Group Care-Claim Form

RELIGARE HEALTH INSURANCE COMPANY LIMITED.

A3, A4, A5 GYS Global, Sector -125,Noida 201301
Telephone: 1800 200 4488 Fax : 1800 200 6677
www.religarehealthinsurance.com
Note: The issue of this form shall not to be taken or deemed to be taken as an admission of liability by Us.

Part A : To be filled in by the Insured

Pre Authorization obtained:

Yes: |__| No: |__|

Details of the Primary Insured :

a. Policy No. :
|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
b. Name :
|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
(Title)
(First Name)
(Last Name)
c. Mailing Address :
|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
Locality : |__|__|__|__|__|__|__|__|__|__|__|__| City :|__|__|__|__|__|__|__|__|__|__|__|
__|
PIN Code : |__|__|__|__|__|__| State :
|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
d.

Contact Details : Landline (R) :|__|__|__|__|__|__|__|__|__| (O) :

|__|__|__|__|__|__|__|__|__|__|__|
(STD Code)
(STD Code)
Mobile No : |__|__|__|__|__|__|__|__|__|__|
E-mail ID :
|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
Details of the Insurance History :
a. Currently covered by any other Mediclaim / Health Insurance : Yes: |__| No: |__|
b. Date of commencement of first insurance without break :
|__|__|/|__|__|/|__|__|__|__|(DD/MM/YYYY) (Attach policy copy)
c. Name of the Insurance Co. : |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
Policy No. : |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
Sum Insured : |__|__|__|__|__|__|__|__|__|__|
d. Have you been hospitalized in the last 4 years : Yes: |__| No: |__|
Date : |__|__|/|__|__|__|__|(DD/MM/YYYY)
Diagnosis : |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
e. Previously covered by any other Mediclaim / Health Insurance : Yes: |__| No: |__|
f. Name of the Insurance Co. : |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
Details of the Insured Person Hospitalized :
a. Name :
|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
(Title)
(First Name)
(Last Name)
b. Gender : |__| (M / F)

Group Care Claim Form

1 of 6

Religare Health Insurance Company Limited.

c.
d.
e.
f.
g.

h.

Age : |__|__| |__|__|

Date of Birth : |__|__|/|__|__|/|__|__|__|__|(DD/MM/YYYY)
Relationship to Proposer : Self |__|Spouse |__| Son |__| Daughter |__| Father |__| Mother |__|
Others |__|, Specify |__|__|__|__|__|__|__|__|__|__|__|__|
Occupation : Service |__| Self Employed |__| Student |__| Retired |__|
Others |__|, Specify |__|__|__|__|__|__|__|__|__|__|__|__|
Address : (If different from above) :
|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
Locality : |__|__|__|__|__|__|__|__|__|__|__|__| City :|__|__|__|__|__|__|__|__|__|__|__| __|
PIN Code :|__|__|__|__|__|__| State : |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
Contact Details : Landline (R) :|__|__|__|__|__|__|__|__|__| (O) : |__|__|__|__|__|__|__|__|__|__|
(STD Code)
(STD Code)
Mobile No : |__|__|__|__|__|__|__|__|__|__|
E-mail ID :
|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|

Details of hospitalization:
a. Name of the Hospital where admitted :
|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
b. Room Category : Day Care |__| Single Occupancy |__| Twin Sharing |__| 3 or more beds |__|
c. Hospitalization due to : Injury |__| Illness |__| Maternity |__|
d. Date of Injury / Disease first detected / Date of delivery :
|__|__|/|__|__|/|__|__|__|__|(DD/MM/YYYY)
e. Date of Admission : |__|__|/|__|__|/|__|__|__|__|(DD/MM/YYYY)
f. Time : |__|__| : |__|__| (HH : MM)
g. Date of Discharge : |__|__|/|__|__|/|__|__|__|__|(DD/MM/YYYY)
h. Time : |__|__| : |__|__| (HH : MM)
i. If Injury, give cause : Self-inflicted |__| Road Traffic Accident |__| Substance Abuse / Alcohol
Consumption |__|
j. If Medico legal : Yes |__| No |__|
k. Reported to Police : Yes |__| No |__|
l. MLC Report & Police FIR attached : Yes |__| No |__|
m. System of Medicine : |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
Details of Claim :
a. Details of the treatment expenses claimed
Pre-hospitalization Expenses
: |__|__|__|__|__|__|__|__|__|__|
Hospitalization Expenses
: |__|__|__|__|__|__|__|__|__|__|
Post hospitalization Expenses
: |__|__|__|__|__|__|__|__|__|__|
Domestic Road
Ambulance Charges
: |__|__|__|__|__|__|__|__|__|__|
Maternity Benefit
: |__|__|__|__|__|__|__|__|__|__|
Pre Natal Expenses
: |__|__|__|__|__|__|__|__|__|__|
Post Natal Expenses
: |__|__|__|__|__|__|__|__|__|__|
New Born Baby Expenses
: |__|__|__|__|__|__|__|__|__|__|
Donor Expenses
: |__|__|__|__|__|__|__|__|__|__|
Out -Patient Treatment
: |__|__|__|__|__|__|__|__|__|__|
Dental Care Cover
: |__|__|__|__|__|__|__|__|__|__|
Alternative methods of Treatments
: |__|__|__|__|__|__|__|__|__|__|
Major Diagnostics
: |__|__|__|__|__|__|__|__|__|__|
Psychiatric Treatment
: |__|__|__|__|__|__|__|__|__|__|
Patient Care
: |__|__|__|__|__|__|__|__|__|__|
Durable Medical Equipment
: |__|__|__|__|__|__|__|__|__|__|

