HDFC ERGO General Insurance Company Limited

CLAIM FORM - AROGYA SANJEEVANI POLICY, HDFC ERGO (GROUP)

CLAIM FORM – PART A

§ Track your Claim Status

§ Please share the original document at the time of submission. Non submission of original bills, NEFT, KYC (Claim Amount over `1 lakh) is the main reason for delay
§ Provide your Mobile Number and E-mail ID to get Claim Updates
§ Duly filled NEFT (National Electronic Funds Transfer) form
§ Duly Filled KYC (Know Your Customer) form and KYC documents (ID and address proof e.g PAN Card, Aadhaar Card, Ration Card, Passport etc) for all claims where in claimed about is `1 lakh and above

To be filled in by the Insured

The issue of this form is not to be taken as an admission of liability (To be filled in block letters)
SECTION A – DETAILS OF PRIMARY INSURED

a) Policy No.: b) Sl. No/ Certificate No.:

c) Company/ TPA ID No.:
d) Name: S U R N A M E F I R S T N A M E M I D D L E N A M E

e) Address:

City: State:

Pin Code: Phone No.: Email ID:

SECTION B- DETAILS OF INSURANCE HISTORY

a) Currently covered by any other mediclaim health insurance: Yes No b) Date of commencement of first insurance without break: D D M M Y Y Y Y

c) If Yes, Company Name: Policy No.:

Sum Insured (Rs): d) Have you been hospitalized in the last four years since inception of the contract : Yes No Date: M M Y Y

Diagnosis: e) Previously covered by any other Mediclaim/Health insurance: Yes No

f) If Yes, Company Name:

SECTION C- DETAILS OF INSURED PERSON HOSPITALISED

a) Name: S U R N A M E F I R S T N A M E M I D D L E N A M E
b) Relationship to
primary Insured: Self Spouse Child Father Mother Other Please Specify:

c) Date of Birth: D D M M Y Y Y Y d) Age: Y Y M M

e) Address (if different
from above)
f) Gender: Male Female

g) Occupation: Service Self employed Homemaker Student Retired Other Please Specify:

City: State: Pin Code:

h) Phone No.: ii) Mobile No.: j) Email ID:
SECTION D- DETAILS OF HOSPITALIZATION
a) Name of the Hospital where admitted:
b) Room Category occupied: Daycare Single Occupancy Twin Sharing 3 or more beds per room

c) Hospitalisation due to: Illness Injury Maternity d) Date of Injury/ Date of disease first detected/ Date of delivery: D D M M Y Y Y Y

e) Date of admission: D D M M Y Y Y Y f) Time: H H : M M g) Date of discharge: D D M M Y Y Y Y h) Time: H H : M M

ii) If injury, give cause: Self Inflicted Road Traffic Accident Substance Abuse Alcohol Consumption

ii) If Medico legal: Yes No ii) Reported to police?: Yes No iii) MLC Report, & Police FIR attached? Yes No
j) System of medicine: Allopathic/ Other systems of medicine
SECTION E- DETAILS OF CLAIM
a) Details of the treatment expenses claimed under Hospitalisation Cover
ii) Pre-Hospitalization Expenses Rs. ii) Hospitalization Expenses Rs.

iii) Post-Hospitalization Expenses Rs. iv) AYUSH Treatments Rs.

CLAIM FORM/Ver - 1 FEB2021

Claim Documents Submitted- Check List:

¨ Photo Identity proof of the patient ¨ Sticker/Invoice of the Implants, wherever applicable.
¨ Medical practitioner's prescription advising admission ¨ MLR(Medico Legal Report copy if carried out and FIR (First information report)
¨ Original bills with itemized break-up if registered, where ever applicable.

¨ Payment receipts ¨ NEFT Details (to enable direct credit of claim amount in bank account) and cancelled
cheque
¨ Discharge summary including complete medical history of the patient along with other
details. ¨ KYC (Identity proof with Address) of the proposer, where claim liability is above
Rs 1 Lakh as per AML Guidelines
¨ Investigation/ Diagnostic test reports etc. supported by the prescription from
attending medical practitioner ¨ Legal heir/succession certificate , wherever applicable
¨ OT notes or Surgeon's certificate giving details of the operation performed (for surgical cases). ¨ Any other relevant document required by Company for assessment of the claim.
HDFC ERGO General Insurance Company Limited. IRDAI Reg. No.146 CIN: U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor, HDFC House, 165-166 Backbay Reclamation, H. T. Parekh Marg, Churchgate, Mumbai –
400 020. Health Claim Services Address : HDFC ERGO General Insurance Co. Ltd. Stellar IT Park, Tower-1 , 5th Floor, C - 25, Noida, Sector 62, 201301, Uttar Pradesh. Service No. 022-62346234 / 0120-62346234 Email:
[email protected] Logo displayed above belongs to HDFC Ltd and ERGO International AG and used by the Company under license. Arogya Sanjeevani Policy, HDFC ERGO (Group) - HDFHLGP21552V012021. 1
 SECTION - F DETAILS OF BILLS ENCLOSED
Sr. No. Bill No. Date Issued By Towards Amount (Rs)
1. D D M M Y Y
2. D D M M Y Y
3. D D M M Y Y
4. D D M M Y Y

