Claim Form May2019 - Bajaj Allianz General Insurance

1 Claim form FOR HEALTH Insurance POLICIES OTHER THAN TRAVEL AND PERSONAL ACCIDENT PART ATO BE FILLED IN BY THE INSURED The issue of this form is not to be taken as an admission of liabilityEmail free no:1800-209-5858020-30305858(To be filled in block letters)DETAILS OF PRIMARY INSUREDa) Policy No: b) Sl. No/Certificate No:c) Company TPA ID No:e) Company Name:_____f) Employee No:_____g) Name: h) Address:City:State: Pin Code: Phone No: Email ID:_____ d) Customer ID:DETAILS OF Insurance HISTORYa) Currently covered by any other Mediclaim / Health InsuranceYesNo b) date of commencement of first Insurance without breakc) If yes, company name:Policy No:Sum Insured (Rs.): d) Have you been hospitalized in the last four years since inception of the contract?

2 Yes No Date:Diagnosis e) Previously covered by any other Mediclaim / Health Insurance :YesNof) If yes, Company Name DETAILS OF INSURED PERSON HOSPITALIZEDa) Name of the Patient: _____b) Health ID card no of the Patient:_____c) Gender: MaleFemaled) Age: years monthse) Date of Birth f) Relationship of Primary insured: Self Spouse Child Father Mother Other (Please Specify)g) Occupation: Service Self Employed Homemaker Student Retired Other (Please Specify)h) Address (if different from above) _____ City:State: Pin Code: I)Phone No: J) Email ID: _____DETAILS OF HOSPITALIZATIONa) Name of Hospital where Admitted: _____b) Room Category occupied: Day Care Single occupancy Twin sharing 3 or more beds per room c) Hospitalisation due to: Injury Illness Maternity d) Date of Injury/Date Disease first detected/Date of Delivery: e) Date of admission f) Time: : g) Date of Discharge h)Time: I) Name of treating doctor_____Diagnosis_____j) 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 and Police FIR attached.

3 Yes No j) System of medicine DDMMYYYYDDMMYYYYHH MMDDMMYYYYDDMMYYYYSECTION ASECTION BSECTION CSECTION DHH MMDDMMYYYYB ajaj Allianz General Insurance Co. Ltd. Bajaj Allianz House, Airport Road, Yerwada, Pune 411006. Reg.: 113 | CIN: U66010PN2000 PLC015329 For more details, log on to : 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 Bajaj Allianz General Insurance Company Limited, to seek necessary medical information / documents from any hospital / Medical Practitioner who ha s 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 ) Details of the treatment expenses claimedI. Pre-Hospitalisation Expenses: Rs. ii. Hospitalisation Expenses Post-Hospitalisation Expenses: Health checkup cost Ambulance Charges: Rs. vi. Others (code) Pre-Hospitalisation period: daysviii. Post Hospitalisation period: daysb) Claim for Domiciliary Hospitalisation: Yes No (If yes, provide details in annexure) c) Details of Lump sum / cash benefit claimed:i. Hospital Daily CashRs. ii. Surgical Cash Critical illness Benefit Rs.

5 Iv. Convalescence Pre/Post hospitalisation Rs. vi. Others Rs. lump sum benefit Total Documents Submitted Check ListClaim form Duly SignedCopy of Claim intimation if anyHospital Main BillOriginal Hospital Breakup Bill Hospital Bill Payment ReceiptHospital Discharge SummaryPharmacy BillOperation Theater NotesECGD octor's PrescriptionsDoctors request for investigation reports (including CT/MRI/USG/HPE)OthersCancelled blank cheque leaf with payee name printed. If name of the payee is not printed on the cheque leaf please attach copy of the first page of the bank Original Original Original Original DETAILS OF BILLS NoDateIssued byTowardsAmount (Rs)1 Hospitalisation Main Bill 2 Pre-Hospitalisation Bills:__Nos 3 Post-Hospitalisation Bills:__Nos 4 Pharmacy Bills 5 6 7 8 9 10 DDMMYYDDMMYYDDMMYYDDMMYYDDMMYYDDMMYYDDMM YYDDMMYYDDMMYYDDMMYYDETAILS OF PRIMARY INSURED'S BANK ACCOUNTa) Name of the Account Holder ( As per Bank Account):_____ b) Account no :c) Bank Name :_____e) Account Type : Saving Current Cash Creditf) MICR No.