Group Care Claim Form

2 of 6

Religare Health Insurance Company Limited.

b.
c.
d.

Maternity Complication
: |__|__|__|__|__|__|__|__|__|__|
Domiciliary Treatment
: |__|__|__|__|__|__|__|__|__|__|
Cover extended outside India
: |__|__|__|__|__|__|__|__|__|__|
Corporate Floater
: |__|__|__|__|__|__|__|__|__|__|
Health Check Up
: |__|__|__|__|__|__|__|__|__|__|
Ayush
: |__|__|__|__|__|__|__|__|__|__|
Additional Services
: |__|__|__|__|__|__|__|__|__|__|
HIV Cover
: |__|__|__|__|__|__|__|__|__|__|
Comprehensive HIV Cover
: |__|__|__|__|__|__|__|__|__|__|
Total
: |__|__|__|__|__|__|__|__|__|__|
Pre-hospitalization period (Days)
: |__|__|__|
Post hospitalization period (Days)
: |__|__|__|
Claim for domiciliary hospitalization : Yes |__| No |__| (If yes, provide the details in annexure)
Total
: |__|__|__|__|__|__|__|__|__|__|

Claim Documents submitted checklist

Duly signed Claim Form
Copy of Claim Intimation
Hospital Main Bill
Hospital Break up Bill
Hospital Bill Payment receipt
Hospital Discharge Summary
Pharmacy Bill
Operation Theatre notes
ECG
Doctors request for investigation
Investigation Reports (Including CT / MRI / USG / HPE)
Doctors prescriptions
Others

: |__|
: |__|
: |__|
: |__|
: |__|
: |__|
: |__|
: |__|
: |__|
: |__|
: |__|
: |__|
: |__|

Details of Bills enclosed:

Sr. #
1
2
3
4
5
6
7
8
9

Bill No.

Date

Issued by

Towards
Hospital Mail Bill
Pre-hospitalization bills
Post hospitalization bills
Pharmacy bills

Amount (INR)

Details of Primary Insureds Bank Account :

a. PAN
: |__|__|__|__|__|__|__|__|__|__|
b. Account No. : |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
c. Bank Name : |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
d. Bank Branch : |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
e. Cheque / DD : |__|__|__|__|__|__|
f. IFSC
: |__|__|__|__|__|__|__|__|__|__|
Preferred Payment Mode : |__| Cheque |__| NEFT (If NEFT, please fill the NEFT mandate form)

Group Care Claim Form

3 of 6

Religare Health Insurance Company Limited.

