Union Bank

of India
1-17d ti•ccbK TT ‘JLiso4-1 A Government of India Undertaking
Employee Benefits Division, Human Resources Department, Central Office Mumbai- 400021
STAFF CIRCULAR NO. 08464 Date: 14.11.2024

To: All Branches/ Offices

Subject : Information on various guidelines Et procedures along-with contact details of 'Heritage

Health Insurance TPA Pvt. Ltd.';
Group Medical Insurance Policy for Retired Employees/Family Pensioners,
Policy Tenure - 01.11.2024 to 31.10.2025

1. The Group Medical Insurance policy for retired employees/ Family Pensioners has been
renewed for a period of one year i.e. from 01.11.2024 up to 31.10.2025.

2. National Insurance Company Limited has informed us that they have allotted us the services
of 'Heritage Health Insurance TPA Pvt. Ltd.' as third party administrator, for the policy year
2024-25. The details regarding the same have already been circulated vide Staff Circular
08452 dated 31.10.2024.

3. Heritage Health Insurance TPA has shared details regarding claim intimation, claim
submission, claim forms and contact details of representatives of 'Heritage Health Insurance
TPA Pvt. Ltd.' Team, as mentioned below and annexed herewith.

Claim intimation Et Claim submission

In terms of the guidelines, details pertaining to 'claim intimation Et claim submission', for the
policy year 2024-25, are provided below:

Claim Intimation:

Notification of claim in case of TPA must be informed :

Cashless facility

In event of planned hospitalization At least 72 (seventy two) hours prior to the insured
person's admission to network provider/ PPN Hospital

In event of emergency Within 24 (twenty four) hours of the insured person's

hospitalization admission to the network provider/ PPN Hospital

Notification of claim in case of TPA must be informed :

Reimbursement

In event of planned Within 48 (forty eight) hours of the insured person's

hospitalization/emergency admission to the network provider/ PPN Hospital
hospitalization

V Ix
➢ Various methods of "claim intimation" are mentioned below:

a) Email Claim intimation can be done by sending a detailed mail on

[email protected]
❖ The mail, in all cases, must contain details like employee no, employee name,
patient name, relationship with the employee, hospital name, treating doctor
name, hospital address, date of admission in hospital, estimated expenses etc.

b) Intimation through website : www.heritagehealthtpa.com

c) Intimation through Mobile App: "Heritage Health Insurance TPA Mobile App"

Upon intimation, a 'claim intimation number' is generated/ provided to the insured. For
all the reimbursement hospitalization/ IPD claims, this claim intimation no. is to be
mandatorily mentioned on the claim form.

➢ Claim Submission: In case of reimbursement claim, all claim documents should be

mandatorily submitted within 30 days of date of treatment/ discharge to the TPA, in
original. The location-wise addresses/ details provided by 'Heritage Health Insurance TPA
Pvt. Ltd.' for submission of 'claim documents' are provided herewith as Annexure-I to this
circular. Retired employees/Family Pensioners are requested to refer to the Annexure and
submit the claim documents accordingly on the basis of their locations.

➢ Claim Forms Et Claim Documents Check-list: Claim form for IPD (Hospitalization)
reimbursement claims, and check-list for claim documents, as shared by Heritage Health
Insurance TPA Pvt. Ltd. are attached herewith as Annexure II a Annexure III respectively.

➢ In case the insured person/ insured person's representative fails to intimate/ notify the
claim to the TPA or fails to submit/ file the claim within the prescribed time limit, 'delay
intimation and/or submission condonation letter' is to be submitted to the TPA.

➢ The contact details/communication of representatives of 'Heritage Health Insurance TPA'

team are provided below for ready reference:

❖ (24 x 7) Helpline : 033-40145200 / 033-40557600

❖ (24 x 7) Toll Free No. : 18001024547
❖ E-mail ID for any complaint : [email protected]

Availability: From 10 A.M. To 6 P.M. (Monday to Saturday)

S. No Concerned Person Contact No. Email

1 Helpdesk 1 6293759872 [email protected]

2 Sonali Das 6293759873 [email protected]

3 Mr.Kamesh 8072992511 [email protected]

4 Vikash Kumar Singh 8527410585 [email protected]

 5 Anil Yadav 9820547808 [email protected]

6 Manoj Shukla 9406768199 [email protected]

Department Concerned Person Contact No. Email

Alok Sahoo 9831265100 [email protected]

Enrolment
Shraddha
9748125245 srmukherjee®bajoria.in
Mukherjee
Ranjit Das 6293760125 [email protected]
Cashless
Facility
Somi Chakraborty 6292321731 cashlesskolkata®heritagehealthtpa.co.in

Reimbursement Sonali Das 6293759873 [email protected]

Grievance Redressal
Department Concerned Person Contact No. Email

Cashless Angshuman Chatterjee 8777016621 angshuman.chatterjee®bajoria.in

Reimbursement Nirjhar Nandi 6292331722 [email protected]

➢ HERITAGE TPA Mobile App "Heritage Health Insurance TPA", which can be downloaded
from Play store (Android Phones) 8 App Store (10S Phones) for checking Card Status, Claim
Status, List of Network hospitals, Policy details, forms for downloading, E card download,
claim intimation etc.

