Claim Form

CLAIM FORM
(The issue of this Form is not to be taken as an admission of liability)

PART A
TO BE FILLED IN BY THE INSURED

SECTION A - DETAILS OF PRIMARY INSURED

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

c) Company/ TPA ID No :

d) Name :

e) Address :

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 for the person (without break) : (DD/MM/YYYY) : D D M M Y Y Y Y

c) If Yes, Company Name :

Policy No. : Sum Insured :

d) Have you been hospitalized in the last four years since inception of the contract? Yes  / No  (DD/MM/YYYY) : D D M M Y Y Y Y

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

f) If Yes, Company Name :

SECTION C - Details of the Insured Person Hospitalised :

a) Name :

b) Relationship : Self  / Spouse  / Child  / Father  / Mother  / Other  c) Date of Birth : D D M M Y Y Y Y

d) Age (YY/MM) :
Y Y M M e) Gender: Male  / Female 

f) Address:
(If different
than above)
g) Occupation : Service  / Self employed  / Homemaker  / Student  / Retired  / Others

h) Telephone No : Mobile No :

i) E-mail ID, if any :

SECTION D - DETAILS OF HOSPITALISATION :

a) Name of the Hospital where admitted :

b) Room Category occupied : Day care  / Single occupancy  / Twin sharing  / 3 or more  beds per room

c) Hospitallisation due to Illness / Injury / Maternity  : Details :

d) Date of Injury/ Date of disease first detected/ Date of delivery : (DD/MM/YYYY) : D D M M Y Y Y Y

e) Date of admission : (DD/MM/YYYY) : f)

D D M M Y Y Y Y Time : (HH/MM) : H H M M

g) Date of discharge : (DD/MM/YYYY) : h)

D D M M Y Y Y Y Time : (HH/MM) : 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 : Allopathic  / Other systems of medicine 

SECTION E - DETAILS OF CLAIM :

a) Details of the treatment expenses claimed :

i) Pre-hospitalisation Expenses Rs. ii) Hospitalisation Expenses Rs.

iii) Post-hospitalisation Expenses Rs. iv) Health-Check up Cost Rs.

v) Ambulance Charges Rs. vi) Others (code) Rs.

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Claim Form
Total Rs.

vii) Pre-hospitalisation Period Days viii) Post -hospitalisation Period Days

b) Claim for Domiciliary Hospitalization : Yes  / No  (if yes, please provide details in annexure)
c) Details of Lumpsum / cash benefit claimed :

i) Hospital Daily Cash Rs. ii) Surgical Cash Rs.

iii) Critical Illness Benefit Rs. iv) Convalescence Rs.

v) Pre/Post hospitalisation lumpsum benefit: Rs. vi) Others Rs.

Claim Documents Submitted- Check List:

 Duly filled and signed Claim Form  Copy of intimation letter, if any
 Hospital Main Bill  Hospital Break Up bill
 Hospital Bill Payment Receipt  Hospital Discharge Summary
 Pharmacy Bill  Operation Threater Notes
 ECG  Doctor’s Request for Investigation
 Investigation Reports ( Including CT, MRI/USG/HPE)  Doctor’s Prescription
 Others  Cancelled cheque for NEFT

SECTION - F DETAILS OF BILLS ENCLOSED :

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

SECTION - G DETAILS OF PRIMARY INSURED’S BANK ACCOUNT :

a) PAN No : b) Account No :

c) Bank Name : Branch :

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

f) MICR No : *Please attach a cancelled cheque pertaining to the same account.

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.

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

GUIDANCE FOR FILLING CLAIM FORM - PART A :

DATA ELEMENT DESCRIPTION FORMAT
SECTION A - DETAILS OF PRIMARY INSURED
a) Policy No. Enter the policy number As allotted by the insurance company
b) SI. No/ Certificate No. Enter the social insurance number or the certificate number of social health As allotted by the organization
insurance scheme

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Claim Form
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 Medi- Indicate whether currently covered by another Mediclaim / Health Insurance Tick Yes or No
claim / Health Insurance?
b) Date of Commencement of first Insur- Enter the date of commencement of first insurance Use dd-mm-yy format
ance 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 the last Indicate whether hospitalized in the last 4 years Tick Yes or No
4 years
Date Enter the date of hospitalization Use mm-yy format
Diagnosis Enter the diagnosis details Open Text
e) Previously Covered by any other Medi Indicate whether previously covered by another Mediclaim / Health Insurance Tick Yes or No
claim/ 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) Relationship to primary Insured Indicate relationship of patient with policyholder Tick the right option. If others, please specify
c) Date of Birth Enter Date of Birth of patient Use dd-mm-yy format
d) Age Enter age of the patient Number of years and months
e) Address Enter the full postal address Include Street, City and Pin Code
f) Gender Indicate Gender of the patient Tick Male or Female
g) Occupation Indicate occupation of patient Tick the right option. If others, please specify
h) Phone No Enter the phone number of patient Include STD code with telephone
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 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 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 CLIAM
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 Enter the amount claimed as lump sum/ cash benefit In rupees (Do not enter paise values)
claimed
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
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 should be made out to Name of the individual/ 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.

