CLAIM FORM FOR HEALTH INSURANCE POLICIES OTHER …

1 CLAIM FORM FOR HEALTH INSURANCE POLICIES OTHER THAN TRAVEL AND PERSONAL ACCIDENT - PART ATO BE FILLED IN BY THE INSUREDThe issue of this Form is not to be taken a s an admission of liability(To be illed in block letters)DETAILS OF PRIMARY INSURED:a) PolicyNo:c) Company/ TPA ID No:City:Pin Code:State:b) SI. No/ Certi icate No:Phone No:d)Namea)Namee)Address:Email lDCity:Pin Code:State:Phone No:g)Address:Email lDDETAILS OF INSURANCE HISTORY:a) Currently covered by any OTHER Mediclaim / HEALTH INSURANCE :YesNoYesNoYesNoYesNoYesNoYesNo YesNob) Date of commencement of irst INSURANCE without break:c) If yes, company namePolicyNo:Sum Insured (Rs.)d) Have you been hospitalized in the last four years since inception of the contract?DateDiagnosise) Previously covered by any OTHER Mediclaim / HEALTH INSURANCE :f) If yes, company nameDETAILS OF INSURED PERSON HOSPITALIZED:b) Gender:c)Age:d) Date of birth:MaleYearsMonthsFemalee) Relationship to Primary insured:SelfSpouseChildFatherMotherOther (Please Specify)f) Occupation:ServiceSelf EmployedHomemakeStudentRetiredOther(Plea se Specify)DETAILS OF HOSPITALIZATION:a) Name ol Hospital where Admitted:b) Room Category occupied:Day careSingle occupancyTwin sharing3 or more beds per roomc) Hospitalization due to:MaternityIllnessInjuryd) Date of Injury / Date Disease irst detected /Date of Delivery:e) Dated of Admission::f)Time::h)Time:g) Date ol Dischargei) If Injury give causeSelf in lictedRoad Traf ic AccidentSubstance Abuse/Alcohol Consumptioni.

2 If Medico legal:ii. Reported to police:iii. MLC Report & Police FIR attached:j) System of Medicine:DETAILS OF CLAIM :a) Details of the treatment expenses claimed:i. Pre-hospitalization Expenses:RsRsRsRsRsRsRsRsRsRsRsRsii. Hospitalization Expenses: CLAIM Documents Submitted- Check List: CLAIM Form Duly signedCopy of the CLAIM intimation, if anyHospital Main BillHospital Break-up BillHospital Bill Payment ReceiptHospital Discharge SummaryOthersOperation Theatre NotesDoctor s PrescriptionsECGD octor's request for investigationInvestigation Reports (Including CT MRI / USG / HPE)iii. Post-hospitalization Expenses:iv. HEALTH -Check up Cost:v. Ambulance Charges:vi. Others (code)TotalRsRsvi. Others (code)Totalvii. Pre-hospitalization period:DaysDaysviii. Post-hospitalization periodb) CLAIM for Domiciliary Hospitalization:(If yes, provide details in annexure)c) Details of Lump sum / cash bene it claimed:i.

3 Hospital Daily Cash:ii. Surgical Cash:iii. Critical Illness Bene it:iv. Convalescence:v. Pre/Post hospitalization Lump sum bene it:DETAILS OF BILLS NoDateIssued ByTowardsAmount (Rs)Vipul MedCorp TPA Pvt Healthcare OF PRIMARY INSURED'S BANK ACCOUNT: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.