Part B : To be filled in by the hospital

Details of Hospital :
a. Name of the Hospital
:
|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
b. Hospital ID
: |__|__|__|__|__|__|__|__|__|
c. Type of Hospital
: Network |__| Non-network |__|
d. Name of the treating doctor
: |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
e. Qualification
: |__|__|__|__|__|__|__|__|__|
f. Registration No. with State Code
: |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
g. Phone No.
: |__|__|__|__|__|__|__|__|__|__|__|__|
Details of the patient admitted :
a. Name of the patient
: |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
b. IP Registration No.
: |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
c. Gender
: Male |__| Female |__|
d. Age
: |__|__| |__|__|
e. Date of Birth
: |__|__|/|__|__|/|__|__|__|__|(DD/MM/YYYY)
f. Date of Admission
: |__|__|/|__|__|/|__|__|__|__|(DD/MM/YYYY)
g. Time
: |__|__| : |__|__| (HH:MM)
h. Date of Discharge
: |__|__|/|__|__|/|__|__|__|__|(DD/MM/YYYY)
i. Time
: |__|__| : |__|__| (HH:MM)
j. Type of Admission
: Emergency |__| Planned |__| Day Care |__| Maternity |__|
k. If Maternity,
Date of Delivery
: |__|__|/|__|__|/|__|__|__|__|(DD/MM/YYYY)
Gravida Status
: |__|__|__|__|__|__|__|__|
l. Status at the time of discharge : Discharge to home |__| Discharge to another hospital |__| Deceased
|__|
Details of Ailment Diagnosed :
a.
Primary Diagnosis
: ICD 10 Code : |__|__|__|__| Description : |__|__|__|__|__|__|__|
Additional Diagnosis
: ICD 10 Code : |__|__|__|__| Description : |__|__|__|__|__|__|__|
Co-morbidities
: ICD 10 Code : |__|__|__|__| Description : |__|__|__|__|__|__|__|
Co-morbidities
: ICD 10 Code : |__|__|__|__| Description : |__|__|__|__|__|__|__|
b.
Procedure 1
: ICD 10 PCS : |__|__|__|__| Description : |__|__|__|__|__|__|__|
Procedure 2
: ICD 10 PCS : |__|__|__|__| Description : |__|__|__|__|__|__|__|
Procedure 3
: ICD 10 PCS : |__|__|__|__| Description : |__|__|__|__|__|__|__|
Details of Procedure
: |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
c. Present ailment is a complication of PED : Yes |__| No |__|
If yes, specify details : |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
d. Pre-authorization obtained : Yes |__| No |__|
e. Pre-authorization no. : |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
f. If authorization by network hospital not obtained, give reason :
|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
g. Hospitalization due to Injury : Yes |__| No |__|
If yes, give reason : Self-inflicted |__| Road Traffic Accident |__| Substance Abuse / Alcohol
Consumption |__|
If Injury due to Substance abuse / Alcohol consumption, Test conducted to establish this : Yes |__| No
|__|
(If yes, attach reports)
If Medico legal
: Yes |__| No |__|
Reported to Police
: Yes |__| No |__|
FIR No.
: |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|

Group Care Claim Form

4 of 6

Religare Health Insurance Company Limited.

If not reported to Police, give reason : |__|__|__|__|__|__|__|__|__|__|__|

Claim Documents Submitted Checklist :

Duly signed Claim Form
Original Pre-authorization request
Copy of Pre-authorization approval letter
Copy of photo ID card of patient verified by hospital
Hospital Discharge Summary
Operation Theatre notes
Hospital Main Bill
Hospital Break up Bill
Hospital Bill Payment receipt
Investigation Reports
CT / MRI / USG / HPE investigation reports
Doctors request for investigation
ECG
Pharmacy Bills
MLC report & Police FIR
Original death summary from hospital where applicable
Others, please specify

: |__|
: |__|
: |__|
: |__|
: |__|
: |__|
: |__|
: |__|
: |__|
: |__|
: |__|
: |__|
: |__|
: |__|
: |__|
: |__|
: |__|

Details in case of non-network hospital (Only fill in case of non-network hospital)

a. Address of the hospital :
Address Line 1
: |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
Address Line 2
: |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
Address Line 3
: |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
City
: |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
State
: |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
PIN Code
: |__|__|__|__|__|__|
Phone no.
: |__|__|__|__|__|__|__|__|__|__|
b. Registration No.
: |__|__|__|__|__|__|__|__|__|__|__|__|__|
c. PAN
: |__|__|__|__|__|__|__|__|__|__|
d. No. of inpatient beds : |__|__|__|
e. Facilities available in the hospital :
OT : Yes |__| No |__|
ICU : Yes |__| No |__|
Others : |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|

Group Care Claim Form

5 of 6

Religare Health Insurance Company Limited.

Declaration by the Insured

Please read very carefully
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, 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 pre / post
hospitalization claim, if any.
Date : |__|__|__|__|__|__|__|__|__|
Place: |__|__|__|__|__|__|__|__|__|__|__|__|
Signature of the Insured Member : _________________________________________.
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 fact, our right to claim under this claim shall be forfeited. The signature of the insured is taken on this
claim form after Part B is fully filled up by us.
Date : |__|__|__|__|__|__|__|__|__|
Place: |__|__|__|__|__|__|__|__|__|__|__|__|
Signature & Seal of the Hospital Authority : _________________________________________.

Group Care Claim Form

6 of 6

Religare Health Insurance Company Limited.