WIXLIB

Checklist for Reimbursement Claims(All Claim Documents to be submitted in Original) Copy of the Intimation Letter / Mail / Intimation NumberDuly filled, Signed & Dated Claim form of insurance companyID Proof & Address proof of patient (Photo Copies are required)Original Discharge Card / Discharge Summary / Day Care Summary duly signed by treating doctorand with hospital stampOriginal Hospital Bill - duly sealed & signed, with Break-up details with serial numbersIf medicine and consumable charged in the hospital then detail break up should be given (Name ofthe medicine / consumables with charges)Original Pre-Numbered hospital payment receipt duly sealed & signed (with revenue stamp)Original Prescriptions / Consultation papers with consultation receiptsOriginal Pharmacy Bills (please make sure patient name is mentioned on the bill)Original Advance Paid receipt if anyIndication given by the treating doctor for lab test/surgeryOriginal Investigation reports along with original bills & payment receipts for the investigations donewithin & outside hospitals.All Imaging Films, ECG Strips, Doppler / Angiogram CD etc. (in case of fracture/major and minorsurgery)Current year Hospital Registration Certificate with total number of bedsAny other original documents related to the claimMLC copy /FIR in case of Accidental cases. (In case of accidental cases, fall from bike, fall at homeetc.)Detailed narration of the incidence, No alcohol certificate from treating doctor (in case of accidentalcases, fall from bike, fall at home etc.)The copy of the cancelled cheque of with IFSC code, printed name of employeeIf employee has availed a cashless but if the same is not utilized, letter from the hospital mentioningthe sameIn case of Maternity claims, obstetric history of the patient (Gravida Para Living Abortion) Certificatefrom the Treating DoctorUSG Report (ultrasonography report Mandatory for Maternity cases)For Cataract claims, IOL sticker & purchase invoice copy of the sticker is mandatoryFor surgery (replacement/PTCA) invoice copy / STICKER mandatory

CLAIM FORM - PART A' to 'CLAIM FORM FOR HEALTH INSURANCE POLICIES OTHER THAN TRAVEL AND PERSONAL ACCIDENT - PART ATO BE FILLED BY THE INSURED(To be Filled in block letters)The issue of this Form is not to be taken as an admission of liablityDETAILS OF PRIMARY INSURED:b) Sl. No/ Certificate no.a) Policy No.:c) Company/ TPA ID No:URNAMEFIRSTNAMEMIDDLENAMSECTION ASd) Name:Ee) Address:City:State:Pin CodePhone No:Email ID:DETAILS OF INSURANCE HISTORY:a) Currently covered by any other Mediclaim / Health Insurance:YesNob) Date of commencement of first Insurance without break: DMMYYYDate:MMYPolicy No.Sum insured (Rs.)Yesd) Have you been hospitalized in the last four years since inception of the contract?NoYYYese) Previously covered by any other Mediclaim /Health insurance : :Diagnosis:NoSECTION Bc) If yes, company name:Df) If yes, company name:DETAILS OF INSURED PERSON HOSPITALIZED: :Sa) Name:b) GenderURMaleNAMEFemaleSelff) OccupationSelf EmployedSpouseYChildHome MakerIRMonths MSTMNAMDd) Date of BirthEMDMIMDYFatherMotherOther(Please Specify)StudentRetiredOther(Please Specify)DLYYDDENAMEYSECTION Ce) Relationship to Primary insured:ServiceFYc) Age yearsg) Address (if diffrent from above) :City:State:Pin CodePhone No:Email ID:DETAILS OF HOSPITALIZATION: :a) Name of Hospital where Admited:Day careb) Room Category occupied:DSelf inflictedDMYYf) TimeHHMHg) Date of Discharge: DSubstance Abuse / Alcohol ConsumptionRoad Traffic Accidentiii. MLC Report & Police FIR attachedii) Reported to Police3 or more beds per roomTwin sharingd) Date of injury / Date Disease first detected /Date of Delivery:YesNoDMMI) If Medico legalYMYMh) Time:YesYYYYHH:MHNoSECTION DMe) Date of Admission:I) If injury give cause:Single occupancyMaternityIllnessInjuryc) Hospitalization due to:j) System of Medicine:DETAILS OF CLAIM:a) Details of the Treatment expenses claimedClaim Documents Submitted - Check List:I. Pre -hospitalization expensesRs.ii. Hospitalization expensesRs.Claim form duly signedCopy of the claim intimation, if anyiii. Post-hospitalization expensesRs.iv. Health-Check up cost:Rs.v. Ambulance Charges:Rs.vi. Others (code):Rs.Hospital Main BillHospital Break-up Billdaysvii. Pre -hospitalization period:Hospital Bill Payment Receiptviii. Post -hospitalization period: daysYesb) Claim for Domiciliary Hospitalization:No(If yes, provide details in annexure)Hospital Discharge SummaryPharmacy BillSECTION ERs.TotalOperation Theater Notesc) Details of Lump sum / cash benefit claimed:i. Hospital Daily cash:Rs.ii. Surgical Cash:Rs.iii. Critical Illness benefit:Rs.iv. Convalescence:Rs.vi. Others:Rs.TotalRs.v. Pre/Post hospitalization Lump sum benefit: Rs.ECGDoctor’s request for investigationInvestigation Reports (Including CT/ MRI / USG / HPE)Doctor’s PrescriptionsOthersDETAILS OF BILLS ENCLOSED:Sl. No.Bill No.DateIssued byTowardsDDMMYYDDMMYYHospital main BillPre-hospitalization Bills:DDMMYYPost-hospitalization Bills:4.5.6.DDMMYYPharmacy Amount (Rs)NosNosSECTION F1.2.3.DETAILS OF PRIMARY INSURED’S BANK ACCOUNT::b) Account Number:c) Bank Name and Branch:d) Cheque / DD Payable details:e) IFSC Code:SECTION Ga) PAN:(IMPORTANT: PLEASE TURN OVER)