➢ HERITAGE TPA Website "www.heritagehealthtpa.com" helps customers to access the

following information: Employee login, claim details, E-Card download, Claim Intimation,
Policy details etc.

➢ Default Login credentials in TPA website and mobile application:-

Username: UNB_Emp ID
Password: Pass®Emp ID

➢ Whatsapp BOT: - 9088893333 for Policy information, Claim form, Network Hospital list, E
card download etc.

Grievances/ complaints, if any, related to IBA Group Medical Insurance Policy may be raised/
addressed on the following e-mail IDs:

a) For Grievances related to Group Medical Insurance Policy, employees may contact of
National Insurance Company at
E-mail ID: [email protected]
 b) For any complaints in processing of claims including any issues with TPA
E-mail ID: [email protected]

The policy document, to be issued by 'National Insurance Co Ltd', pertaining to policy year 2024-
25, would be shared/ communicated in due course of time.

Contact Details: For any kind of query, regarding 'Group Medical Insurance Policy for Retired
Employees/Family Pensioners for the policy period 2024-25, team members may be contacted on
the following numbers:

Union Bank of India, Central Office, Mumbai -

Landline Nos : 022 - 22896255/ 22896383
IP Nos 116252/ 116253/ 116264/ 116254
E-mail ID • [email protected]

All concerned are requested to take a careful note of the above.

(Gir' andra Joshi)

General Manager

List of Annexures:
Annexure I: Location-wise address for submission of Claim Documents
Annexure II: Claim Form Part A a B
Annexure III: Checklist for Reimbursement/ Domiciliary Under IBA Corporate
Annexure IV: Process flow for e-card, claim status a web intimation
 Annexure - IIto
to SC 08464

KH
HERITAGE HEALTH
HERITAGE HEALTH INSURANCE WA PVT. LTD.

Location Wise
Location Wise Office Address for
Office Address for Submission
Submission of
of Claim Documents:
Claim Documents:

SL NO Location Address Office Contact no

1 KOLKATA
KOLKATA NICCO HOUSE,
NICCO HOUSE, 5th
5th Floor,
Floor, 2
2 Hare
Hare Street,
Street, Kolkata
Kolkata -- 700001
700001 Ph.- (033) 4014
Ph.- (033) 4014 5100
5100

CHAMPION BUILDING,
CHAMPION BUILDING, GROUND
GROUND FLOOR,
FLOOR, 15, 15, PARSI
PARSI
2 MUMBAI
MUMBAI Ph.- (022)
Ph.- (022) 61273891/3892/3893
61273891/3892/3893
PANCHAYAT ROAD,Andheri(East)
PANCHAYAT PIN -- 400069
ROAD,Andheri(East) PIN 400069

Sri Siva
Sri Rama Towers,
Siva Rama Towers, 3-6-288/3,
3-6-288/3, Flat No 502,
Flat No 502,
3 HYDERABAD
HYDERABAD 4th Floor,
4th Floor, Hyderguda,(Above
Hyderguda,(Above HDFC
HDFC Bank,
Bank, Hyderguda
Hyderguda Branch)
Branch) Ph.- (040) 2324
Ph.- (040) 2324 4264
4264
Hyderabad —– 500029
Hyderabad 500029

D/No. 8-1-75,
D/No. 8-1-75, Behind
Behind Vishaka
Vishaka Eye,
Eye, Chinmaya Marg, Pedda
Chinmaya Marg, Pedda Waltair,
Waltair,
4 VIZAG
VIZAG Ph.- (0891)
Ph.- (0891) 2713917
2713917
Vishakapatnam, PIN
Vishakapatnam, PIN -- 530017
530017

102 &
102 & 103,
103, 1st
1st Floor,
Floor, Prince
Prince Centre
Centre |I No.
No. 709-710, Mount Road,
709-710, Mount Road,
5 CHENNAI
CHENNAI Ph.- (044)
Ph.- (044) 2829
2829 0400/
0400/ 2829
2829 0430
0430
Thousand Lights,Chennai
Thousand Lights,Chennai —– 600006
600006

411, 4th
411, Floor Laxmi
4th Floor Laxmi Deep
Deep Building,
Building, Laxminagar
Laxminagar District
District Centre,
Centre,
6 DELHI
DELHI Ph.- (011) 4300
Ph.- (011) 4300 9540/41/42/43/44
9540/41/42/43/44
Laxminagar New
Laxminagar New Delhi
Delhi -- 110092
110092

203- 206,
203- 206, Second
Second Floor,
Floor,
Ph.-
Ph.-
7 AHMEDABAD
AHMEDABAD Sakar-II, B/h
Sakar-II, B/h Sanyash
Sanyash Ashram, Ashram Rd,
Ashram, Ashram Rd, Opposite Ellisbridge,
Opposite Ellisbridge,
(079) 4027
(079) 4027 2801-04
2801-04
Ahmedabad
Ahmedabad -- 380009
380009

601, 6th FLOOR,

601, 6th FLOOR, MERIDIAN
MERIDIAN TOWER,
TOWER, B/s
B/s APPLE
APPLE HOSPITAL
HOSPITAL,,
8 SURAT
SURAT Ph.- (0261) 400
Ph.- (0261) 400 0046/403 1544-46
0046/403 1544-46
UDHNA DARWAJA,
UDHNA DARWAJA, SURAT
SURAT -- 395002
395002

