To ensure priority processing, please complete all sections in CAPITAL letters. Please tick  in the relevant boxes.

CLAIM FORM FOR HEALTH INSURANCE POLICIES

OTHER THAN TRAVEL AND PERSONAL ACCIDENT
The issue of this form is not to be taken as an admission of liability.
(Guidance for filling claim form - Part A is available on our website: www.royalsundaram.in)
Please note that accepting claim intimation does not indicate claim admissibility. Claim will be processed as per policy terms and conditions. Also, please note that
claims arising from Excluded hospitals will not be approved, as per policy terms and conditions. Please refer our website www.royalsundaram.in for list of
Excluded hospitals. PART A
DETAILS OF PRIMARY INSURED (PROPOSER) (TO BE FILLED IN BY THE INSURED)
a) Policy No. b) Sl. No./
Certificate No.
c) Membership No./
TPA ID No.
d) Name

e) Address

SECTION A
City State
Land Line
Pin Code
(with STD Code)
Claims status will be shared on
Mobile No. WhatsApp No.
IMPORTANT

WhatsApp no wherever possible

MOST

PLEASE PROVIDE ACTIVE EMAIL ID ONLY AS CLAIMS CORRESPONDENCE WILL BE DONE TO THIS EMAIL ID.
Email ID
Alternate
Email ID
DETAILS OF INSURANCE HISTORY (MANDATORY)
a) Currently covered by any other Mediclaim/Health Insurance Yes No
b) If yes, Company
Name

SECTION B
Policy No. c) Date of commencement of
D D M M Y Y Y Y
first Insurance without break
e) Have you been hospitalized in the last
d) Sum Insured (Rs.) Yes No f) Date D D M M Y Y Y Y
four years since inception of the contract?
g) Diagnosis

DETAILS OF INSURED PERSON HOSPITALIZED

a) Name

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

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

SECTION C
f) Communication
Address

City State

Pin Code Land Line

(with STD Code)
g) Occupation Doctor Service Self Employed Homemaker Student Retired Other (Please Specify) _____________
h) Name of the
Employer
i) Address of the
Employer

DETAILS OF HOSPITALIZATION
a) Name & Address
of Hospital
where Admitted

City State

Pin Code Land Mark

b) Room Category Day care Single occupancy 3 or more beds per room Any other category, Pls specify__________________________
occupied
SECTION D

c) Hospitalization Injury Illness Maternity d) Date of Injury/Date Disease first detected D D M M Y Y Y Y

due to
e) Date of D D M M Y Y Y Y Time H H : M M f) Date of D D M M Y Y Y Y Time H H : M M
Admission Discharge
g) In case of
1 Date of Delivery D D M M Y Y Y Y 2 Gravida Status _____________________________________________________
maternity,
h) If Injury,
Self inflicted Road Traffic Accident Substance Abuse/Alcohol Consumption
give cause
1. If Medico legal Yes No 2. Reported to police Yes No 3. MLC Report & Police FIR attached Yes No
ii) System of Medicine_________________________________________________________________________________________________________________

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DETAILS OF CLAIM
a) Details of the treatment expenses claimed
1. Pre-hospitalization Expenses Rs. 2. Hospitalization Expenses Rs.
3. Post-hospitalization Expenses Rs. 4. Health-Check up Cost Rs.
5. Ambulance Charges Rs. 6. Others Rs.
Total amount claimed Rs.
b) Claim for Domiciliary Hospitalization Yes No (If yes, please provide summary of bills in separate sheet)
c) Details of Lump sum / cash benefit claimed:
1. Hospital Daily Cash Rs. 2. Surgical Cash Rs.

