PARAMOUNT HEALTH SERVICES & INSURANCE TPA PRIVATE LIMITED (IRDA License No.

006)

[formerly known as PARAMOUNT HEALTH SERVICES (TPA) PVT.LTD]

Plot no.A-442, Road No-28,M.I.D.0 Industrial Area, Wagale Estate, Ram Nagar, Vitthal Rukmani Mandir, Thane (W), Mumbai, Pin Code — 400 604

CLAIM ACKNOWLEDGMENT SHEET

Name of Insurer : PHS ID :
Insured Name : Employee No :
Patient Name : Mobile No :
Policy No : Phone (STD) :
Name of Corporate:
Type of Claim (To Main Hospitalisation / Pre-Post Hospitalisation / OPD Claim / Deficiency Retrieval / Critical Illness / Cash Benefit E-Mail ID of
primary insured :
be ticked) :
CLAIM DOCUMENT CHECK LIST
Sr. No Description Document Remarks
Status(Y/N)
IRDA Claim Form duly signed by the Insured & Hospital
1
Part-A: Duly signed by the insured with Claimed amount ,Mobile number & Email ID along with PHS ID

Part-B: Duly signed and stamped by hospital

Declaration form duly signed & stamped by the hospital in case treatment taken is under PPN/GIPSA hospitals.
1.a Policy Declaration Form duly signed by the Insured & Hospital hospitals.
2 In case of No Intimation / Delay Intimation & Delay in submission of claim, a letter from insured is required stating
reason for the same.

3 Original Cancelled Cheque Leaf of Employee/Proposer with the Name of the AccountHolder Printed on the Cheque
Leaf.

4 ID Proof of Employee / Primary Insured- Any of one (Passport,Voter ID, Driving License, Or any Government
Approved ID ) . If Claim is above 1 lakh- PAN is mandatory with address Proof
5 ID Proof of Patient- Any of one (Passport,Voter ID, Driving License, Or any Government Approved ID )

6 Original detailed Discharge Summary as per IRDA Format / Day care summary from the hospital (in case of Day Care
Treatment) / Death Summary (in Case of Death Claim)

6.a Copy of the Legal heir certificate (if the claim is for the death of the principle insured)

6.b Copy of Post Mortem Report & Death Certificate (In Accidental Death cases)

7 Policy Copy ( if individual policy)

8 64VB Compliance Certificate ( If individual policy)
9 Original Final Hospital bill with cost wise breakup of each Item
10 Original Payment Receipt of Main Hospital bill ( both Deposit / Refund)
10.a Receipt Of Payments made at the Hospital by Credit Card : Please attach the Xerox Copy of the Credit Card Payment
Slip as received from the Vendor

11 Original copy of Implant Invoice along with Payment Receipts & Implant Labels / Stickers for Stents/ Mesh/ IOL

12 Original bills, original Payment Receipts and investigation / Laboratory Reports

13 Original medicine bills specifying Patient Name and date of purchase along with supporting Prescriptions.

14 Original copy of First Consultation letter and subsequent Prescriptions.

15 Hospital Registration certificate issued by Competent authority as per Indian nursing council Act 1947 (If hospital not
falls in GIPSA/PPN )
16 OTHER DOCUMENTS
16.a Original copy of Obstetric history (Gravida, Para, Living children, Abortions) from treating doctor. (Maternity Claim)

16.b Original Sonography Report in case of Maternity Claim

16.c Original A-Scan Report along with IOL Sticker and Tax paid invoice in case of Cataract
Claim

16.d Copy of the First Information Report (FIR) from Police Department / Copy of the Medico-Legal Certificate (MLC) in
case of Road Traffic Accident (RTA)
A medical certificate from a doctor not less qualified than MD/MS confirming the diagnosis of critical illness along
16.e
with the Investigation reports/Other related documents reflecting the critical illness diagnosis. (Critical Illness
Cases)
In case of claims where the insured has submitted documents to another insurance cofTPA, he needs to submit
16.f
attested Photocopies of all the documents along with detailed claim settlement letter from the TPA and any unpaid bills
and receipt for the same in originals.
Claims Submitted by : Insured / Corporate / Agent / Broker / Insurer / Hospital
Claim Submitted by: Mobile No.

Date of Claim DD /MM/YYYY HH:MM PHS Executive

Submission: Name:
,
Claim Submitted at: PHS - (Location) / Help Des! Signature:

Important Points to Remember:-

1. Please mark either V or x against respective check box
2. Date of File Received will be considered as next working day for Claim Files picked up at Help Desk
3. Claim Need to be Submitted within 7 Working Days from Date of Discharge from Hospital
4. The above list of documents is indicative. In case of any other document requirement as specified by the Insurance Company, our document recovery team will contact you on receipt
of your claim documents by us
5. Please visit us at www.paramounttpa.com to check Online Claim Status or download Paramount Mobile App
6. Member is advised to keep photocopies of all the papers since Insurer requires all the above documents in original. Documents once submitted will not returned unless approved &
agreed by Insurer
7. Corrections in any documents are not allowed, otherwise it will not be entertained during adjudication.
CLAIM FORM FOR HEALTH INSURANCE POLICIES OTHER THAN TRAVEL
AND PERSONAL ACCIDENT - PART A TO BE FILLED IN BY THE INSURED
The issuance of this Form is not to be taken as an admission of liability

