENTDESCRIPTIONFORMATSECTION A - DETAILS OF PRIMARY INSUREDa) Policy the policy numberAs allotted by the Insurance Companyb) Sl. No/ Certificate the social Insurance number or the certificate number ofAs allotted by the oraganizationsocial health insurance schemec) Company TPA ID the TPA ID number as allotted by IRDA and printedin TPA ) Name Enter the full name of the policyholderSurname, First name, Middle nameInclude Street, City and Pin codeEnter the full postal addresse) AddressSECTION B -DETAILS OF INSURANCE HISTORYa) Currently covered by any other Mediclaim / Health Insurance?

4 Indicate whether currently covered by another Mediclaim /Health InsuranceTick Yes or Nob) Date of commencement of first Insurance without breakEnter the date of commencement of first InsuranceUse dd-mm-yy-forrmatc) Company NameEnter the full name of the Insurance CompanyName of the organization in fullPolicy the policy numberAs allotted by the Insurance CompanyIn rupeesEnter the total sum insured as per the policySum insuredd) Have you been Hospitalized in the last four years since Inception of the contract? Indicate whether hospitalized in the last four yearsTick Yes or NoDateEnter the date of HospitalizationUse mm-yy formatDiagnosisEnter the diagnosis detailsOpen TextTick Yes or Noe) Previously covered by any other Mediclaim / Health Insurance?Indicate whether previously covered by another mediclaim / Health Insurancef) Company NameEnter the full name of the Insurance CompanyName of the organization in fullSECTION C -DETAILS OF INSURED PERSON HOSPITALIZEDa) Name Enter the full name of the patientSurname, First name, Middle nameb) GenderIndicate Gender of the patientTick Male or Femalec) AgeEnter age of the patientNumber of years and monthsd) Date of BirthEnter Date of Birth of patientUse dd-mm-yy formate) Relationship to primary InsuredIndicate relationship of patient with policyholderTick the right option, if others, please specifyf) Occupationindicate occupation of patientTick the right option.

5 If others, please ) AddressEnter the full postal addressInclude Street, City and Pin codeInclude STD code with telephone numberComplete e-mail addressh) Phone No1) E-mail IDEnter the phone number of patientEnter e-mail address of patientSECTION D - DETAILS OF HOSPITALIZATIONa) Name of Hospital where admitedEnter the name of hospitalName of hospital in fullTick the right optionTick the right optionUse dd-mm-yy formatUse dd-mm-yy formatUse hh-mm- formatUse dd-mm-yy formatUse hh-mm- formatTick the right optionTick Yes or NoTick Yes or NoTick Yes or NoOpen Textb) Room category occupiedc) Hospitalization due tod) Date of injury/Date Disease first detected / Date of Deliverye) Date of admissionf) Timeg) Date of dischargeh) TimeI) If injury give cause If Medico legalReported to PoliceMLC Report & Police FIR attachedj) System of Mediceneindicate the room category occupiedindicate reason of hospitalizationEnter the relevant dateEnter date of admissionEnter time of admissionEnter date of dischargeEnter time of dischargeindicate cause of injuryindicate whether injury is medico legalindicate whether police report was filedindicate whether MLC report and Police FIR attachedEnter the system of medicine followed in treating the patientSECTION E - DETAILS OF CLAIMa) Details of Treatment Expencesb) Claim for Domiciliary Hospitalizationc) Details of Lump sum/ Cash benifit claimedd)

6 Claim documents Submitted-Check ListEnter the amount claimed as treatment expencesindicate whether Claim is for domiciliary hospitalizationEnter the amount claimed as lump sum / cash benefitindicate which supporting documents are submittedTick Yes or NoTick the right optionIn rupees (Do not enter paise values)In rupees (Do not enter paise values)SECTION F - DETAILS OF BILLS ENCLOSEDI ndicate which bills are enclosed with the amount in rupeesSECTION G - DETAILS OF PRIMARY INSURED s BANK ACCOUNTa) PANb) Account Numberc) Bank Name and Branchc) Cheque/ DD payable detailsc) IFSC CodeEnter the permanent account numberEnter the Bank account numberEnter the Bank name along with the branchEnter the name of the beneficiary the cheque / DD should bemade out toEnter the IFSC code of the Bank branchAs allotted by the Income Tax DepartmentAs allotted by the BankName of the Bank in fullName of the individual / organization in fullIFSC code of the Bank branch in fullSECTION H - DECLARATION BY THE INSUREDRead declaration carefully and mention date (in dd:mm:yy format), place (open text) and OF Claim DOCUMENTS1 Completely filled Claim form with primary insured and patient photo ID proof (Passport copy, Electrol ID card).

7 3 Know your customer details if Claim amount is more than Rs. 1 Lac (Address proof.)4 Photocopy of Employee Id Proof For Corporate Policies (Employee ID Card Copy).5 Cancelled Cheque of Primary Beneficiary along with IFSC Pre numbered Cash Paid Receipts of Final paid receipts if any8 Original Final Consolidated Bill Along With Break Up of lab, medicines, room rent, any services Discharge Summary with date & time of admission and date & time of discharge, diagnosis, course of hospitalization, treatment Diagnostic/investigation/Lab reports with advise prescription/s11 Original Pharmacy / Medicine Bills (Date Wise) Along With Relevant Prescriptions in case of pre and post hospitalizations & Investigation cash memos / bills(Along with supportive doctor s prescriptions and Investigation reports & films)12 Original Lab Bills along with reports for each lab bill claimed13 Requisition Slips/Consultation Papers for consultation fees claimed14 First consultation doctors notes in case of planned and non emergency hospitalization claims15 Original Lab Reports, ECG Reports/Charts, Physiotherapy charts in case of physiotherapy, dialysis charts for dialysis Ray Films /CT scans/MRI along with reports in case of fracture or head injury legal/FIR copy in case of all Road traffic accident cases (Mandatory for accidental / burns / suicidal / poisoning /other injury cases.)

8 In case not done, reason for the same given by the hospital on letter head signed and stamped by the hospital authority required)Certificate from treating doctor whether patient was under influence/consumption of alcohol at time of an accident (All Road traffic accident claims).For ectopic pregnancy cases, gynecologist letter stating that the condition is life threatening and requires immediate intervention(for documentation purpose)For abortion cases, fibroid uterus , missed abortion - USG SCAN mandatory along with GPLA statusFor maternity claims, GPLA status is mandatoryFor fever cases, temperature chart and for any viral(dengue - dengue test, typhoid - WIDAL, malaria - plasmodium test etc.)For any surgical case (appendectomy, hernia, cholecystectomy, hysterectomy, Heart surgery, joint surgery, head surgery, cataract-A SCAN, fracture surgery, dental surgery ) --- supporting lab neonatal jaundice cases, serum bilirubin case of new born baby admission, reason for admission along with discharge summary and supporting lab chest related complaints and admission, chest X ray -mandatory for lung complaints, ECG/2D echo for heart related case of implants-implant invoice and stents - stent invoice , intraocular lens- lens(IOL) sticker (In case of self-purchase of Implants used in Cataract, Heart surgeries, Abdominal Surgeries,Knee replacement surgeries etc.

9 , vendor invoice and payment receipt also required)For blood bank receipts, blood bank stickerFor ambulance charges, mention place FROM where TO where ambulance service was used along with date. : from home to Apollo hospital, from Apollo hospital to home etc.