CLAIM FORM - PART A TO BE FILLED IN BY THE INSURED …

1 CLAIM FORM - PART ATO BE FILLED IN BY THE INSURED (To be FILLED in block letters)DETAILS OF PRIMARY INSUREDa) Policy no:c) Company/ TPA ID No:SECTION Ad) Name:SECTION Ae) Address:City:State:Pin Code:Phone No:Email ID:DETAILS OF INSURANCE HISTORYYesNob) Date of commencement of first insurance without break:SECTION Bc) If yes, company name:Policy No:d) Have you been hospitalized in the last four years since inception of the contract? YesNoDate: Diagnosis:YesNof) If yes, Company Name : DETAILS OF INSURED PERSON HOSPITALIZEDa) Name :b) Gender :Male Female c) Age: years months d) Date of Birth: Self Spouse Child Father Mother Other (Please specify)SECTION Cf) Occupation: Service Self Employed Homemaker Student Retired Other (Please specify)g) Address (if different from above): City:State:Pin Code:Phone No: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 SECTION Dc) Hospitalization 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.

2 I) If injury, give cause:Self inflicted Road Traffic Accident Substance abuse / Alcohol Consumption i. If Medico Legal: YesNoii. Reported to police:YesNoiii. MLC Report & Police FIR attached: YesNoj) System of medicine: DETAILS OF CLAIMa) Details of treatment expenses claimedClaim Documents Submitted- Check List:`ii. Hospitalization Expenses`iii. Post Hospitalization Expenses`iv. Health Check up Cost`Copy of the CLAIM intimation, if anyv. Ambulance Charges`vi. Others (code):`Hospital Main billTotal`Hospital Break-up billSECTION EdaysdaysHospital Discharge Summaryb) CLAIM for Domiciliary Hospitalization:YesNoPharmacy Billc) Details of Lump sum / cash benefit claimed:i. Hospital Daily Cash: `ii. Surgical Cash:`ECGiii. Critical Illness Benefit:`iv.

3 Convalescence:`Doctor's request for investigation`vi. Others:`Investigation Reports (including CT / MRI / USG / HPE)Total`Doctor's PrescriptionOthersDETAILS OF BILLS ENCLOSEDBill ByTowards1 Hospital Main Bill234 Pharmacy Bills: SECTION F5678910 DETAILS OF PRIMARY INSURED 'S BANK ACCOUNTa) PAN:b) Account Number: SECTION Gc) Bank Name and BranchThe issue of theis form is not to be taken as admission of liabilityb) Sl. No/ Certificate No:a) Currently covered by any other Mediclaim/ Health Insurance:Sum INSURED (`):e) Previously covered by any other Mediclaim/ Health Insurance : e) Relatuionship to Primary INSURED : i. Pre Hospitalization ExpensesClaim FormDuly signedvi. Pre hospitalization period:vii. Pre hospitalization period:(if yes, provide details in annexure)Operation Theatre Notesv.

4 Pre/Post hosp. Lump sum benefit:Sl. (`)Pre hospitalisation Bills: ___ NosPost hospitalisation Bills: ___ Nos UNITED INDIA INSURANCE COMPANY LIMITED REGISTERED & HEAD OFFICE: 24, WHITES ROAD, CHENNAI-600014 e) IFSC Code: SECTION GDECLARATION BY THE INSUREDSECTION HDate: Place: Signature of the INSURED : GUIDANCE 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) SI. No/ Certificate allotted by the organizationc) Company TPA ID the TPA ID Nod) NameEnter the full name of the policyholderSurname, First name, Middle namee) AddressEnter the full postal addressInclude Street, City and Pin CodeSECTION B - DETAILS OF INSURANCE HISTORYTick Yes or Nob) Date of Commencement of first Insurance without breakEnter the date of commencement of first insurancec) Company NameEnter the full name of the insurance companyName of the organization in fullPolicy the policy numberAs allotted by the insurance companySum InsuredEnter the total sum INSURED as per the policyIn rupeesd) Have you been Hospitalized in the last 4 years since inception of the contract?