6 G)IFSC Code: ( As appearing in the cheque book)d) Branch Name & Address:_____:h) PAN: i) Cheque / DD Payable Details:Date: Place:Signature of the InsuredDDMMYYYYSECTION ESECTION FSECTION GSECTION HDETAILS OF Claim Claim form - PART BDETAILS OF AILMENT DIAGNOSED (PRIMARY)a) ICD 10 Codes Descriptioni) Primary Diagnosis: ii)Additional Diagnosis: iii)Co-morbidities :iv)Co-morbidities :b) ICD 10 PCS Description i) Procedure 1: ii) Procedure 2:iii) Procedure 3: iv) Details of Procedure:d) Pre-Authorization Obtained: Yes No e) Pre-Authorization Number:f) If authorization by network hospital no obtained, give reason: _____g) 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)Medico Legal: Yes Noiv)Reported to Police: Yes No v) FIR no: _____vi) if not reported to police give reason: _____a)Name of the patient :_____b)IP registration Number : _____c) Gender: Male Female d) Age : Years Months: e) Date of birth:f) Date of admission: g) Time : h) Date of discharge : i) Time.

7 J)Type of Admission : Emergency Planned Day Care Maternity k) If Maternity i) Date of delivery ii)Gravida Status: l)Status at time of discharge: Discharge to home Discharge to another hospital Deceased: m) Total claimed Amount:DETAILS OF THE PATIENT ADMITTEDSECTION ASECTION BSECTION CEmail id: Toll free no. 1800-209-5858, MMDDMMYYDDMMYYHH MMDDMMYYDETAILS OF HOSPITALTO BE FILLED IN BY THE HOSPITALThe issue of this form is not to be taken as admission of liabilityPlease include the original preauthorization request form in lieu of PART-A(To be filled in block letters)a)Name of the hospital : _____b)Hospital ID :_____c) Type of hospital : Network Non-Network (If non-network fill section E)d) Name of treating doctor:e)Qualification: f) Registration No with State Code_____ g) Phone No.

8 _____ Claim DOCUMENTS -CHECK LISTC laim form duly signed Ingestion reportsOriginal Pre-Authorization requestCT/MR/USG/HPE investigation reportCopy of Pre-Authorization letterDoctor's reference slip for investigationCopy of photo ID card of patient verified by hospital ECGH ospital discharge summary Pharmacy bills Operation theatre notesMLC report & Police FIRH ospital main bill Original death summary from hospital where applicable Hospital break up bill Any other, please specifyADDITIONAL DETAILS IN CASE OF NON NETWORK HOSPITAL (ONLY FILL IN CASE OF NON NETWORK HOSPITAL) a)Address of hospital_____ City:_____ State: _____ Pin Code: _____Phone No: _____ c) Registration no with State Code: _____ d) Hospital PAN:_____e) Number of Inpatient beds: Facilities available in hospital: i) OT: Yes No ii) ICU: Yes Noiii) Others: _____DECLARATION BY THE HOSPITAL: (PLEASE READ VERY CAREFULLY)We hereby declare that the information furnished in the Claim form is true and correct to the best of our knowledge and belief.

9 If we have made any false and untrue statement, suppression or concealment of any material fact, our right to Claim under this Claim shall be : Place : _____ Signature and Seal of the Hospital Authority DDMMYYSECTION DSECTION ESECTION Fh) Rohini CodeBajaj Allianz General Insurance Co. Ltd. Bajaj Allianz House, Airport Road, Yerwada, Pune 411006. Reg.: 113 | CIN: U66010PN2000 PLC015329 For more details, log on to : ) NABH CODE j) State Level Certificate k) Higher Level Certificate l) National Quality Assurance Standards m) National Health System Resource Center GUIDANCE FOR FILLING Claim form - PART B (To be filled in by the hospital)DATA ELEMENTDESCRIPTION FORMATSECTION A - DETAILS OF HOSPITALa)Name of HospitalEnter the name of hospitalName of hospital in fullb)Hospital IDEnter ID number of the hospital As allocated by TPA c)Type of Hospital Indicate whether in network or non network hospital Tick the right optiond)Name of Treating doctor Enter the name of treating doctorName of doctor in full e)

10 QualificationEnter the qualification of treating doctorabbreviations of educational qualificationsf)Registration No with state codeEnter the registration no of treating doctor As allocated by the medical along with state codecouncil of Indiag)Phone NoEnter the phone no of doctorInclude STD code with telephone numbera) Name of the patientEnter the name of hospitalName of hospital in fullb) IP Registration numberEnter the Insurance provide registration numberAs allocated by the Insurance providec)Gender Indicate Gender of the patientTick Male or Femaled)AgeEnter age of the patientNumber of years and monthse)Date of BirthEnter date of admissionUse dd-mm-yy formatf)Date of AdmissionEnter date of admissionUse dd-mm-yy formatg)TimeEnter date of admissionUse hh:mm formath)Date of DischargeEnter date of dischargeUse dd-mm-yy formati) Time Enter time of dischargeUse hh.