REIMBURSEMENT CLAIM FORM

Family Health Plan(TPA) Limited TO 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 liablity

DETAILS OF PRIMARY INSURED:

a) Policy No.: b) Sl. No/ Certificate no.
c) Company / TPA ID (MA 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:

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:

DETAILS OF INSURED PERSON HOSPITALIZED:

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) Gender Male Female c) Age years Y Y Months M M d) Date of Birth D D M M Y Y Y Y

e) Relationship to Primary insured: Self Spouse Child Father Mother Other (Please Specify)

f) Occupation Service Self Employed Home Maker Student Retired Other (Please Specify)

g) Address (if diffrent from above) :

City: State:

Pin Code Phone No: Email ID:

DETAILS OF HOSPITALIZATION:
a) Name of Hospital where Admited:
b) Room Category occupied: Day care Single occupancy Twin sharing 3 or more beds per room
c) Hospitalization due to: Injury Illness Maternity d) Date of injury / Date Disease first detected /Date of Delivery: D D M M Y Y Y Y
e) Date of Admission: D D M M Y Y f) Time H H M H g) Date of Discharge: D D M M Y Y h) Time: H H : M H
I) If injury give cause: Self inflicted Road Traffic Accident Substance Abuse / Alcohol Consumption I) If Medico legal Yes No
ii) Reported to Police iii. MLC Report & Police FIR attached Yes No j) System of Medicine:
DETAILS OF CLAIM:
a) Details of the Treatment expenses claimed Claim Documents Submitted - Check List:
I. Pre -hospitalization expenses Rs. ii. Hospitalization expenses Rs. Claim form duly signed
iii. Post-hospitalization expenses Rs. Copy of the claim intimation, if any
iv. Health-Check up cost: Rs.
v. Ambulance Charges: Rs. Hospital Main Bill
vi. Others (code): Rs.
Hospital Break-up Bill
Total Rs. Hospital Bill Payment Receipt
vii. Pre -hospitalization period: days viii. Post -hospitalization period: days Hospital Discharge Summary
Pharmacy Bill
b) Claim for Domiciliary Hospitalization: Yes No (If yes, provide details in annexure)
c) Details of Lump sum / cash benefit claimed: OperationTheater Notes
i. Hospital Daily cash: Rs. ii. Surgical Cash: Rs. ECG
iii. Critical Illness benefit: Rs. iv. Convalescence: Rs. Doctor’s request for investigation
Investigation Reports (Including CT /
v. Pre/Post hospitalization Lump sum benefit:Rs. vi. Others: Rs. MRI / USG / HPE)
Doctor’s Prescriptions
Total Rs. Others
DETAILS OF BILLS ENCLOSED:
Sl. No. Bill No. Date Issued by Towards Amount (Rs)
1. D D M M Y Y Hospital main Bill
2. D D M M Y Y Pre-hospitalization Bills: Nos
3. D D M M Y Y Post-hospitalization Bills: Nos
4. D D M M Y Y Pharmacy Bills
5. D D M M Y Y

6. D D M M Y Y

7. D D M M Y Y

8. D D M M Y Y

9. D D M M Y Y

10. D D M M Y Y
DETAILS OF PRIMARY INSURED’S BANK ACCOUNT:
a) PAN: b) Account Number:

c) Bank Name and Branch:

d) Cheque / DD Payable details: e) IFSC Code:

DECLARATION BY THE INSURED:
I 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, suppression or 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-hospitalization claim, if any.

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

(IMPORTANT: PLEASE TURN OVER)

 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) Sl. No/ Certificate No. As allotted by the oraganization
social health insurance scheme
Licence number as allotted by IRDA and printed
c) Company TPA ID No. Enter the TPA ID No. 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-forrmat
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 four years since Tick Yes or No
Indicate whether hospitalized in the last four years
Inception of the contract?
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
1) E-mail ID Enter e-mail address of patient Complete e-mail address
SECTION D - DETAILS OF HOSPITALIZATION
a) Name of Hospital where admited 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 Medicene Enter the system of medicine followed in treating the patient Open Text
SECTION E - DETAILS OF CLAIM
a) Details of Treatment Expences Enter the amount claimed as treatment expences 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 benifit 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 amount 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
c) Cheque/ DD payable details Name of the individual / organization in full
made out to
c) 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.