5 Indicate whether hospitalized in the last 4 yearsTick Yes or NoDateEnter the date of hospitalizationDiagnosisEnter the diagnosis detailsOpen TextTick Yes or Nof) Company NameEnter the full name of the insurance companyName of the organization in fullSECTION C - DETAILS OF INSURED PERSON HOSPITALIZEDa) NameEnter 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 patiente) 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 addressSECTION D - DETAILS OF HOSPITALIZATIONa) 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 first detected/ Date of DeliveryEnter the relevant datee) Date of admissionEnter date of admissionf) TimeEnter time of admissiong) Date of dischargeEnter date of dischargeh)

6 TimeEnter time of dischargei) If Injury give causeIndicate cause of injuryTick the right optionIf Medico legalIndicate whether injury is medico legalTick Yes or NoReported to PoliceIndicate whether police report was filedTick Yes or NoMLC Report & Police FIR attachedIndicate whether MLC report and Police FIR attachedTick Yes or Noj) System of MedicineEnter the system of medicine followed in treating the patientOpen TextSECTION E - DETAILS OF CLAIMa) Details of Treatment ExpensesEnter the amount claimed as treatment expensesb) CLAIM for Domiciliary HospitalizationIndicate whether CLAIM is for domiciliary hospitalizationTick Yes or Noc) Details of Lump sum/ cash benefit claimedEnter the amount claimed as lump sum/ cash benefitd) CLAIM Documents Submitted-Check ListIndicate which supporting documents are submittedTick the right optionSECTION F - DETAILS OF BILLS ENCLOSEDI ndicate which bills are enclosed with the amounts in rupeesSECTION G - DETAILS OF PRIMARY INSURED S BANK ACCOUNTa) PANE nter the permanent account numberAs allotted by the Income Tax departmentb) Account NumberEnter the bank account numberAs allotted by the bankc) Bank Name and BranchEnter the bank name along with the branchName of the Bank in fullName of the individual/ organization in fulle) IFSC CodeEnter the IFSC code of the bank branchIFSC code of the bank branch in fullSECTION H - DECLARATION BY THE INSUREDd) Cheque/ DD Payable details.

7 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 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 the social insurance number or the certificate number of social health insurance schemeLicense number as allotted by IRDA and printed in TPA ) Currently covered by any other Mediclaim / Health Insurance?

8 Indicate whether currently covered by another Mediclaim / Health InsuranceUse dd-mm-yy formatUse mm-yy formate) Previously Covered by any other Mediclaim/ Health Insurance?Indicate whether previously covered by another Mediclaim / Health InsuranceUse dd-mm-yy formatUse dd-mm-yy formatUse dd-mm-yy formatUse hh:mm formatUse dd-mm-yy formatUse hh:mm formatIn rupees (Do not enter paise values)In rupees (Do not enter paise values)d) Cheque/ DD payable detailsEnter the name of the beneficiary the cheque/ DD should be made out toRead declaration carefully and mention date (in dd:mm:yy format), place (open text) and ACLAIM FORM - PART BTO BE FILLED IN BY THE HOSPITAL(To be FILLED in block letters)DETAILS OF HOSPITALa) Name of the Hospital:SECTION Ac) 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.

9 With state code: g) Phone No. DETAILS OF PATIENT ADMITTEDa) Name of Patient: b) IP Registration No.: c) Gender :Male Female d) Age: years months e) Date of Birth: SECTION Bf) Date of Admission: g) Time: :h) Date of Discharge: i) Time: :j) Type of Admission: EmergencyPlanned Day Care Maternityk) If Maternity: i. Date of Delivery: l) Status at time of discharge:Discharged to home Discharged to another hospital Deceased m) Total claimed amount DETAILS OF AILMENT DIAGNOSED (PRIMARY)a)ICD 10 CodesDescriptionb)ICD 10 PCSD escriptioni. Primary Diagnosis :i. Procedure 1 :ii. Additional Diagnosis :ii. Procedure 2 :iii. Co-morbidities :iii. Procedure 3 :SECTION Civ. Co-morbidities :iv. Details of Procedure :YesNoe) If authorization by network hospital not obtained, give reason: f) Hospitalization due to injury: YesNoi.

10 If yes, give cause Self inflicted Road Traffic AccidentSubstance abuse / alcohol consumption YesNo(if yes, attach reports)iii. If Medico Legal: YesNoiv. Reported to Police: YesNov. FIR No. vi. If not reported to police, give reason: CLAIM DOCUMENTS SUBMITTED - CHECKLISTC laim Form duly signedInvestigation reportsCT/ MRI/ USG/ HPE/ Investigation reportsSECTION DCopy of photo ID card of patient verified by hospitalECGH ospital discharge summaryPharmacy billsMLC report & Police FIRH ospital main billOriginal death summary from hospital, where applicableHospital break-up billAny other, please specifya) Address of the hospital:SECTION ECity:State:Pin Code:b) Phone No:c) Registration No. with State Code: d) Hospital PANe) Number of inpatient beds f) Facilities available in the hospital: i.