202, Square
202, Square Plaza,
Plaza, B/h
B/h National
National Plaza,
Plaza,
9 BARODA
BARODA Ph.- (0265)
Ph.- (0265) 3509691,
3509691, 3516744
3516744
31-Vishwas Colony,
31-Vishwas Colony, Alkapuri,
Alkapuri, Vadodara
Vadodara — – 390007
390007

10 INDORE
INDORE 110, 1st
110, 1st Floor,
Floor, Banshi
Banshi Trade
Trade Centre,
Centre, 581-M.G.Road, Indore -- 452001
581-M.G.Road, Indore 452001 Ph.- (0731)
Ph.- (0731) 400
400 1370
1370 // 72
72

657, Badami
657, Badami Arcade,
Arcade, 2nd
2nd Floor,
Floor, Above
Above State
State Bank
Bank of
of ,2nd
,2nd Main,
Main, 7th
7th
11 BANGALORE
BANGALORE Ph.- 080-26423736,
Ph.- 080-26423736, 080-26423746
080-26423746
Block, BSK
Block, BSK 3rd
3rd Stage,
Stage, Bangalore
Bangalore -- 560085
560085

OCHC Complex
OCHC Complex ,, 1st
1st Floor
Floor ,, Near
Near Ram
Ram Mandir,
Mandir, Janpath, UNIT-III,
Janpath, UNIT-HI,
BHUBANESWA
BHUBANESWA
12 R Kharavela Nagar,
Kharavela Nagar, Bhubaneswar
Bhubaneswar -- 751001,
751001, Orissa,
Orissa, Ph.- (0674) 239
Ph.- (0674) 239 3107
3107
R

Room No 210,
Room No 210, 2ND
2ND Floor,Hari
Floor,Hari Narayan
Narayan Complex, Exhibition Road,
Complex, Exhibition Road,
13 PATNA
PATNA Ph.- +91- 9199863707
Ph.- +91- 9199863707
Patna, Bihar
Patna, Bihar -- 800001
800001

MANIRAM DEWAN
MANIRAM DEWAN LANE (NEAR ULUBARI
LANE (NEAR ULUBARI FLY
FLY OVER) HOUSE
OVER) HOUSE
14 GUWAHATI
GUWATIATI NO-2,2ND FLOOR,G.S
NO-2,2ND FLOOR,G.S ROAD,
ROAD, ULUBARI
ULUBARI Guwahati,
Guwahati, Assam, PIN:
Assam, PIN: Ph.-
Ph.- 0361-2450007
0361-2450007
781007
781007

No.3/121, DPF
No.3/121, DPF Street,
Street, Pappanaickenpalayam,
Pappanaickenpalayam, Coimbatore, Tamil Nadu
Coimbatore, Tamil Nadu --
15 COIMBATORE
COIMBATORE Ph.- (0422)4337117,
Ph.- (0422)-4337117, 2247117
2247117
641037
641037
 Office No.-
Office No.- 413-416,
413-416, 4th
4th Floorjaipur
Floor,jaipur Textile Market Building,Plot
Textile Market Building,Plot No.-
No.-
16 JAIPUR
JAIPUR B2
B2 Ph.- 0141-294
Ph.- 0141-294 4765
4765
Malviya Nagarjaipur,Rajasthan-302017
Malviya Nagar,jaipur,Rajasthan-302017

No. 61/890,
No. 61/890, Bl,
B1, 4th
4th Floor
Floor
17 COCHIN
COCHIN Ph.- 0484-3545259
Ph.- 0484-3545259
Vallamattom Estate,MG
Vallamattom Estate,MG Road,Emakulam
Road,Ernakulam -- 682015
682015

2nd floor,
2nd floor, 90
90 Ishwari
Ishwari Dayal
Dayal Hata
Hata Arya
Arya Samaj Mandir Road;
Samaj Mandir Road; Ganesh
Ganesh
18 LUCKNOW
LUCKNOW Gang;
Gang; Ph.- —(0522)424-8870
Ph.- –(0522)424-8870
Lucknow -- 226018
Lucknow 226018
1st Floor,
1st Floor, Shakambari Bhawan,Above SBI
Shakambari Bhawan,Above ATM, Ranchi
SBI ATM, Ranchi Railway
Railway Station
Station
19 RANCHI
RANCHI Road,
Road, Ph.- (091)80510
Ph.- (091)80510 60367
60367
Landmark :: Chutia
Landmark Chutia Police
Police Station,
Station, Ranchi
Ranchi -- 834001
834001

6/1 Vivekananda
6/1 Vivekananda Road,
Road,
20 DURGAPUR
DURGAPUR Ph.- (+91)
Ph.- (+91) 9434147391
9434147391
A-Zone (Near
A-Zone (Near Durgapur
Durgapur House)
House) Durgapur-
Durgapur- 713204
713204

Ambika Arcade,
Ambika Arcade, No.25/651/11,Ground
No.25/651/11,Ground Floor,M
Floor,M G
G Road,
Road,
21 THRISSUR
THRISSUR Ph.- 0487-2321198
Ph.- 0487-2321198
Thrissur
Thrissur -- 680001
680001

