PARAMOUNT HEALTH SERVICES & INSURANCE TPA PRIVATE LIMITED (IRDA License No.

006)
[formerly known as PARAMOUNT HEALTH SERVICES (TPA) PVT.LTD]
Plot no.A-442, Road No-28,M.I.D.C Industrial Area, Wagale Estate, Ram Nagar, Vitthal Rukmani Mandir, Thane (W), Mumbai, Pin Code – 400 604
CLAIM ACKNOWLEDGMENT SHEET
Name of Insurer : PHS ID :
Insured Name : Employee No :
Patient Name : Mobile No :
Policy No : Phone (STD) :
Name of Corporate:
Type of Claim (To Main Hospitalisation / Pre-Post Hospitalisation / OPD Claim / Deficiency Retrieval / Critical Illness / Cash Benefit E-Mail ID of
be ticked) : primary insured :
CLAIM DOCUMENT CHECK LIST
Document
Sr. No Description Remarks
Status(Y/N)
IRDA Claim Form duly signed by the Insured & Hospital
Part-A: Duly signed by the insured with Claimed amount ,Mobile number & Email ID along with PHS ID
1 Part-B: Duly signed and stamped by hospital
Declaration form duly signed & stamped by the hospital in case treatment taken is under PPN/GIPSA hospitals.

In case of No Intimation / Delay Intimation & Delay in submission of claim, a letter from insured is required stating
2 reason for the same.
Original Cancelled Cheque Leaf of Employee/Proposer with the Name of the Account Holder Printed on the Cheque
3 Leaf.
ID Proof of Employee / Primary Insured- Any of one (Passport,Voter ID, Driving License, Or any Government Approved
4
ID ) . If Claim is above 1 lakh- PAN is mandatory with address Proof
5 ID Proof of Patient- Any of one (Passport,Voter ID, Driving License, Or any Government Approved ID )
Original detailed Discharge Summary as per IRDA Format / Day care summary from the hospital (in case of Day Care
6 Treatment) / Death Summary (in Case of Death Claim)

6.a Copy of the Legal heir certificate (if the claim is for the death of the principle insured)

6.b Copy of Post Mortem Report & Death Certificate (In Accidental Death cases)
7 Policy Copy ( if individual policy)
8 64VB Compliance Certificate ( If individual policy)
9 Original Final Hospital bill with cost wise breakup of each Item
10 Original Payment Receipt of Main Hospital bill ( both Deposit / Refund)
Receipt Of Payments made at the Hospital by Credit Card : Please attach the Xerox Copy of the Credit Card Payment Slip
10.a as received from the Vendor
Original copy of Implant Invoice along with Payment Receipts & Implant Labels / Stickers for Stents/ Mesh/ IOL
11

12 Original bills, original Payment Receipts and investigation / Laboratory Reports

Original medicine bills specifying Patient Name and date of purchase along with supporting Prescriptions.
13

14 Original copy of First Consultation letter and subsequent Prescriptions.

Hospital Registration certificate issued by Competent authority as per Indian nursing council Act 1947 (If hospital not
15
falls in GIPSA/PPN )
16 OTHER DOCUMENTS
Original copy of Obstetric history (Gravida, Para, Living children, Abortions) from treating doctor. (Maternity Claim)
16.a

16.b Original Sonography Report in case of Maternity Claim

Original A-Scan Report along with IOL Sticker and Tax paid invoice in case of Cataract
16.c
Claim
Copy of the First Information Report (FIR) from Police Department / Copy of the Medico-Legal Certificate (MLC) in case
16.d of Road Traffic Accident (RTA)
A medical certificate from a doctor not less qualified than MD/MS confirming the diagnosis of critical illness along with
16.e the Investigation reports/Other related documents reflecting the critical illness diagnosis. (Critical Illness Cases)

In case of claims where the insured has submitted documents to another insurance co./TPA, he needs to submit
16.f attested Photocopies of all the documents along with detailed claim settlement letter from the TPA and any unpaid bills
and receipt for the same in originals.
Claims Submitted by : Insured / Corporate / Agent / Broker / Insurer / Hospital
Claim Submitted by: Mobile No.
Date of Claim PHS Executive
DD/MM/YYYY HH:MM
Submission: Name:
Claim Submitted at: PHS - (Location) / Help Desk Signature:
Important Points to Remember:-
1. Please mark either √ or × against respective check box
2. Date of File Received will be considered as next working day for Claim Files picked up at Help Desk
3. Claim Need to be Submitted within 7 Working Days from Date of Discharge from Hospital
4. The above list of documents is indicative. In case of any other document requirement as specified by the Insurance Company, our document recovery team will contact you on receipt of
your claim documents by us
5. Please visit us at www.paramounttpa.com to check Online Claim Status or download Paramount Mobile App
6. Member is advised to keep photocopies of all the papers since Insurer requires all the above documents in original. Documents once submitted will not returned unless approved & agreed
by Insurer
7. Corrections in any documents are not allowed, otherwise it will not be entertained during adjudication.
 Annexure - III

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 Annexure - III

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 & authorize TPA / insurance company, to seek necessary

SECTION H
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.

