Escolar Documentos
Profissional Documentos
Cultura Documentos
SECTION A
d) Name :
e) Address :
City:
State:
Pin Code:
Phone No:
Email ID :
No
Date:
Policy No.
d) Have you been hospitalized in the last four years since inception of the contract?
Diagnosis:
Yes
No
Yes
No
SECTION B
a) Name:
b) Gender:
Male
Female
c) Age: years Y
Self
Spouse
f) Occupation:
Self Employed
Child
Homemaker
months M M
d) Date of Birth:
M
M M
Father
Mother
Other
(Please Specify)
Student
Retired
Other
(Please Specify)
SECTION C
City:
State:
Pin Code:
Phone No:
E-mail ID:
DETAILS OF HOSPITALIZATION:
a) Name of Hospital where Admitted:
Day care
Injury
e) Date of Admission:
Self inflicted
Illness
Yes
Single occupancy
Maternity
Y
f) Time:
Twin sharing
g) Date of Discharge: D
Yes
No
i. If Medico legal:
D
Y
M M
h) Time:
Yes
No
SECTION D
j) System of Medicine:
DETAILS OF CLAIM:
a) Details of the treatment expenses claimed
i. Pre-hospitalization Expenses:
Rs.
Rs.
Rs.
Rs.
v. Ambulance Charges:
Rs.
Rs.
Total
vii. Pre-hospitalization period:
days
Yes
No
Rs.
days
Rs.
Rs.
Rs.
iv. Convalescence:
Rs.
vi. Others:
Rs.
Total
Rs.
SECTION E
ECG
Doctor's request for investigation
Investigation Reports (Including CT
/ MRI / USG / HPE)
Doctor's Prescriptions
Others
Bill No
Issued by
Date
D
3.
4.
5.
6.
7.
8.
9.
10
Towards
Hospital Main Bill
Pre-hospitalization Bills:
Post-hospitalization Bills:
Pharmacy Bills
Amount (Rs)
SECTION F
1.
2.
Nos
Nos
SECTION G
a) PAN:
c) Bank Name and Branch:
b) Account Number:
e) IFSC Code:
Date: D
Place:
GUIDANCE FOR FILLING CLAIM FORM PART A (To be filled in by the insured)
DATA ELEMENT
DESCRIPTION
FORMAT
Policy No.
b)
c)
d)
Name
e)
Address
a)
b)
c)
Company Name
Policy No.
Sum Insured
Have you been Hospitalized in the last four years since
inception of the contract?
Date
In rupees
Tick Yes or No
Diagnosis
Previously Covered by any other Mediclaim/ Health
Insurance?
Company Name
Open Text
d)
e)
f)
Tick Yes or No
Use dd-mm-yy format
Tick Yes or No
Name of the organization in full
Name
b)
Gender
c)
Age
d)
Date of Birth
e)
f)
Occupation
g)
Address
h)
Phone No
i)
E-mail ID
b)
c)
d)
e)
Hospitalization due to
Date of Injury/Date Disease first detected/ Date of
Delivery
Date of admission
f)
Time
g)
Date of discharge
h)
Time
i)
If Medico legal
Tick Yes or No
Reported to Police
Tick Yes or No
Tick Yes or No
System of Medicine
Open Text
j)
b)
Tick Yes or No
c)
d)
PAN
b)
Account Number
c)
d)
e)
IFSC Code
Read declaration carefully and mention date (in dd:mm:yy format), place (open text) and sign.
SECTION H
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 any.
DETAILS OF HOSPITAL
a) Name of the hospital:
c) Type of Hospital:
e) Qualification:
Network
Non Network
SECTION A
b) Hospital ID:
g) Phone No.
c) Gender:
D
f) Date of Admission:
j) Type of Admission:
Emergency
Planned
Discharge to home
g) Time:
Day Care
Male
H
Female
d) Age: Years Y
h) Date of Discharge:
k) If Maternity
Maternity
Months M
i. Date of Delivery: D
Deceased
e) Date of birth: D
i ) Time:
SECTION B
b) IP Registration Number:
ICD 10 Codes
ICD 10 PCS
b)
Description
i. Procedure 1:
ii. Procedure 2:
iii. Co-morbidities:
iii. Procedure 3:
iv. Co-morbidities:
d) Pre-authorization obtained:
Yes
No
SECTION C
i. Primary Diagnosis:
Description
e) Pre-authorization Number:
Yes
No
Self-inflicted
ii. If Injury due to Substance abuse / alcohol consumption, Test Conducted to establish this:
v. FIR no.
Yes
Yes
No
Yes
No
ECG
Pharmacy bills
SECTION D
State:
Pin Code:
b)Phone No.
d) Hospital PAN:
i. OT :
Yes
No
ii. ICU :
Yes
No
SECTION E
City:
iii. Others :
Date:
Place:
SECTION F
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.
GUIDANCE FOR FILLING CLAIM FORM PART B (To be filled in by the hospital)
DATA ELEMENT
DESCRIPTION
FORMAT
Name of Hospital
b)
Hospital ID
c)
Type of Hospital
d)
e)
Qualification
f)
g)
Phone No.
Name of Patient
b)
IP Registration Number
c)
Gender
d)
Age
e)
Date of Birth
f)
Date of Admission
g)
Time
h)
Date of Discharge
i)
Time
j)
Type of Admission
k)
If Maternity
Date of Delivery
Gravida Status
l)
m)
ICD 10 Code
Enter the ICD 10 Code and description of the primary
diagnosis
Enter the ICD 10 Code and description of the additional
diagnosis
Enter the ICD 10 Code and description of the co-morbidities
Primary Diagnosis
Additional Diagnosis
Co-morbidities
b)
ICD 10 PCS
Procedure 1
Procedure 2
Procedure 3
Details of Procedure
Open text
c)
Pre-authorization obtained
Tick Yes or No
d)
e)
Pre-authorization Number
If authorization by network hospital not obtained, give
reason
Hospitalization due to injury
As allotted by TPA
Open text
Tick Yes or No
Cause
If injury due to substance abuse/alcohol consumption,
test conducted to establish this
Medico Legal
Tick Yes or No
Tick Yes or No
Reported To Police
Tick Yes or No
FIR No.
Open Text
f)
Address
b)
Phone No.
c)
d)
Hospital PAN
e)
Digits
f)