SECTION – G DETAILS OF PRIMARY INSURED'S BANK ACCOUNT

a) PAN: b) Account Number:

c) Bank Name/ Branch:
d) Payable details: Cheque/ DD:
*e) IFSC Code: *f) MICR No.:
*Please attach a cancelled cheque pertaining to the same.
Note: It is agreed that the Policyholder/Claimant will intimate in writing to HDFC ERGO General Insurance Co. Ltd. about any change in bank account details. In an event Insured
person bears expenses for treatment please provide account details of Insured Persons in the above format along with proof of incurring such expenses.

SECTION H – 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 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.
I/We hereby understand, declare, consent and authorise the Company that personal health details, medical history and financial information, as provided to the Company may be
utilised for processing the claim made under the Policy. I/We hereby also understand, declare and consent that the Company shall have right to retain and disseminate the same to any
service provider for providing services related to insurance.

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

CLAIM FORM – PART B

§ Track your Claim Status
§ Please share the original document at the time of submission. Non submission of original bills, NEFT, KYC (Claim Amount over `1 lakh) is the main reason for delay
§ Provide your Mobile Number and E-mail ID to get Claim Updates
§ Duly filled NEFT (National Electronic Funds Transfer) form
§ Duly Filled KYC (Know Your Customer) form and KYC documents (ID and address proof e.g PAN Card, Aadhaar Card, Ration Card, Passport etc) for all claims where in claimed about is `1 lakh and above

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 (To be filled in block letters)
SECTION A – DETAILS OF HOSPITAL

a) Name of the Hospital where treated:

b) Hospital ID: c) Type of Hospital: Network Non Network (If non network fill section E)

d) Name of the treating Doctor: S U R N A M E F I R S T N A M E M I D D L E N A M E

e) Qualification: f) Registration No with state Code: g) Phone No:

SECTION B – DETAILS OF PATIENT ADMITTED

a) Name of the patient: S U R N A M E F I R S T N A M E M I D D L E N A M E

b) IP Registration Number: c) Gender: Male Female d) Age: Y Y M M e) Date of Birth: D D M M Y Y Y Y

f) Date of admission: D D M M Y Y Y Y g) Time: H H : M M h) Date of discharge: D D M M Y Y Y Y ii) Time: H H : M M

j) Type of Admission: Emergency Planned Daycare Maternity k) If Maternity: ii) Date of Delivery D D M M Y Y Y Y ii) Gravida Status

l) Status at time of discharge: Discharged to Home Discharged to another Hospital Deceased Total Claimed Amount

SECTION C – DETAILS OF AILMENTS DIAGNISED (PRIMARY)

a) ICD 10 Codes Description b) ICD 10 PCS Description

Primary Diagnosis Procedure 1

Additional Diagnosis Procedure 2

Co-morbidities Procedure 3

Co-morbidities Details of Procedure:

c) Pre-authorization obtained: Yes No d) Pre-authorization Number:

e) If authorization by network hospital not obtained, give reason:

f) Hospitalization due to Injury: ii) If yes, give cause Self inflicted? Road Traffic Accident Substance Abuse /Alcohol Consumption

ii) If Injury due to Substance abuse/ alcohol consumption, Test Conducted to establish this: Yes No No (If yes, attach reports)

iii) Medico Legal: Yes No iv) Reported to Police : Yes No v) FIR No:
vi) If not reported to Police give reasons :

HDFC ERGO General Insurance Company Limited. IRDAI Reg. No.146 CIN: U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor, HDFC House, 165-166 Backbay Reclamation, H. T. Parekh Marg, Churchgate, Mumbai –
400 020. Health Claim Services Address : HDFC ERGO General Insurance Co. Ltd. Stellar IT Park, Tower-1 , 5th Floor, C - 25, Noida, Sector 62, 201301, Uttar Pradesh. Service No. 022-62346234 / 0120-62346234 Email:
[email protected] Logo displayed above belongs to HDFC Ltd and ERGO International AG and used by the Company under license. Arogya Sanjeevani Policy, HDFC ERGO (Group) - HDFHLGP21552V012021. 2
 SECTION D – CLAIM DOCUMENTS SUBMITTED – CHECKLIST
Claim Documents Submitted- Check List:

¨ Claim form duly filled and signed ¨ Sticker/Invoice of the Implants, wherever applicable.
¨ Photo Identity proof of the patient ¨ MLR(Medico Legal Report copy if carried out and FIR (First information report)
¨ Medical practitioner's prescription advising admission if registered, where ever applicable.

