Easy Health

Claim Form

10th Floor, Building No. 10, Tower B, DLF City Phase II, DLF Cyber City, Gurgaon-122002

PART A

TO BE FILLED IN BY THE INSURED

The issue of this Form is not to be taken as an admission of liability
1.
Policy No. :
2. Sl. No/ Certificate No. :
3. Company/ TPA ID No :
4. Name & Address of the Policyholder :

5. Details of the Insured Person Hospitalised :

a) Name :

b) Relationship :
c) Date of Birth :
d) Age/Years :

e) Address :

f) Gender: Male / Female
g) Occupation :

h) Telephone No :
i) Mobile No :

j) E-mail ID, if any :
6. Hospitallisation due to Illness / Injury / Maternity : Details :

a) Date of Injury sustained/ Disease first detected / LMP :

b) If injury, how it occurred :


c) If injury, whether Medico legal : Yes / No
d) If MLC, whether reported to police? Yes / No

e) System of medicine : Allopathic / Other systems of medicine
7.
Insurance History :

a) Date of commencement of first Insurance for the person (without break) :

b) Are you presently covered with any other Mediclaim / Health Insurance? : Yes / No

c) If Yes, give details - Company / Policy Number / Sum Insured (copies of policies to be attached) :

8. Name of the Hospital where admitted :
9. Room Category occupied : Day care / Single occupancy / Twin sharing / 3 or more
10. Past Hospitalisation History :

a) Have you been hospitalised in the last 4 years? : Yes / No

b) If Yes, Diagnosis :

c) Month and Year :
11. Is claim is for Domiciliary Hospitalisation? : Yes / No (If Yes, provide details in annexure)
12. Policyholders Bank Account particulars :

Payable details: Cheque / DD / NEFT *
Payable to :

Bank Name :
Bank Branch :

Bank Account Number :
IFSC Code :
Policyholders PAN :

MICR No. :
Note: It is agreed that the Policyholder/ Claimant will intimate in writing to Apollo Munich about any change in bank account details.
*Please attach a cancelled cheque pertaining to the same account.

13.



13A.




14.

Details of the treatment expenses claimed :

a) Pre-hospitalisation Expenses : Rs.
c) Post-hospitalisation Expenses : Rs.
e) Ambulance Charges : Rs.
Details of Lumpsum / cash benefit claimed :
a) Hospital Daily Cash : Rs.
c) Critical Illness Benefit :
e) Pre / Post hospitalisation lumpsum benefit :
f) Others :
Details of bills enclosed :

Sl. No.

Bill No.

Date

Issued by

b)
d)
f)

Hospitalisation Expenses : Rs.

Health check-up Cost : Rs.
Others (code) : Rs.

b)
d)

Surgical Cash : Rs.

Convalescence :

Towards

(If there is insufficient space to provide additional relevant information, whether as requested or otherwise, please attach extra sheet duly signed.)

15.

For details of Claim Documents to be submitted, please refer CHECK LIST.

Date :

Signature of the Policyholder / Claimant :

Amount

Easy Health
Claim Form

10th Floor, Building No. 10, Tower B, DLF City Phase II, DLF Cyber City, Gurgaon-122002

PART B

TO BE FILLED IN BY THE HOSPITAL

The issue of this Form is not to be taken as an admission of liability
Please include the original preauthorisation request form in lieu of PART A
1.
Name of the Hospital where treated :
2. Hospital ID :
3. Type of Hospital : Network / Non-Network
4. In case of non network , please provide below details :

a) Address of the Hospital with Pin Code :


b) Telephone No :
c) Registration No :

d) Number of Inpatient beds :
e) PAN :

f) Other Facilities available in the hospital :

i) OT : Yes / No ii) ICU : Yes / No
iii) Others :
5. Details of the patient admitted :

a) Name of the patient :

b) IP Registration Number :
c) Gender: Male / Female
d) Age :

e) Date of Admission (DD/MM/YYYY) :
f) Time of Admission :

g) Date of Discharge (DD/MM/YYYY) :
h) Time of Discharge :
6. Ailment Diagnosed (Primary) :

a) ICD 10 Code :