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Claim Form
PART B
(TO BE FILLED IN BY THE HOSPITAL IN CASE OF CASHLESS CLAIMS)
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

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 form 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 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 N A M E

b) IP Registration Number : c) Gender: Male  / Female 

d) Age (YY/MM) : Y Y M M Date of Birth (DD/MM/YYYY) : H H M M

e) Date of Admission (DD/MM/YYYY) : D D M M Y Y Y Y f) Time of Admission (HH/MM) : H H M M

g) Date of Discharge (DD/MM/YYYY) : D D M M Y Y Y Y h) Time of Discharge (HH/MM) : H H M M

i) Type of Admission : Emergency  / Planned  / Day-care  / Maternity 

j) If Maternity
i) Date of delivery (DD/MM/YYYY) : D D M M Y Y Y Y ii) Gravida Status :

k) Status at time of discharge : Discharged to Home  / Discharged to another Hospital  / Deceased 

Total Claimed Amount Rs.

SECTION C - DETAILS OF AILMENTS DIAGNOSED (PRIMARY)

a) ICD 10 Codes Description
i) Primary Diagnosis :

ii) Additional Diagnosis :

iii) Co-morbidities :

iv) Co-morbidities :

b) ICD 10 PCS Description

i) Procedure 1 :

ii) Procedure 2 :

iii) Procedure 3 :

iv) Details of Procedure :

c) Pre-authorization obtained : Yes  / No  d) Pre-authorization No. :

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

f) Hospitalisation due to Injury ? Yes  / No 

i) If Yes, give cause

Self inflicted? Yes  / No  Road Traffic Accident Yes  / No  Substance Abuse /Alcohol Consumption Yes  / No 
ii) IIf Injury due to Substance abuse / alcohol consumption, Test Conducted to establish this: Yes  / No  (If yes, attach reports)
iii) Medico Legal Yes  / No  iv) Reported to Policy Yes  / No  v) FIR No :

vi) If not reported to Policy give reasons

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Claim Form
SECTION D - CLAIM DOCUMENTS SUBMITTED - CHECKLIST

 Claim form duly filled and signed  Investigation reports

 Original Pre authorization Request  CT/MRI/USG/HPE investigation Report

 Copy of Pre-authorization approval Letter  Doctor’s reference slip for Investigation

 Copy of photo ID card of patient verified by Hospital  ECG

 Hospital Discharge Summary  Pharmacy Bills

 Operation Theatre Notes  MLC Report & Police FIR

 Hospital Main Bill  Original death summary from hospital where applicable

 Hospital break up Bill  Any other, Pls specify

SECTION E - ADITIONAL DETAILS IN CASE OF NON NETWORK HOSPITAL

a) Address of the Hospital :

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

d) Hospital PAN : e) No of In-patient Beds :

f) Facilities available in Hospital :

i) 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 and seal of the Hospital Authority : 

GUIDANCE FOR FILLING CLAIM FORM - PART B :

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 Hospital 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 qualification
f) Registration No. with State Code Enter the registration number of the doctor along with the state code As allocated by the Medical Council of India
g) Phone No. Enter the phone number of doctor Include STD code with telephone number
SECTION B - DETAILS OF THE PATIENT
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

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Claim Form

SECTION C - DETAILS OF AILMENT DIAGNOSED (PRIMARY)

a) ICD 10 Code
Primary Diagnosis Enter the ICD 10 Code and description of the primary diagnosis Standard Format and Open text
Additional Diagnosis Enter the ICD 10 Code and description of the additional diagnosis Standard Format and Open text
Co-morbidities Enter the ICD 10 Code and description of the co-morbidities Standard Format and Open text
b) ICD 10 PCS Standard Format and Open text
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
Details of Procedure Enter the details of the procedure Open text
c) Present Ailment is a Complication of PED Indicate whether present ailment is a complication of some pre- existing disease Tick Yes or No
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 Enter reason for not obtaining pre-authorization number Open text
obtained, give 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 Indicate whether test conducted Tick Yes or No
consumption, 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
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

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Claim Form

CUSTOMER IDENTIFICATION PROCEDURE (AS PER KYC NORMS OF IRDA)

Please submit clear and legible copy of one document (valid and effective as on date of claim submission) each from Part A and Part B and your recent passport size photograph (not
more than 6 months old) incase claim amount exceeds Rs 100,000.

