CLAIM FORM FOR HEALTH INSURANCE POLICIES OTHER THAN

Vipul Medcorp lnsurance TPA Pvt Ltd. TRAVEL AND PERSONAL ACCIDENT - PART A
Redefining Healthcare TO BE FILLED IN BY THE INSURED
Services... The issue of this Form is not to be taken aass an admission of liability
DETAILS OF PRIMARY INSURED: (To be filled in block letters)

a) PolicyNo: b) SI. No/ Certificate No:

c) Company/ TPA ID No:

d)Name

e)Address:

State:

City:

Pin Code:
Phone Email lD
No:
DETAILS OF INSURANCE HISTORY:

a) Currently covered by any other Mediclaim / Health Insurance: Yes No b) Date of commencement of first Insurance without break:

c) If yes, company name iLink Multi TechSolition Pvt Ltd Policy No:

Sum Insured (Rs.)

d) Have you been hospitalized in the last four years since inception of the contract? Yes No Date
Diagnosis
e) Previously covered by any other Mediclaim / Health insurance: Yes No

f) If yes, company name

DETAILS OF INSURED PERSON HOSPITALIZED:

a) Name V E D I A P P A N M

b) Gender:
Male Female c)Age: Years Months d) Date of birth: 1 3 0 5 1 9 8 7

e) Relationship to Primary insured: Self

Spouse Child Fathe Mother Other (Please Specify)
r

f) Occupation: Service Self Employed Homemake Student Other (Please Specify)

Retired

g) Address: 3/1, PKR NAGAR, PRESS COLONY POST

KARAMADAI, VEERAPANDI PERIVU, COIMBATORE

City: C O I M B A T O R E State: T A M I L N A D U

Pin Code: 9 8 4 0 6 3 0 8 6 8 [email protected]

6 4 1 0 1 9 Phone Email lD
No:
DETAILS OF HOSPITALIZATION:

a) Name ol Hospital where Admitted: V E N U G O P A L H O S P I T A L C O I M B T O R E

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
e) Dated of Admission: Delivery:
f)Time: h) Time: :
: g) Date ol Discharge

i) If Injury give cause Self inflicted i. If Medico legal:YesNo

Road Traffic Accident Substance Abuse/Alcohol Consumption
ii. Reported to police:
Yes No iii. MLC Report & Police FIR attached: Yes No j) System of Medicine:
DETAILS OF CLAIM:

a) Details of the treatment expenses Claim Documents Submitted- Check List:

claimed:
ii. Hospitalization Expenses: Rs Claim Form Duly signed
i. Pre-hospitalization Expenses: Rs
iv. Health-Checkup Cost: Rs Copy of the claim intimation, if any
iii. Post-hospitalization Expenses: Rs
vi. Others(code) Rs
v.Ambulance Charges: Hospital Main Bill
Rs
Total Rs Hospital Break-up Bill
Hospital Bill Payment Receipt
vii. Pre-hospitalization period: Days viii. Post-hospitalizationperiod Days HospitalDischarge Summary
b) Claimfor Domiciliary Hospitalization: Yes No (If yes, provide details in annexure) Operation Theatre Notes

c) Details of Lump sum / cash benefit ECG

claimed:
Doctor's request for investigation
ii. Surgical Cash: Rs
i. Hospital Daily Cash: Rs
Investigation Reports (Including CT
iv. Convalescence: Rs MRI / USG / HPE)
iii. Critical Illness Benefit: Rs
v. Pre/Post hospitalization Lump Rs vi. Others (code) Rs Doctor’s Prescriptions
sum benefit: Others
Total Rs

DETAILS OF BILLS ENCLOSED:

S.No Bill No Date Issued By Towards Amount (Rs)

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
 DETAILS OF PRIMARY INSURED'S BANK ACCOUNT:

a) PAN: 5 0 1 0 0 2 3 7 5 8 3 3 2 6
A H E P V 3 0 Number:
b) Account 2 9 M

c) Bank Name and Branch: N O: 1 0 5 F I R S T M A I N R O A D G A N D H I N A G A R, CH - 600 20

-
d) Cheque/ DD Payable details: H D F C 0 0 0 4 2 9 7
e) 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, 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-hospitalizationclaim, if any.

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

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

b) Date of Commencement of first Insurance Enter the date of commencement of first insurance Use dd-mm-yy format
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 a s per the policy In rupees
d) Have you been Hospitalized in the last four
years since inception of the contract? Indicate whether hospitalized in the last four years Tick Yes or No
Date Enter the date of hospitalization Use mm-yy format
Diagnosis Enter the diagnosis details Open Text
e) Previously Covered by any other Mediclaim Indicate whether previously covered by another Mediclaim /
/ Health Insurance? Health Insurance Tick Yes or No
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 policyholder 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
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 detected/
Date of Delivery Enter the relevant date Use dd-mm-yy format
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 Enter date of discharge
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 CLAIM
a) Details of Treatment Expenses Enter the amount claimed a s 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 claimed Enter the amount claimed a s 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 amounts in rupees