Office no.6;
Office no.6; K.K.
K.K. Market
Market 6th
6th floor G- wing
floor G- wing ,Pune
,Pune Satara Road.
Satara Road.
22 PUNE
PUNS Ph.- 08421787005
Ph.- 08421787005
Dhankawadi,Pune, Maharshtra.
Dhankawadi,Pune, Maharshtra. PIN
PIN -- 411043
411043

East Shib
East Nagar,
Shib Nagar,
23 AGARTALA
AGARTALA Ph.- 8486477749
Ph.- 8486477749
Near Ram
Near Ram Thakur Asram, East
Thakur Asram, East Agartala,
Agartala, West-Tripura,
West-Tripura, Pin-799004
Pin-799004

Nazrul Sarani,Ashrampara,Hakimpara
Nazrul siliguri, west
Sarani,Ashrampara,Hakimpara siliguri, west Bengal,
Bengal,
24 SILIGURI
SILIGURI Ph.- 8972860739
Ph.- 8972860739
Pin-734001
Pin-734001

SCO-102 ,First
SCO-102 ,First Floor,
Floor, Sector-40
Sector-40 Chandigarh,
Chandigarh,
25 CHANDIGARH
CHANDIGARH Ph.- 9877774693
Ph.- 9877774693
Near DPS
Near DPS (Delhi
(Delhi Public
Public School), Pin-160036
School), Pin-160036
 Annexure - II to SC 08464

CLAIM FORM FOR HEALTH INSURANCE POLICIES OTHER THAN TRAVELAND TRAVEL AND PERSONALACCIDENT
PERSONAL ACCIDENT - PART A

I*1
HERITAGE HEALTH
TO BE FILLED IN BY THE INSURED
The issue of this Form is not to be taken as an admission of liability

IRDAI License No. 008

DETAILS OF PRIMARY INSURED: (To be filled in block letters)

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

b) SI.
c) Company/TPA ID No:

V N011029
SECTION A
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 :
e)Address

City : State :
Pin Code : No :
Phone No: Email ID :
DETAILS OF INSURANCE HISTORY:

a) Currently covered by any other Medidaim/Health

Mediclaim/Health insurance:
n Yes ri No b) Date of commencement of first insurance without break: D D M M Y Y
c) If yes, company name : Policy No.

9 N011029
SECTION B
Sum Insured (Rs.) d) Have you been hospitalized in the last four years since inception of the contract ? piYes n No Date: M M Y Y
Diagnosis : e) Previously covered by any other Mediclaim/Health Insurance: pi Yes piNo
f) If yes, Company Name :
t) If

DETAILS OF INSURED PERSON HOSPITALIZED:

a. Name:
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 ri ri c) Age : Years Y Y
Female Months M M d) Date of Birth : D D M M Y Y
e) Relationship to Primary Insured: Self ri Spouseri Childri Father ri Motherri ri (Please

0 NO11029
Other Please Specify)

SECTION C
t) Occupation: Serviceri Self Employed pi Homemaker pi Student pi Retired pi
f) Other pi (Please Specify)

g) Address (if different from above) :

City : State :
Pin Code : Phone No : Email ID :

DETAILS OF HOSPITALIZATION:

a) Name of
of Hospital where Admitted :
b) Room Category occupied : Day care n Single occupancy pi Twin sharing pi 3 or more beds per room pi

a NO11029
c) Hospitatization due to : Injury Illness Maternity d) Date of injury/Date Disease first detected/Date of Delivery

SECTION D
D D M M Y Y
e) Date of Addmission : D D M M Y Y f) Time :
t) H H M M g) Date of Discharge : D D M M Y Y h) Time : H H M M
i) If injury give cause : Self inflicted n Road Traffic Accident ri Substance Abude /Alcohol Consumption n i) IfIf Medico legal: ri Yes ri No
ii) Reported to police : piYes ri No iii) MLC Report & Police FIR attached pi Yes ri 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. ri Claim Form Duly signed
iii. Post-Hospitalization Expenses : Rs.
M. iv. Health-Check up Cost : Rs. pi Copy of the claim intimation, if any
v. Ambulance Charges : Rs. vi. Others (code) : Rs. pi Hospital Main Bill
2 NO11029
SECTION E

Total Rs. ri Hospital Break-up Bill

vii. Pre-Hospitalization period : Days Post-Hospitalization period :
viii. Post-Hospitalization Days n Hospital Bill Payment Receipt

n Hospital Discharge Summary

b) Claim for Domiciliary Hospitalization : ri Yes ri No (If yes, provide details in annexure) n Pharmacy Bill

ri Operation Theatre Notes

c) Details of Lump sum / cash benefit claimed: n ECG
i. Hospital Daily Cash Rs. ii. Surgical Cash: Rs. pi Doctor's
Doctor’s request for investigation
iii. Critical illness Benefit: Rs. iv. Convalescence : Rs. pi Investigation Reports (including CT/MRI/USG/HPE)
v. Pre/Post Hospitlaization vi. Others : Rs. ri Doctor's
Doctor’s Prescriptions

Lump sum benefit Rs. 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 Bill: Nos. MOO=
3 D D M M Y Y Post-hospitalization Bill: Nos. DEEIODEI
4 D D M M Y Y Pharmacy Bills DOM= cn
SECTION F