Primary Diagnosis :

Additional Diagnosis :

Co-morbidities :

b) Details of Procedure/s done :


c) ICD 10 PCS :

Procedure 1 :

Procedure 2 :

Procedure 3 :
7.
a) Type of Admission : Emergency / Planned / Day-care / Maternity
c) Gravida Status :

b) Date of delivery, if maternity (DD/MM/YYYY) :
8. Is the treatment for an injury? If Yes, give details

a) Was it self inflicted? : Yes / No
b) Whether RTA : Yes / No

c) If MLC, whether notified to police : Yes / No
d) MLC / FIR No :

e) If MLC not notified, give reasons :
9. Was the Injury/ disease caused due to Substance abuse / Alcohol consumption : Yes / No

a) If Yes, whether any test was conducted to establish this? : Yes / No If Yes, please attach Report.
10. Whether the present ailment is a complication of any illness suffered in the past : Yes / No
If Yes, specify details :
11. Whether Pre-authorisation obtained : Yes / No

a) If Yes, Pre Auth Number :

b) If authorisation by network hospital not obtained, give reason :

12. Details of the Treating Doctor :

a) Name of the Treating Doctor:

b) Registration No with state code :

c) Mobile No. :
d) Qualification :
13. For details of Claim Documents to be submitted, please refer CHECK LIST.
DECLARATION BY THE INSURED
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 & authorise TPA / Insurance Company., to seek necessary medical information / documents from any hospital / Medical Practitioner/ Insurer 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 hospitalisation claim, if any.
DECLARATION BY THE HOSPITAL
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.

Signature of the Insured :

Seal & Signature of the Hospital Authority :

Date :

Date :

Easy Health
Claim Form

10th Floor, Building No. 10, Tower B, DLF City Phase II, DLF Cyber City, Gurgaon-122002

PART C
For Office Use Only (Refer IRDA / TAC Master for codes wherever applicable)
1.

TPA Code :

2. Insurer Code :

3.

Product Code :

4. Policy Number :

5.

Policy Start Date :

6. Policy End Date :

7.

Sum Insured :

8. Bonus Sum Insured Accrued, if any :

9.

Master Claim ID :

10.

Diagnosis Code :

Primary Diagnosis :

Additional Diagnosis :

Co-morbidities :

11.

Procedure Code :

Procedure 1 :

Procedure 2 :

Procedure 3 :

12.

Details of Claim Paid :

A) Indemnity Benefit :

a) Room & Nursing Charges :

b) ICU Charges :

c) OT Charges :

d) Medicine & Consumable Charges :

e) Professional Fees Charges :

f) Investigation Charges :

g) Ambulance Charges :

h) Miscellaneous Charges :

B) Fixed / Lumpsum Benefit :

a) Hospital Daily Cash :

b) Surgical Cash :

c) Critical Illness Benefit :

d) Convalescence :

e) Pre / Post hospitalisation lumpsum benefit :

f) Others :

13.

Total Claim Paid :

14.

Total Rejected Amount :

15.

Reason for Rejection of Claim :

16.

Reason for Reduction of Claim :

17.

Whether claim paid was for PED :

18.

If Yes, PED Code :

19.

Whether claim paid under alternate medicine : Yes / No

20. Amount of co-payment / deductible applicable :

21.

Corporate Buffer Utilised, if any :

22. Date of Payment (DD/MM/YYYY) :

23. Payment Reference Number :
24. Date of Claim Intimation (DD/MM/YYYY) :
25. Date of receipt of complete claim documents (DD/MM/YYYY) :

Duly filled and signed Claim Form.