4 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 :Place:Signature of the InsuredGUIDANCE FOR FILLING CLAIM FORM - PART A (To be illed in by the insured)SECTION A - DETAILS OF PRIMARY INSUREDSECTION B - DETAILS OF INSURANCE HISTORYSECTION C - DETAILS OF INSURED PERSON HOSPITALIZEDSECTION D - DETAILS OF HOSPITALIZATIONSECTION E - DETAILS OF CLAIMSECTION F - DETAILS OF BILLS ENCLOSEDDATA ELEMENTDESCRIPTIONFORMATa) Policy ) SI. No/ Certi icate ) Company TPA ID ) Namee) AddressEnter the full name of the policyholderEnter the full postal addressInclude Street, City and Pin CodeSurname, First name, Middle namea) NameEnter the full name of the policyholderSurname, First name, Middle namea) Details of Treatment ExpensesIndicate which bills are enclosed with the amounts in rupeesEnter the amount claimed a s treatment expensesIn rupees (Do not enter paise values)b) CLAIM for Domiciliary HospitalizationIndicate whether CLAIM is for domiciliary hospitalizationTick Yes or Noc) Details of Lump sum/ cash bene it claimedEnter the amount claimed a s lump sum/ cash bene itIn rupees (Do not enter paise values)d) CLAIM Documents Submitted-Check ListIndicate which supporting documents are submittedTick the right optionb) GenderIndicate Gender of the patientTick Male or Femalec)

5 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 ) OccupationIndicate occupation of patientTick the right option. If others, please ) AddressEnter the full postal addressInclude Street, City and Pin Codeh) Phone NoEnter the phone number of patientInclude STD code with telephone numberi) E-mail IDEnter e-mail address of patientComplete e-mail addressEnter the policy numberEnter the TPA ID NoEnter the social INSURANCE number or the certi icate number of social HEALTH INSURANCE schemeAs allotted by the INSURANCE companyAs allotted by the organizationLicense number a s allotted by IRDA and printed in TPA ) Currently covered by any OTHER Mediclaim / HEALTH INSURANCE ?Indicate whether currently covered by another Mediclaim / HEALTH InsuranceTick Yes or Nob) Date of Commencement of irst INSURANCE without breakc) Company NameEnter the date of commencement of irst insuranceEnter the full name of the INSURANCE companyUse dd-mm-yy formatName of the organization in fullf ) Company NameEnter the full name of the INSURANCE companyName of the organization in full Policy the policy numberAs allotted by the INSURANCE company Sum InsuredEnter the total sum insured a s per the policyIn rupeesd) Have you been Hospitalized in the last four years since inception of the contract?

6 Indicate whether hospitalized in the last four yearsTick Yes or Noe) Previously Covered by any OTHER Mediclaim / HEALTH INSURANCE ?Indicate whether previously covered by another Mediclaim / HEALTH InsuranceTick Yes or No DateEnter the date of hospitalizationUse mm-yy format DiagnosisEnter the diagnosis detailsOpen Texta) Name of Hospital where admittedEnter the name of hospitalName of hospital in fullb) Room category occupiedIndicate the room category occupiedTick the right optionc) Hospitalization due toIndicate reason of hospitalizationTick the right optiond) Date of Injury/Date Disease irst detected/ Date of DeliveryEnter the relevant dateUse dd-mm-yy formate) Date of admissionEnter date of admissionUse dd-mm-yy formatf ) TimeEnter time of admissionUse hh:mm formatg) Date of dischargeEnter date of dischargeEnter date of dischargeh) TimeEnter time of dischargeUse hh.

7 Mm formati) If Injury give causeIndicate cause of injuryTick the right optionj) System of MedicineEnter the system of medicine followed in treating the patientOpen TextIf Medico legalIndicate whether injury is medico legalTick Yes or NoReported to PoliceIndicate whether police report was iledTick Yes or NoMLC Report & Police FIR attachedIndicate whether MLC report and Police FIR attachedTick Yes or NoCLAIM FORM - PART BTO BE FILLED IN BY THE HOSPITALThe issue of this Form is not to be taken a s an admission of liabilityPlease indude the original preauthorization request form in lieu of PART A(To be illed in block letters)DETAILS OF HOSPITALV ipul MedCorp TPA Pvt Healthcare ) Name of the hospital:b) Hospital ID:c) Type of Hospital:NetworkNon Network(If non network ill section E)d) Name of the treating doctor:e) Quali ication:f) Registration No. with State Code:g) Phone OF THE PATIENT ADMITTEDa) Name of the Patient:b) IP Registration Numberc) Gender:d)Age:e) Date of birth:MaleYearsMonthsFemalef) Dated of Admission::g)Time::i)Time:h) Date ol Dischargej) Type of Admission:EmergencyPlannedDay CareMaternityk) If Maternityi.