5 D D M M Y Y m
6 D D M M Y Y MOO= 2
7 D D M M Y Y DOEIDEEI 9
8 D D M M Y Y DOCIODO
9 D D M M Y Y MEMO
10 D D M M Y Y MOO=
INSURED’S BANK ACCOUNT :
DETAILS OF PRIMARY INSURED'S

cn
SECTION G

a) PAN b) Account Number : m

C)
c) Bank Name and Branch :
0
d) Cheque/DD Payable details : e) IFSC Code: z

OVER) ■
(IMPORTANT:PLEASE TURN OVER
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 If I have made any false or untrue statement, suppression or
•

H NOLLOBS
SECTION H
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 & authorise
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
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 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) SI. No./Certificate No. Enter the social insurance number of the certificate As allotted by the organization
number of social health insurance scheme
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? Medicliam / Health Insurance
of Commencement of first insurance without break
b) Date of Enter the date of commencement of first insurance Use dd-mm-yy format
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 Indicate whether hospitalized in the last four years Tick Yes or No
inception of the contract?
Date Enter the date of hospitalization User 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
t) 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
of the patient Number of years and months
d) Date of Birth of Birth of patient
Enter Date of Use dd-mm-yy format
e) Relationship to primary Insured of patient with policyholder
Indicate relationship of Tick the right option, if others, please specify
f) Occupation
t) 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 of hospital
Enter the name of Name of hospital in full
b) Room category occupied Indicate the room category occupied Tick the right option
c) Hospitalization due to of hospitalization
Indicate reason of Tick the right option
d) Date of Injury / Date Disease first detected Enter the relevant date Use dd-mm-yy format
/ Date of Delivery
of admission
e) Date of Enter date of admission Use dd-mm-yy format
f) Time
t) Enter time of admission Use hh:mm format
of discharge
g) Date of 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 in 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 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 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 amounts in rupees
SECTION G - DETAILS OF PRIMARY INSURED'S
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 bank name along with the branch Name of the bank in full
d) Cheque/DD payable details Enter the name of
of beneficiary the cheque/ Name of the individual/organization in full
DD should be made out to
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.
 CLAIM FORM - PART B
I*1
HERITAGE HEALTI
TO BE FILLED IN BY THE HOSPITAL
The issue of this Form is not to be taken as an admission of liability
Please include the original preauthorization request Form in lieu of PART A
IRDAI License No. 008 (To be filled in block letters)
DETAILS OF HOSPITAL

a) Name of the Hospital :

V NO11033
b) Hospital ID : c) Type of Hospital : Network Non Network (if non network fill section E)

d) Name of the treating doctor :

e) Qualification : f) Registration No. with State Code: g) Phone No.

DETAILS OF THE PATIENT ADMITTED

a) Name of the patient :

b) IP Registration Number : c) Gender : Male ❑ Females d) Age: Years Months e) Date of Birth:

f) Date of Admission : g) Time: h) Date of Discharge: i) Time

El NO11033
j) Type of Admission : Emergency ❑ Planned ❑ Day Caren Maternity ❑ k) if Maternity i) Date of Delivery: ii) Gravida Status:

I) Status at time of discharge : Discharge to home ❑ Discharge to another hospital ❑ Deceased ❑ m) Total claimed amount

DETAILS OF AILMENT DIAGNOSED (PRIMARY)

a) ICD 10 Codes Description b) ICD 10 PCS Description

i. Primary Diagnosis i. Procedure 1 :

ii. Additional Diagnosis ii. Procedure 2 :

iii. Co-morbidities iii. Procedure 3 :

iv. Co-morbidities iv. Details of Procedure

0 N01.1.033
c) Pre-authorization obtained : ❑ Yes ❑ No d) Pre-authorization Number :

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

f) Hospitalization due to injury : ❑ Yes ❑ No i. if Yes, give cause Self-inflicted n Road Traffic Accidents Substance abuse / alcohol consumption ❑
ii. If Injury due to Substance abuse/alcohol consumption, Test Conducted to establish this: ❑ Yes ❑ No (If Yes, attach reports) iii. If Medico legal: ❑ Yes ❑ No
iv. Reported to Police : ❑ Yes ❑ No v. Fir no. :

vi. If not reported to police give reason

CLAIM DOCUMENTS SUBMITTED - CHECK LIST

Claim Form duly signed Investigation reports

Original Pre-authorization request CT/MRI/USG/HPE investigation reports
a NO11033

Copy of the 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 reports & Police FIR
Hospital main bill Original death summary from hospital where applicable
Hospital break-up bill Any other, please specify

ADDITIONAL DETAILS IN CASE OF NON-NETWORK HOSPITAL (ONLY FILL IN CASE OF NON-NETWORK HOSPITAL)

a) Address of the Hospital :

City : State :
Pin Code : b) Phone No.: c) Registration No. with State Cod
3 NO11033

d) Hospital PAN : e) Number of Inpatient beds:

f) Facilities available in the hospital: i. OT : ri Yes ri No ii. ICU : ❑ Yes pi No
iii) Others :

DECLARATION BY THE HOSPITAL (PLEASE READ VERY CAREFULLY)