Photograph

i. Pan Card

ii. If Pan Card is not available please submit any of the documents mentioned below stating reason for not having
Pan Card.
Part A
Proof of legal name and a) Passport
any other names used b) Voter’s Identity Card
c) Driving License
d) Personal Identification and Certification of the employees for your identity.
e) Letter issued by Unique identification Authority of India containing details of name address and Aadhar Number
f) Job Card issued by NREGA duly signed by an officer of the State Government

i. Electricity Bill not older than 6 months from the date of Insurance Contract
ii. Telephone Bill pertaining to any kind of telephone connection like mobile, landline, wireless etc. Provided it is not
older than 6 months from the date of claim submission
iii. Ration Card
Part B
iv. Valid lease agreement along with rent receipts which is not more than 3 months old as a residence proof
Proof of Residence
v. Saving Bank Passbook with details of permanent/ present residence address ( updated upto 1 month prior to
claim submission document)
vi. Statement of saving bank account with details of present/ present address ( updated upto 1 month prior to
claim submission document)

I hereby declare that I have submitted above mentioned documents and recent photograph (not more than 6 months old) for the purpose of claim and the said documents are valid and
effective.

Date : D D M M Y Y Y Y Signature of Policyholder : 

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Claim Form
CHECK LIST OF ENCLOSURES FOR SUBMISSION OF CLAIM

In-patient Treatment /Day Care Procedures Daily Cash Benefit

q Duly filled and signed Claim Form. q Duly filled and signed Claim Form.
q Photocopy of ID card / Photocopy of current year policy. q Photocopy of ID card / Photocopy of current year policy.
q Original Detailed Discharge Summary / Day care summary from the hospital.
q Original consolidated hospital bill with break up of each Item, duly signed by the
insured. Organ Donation/Transplantation
q Original payment Receipt of the hospital bill. In addition to the documents of general hospitalization
q First Consultation letter and subsequent Prescriptions. q Organ Function test / blood test proving organ failure.
q Original bills, original payment receipts and Reports for investigation. q Treatment Certificate issued by the Transplant Surgeon of the hospital
concerned.
q Original medicine bills and receipts with corresponding Prescriptions.
q Original invoice/bills for Implants (viz. Stent /PHS Mesh / IOL etc.) with original
payment receipts.
Ambulance Benefit
q Duly filled and signed Claim Form.
Road Traffic Accident
q Photocopy of ID card / Photocopy of current year policy.
In addition to the In-patient Treatment documents:
q Original Bill with Original Payment Receipt.
q Copy of the First Information Report from Police Department / Copy of the q Treating Doctor’s consultation prescription indicating Emergency Hospitalization.
Medico-Legal Certificate.
In Non Medico legal cases
q Treating Doctor’s Certificate giving details of injuries (How, when and where
injury sustained)
Maternity Expenses
In Accidental Death cases
In addition to the In-patient Treatment documents:
q Copy of Post Mortem Report & Death Certificate
q Obstetric history (Gravida, Para, Living children, Abortions) from treating doctor.

For Death Cases

In addition to the In-patient Treatment documents: Critical Illness Benefit
q Original Death Summary from the hospital. q Duly filled and signed Claim Form.
q Copy of the Death certificate from treating doctor or the hospital authority. q Photocopy of ID card / Photocopy of current year policy.
q Copy of the Legal heir certificate, if the claim is for the death of the principle q A medical certificate confirming the diagnosis of critical illness from a doctor not
insured. less qualified than MD/MS.
q Investigation reports/ other related documents reflecting the critical illness
diagnosis.
Pre and Post-hospitalisation expenses
q Duly filled and signed Claim Form.
q Photocopy of ID card / Photocopy of current year policy.
q Original Medicine bills, original payment receipt with prescriptions. Health Check up
q Original Investigations bills, original payment receipt with prescriptions and q Duly filled and signed Claim Form.
report. q Photocopy of ID card / Photocopy of current year policy.
q Original Consultation bills, original payment receipt with prescription. q Original Investigation bills, original payment receipts with Reports.
q Copy of the Discharge Summary of the main claim. q Original Consultation bills and original payment receipts with prescription.

Outpatient Benefit/Dental
q Duly filled and signed Claim Form.
q Photocopy of ID card / Photocopy of current year policy.
Expenses for spectacles/contact lenses, hearing aids
q Duly filled and signed Claim Form.
q Original Medicine bills, original payment receipt.
q Photocopy of ID card / Photocopy of current year policy.
q Original Investigations bills, original payment receipt with report.
q Prescription of the Treating Doctor.
q Original Consultation bills, original payment receipt with prescription.
q Original Invoice/bills, original payment receipt of the device, appliances, lens
q Details of any Outpatient Procedures, If any
etc.
q Dental X-ray film.

We would be happy to assist you. For any help contact us at: E-mail: [email protected] Customer care: 022 6234 6234 / 0120 6234 6234
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.