¨ Original bills with itemized break-up ¨ NEFT Details (to enable direct credit of claim amount in bank account) and cancelled
cheque
¨ Payment receipts
¨ Discharge summary including complete medical history of the patient along with other ¨ KYC (Identity proof with Address) of the proposer, where claim liability is above
Rs 1 Lakh as per AML Guidelines
details.
¨ Investigation/ Diagnostic test reports etc. supported by the prescription from ¨ Legal heir/succession certificate , wherever applicable
attending medical practitioner ¨ Any other relevant document required by Company for assessment of the claim.
¨ OT notes or Surgeon's certificate giving details of the operation performed (for surgical cases).
SECTION E – DETAILS IN CASE OF NON NETWORK HOSPITAL
a) Address of the Hospital:

City: State:

Pin Code: b) Phone No.: c) Registration no with State Code:

d) Hospital PAN: e) No of In-patient Beds: f) Facilities available in Hospital: ii) OT: Yes No ii) ICU: Yes No

iii)Others:

SECTION F – DECLARATION BY 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.

Date: D D M M Y Y Y Y Place: Signature of Hospital:

CHECK LIST OF ENCLOSURES FOR SUBMISSION OF CLAIM

Note:
1. When original bills, receipts, prescriptions, reports and other documents are submitted to the other insurer or to the reimbursement provider, verified
photocopies attested by such other organisation/ provider have to be submitted.
2. If original bills, receipts, prescriptions, reports and other documents are submitted to Us and Insured Person requires same for claiming from other
organization/provider, then on request from the Insured Person We will provide attested copies of the bills and other documents submitted by the
Insured Person.
3. If below mentioned documents are not provided in full or are insufficient for Us to consider the claim, then We may request additional information or
documentation.

In-patient Treatment /Day Care Procedures

Duly filled and signed Claim Form.
Photocopy of ID card / Photocopy of current year policy.
Original Detailed Discharge Summary with date of admission & discharge, clinical history, past history / procedure details/ Day care summary
from the hospital.
Original consolidated hospital bill with break up of each Item, duly signed by the insured.
Original payment Receipt of the hospital bill.
First Consultation letter and subsequent Prescriptions.
Original bills, original payment receipts and Reports for investigation.
Original medicine bills and receipts with corresponding Prescriptions.
Original invoice/Sticker of implants/bills for Implants (viz. Stent /PHS Mesh/ IOL etc.) with original payment receipts

Pre and Post-Hospitalization expenses

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

Original bill and receipt from the diagnostic centre.

HDFC ERGO General Insurance Company Limited. IRDAI Reg. No.146 CIN: U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor, HDFC House, 165-166 Backbay Reclamation, H. T. Parekh Marg, Churchgate, Mumbai –
400 020. Health Claim Services Address : HDFC ERGO General Insurance Co. Ltd. Stellar IT Park, Tower-1 , 5th Floor, C - 25, Noida, Sector 62, 201301, Uttar Pradesh. Service No. 022-62346234 / 0120-62346234 Email:
[email protected] Logo displayed above belongs to HDFC Ltd and ERGO International AG and used by the Company under license. Arogya Sanjeevani Policy, HDFC ERGO (Group) - HDFHLGP21552V012021. 3
 HDFC ERGO General Insurance Company Limited
CLAIM FORM - AROGYA SANJEEVANI POLICY, HDFC ERGO (GROUP)

CUSTOMER IDENTIFICATION PROCEDURE (AS PER KYC NORMS OF IRDAI)

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) Passport/ PAN Card/ Voter's Identity Card/ Driving License/ Letter from a
recognized public authority or public servant verifying the identity and residence
of the customer
Proof of Residence (Any one of the mentioned documents) Telephone bill/ Bank account statement/ Letter from any recognized public
authority/ Electricity bill/ Ration card

HDFC ERGO General Insurance Company Limited. IRDAI Reg. No.146 CIN: U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor, HDFC House, 165-166 Backbay Reclamation, H. T. Parekh Marg, Churchgate, Mumbai –
400 020. Health Claim Services Address : HDFC ERGO General Insurance Co. Ltd. Stellar IT Park, Tower-1 , 5th Floor, C - 25, Noida, Sector 62, 201301, Uttar Pradesh. Service No. 022-62346234 / 0120-62346234 Email:
[email protected] Logo displayed above belongs to HDFC Ltd and ERGO International AG and used by the Company under license. Arogya Sanjeevani Policy, HDFC ERGO (Group) - HDFHLGP21552V012021. 4