We hereby declare that the information furnished this Claim Form is true & correct to the best of our knowledge & 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 forfieted
d NO11033

Date :

Place : Signature and Seal of the Hospital Authority : •

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

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

a) Name of Patient Enter the name of patient 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 Birth Enter date of birth Use dd-mm-yy format
f) Date of Admission Enter date of admission Use dd-mm-yy format
g) Time Enter time of admission Use hh-mm format
h) Date of Discharge Enter date of discharge Use dd-mm-yy format
i) Time Enter time of discharge Use hh-mm format
j) Type of Admission Indicate type of admission of patient Tick the right option
k) If Maternity
Date of Delivery Enter Date of Delivery if maternity User dd-mm-yy format
Gravida Status Enter Gravida status if maternity Use standard format
I) Status at time of discharge Indicate status of patient at time of discharge Tick the right option
m) Total claimed amount Indicate the total claimed amount In rupees (Do not enter paise values)

SECTION C - DETAILS OF THE AILMENT DIAGNOSED (PRIMARY)

a) ICD 10 Code
Primary Diagnosis Enter the ICD 10 Code and description of the Standard Format and Open text
primary diagnosis
Additional Diagnosis Enter the ICD 10 Code and description of the Standard Format and Open text
additional diagnosis
Co-morbidities Enter the ICD 10 Code and description of the co-morbidites Standard Format and Open text
b) ICD 10 PCS
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 Standard Format and Open text
Details of Procedure Enter the details of the procedure Open text
c) Pre-authorization obtained Indicate whether pre-authorization obtained Tick Yes or No
d) Pre-authorization Number Enter pre-authorization number As allotted by TPA
e) If authorization by network hospital Enter reason for not obtaining pre-authorization number Open text
not obtained, give reason
f) 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. with State Code Enter the registration number of the doctor along with As allocated by the Medical Council of India
the state code
d) Hospital 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 specify

SECTION F - DECLARATION BY THE HOSPITAL

Read declaration carefully and mention date (in dd:mm:yy format), place (open text) and sign and stamp
 Annexure - III to SC 08464

HERITAGE HEALTH INSURANCE TPA PVT. LTD.

IRDAI LICENSE NO. : 008 • CIN : U85195WB1998PTC088562
NICCO HOUSE, 5th FLOOR, 2 HARE STREET, KOLKATA - 700 001
HERITAGE HEALTH PHONE : (033) 2248 6430 / 2784 • Fax : (033) 2231 0287 / 2210 0837 Email : heritage_healthQbaioria.in

IBA GMC Policy Check List

Please find the details while claiming in Cashless, Reimbursement and Domiciliary.

For claiming Cashless

1. Ensuring if the hospital is in empanelment with the TPA. For empanelled hospital, link is
http://223.31.103.204/HeritageHealthTPA/Home/Empanneled_Hospitals1.aspx
http://223.31.103.204/HeritageHea IthTPA/Home/Em pa nneled_Hospita IsLaspx
2. If cashless is entertained in our empanelled hospital, kindly request to process the Pre-a
Pre-auth
uth with
the employee SR number to [email protected]

For Claiming Reimbursement

Further in case of PPN Procedures in GIPSA PPN Network Hospital, same Package rates will apply in both
Cashless & Reimbursement claims subject to limit/sublimit in the policy.
If intimated for cashless and not utilized, kindly keep a copy of the intimation mail along with the
documents that will be submitted.
Claim Intimation Copy duly received by TPA.( For planned hospitalization minimum 48hrs before from
date of Admission & For Emergency hospitalization with in 48hrs from date of Admission ).
}.
All supporting documents relating to claim must be filed with the office of the Bank or TPA within 30
days from date of discharge. In post hospitalization, all claim documents should be submitted within 30
days after completion of such treatment.

Exact reason of delay in submission of documents/intimation copy, if not submitted timely as per Policy
terms & conditions
1. Duly filled claim form & signed by the beneficiary.
--Claim Form A (by insured)
--Claim Form B (by Hospital)
Duly filled in Original claim Form Part -A (for Insured) & Part -B (from Hospital), with Claimant Signature
mentioning exact Claim Amount, Contact details, e-mail Id etc.

2. GIPSA PPN Network Declaration Form

3. Original cancel cheque copy or Passbook front page of Employee (Mandatory)
Complete bank details for RIGS
RTGS / N
NEFT
EFT cancelled cheque
.
 4. Photocopy of Gov. Recognized Photo ID proof ( Aadhar Card / PAN Card of the Insured Patient/
Passport)
5. Original advice for admission to hospital or reference letter for admission
Advice for Admission and first prescription with clinical notes, in original
6. Original Discharge Card (In case of Day Care procedure to provide Day care Discharge summary).
Hospital Discharge Certificate in original with Date & Time and details of treatment
7. All original investigation reports included Pre Hospital & Post hospital (If any).
All the prescriptions, money receipt/cash memo, Investigation reports, hospital requisition and other
supporting documents in original.