Date: D D M M Y Y Place: Signature of the Insured

GUIDANCE FOR FILLING CLAIM FORM – PART A (To be filled in by the insured)
DATA ELEMENT DESCRIPTION FORMAT
SECTION A - DETAILS OF PRIMARY INSURED
a) Policy No. Enter the policy number As allotted by the insurance company
Enter the social insurance number or the certificate number of
b) SI. No/ Certificate No. As allotted by the organization
social health insurance scheme
License number as allotted by IRDA and
c) Company TPA ID No. Enter the TPA ID No
printed in TPA documents.
d) Name Enter the full name of the policyholder Surname, First name, Middle name
e) Address Enter the full postal address Include Street, City and Pin Code
SECTION B - DETAILS OF INSURANCE HISTORY
a) Currently covered by any other Mediclaim / Health Indicate whether currently covered by another Mediclaim /
Tick Yes or No
Insurance? Health Insurance
b) Date of Commencement of first Insurance without break Enter the date of commencement of first insurance Use dd-mm-yy format
c) Company Name Enter the full name of the insurance company Name of the organization in full
Policy No. Enter the policy number As allotted by the insurance company
Sum Insured Enter the total sum insured as per the policy In rupees
d) Have you been Hospitalized in the last 4 years Indicate whether hospitalized in the last 4 years Tick Yes or No
Date Enter the date of hospitalization Use mm-yy format
Diagnosis Enter the diagnosis details Open Text
e) Previously Covered by any other Mediclaim/ Health Indicate whether previously covered by another Mediclaim /
Tick Yes or No
Insurance? Health Insurance
f) Company Name Enter the full name of the insurance company Name of the organization in full
SECTION C - DETAILS OF INSURED PERSON HOSPITALIZED
a) Name Enter the full name of the patient Surname, First name, Middle name
b) Gender Indicate Gender of the patient Tick Male or Female
c) Age Enter age of the patient Number of years and months
d) Date of Birth Enter Date of Birth of patient Use dd-mm-yy format
e) Relationship to primary Insured Indicate relationship of patient with policyholder Tick the right option. If others, please specify.
f) Occupation Indicate occupation of patient Tick the right option. If others, please specify.
g) Address Enter the full postal address Include Street, City and Pin Code
h) Phone No Enter the phone number of patient Include STD code with telephone number
i) E-mail ID Enter e-mail address of patient Complete e-mail address
SECTION D - DETAILS OF HOSPITALIZATION
a) Name of Hospital where admitted Enter the name of hospital Name of hospital in full
b) Room category occupied Indicate the room category occupied Tick the right option
c) Hospitalization due to Indicate reason of hospitalization Tick the right option
d) Date of Injury/Date Disease first detected/ Date of
Enter the relevant date Use dd-mm-yy format
Delivery
e) Date of admission Enter date of admission Use dd-mm-yy format
f) Time Enter time of admission Use hh:mm format
g) Date of discharge Enter date of discharge Use dd-mm-yy format
h) Time Enter time of discharge Use hh:mm format
i) If Injury give cause Indicate cause of injury Tick the right option
If Medico legal Indicate whether injury is medico legal Tick Yes or No
Reported to Police Indicate whether police report was filed Tick Yes or No
MLC Report & Police FIR attached Indicate whether MLC report and Police FIR attached Tick Yes or No
j) System of Medicine Enter the system of medicine followed in treating the patient Open Text
SECTION E - DETAILS OF CLAIM
a) Details of Treatment Expenses Enter the amount claimed as treatment expenses In rupees (Do not enter paise values)
b) Claim for Domiciliary Hospitalization Indicate whether claim is for domiciliary hospitalization Tick Yes or No
c) Details of Lump sum/ cash benefit claimed Enter the amount claimed as lump sum/ cash benefit In rupees (Do not enter paise values)
d) Claim Documents Submitted-Check List Indicate which supporting documents are submitted Tick the right option
SECTION F - DETAILS OF BILLS ENCLOSED
Indicate which bills are enclosed with the amounts in rupees
SECTION G - DETAILS OF PRIMARY INSURED’S BANK ACCOUNT
a) PAN Enter the permanent account number As allotted by the Income Tax department
b) Account Number Enter the bank account number As allotted by the bank
c) Bank Name and Branch Enter the bank name along with the branch Name of the Bank in full
Enter the name of the beneficiary the cheque/ DD should be
d) Cheque/ DD payable details Name of the individual/ organization in full
made out to
e) IFSC Code Enter the IFSC code of the bank branch IFSC code of the bank branch in full
SECTION H - DECLARATION BY THE INSURED
Read declaration carefully and mention date (in dd:mm:yy format), place (open text) and sign.
 Annexure - III