DECLARATION BY THE INSURED:DateDDMMYYYYPlace:Signature of the InsuredGUIDANCE FOR FILLING CLAIM FORM - PART A (To be filled in by the insured)DATA ELEMENTDESCRIPTIONFORMATSECTION A - DETAILS OF PRIMARY INSUREDa)Policy No.b)Sl. No/ Certificate No.c)Enter the policy numberEnter the social Insurance number or the certificate number ofsocial health insurance schemeCompany TPA ID No.d)Namee)AddressAs allotted by the Insurance CompanyAs allotted by the oraganizationEnter the TPA ID No.Licence number as allotted by IRDA and printedin TPA documents.Enter the full name of the policyholderSurname, First name, Middle nameEnter the full postal addressInclude Street, City and Pin codeSECTION B -DETAILS OF INSURANCE HISTORYa)Currently covered by any other Mediclaim / HealthInsurance?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 No.Enter the policy numberAs allotted by the Insurance CompanySum insuredEnter the total sum insured as per the policyIn rupeesHave you been Hospitalized in the last four years sinceInception of the contract?Indicate whether hospitalized in the last four yearsTick Yes or NoDateEnter the date of HospitalizationUse mm-yy formatDiagnosisPreviously covered by any other Mediclaim / HealthInsurance?Company NameEnter the diagnosis detailsIndicate whether previously covered by another mediclaim /Health InsuranceEnter the full name of the Insurance CompanyOpen Textd)e)f)Tick Yes or NoName 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 patientUse dd-mm-yy formate)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 specify.g)AddressEnter the full postal addressInclude Street, City and Pin codeh)Phone NoEnter the phone number of patientInclude STD code with telephone number1)E-mail IDEnter e-mail address of patientComplete e-mail addressSECTION D - DETAILS OF HOSPITALIZATIONa)Name of Hospital where admitedEnter 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 ofDeliveryEnter the relevant dateUse dd-mm-yy formate)Date of admissionEnter date of admissionUse dd-mm-yy formatEnter time of admissionUse hh-mm- formatf)Timeg)Date of dischargeEnter date of dischargeUse dd-mm-yy formath)TimeEnter time of dischargeUse hh-mm- formatI)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 NoSystem of MediceneEnter the system of medicine followed in treating the patientOpen Textj)SECTION E - DETAILS OF CLAIMa)Details of Treatment ExpencesEnter the amount claimed as treatment expencesIn rupees (Do not enter paise values)b)Claim for Domiciliary Hospitalizationindicate whether claim is for domiciliary hospitalizationTick Yes or Noc)Details of Lump sum/ Cash benifit claimedEnter the amount claimed as lump sum / cash benefitIn rupees (Do not enter paise values)d)Claim documents Submitted-Check Listindicate which supporting documents are submittedTick the right optionSECTION F - DETAILS OF BILLS ENCLOSEDIndicate which bills are enclosed with the amount in rupeesSECTION G - DETAILS OF PRIMARY INSURED’s BANK ACCOUNTa)PANEnter the permanent account numberb)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 fullc)Cheque/ DD payable detailsc)IFSC CodeEnter the name of the beneficiary the cheque / DD should bemade out toEnter the IFSC code of the Bank branchSECTION H - DECLARATION BY THE INSUREDRead declaration carefully and mention date (in dd:mm:yy format), place (open text) and sign.As allotted by the Income Tax DepartmentName of the individual / organization in fullIFSC code of the Bank branch in fullSECTION HI hereby declare that the information furnished in the claim form is true & correct to the best of my knowledge and belief. If I have made any false or untrue statement, suppressionor concealent of any material fact 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-hospitalizationclaim, if any.