8. Hospital bill with detailed break up along with money Receipts in original
9. All original Prescription of medicines & investigation which have been done attaching supportive
advice of physician.
In case of Implant- sticker & tax Invoice with money Receipt in original. (For Cataract, Patient lens
identification card mandatory).
10. X-ray report with plate (Compulsory for fracture cases).
11. Indoor case papers (ICP)
12. Original Hospital bill (Pre-printed numbered bill).
13. Original pre-printed numbered Hospital bill payment receipt.
14. First Doctor Consultation paper and all previous treatment papers
15. MLC/FIR copy compulsory for accident cases.
In accidental cases self statement/FIR/Medico legal report.

Other relevant documents pertaining to claim

For claiming Domiciliary

Provide the Domiciliary claim form, treating doctor’s
doctor's prescription, original bills for medicines and reports
if any.
Please find the IRDAI claim form enclosed for your perusal.
 08464
Annexure - IV to SC 08464

HERITAGE HEALTH INSURANCE WA PVT. LTD.

HERITAGE HEAT
IRDAI license No 008(Valid Till 20/03/2023) CIN U851951NB1998PTC088562 An ISO 9001:2015 Company

Screenshots for Ecard Generation & Claim Search

1. Go to our website : http://www.heritagehealthtpa.com

Home Page • WelCome to He x — a x

C 9 0 223.31.103.204ThentageHedithIPM1PME/Homeasp,

Q Getting Started %GP Dashbaord 7,1 comet" om 1520 W... Other Bookmarks

HERITAGE HEALTH INSURANCE TPA PVT. LTD.

IRDAI license No 008(Valid Till 20/03/2023) CIN U85195W61998PTC088562 An ISO 9001:2015 Company
HERITAGE HEALTH

HOME ABOUT US HOSPITALS + FAGS CONTACT US GRIEVANCES SENIOR CITIZENS

Andhra Bank OMP LIC Download Forms

LOGIN ! REGISTRATION
lirkarogya Seto kor ad the app for Phone I eCOVID-19 I App for GS and Android I Available in 11 dfferen1

223.31.103.204rHelegeHeahnPArHOMfiearneaspri

Ø Default Login
* Default credentials in
Login credentials in TPA
TPA website and mobile
website and mobile application:-
application:-

Username: UNB_Emp ID
Username: UNB_Emp ID
Password: Pass@Emp ID
Password: Pass@Emp ID
 HERITAGE HEALTH INSURANCE WA WE LTD.
HERITAGE HEALTH
IRON license No 008(Valid Till 20/03/2023) CIN U85195WB1998PTC088562 An ISO 9001:2015 Company

2. Please use your User Name and Password to Login

LogIn
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-: Login :-

User ID •

Password

Forgot Password

Login Reset
you are not a regaterea user, you can Register Here..

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3. Once Logged in you can see various option like

a. Change Password
b. View Profile.
c. Card / Claim Status Check
d. Intimate your Claim
e. If you know your Unique CCN for any claim, you can use the option “Search CCN”
"Search By CCN"
without logging In.
f. You can download your Ecard from the website, without Logging In, from the option
“Download Card”
"Download E Card"

CONTACT US GRIEVANCES SENIOR CITIZENS

Welcome Ms Shilpa Sharma Sarkar

Layout

DOWANLOAD E CARD USER PROFILE

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CORPORATE NAME' UNION BANK OF INDIA

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2021 - 2022 • SEARCH BY CCN

Policy Year
• ECARO DOWNLOAD
EmplD 2363311 • WEB IIMMATION

MIS REPORTS
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• OUTSTANDING REPORT

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MOBILE APPS »

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for Android
 HERITAGE HEALTH INSURANCE TPA PVT. LTD.
HERITAGE HEALTH
IRDAI license No 008(Valid Till 20/03/702?` CIN U85195WB1998PTC088562 An ISO 9001:2015 Company

4. You must be logged in to use the following option like CARD / CLAIM Status Search

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Welcome Rept Chose

LogOut

USER PROFILE
CI to downleed the android app from be Ow Mere
• CHANGE PASSWORD
. pROpFLE

[(Click here to submit your Claim online]]

CARD / CLAIM STATUS

r Gem/ MAWS

WELCOME • SEARCH BY CC II

• ECARD DOWNLOAD
Merger Heal(/' Insurance TPA PA Lld (Hentage Meath) believes n quality servce and customer salesfecion through is efficent & trey • WEE onintAnOli
"as
server, delvery AS e prose lieeti Serweeslo ale Heel. InSurenee pacyhOiderS of Indian Insurenfe COnylankS The earipeny
establethed me year 1998 and TPAs were eitroduced el India us 2001 !Waugh 'Insurance Regulatory and Development Amor
u ty of MIS REPORTS
Undue (RDAI) regulations after opering up of the Insurance sector n the country View More..

HEALTH TOOLS HEALTH TIPS NEWS

Vew IledicalTaols Yew uedicsillps Insurance Co News MOBILE APPS >5

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 HERITAGE HEALTH INSURANCE TPA PVT. LTD.
HERITAGE HEALTH
IRDAI license No 008(Valicl Till 20/03/2023) CIN U85195W81998PTC088562 An ISO 9001:2015 Company

MAIL AB.. OS HOSPITALS • MOS CONTACT US OINEVANCES SEWN CRUM

&Coil Gillecaltke

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Click Download All for Ecard of All Member or you can download Ecard for each member.

