MediPrime Claim Form-Part A

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To be filled in by the insured

The issue of this Form is not to be taken in as admission of liability
(To be filled in block letters)

DETAILS OF PRIMARY INSURED (SECTION A)

a) Policy No.:
b) Sl. No. Certification No.: c) Company TPA ID No.:
d) Name: Surname First name Middle name

e) Address

City:
State: PIN:
Phone No.: Email ID:

DETAILS OF INSURANCE HISTORY (SECTION B)

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: D D M M Y Y Y Y Diagnosis:
e) Previously covered by any other Mediclaim/Health Insurance Yes No
f) If yes, Company Name:

DETAILS OF INSURED PERSON HOSPITALIZED (SECTION C)

a) Name: Surname First name Middle name

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 Self Spouse Child Father
Primary Insured: Mother Other (Please Specify)

f) Occupation: Service Self Employed Homemaker Student

Retired Other (Please Specify)
g) Address
(if different from above)

City:
State: PIN:
Phone No.: Email ID:

DETAILS OF HOSPITALIZATION (SECTION D)

a) Name of Hospital
where Admitted:
b) Room Category occupied: Day Care Single occupancy Twin sharing 3 or more beds per room
c) Hospitalizaton 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 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
i) If Injury give cause: Self Inflicted Road Traffic Accident Substance Abuse/Alcohol Consumption
i) If Medico legal: Yes No ii) Reported to police: Yes No
iii) MLC Report & Police FIR attached: Yes No
j) System of Medicine:

DETAILS OF CLAIM (SECTION E)

a) Details of the treatment expenses claimed:

i) Pre-hospitalization Expenses Rs. ii) Hospitalization Expenses Rs.
iii) Post-hospitalization Expenses Rs. iv) Health-Check up Cost Rs.
v) Ambulance Charges Rs. vi) Other (Code) Rs.
Total Rs.
vii) Pre-hospitalization period days viii) Post-hospitalization period days
b) Claim for Domiciliary Hospitalization: Yes No (If yes, provide details in annexure)
c) Details of Lump sum/cash benefit claimed
i) Hospital Daily Cash Rs. ii) Surgical Cash Rs.
iii) Critical Illness Benefit Rs. iv) Convalescence Rs.
v) Pre/Post hospitalization Rs. vi) Others Rs.
Lump sum benefit Total Rs.
CLAIM DOCUMENTS SUBMITTED-CHECK LIST

Claim Form duly signed Copy of the claim intimation, if any

Hospital Main Bill Hospital Break-up Bill
Hospital Bill Payment Receipt Hospital Discharge Summary
Pharmacy Bill Operation Theatre Notes
ECG Doctor’s request for investigation
Investigation Reports (Including CT/MRI/USG/HPE) Doctors Prescription
Others

DETAILS OF BILLS ENCLOSED: (SECTION F)

Sl. Bill No. Date Issued by Towards Amount (Rs.)

No.

1. D D M M Y Y Y Y Hospital Main Bill

2. D D M M Y Y Y Y Pre-hospitalization Bills Nos.

3. D D M M Y Y Y Y Post-hospitalization Bills Nos.

4. D D M M Y Y Y Y Pharmacy Bills

5. D D M M Y Y Y Y

6. D D M M Y Y Y Y

7. D D M M Y Y Y Y

8. D D M M Y Y Y Y

9. D D M M Y Y Y Y

10. D D M M Y Y Y Y

DETAILS OF PRIMARY INSURED BANK ACCOUNT (SECTION G)

a) PAN: b) Account Number:

c) Bank Name and Branch:
d) Cheque/DD Payable details: e) IFSC Code:
DECLARATION BY THE INSURED (SECTION H)

I hereby declare that the information furnished in this Claim From 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.

Date: D D M M Y Y 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

b) Sl. No./Certificate No. Enter the social insurance number or the certificate As allotted by the
number of social health insurance scheme organization

c) Company TPA ID No. Enter the TPA ID No. License number as allotted
by IRDA and 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 Indicate whether currently covered by another Tick Yes or No
Mediclaim/Health Insurance? Mediclaim/Health Insurance

b) Date of Commencement of first Enter the date of commencement of first Insurance Use dd-mm-yy format
Insurance without break

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 Indicate whether hospitalized in the last four years Tick Yes or No
the last four years since
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 Indicate whether previously covered by another Tick Yes or No
Mediclaim/Health Insurance? Mediclaim/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

 GUIDANCE FOR FILLING CLAIM FORM-PART A (To be filled in by the hospital) (Contd...)

DATA ELEMENT DESCRIPTION FORMAT

SECTION C: DETAILS OF PRIMARY INSURED (Contd...)

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 Enter the name of hospital Name of hospital in full
admitted
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 Enter the relevant date Use dd-mm-yy format
detected/Date of 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 failed Tick Yes or No
MLC Report & Police Indicate whether MLC report and Police FIR attached Tick Yes or No
FIR attached
j) System of Medicine Enter the system of medicine followed in treating Open Text
the patient
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 Indicate whether claim is domiciliary hospitalization Tick Yes or No
Hospitalization
c) Details of Lump sum/cash Enter the amount claimed as lump sum/cash benefit In rupees (Do not enter
benefit claimed paise values)
d) Claim Documents submitted- Indicate which supporting documents are submitted Tick the right option
Check List
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
d) Cheque/DD payable details Enter the name of the beneficiary the cheque/DD Name of the individual/
should be made out to organization in full
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.