SECTION E
3. Critical Illness Benefit Rs. 4. Convalescence Rs.
5. Pre/Post hospitalization
Rs. 6. Others________________ Rs.
Lump sum benefit:
No of days (Pre Hospitalisation)_______________________ Total amount claimed Rs.
No of days (Post Hospitalisation)______________________
Check List of Claim Documents to be submitted (In original)* - Please tick relevant box
(For Hospital Cash benefit, photocopies of claim documents are acceptable)
Claim Form Duly signed Copy of the claim intimation, if any Original Death Summary (Wherever applicable)
Advance payment Receipt (Mandatory) Final Bill Payment Receipt (Mandatory) Hospital Main Bill Hospital Break-up Bill
Pharmacy Bill Doctor's request for investigation Hospital Discharge Summary
Doctor s prescription for medicines purchased outside the hospital and Investigation Reports (Including CT/MRI/USG/HPE/ECG)
investigation done outside hospital
Test report and prescription relating to first
Cancelled Cheque leaf of the bank account held in the name of the consultation for the illness
primary insured (Mandatory)
FIR/MLC in case of accident injury and English
CKYC Registration Number of the Proposer (In case already registered for CKYC - translation of the same if it is in any other language
enter register numbers):
CKYC Registration Number is not available
CKYC documents Address proof and ID proof along with duly filled CKYC Registry
Form with recent colour PP size photograph (for claims exceeding Rs.1 Lakh only)
*Please retain copy of complete set of claim documents for your records
DETAILS OF BILLS ENCLOSED

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

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: (Nos_____)

SECTION F
5 D D M M Y Y Y Y
Hospital Main Bill Payment Receipts only
Receipt No Date Amount Please Tick Relevant Box
D D M M Y Y Y Y Advance Receipt Final Receipt
D D M M Y Y Y Y Advance Receipt Final Receipt
D D M M Y Y Y Y Advance Receipt Final Receipt
D D M M Y Y Y Y Advance Receipt Final Receipt
Note : Please attach separate sheet if necessary

PLEASE PROVIDE YOUR BANK DETAILS: (PLEASE ATTACH CANCELLED CHEQUE LEAF OF BANK ACCOUNT IN THE NAME OF PRIMARY
INSURED WITHOUT FAIL)
SECTION G

a) PAN b) Account Number

c) Bank Name and Branch

d) IFSC Code

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,
SECTION H

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.

Signature of primary
Date D D M M Y Y Y Y Place insured /proposer

Royal Sundaram General Insurance Co. Limited

(Formerly known as Royal Sundaram Alliance Insurance Company Limited)
Corporate Office: Vishranthi Melaram Towers, No. 2 / 319, Rajiv Gandhi Salai (OMR), Karapakkam, Chennai - 600097.
IRDAI Registration No.102 | CIN: U67200TN2000PLC045611
1860 425 0000 [email protected] www.royalsundaram.in PR19216/NOV19

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To ensure priority processing, please complete all sections in CAPITAL letters. Please tick  in the relevant boxes.

CLAIM FORM PART B

TO BE FILLED IN BY THE HOSPITAL
The issue of this Form is not to be taken as an admission of liability
(Guidance for filling claim form- Part B is available on our website: www.royalsundaram.in)

DETAILS OF HOSPITAL
a) Name of the
hospital

b) Hospital ID
(For Office use only)
c) Type of Hospital Network Non Network (If non network fill section D)

SECTION A
d) Name of the
treating Doctor

e) Qualification

f) Registration No.
with State Code

g) Phone

DETAILS OF THE PATIENT ADMITTED

a) Name of the
Patient:
b) IP Registration
Number
c) Gender Male Female d) Age Y Y Years M M Months e) Date of Birth D D M M Y Y Y Y

f) Type of Emergency Day Care Maternity

Planned

SECTION B
Admission
g) Date of Time H H : M M
D D M M Y Y Y Y
Admission
h) Date of
D D M M Y Y Y Y Time H H : M M
Discharge
ii) If Maternity
1.Date of Delivery D D M M Y Y Y Y 2.Gravida Status ______________________________________________________________________
j) Status at time of
discharge Discharge to home Discharge to another hospital Deceased