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 Annexure - III

GUIDANCE FOR FILLING CLAIM FORM – PART B (To be filled in by the hospital)
DATA ELEMENT DESCRIPTION FORMAT
SECTION A - DETAILS OF HOSPITAL
a) Name of Hospital Enter the name of hospital Name of hospital in full
b) Hospital ID Enter ID number of hospital As allocated by the TPA
c) Type of Hospital Indicate whether In network or non network nospital Tick the right option
d) Name of treating doctor Enter the name of the treating doctor Name of doctor in full
e) Qualification Enter the qualifications of the treating doctor Abbreviations of educational qualifications
Enter the registration number of the doctor along with the state
f) Registration No. with State Code As allocated by the Medical Council of India
code
g) Phone No. Enter the phone number of doctor Include STD code with telephone number
SECTION B – DETAILS OF THE PATIENT ADMITTED
a) Name of Patient Enter the name of hospital Name of hospital in full
b) IP Registration Number Enter insurance provider registration number As allotted by the insurance provider
c) Gender Indicate Gender of the patient Tick Male or Female
d) Age Enter age of the patient Number of years and months
e) Date of Admission Enter date of admission Use dd-mm-yy format
f) Time Enter time of admission Use hh:mm format
g) Date of Discharge Enter date of discharge Use dd-mm-yy format
h) Time Enter time of discharge Use hh:mm format
i) Type of Admission Indicate type of admission of patient Tick the right option
j) If Maternity
Date of Delivery Enter Date of Delivery if maternity Use dd-mm-yy format
Gravida Status Enter Gravida status if maternity Use standard format
k) Status at time of discharge Indicate status of patient at time of discharge Tick the right option
SECTION C – DETAILS OF AILMENT DIAGNOSED (PRIMARY)
a) ICD 10 Code
Enter the ICD 10 Code and description of the primary
Primary Diagnosis Standard Format and Open text
diagnosis
Enter the ICD 10 Code and description of the additional
Additional Diagnosis Standard Format and Open text
diagnosis
Co-morbidities Enter the ICD 10 Code and description of the co-morbidities Standard Format and Open text
b) ICD 10 PCS
Procedure 1 Enter the ICD 10 PCS and description of the first procedure Standard Format and Open text
Procedure 2 Enter the ICD 10 PCS and description of the second procedure Standard Format and Open text
Procedure 3 Enter the ICD 10 PCS and description of the third procedure Standard Format and Open text
Details of Procedure Enter the details of the procedure Open text
Indicate whether present ailment is a complication of some pre-
c) Present Ailment is a Complication of PED Tick Yes or No
existing disease
d) Pre-authorization obtained Indicate whether pre-authorization obtained Tick Yes or No
e) Pre-authorization Number Enter pre-authorization number As allotted by TPA
f) If authorization by network hospital not obtained, give
Enter reason for not obtaining pre-authorization number Open text
reason
g) Hospitalization due to injury Indicate if hospitalization is due to injury Tick Yes or No
Cause Indicate cause of injury Tick the right option
If injury due to substance abuse/alcohol consumption,
Indicate whether test conducted Tick Yes or No
test conducted to establish this
Medico Legal Indicate whether injury is medico legal Tick Yes or No
Reported To Police Indicate whether police report was filed Tick Yes or No
FIR No. Enter first information report number As issued by police authorities
If not reported to police, give reason Enter reason for not reporting to police Open Text
SECTION D – CLAIM DOCUMENTS SUBMITTED-CHECK LIST
Indicate which supporting documents are submitted
SECTION E – DETAILS IN CASE OF NON NETWORK HOSPITAL
a) Address Enter the full postal address Include Street, City and Pin Code
b) Phone No. Enter the phone number of hospital Include STD code with telephone number
c) Registration No. Enter the registration number of patient As allocated by the Hospital
d) PAN Enter the permanent account number As allotted by the Income Tax department
e) Number of Inpatient Beds Enter the number of inpatient beds Digits
f) Facilities available in the hospital Indicate facilities available in the hospital Tick the right option. If others, please specify
SECTION F - DECLARATION BY THE INSURED
Read declaration carefully and mention date (in dd:mm:yy format), place (open text) and sign.
SECTION G - DECLARATION BY THE HOSPITAL
Read declaration carefully and mention date (in dd:mm:yy format), place (open text) and sign and stamp