Easy Health
Claim Form

10th Floor, Building No. 10, Tower B, DLF City Phase II, DLF Cyber City, Gurgaon-122002

Check List of Enclosures for Submission of Claim

In-patient Treatment /Day Care Procedures

q Duly filled and signed Claim Form.

q Photocopy of ID card / Photocopy of current year policy.
q Original Detailed Discharge Summary / Day care summary from the hospital.
q Original consolidated hospital bill with break up of each Item, duly signed by
the insured.
q Original payment Receipt of the hospital bill.
q First Consultation letter and subsequent Prescriptions.
q Original bills, original payment receipts and Reports for investigation.
q Original medicine bills and receipts with corresponding Prescriptions.
q Original invoice/bills for Implants (viz. Stent /PHS Mesh / IOL etc.) with
original payment receipts.

Road Traffic Accident

In addition to the In-patient Treatment documents:

q Copy of the First Information Report from Police Department / Copy of the
Medico-Legal Certificate.
In Non Medico legal cases
q Treating Doctors Certificate giving details of injuries (How, when and where
injury sustained)
In Accidental Death cases
q Copy of Post Mortem Report & Death Certificate

For Death Cases

In addition to the In-patient Treatment documents:

q Original Death Summary from the hospital.
q Copy of the Death certificate from treating doctor or the hospital authority.
q Copy of the Legal heir certificate, if the claim is for the death of the principle
insured.

Pre and Post-hospitalisation expenses

q Duly filled and signed Claim Form.

q Photocopy of ID card / Photocopy of current year policy.
q Original Medicine bills, original payment receipt with prescriptions.
q Original Investigations bills, original payment receipt with prescriptions and
report.
q Original Consultation bills, original payment receipt with prescription.
q Copy of the Discharge Summary of the main claim.

Outpatient Benefit/Dental

q Duly filled and signed Claim Form.

q Photocopy of ID card / Photocopy of current year policy.
q Original Medicine bills, original payment receipt.
q Original Investigations bills, original payment receipt with report.
q Original Consultation bills, original payment receipt with prescription.
q Details of any Outpatient Procedures, If any
q Dental X-ray film.

Daily Cash Benefit

q Duly filled and signed Claim Form.
q Photocopy of ID card / Photocopy of current year policy.

Organ Donation/Transplantation

In addition to the documents of general hospitalization

q Organ Function test / blood test proving organ failure.

q Treatment Certificate issued by the Transplant Surgeon of the hospital

concerned.

Ambulance Benefit

q Duly filled and signed Claim Form.

q Photocopy of ID card / Photocopy of current year policy.

q Original Bill with Original Payment Receipt.

q Treating Doctors consultation prescription indicating Emergency

Hospitalization.

Maternity Expenses

In addition to the In-patient Treatment documents:

q Obstetric history (Gravida, Para, Living children, Abortions) from treating

doctor.

Critical Illness Benefit

q Duly filled and signed Claim Form.

q Photocopy of ID card / Photocopy of current year policy.
q A medical certificate confirming the diagnosis of critical illness from a doctor
not less qualified than MD/MS.
q Investigation reports/ other related documents reflecting the critical illness
diagnosis.

Health Check up

q Duly filled and signed Claim Form.

q Photocopy of ID card / Photocopy of current year policy.

q Original Investigation bills, original payment receipts with Reports.

q Original Consultation bills and original payment receipts with prescription.

Expenses for spectacles/contact lenses, hearing aids

q Duly filled and signed Claim Form.

q Photocopy of ID card / Photocopy of current year policy.

q Prescription of the Treating Doctor.

q Original Invoice/bills, original payment receipt of the device, appliances, lens

etc.

Customer Identification Procedure (as per KYC norms of IRDA)

Please submit the following documents in case of claim amount exceeds Rs. 100,000
Legal name and any other names used
(Any one of the mentioned documents)

Proof of Residence

(Any one of the mentioned documents)

Passport/ PAN Card/ Voters Identity Card/ Driving License/ Letter from a recognized public authority or public servant
verifying the identity and residence of the customer
Telephone bill/ Bank account statement/ Letter from any recognized public authority/ Electricity bill/ Ration card

E-mail : [email protected]

toll free : 1800-102-0333 www.apollomunichinsurance.com

AMHI/PR/H/0018/0044/102010/P