DETAILS OF AILMENT DIAGNOSED

ICD 10 Codes Description Duration
1. Primary Diagnosis M M Y Y Y Y

2. Additional Diagnosis M M Y Y Y Y

3. Co-morbidities M M Y Y Y Y

4. Co-morbidities M M Y Y Y Y

ICD 10 PCS Codes

1. Procedure(1)
SECTION C

2. Procedure(2)

3. Procedure(3)

4. Details of any other Procedure

a) Whether preauthorisation obtained Yes No. If yes, Preauthorisation No._____________________________________________________________

b) If Authorisation by network hospital not obtained, please give reason_______________________________________________________________________

c) Hospitalization due to Injury Yes No If Yes, give cause
1. Self-inflicted Road Traffic Accident Substance abuse/alcohol consumption
2. If Injury due to Substance abuse/alcohol consumption, Test Conducted to establish this: Yes No
If Yes, details of tests conducted___________________________________________________________________________________________________

3. If Medico legal Yes No 4. Reported to Police Yes No 5. FIR No.

6. If not reported to police, give reason_______________________________________________________________________________________________

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d) When did the patient start suffering Date of first consultation
D D M M Y Y Y Y
with the complaint? (prior to hospitalisation)

e) Please give previous medical history of the patient

f) Is the patient suffering from any of the following diseases. If "yes" Please mention the duration below.

Say Yes/No Duration in Year Duration in Month

1. Bronchial Asthma

2. Chronic Obstructive Pulmonary disease

3. Hypertension

4. Diabetes

5. Heart ailment

6. Arthritis of any kind

7. Cerebro vascular attack

8. Seizure disorder

9. Renal/Kidney Disorder

10. Congenital conditions

11. Developmental anomalies

12. Any other

g) Is the ailment a complication / sequel

of a pre-existing disease or condition?
If Yes , please give details

h) History of alcoholism Yes No

If yes : No of years ________________
Quantity consumed per day ________________
i) History of Smoking/ Tobacco chewing Yes No
If yes : No of years ________________
Units consumed per day ________________

ADDITIONAL DETAILS IN CASE OF NON-NETWORK HOSPITAL

a) Address of the
Hospital
b) Hospital
Registration No
c) Hospital

SECTION D
Registered with
City State

d) Hospital PAN e) Number of Inpatient beds

f) Facilities 1. OT Yes No 2. ICU Yes No 3. Round the clock Doctor/Nurses Yes No

available
in the hospital: 4. Maintains daily record of patients Yes No

5. Others _________________________________________________________________________________________________________

DECLARATION BY THE HOSPITAL (PLEASE READ VERY CAREFULLY)

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, insured s right to claim under this policy shall be for feited.
SECTION E

Signature and Seal

Date D D M M Y Y Y Y Place of the Hospital Authority

Royal Sundaram General Insurance Co. Limited

(Formerly known as Royal Sundaram Alliance Insurance Company Limited)
Corporate Office: Vishranthi Melaram Towers, No. 2 / 319, Rajiv Gandhi Salai (OMR), Karapakkam, Chennai - 600097.
IRDAI Registration No.102 | CIN: U67200TN2000PLC045611

1860 425 0000 [email protected] www.royalsundaram.in PR19216/NOV19

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 Authorization Letter (Mandatory)

Date:

From:

To:

The Manager/ Medical Superintendent,

Medical Records

Dear Sir

Reg : Authorization Letter.

Name of the Patient:______________________________

IP Number_________________________ (First admission) in __________________________Hospital

IP Number_________________________ (Second admission) in _______________________Hospital

IP Number_________________________(Third admission) in __________________________Hospital

I consent and authorize M/s Royal Sundaram General Insurance Co. Limited and their Authorized Service Providers to
seek medical information from your hospital and share copies of indoor case sheets and such other relevant medical
records and/or meet/obtain statement from the Medical Practitioner who has at any time attended on the patient for the
hospitalization dated .............................. to .......................................

Thanking you,

Yours sincerely,

Signature of the Proposer Signature of the Patient

PR19216/JAN21