8 Date of Deliveryii. Gravida Status:I) Status at time of discharge:Discharge to homeDischarge to another hospitalDeceasedm) Total claimed amountDETAILS OF AILMENT DIAGNOSED (PRIMARY)a) ICD10 Codesi. Primary Diagnosisii. Additional Diagnosis:iii. Co-morbidities:iv. Co-morbidities:DescriptionDescriptionb) ICD 10 PCSi. Procedure1ii. Procedure2:iii. Procedure3:iv. Details of Procedure:c) Pre-authorization obtained:YesNoYesNoYesNoYesNoYesNoYesNoY esNod) Pre-authorization Number:e) If authorization by network hospital not obtained, give reason:f) Hospitalization due to Injury:i. If Yes, give causeSelf-in lictedRoad Traf ic AccidentSubstance abuse / alcohol consumptionii. If Injury due to Substance abuse / alcohol consumption, Test Conducted to establish this:(If Yes, attach reports)iii. If Medico legaliv. Reported to Police:v. FIR If not reported to police give reasonCLAIM DOCUMENTS SUBMITTED - CHECK LISTC laim Form duly signedCopy of the Pre-authorization approval letterInvestigation reportsOriginal Pre-authorization requestDoctor s reference slip for investigationCopy of photo ID card of patient veri ied by hospitalECGH ospital Discharge summaryPharmacy billsOperation Theatre notesMLC report & Police FIRH ospital main billAny OTHER , please specifyHospital break-up billOriginal death summary from hospital where applicableCT/MR/USG/HPE investigation reportsADDITIONAL DETAILS IN CASE OF NON NETWORK HOSPITAL (ONLY FILL IN CASE OF NON-NETWORK HOSPITAL)a) Address of the HospitalCity:Pin Code:State:b) Phone No:c) Registration No.

9 With State Coded) Hospital PAN:e) Number of inpatient beds:d) Facilities available in the Hospital :i) OT:ii) ICU: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 fad, our right to CLAIM under this CLAIM shall be :Place :Signature and Seal of the Hospital AuthorityGUIDANCE FOR FILLING CLAIM FORM - PART B (To be illed in by the hospital)SECTION A - DETAILS OF HOSPITALDATA ELEMENTDESCRIPTIONFORMATa) Name of Hospitalb) Hospital IDc) Type of Hospitald) Name of treating doctore) Quali icationEnter the name of the treating doctorEnter the quali ications of the treating doctorAbbreviations of educational quali icationsf ) Registration No.

10 With State CodeEnter the registration number of the doctor along with the state codeAs allocated by the Medical Council of Indiag) Phone the phone number of doctorInclude STD code with telephone numberName of doctor in fullEnter the name of hospitalIndicate whether In network or non network hospitalEnter ID number of hospitalName of hospital in fullAs allocated by the TPATick the right optiona) Name of Patientb) IP Registration Numberc) Genderd) Agee) Date of BirthEnter age of the patientEnter date of admissionUse dd-mm-yy formatf ) Date of AdmissionEnter date of admissionUse dd-mm-yy formatg) TimeEnter time of admissionUse hh:mm formath) Date of DischargeEnter date of dischargeUse dd-mm-yy formati) TimeEnter time of dischargeUse hh:mm formatj) Type of AdmissionIndicate type of admission of patientTick the right optionk) If Maternity Date of DeliveryEnter Date of Delivery if maternityUse dd-mm-yy formata) ICD 10 Codeb)