Th s1HEALTH
t CARD tt —

ID Numb. NTS15700605946
Rama Of Inaund UDAY ONAWAN
" T. EmPlOY. UDAY THAWAN No Pholograph
Emp No. 236331 Ask for
RELATON Self RANO Photo ID Proof
AGE:59

HERITAGE HEALTH INSURANCE PA PVT. LTD.

Rlcco NOUSE, Sth Nov, x Nue Street. Indiata .714•11
INTIAGI slsatN Toll Fro* 1100 102 4547

TN.c.o.tor lane...eon fe, m•acia. Anus* cref

24 hours NOWfR1Inel 1890101454?

Crt.t nv tarts Graeal 03140334141

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KN IARITA0/ REALM INSURANCE TPA PVT LTD.

,HEALTH CARDttue—
 HERITAGE HEALTH INSURANCE WA WE LTD.
HERITAGE HEALTH
IRON license No 008(Valid Till 20/03/2023) CIN U85195WB1998PTC088562 An ISO 9001:2015 Company

You can view the claim Details by Clicking the Claim Details Option.

HERITAGE HEALTH INSURANCE TPA PVT. LTD.

IERITAGE HEALTH
IRDAI license No 008(Valid Till 20/03/2023) CIN U85195W91998PTC0815562 An ISO 9001:2015 Company

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Welcome MS Shilpa Sharrila Sarkar

« Back LogOul

Show110 .I MOOS Search:

1 Insured Name: Shrl 'Mesh Kumar CCN 1111/722421175 bale Of Admission 02110/2021 oetalls0 claim_Documents
Carlini° 1111S1.07006135869 lebmalion Date: 01/102021 Dale OlDscharge 05/13/2021
Claim Amount: 341200.00 Claim Type: Cash Less Illness'. GRADE Ill HAEMORRHOIDS
Bill Type MINOT Entered

SI 'nand Particulars Claim Particulars Hospital Particulars CLAIM WIATIJS DOCUMENT VIEW

snowing -I to 1 al 1 entries Previous 1 Next

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« Back LOgOUI

0 INSURED DETAILS

Q CLAIM DETAILS

0 QUERY DETAILS

0 PRE AUTHORIZATION DETAILS

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0 INSURED DETAILS

INSOREDNAME Snn Rdosh Kumar POLICY NUMNER 2211005021100001.39

CARO NO: HN91 0700605389 AGE 32

ORGANISATION UNION BANN OP INDIA RELATION Self (Male)

Head of The Family Shri %tea AIM, Head 01 The Card Number 1+19 .1 0700605E59

0 CLAIM DETAILS

NH172242875 CLAAMPE: Cash Less

HOSPITAL NAME ICCHosptial ICOWEIATOREI MO SPITAL CITY: CONABATORE

DOA 02)1012021 0013: 35110/2021

INTIMATION DATE: 01/112021 DOCUMENT RECEMEDIDATE DONMealnot received

CLAIM STATUS: Claim Intrnaud SETTLE AMOUNT:

SETTLEMENT DATE CLOSEDICEJECT DATE

PROVISIONAL REJECT DATE WARMER AMOUNT:

IRAN LEER DATE: VTR Ma:

- QUERY DETAILS
 HERITAGE HEALTH INSURANCE TPA PVT. LTD.
HERITAGE HEALTH
IRDAI license No 008(Valid Till 2010312023) ON U85195VVB1998PTC0138562 M ISO 9001:2015 Company

5. Intimate Your claim by using the Option Web Intimation

Welcome Ms Shilpa Sharma Sarkar

Iscput

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CARD ! CLAIM STATUS

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• CARD CLAIM STATUS

Card Number • SEARCH BY CCN

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Smell) 625191
• WEB INTIMAliON

Policy Year • 2021-2022

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 HERITAGE HEALTH INSURANCE TPA PVT. LTD.
HERITAGE HEALTH IRDAI license No 008(Valid Till 20/03/2023) CIN U85195WB1998PTC088562 An ISO 9001:2015 Company

HOME ABOUT US HOSPITALS + FAQ S CONTACT US GRIEVANCES SENIOR CITIZENS

Name shnRitesh Kumar Debrered No Returned' No Acid Web inhrnahen

"ttr * Reialion Sell iMale)
TROD 111191.0100609169 Sex Male Through NIA
PeliCyValldltr. 01/1012021 • 30)0912022 EMPID 625191

Name Pomade Choudhary Belle red: No Returned. No All Wes !amass

Relation: Father
TPA ID HRS1.0700505871 Sex Male Tbrough N/A
Policy Validity 011100021 40/0912022 EMPID A25191

Name URMILA DEVI Delivered . No Returned No API Web inernahcp

•6::14:6.• Relation Mother

WA ID FIRS1.02006051171 Sax Female Pnrough WA
Policy ValiCitly 0411012021 • 3043912022 BAPS) 625191

4 Name: Juni Kaman Delivered :No Returned No all Wes miimalion

Relation Wife
TPA ID 111151.0700605972 Sex Female Through Nth
Polio Validity 0111012021 • 30/0W2022 EMPID 625191

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WEB INTIMATION USER PROFILE

• CHorde mSMORD
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ContactIllobile • • SEARCH Br CCN

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Describe Illness:Probable Diagnosis

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