REIMBURSEMENT CLAIM FORM21 - FHPL

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.

2 No. Bill 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::NoYesI) If Medico legalj) System of Medicine:Substance Abuse / Alcohol ConsumptionI) If injury give cause: Self inflictedRoad Traffic Accidentiii.

3 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.

4 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)DECLARATION 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.

5 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 Health Plan(TPA) LimitedGUIDANCE 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.

6 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?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?

7 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)

8 Relationship to primary InsuredIndicate relationship of patient with policyholderTick the right option, if others, please specifyf) Occupationindicate occupation of patientTick the right option. 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)

9 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)

10 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 sign.