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

a) Policy No: b) SI. No/ Certificate No:
c) Company/ TPA ID No:
d) Name:
e) Address:
City: State:
Pin Code: Landline (With STD Code):
Mobile No:
[PLEASE PROVIDE ACTIVE EMAIL ID ONLY AS CLAIMS CORRESPONDENCE WILL BE SENT TO THIS EMAIL ID.]
Email ID:
Alternate Email ID:

SECTION B - DETAILS OF INSURANCE HISTORY:

a) Currently covered by any other Mediclaim / Health Insurance: Yes No b) If yes, Policy Type: Individual Group
Company Name: Policy No.:
c) Date of commencement of first Insurance without break: d) Sum Insured (Rs.):
Have you been hospitalised in the last four years since inception of the contract? Yes No
Diagnosis:
f) Previously covered by any other Mediclaim / Health Insurance: Yes No
g) If yes, Company Name:

SECTION C - DETAILS OF INSURED PERSON HOSPITALISED:

a) 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 Primary Insured: Self Spouse Child Father Mother Other (Please Specify)
f) Address (if different from above):
City: State:
Pin Code: Phone No:
Email ID:
g) Occupation: Service Self Employed Homemaker Student Retired Other (Please specify)
h) Name of Employer/
Firm's Name:
i) Address of the
Employer/Firm:

SECTION D - DETAILS OF HOSPITALISATION:

a) Name & Address of
Hospital where Admitted:
City: State:
Pin Code: Landmark:
b) Room Category occupied: Day care Single occupancy Twin sharing 3 or more beds per room
Other (Please specify)
c) Hospitalisation 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 f) Time: H H : M M g) Date of Discharge: D D M M Y Y h) Time: H H : M M
i) In case of maternity, I) Date of Delivery: D D M M Y Y II) Gravida Status:
j) 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
k) System of Medicine:

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CLAIM FORM FOR HEALTH INSURANCE POLICIES OTHER THAN TRAVEL
AND PERSONAL ACCIDENT - PART A TO BE FILLED IN BY THE INSURED
The issuance of this Form is not to be taken as an admission of liability

SECTION E - DETAILS OF CLAIM:

a) Details of the other treatment expenses claimed
S.N. Cover Name Amount (in Rs) S.N. Cover Name Amount (in Rs)
Pre Hospitalization Expenses Green channel benefit claim against
Health wearable device
Post Hospitalization Expenses Compassionate Visit in case of CI
Ambulance Cover Vaccination for new born
Organ Donor Expenses Out-patient Cover
Green channel benefit claim against Air Ambulance
Non payable expenses
• For new born baby cover, separate claim form to be filled & submitted. • For Fitness Reward points, please fill separate form "Fitness reward earning claim form" available on
our website. • Benefits under Cumulative Bonus, Early joining Benefit, Restoration of Sum Insured will be provided automatically. You need not file a claim separately for these.

b) Details of Lump sum / cash benefit claimed

S.N. Cover Name Claimed S.N. Cover Name Claimed
Hospital Cash Yes No Companion Benefit Yes No
Loss of income benefit Yes No Convalescence Benefit Yes No
Enhanced Daily cash benefit Yes No Benefit under Critical Illness optional Cover, if opted Yes No
Home treatment additional daily Cash benefit Benefit under Personal Accident optional
Yes No Yes No
Cover, if opted
Amount as per above covers, if claimed by you, will be paid as per the terms and conditions of the Policy plan.
Check List of Claim Documents to be submitted (In original)* - Please (P ) tick relevant box
(For Hospital Cash benefit, photocopies of claim documents are acceptable)
Claim Form duly filled and signed Copy of the Claim Intimation, if any Hospital Bill Payment receipt
Hospital Main Bill Hospital Break-up Bill Doctor's request for investigation
Hospital Discharge Summary Pharmacy Bill Operation Theatre Notes
Investigation Reports (Including CT / MRI / USG / HPE / ECG) Test report and prescription relating to first
consultation for the Illness
Doctor's prescription for medicines purchased outside the hospital and FIR / MLC in case of accident injury and English
investigation done outside hospital translation of the same if it is in any other language
KYC document (Address proof, ID proof only for claims exceeding `1 Lakh) Original Death Summary (Wherever applicable)
Cancelled cheque leaf of the bank account held in the name of the Any Other
primary insured (Mandatory)
*Please retain copy of complete set of claim documents for your records

SECTION F - DETAILS OF BILLS ENCLOSED:

Sl. No Bill No Date Issued by Towards Amount (Rs)
1. Hospital Main Bill
2. Pre-hospitalisation Bills: Nos
3. Post-hospitalisation Bills: Nos
4. Pharmacy Bills
5.
6.
7.
8.
9.
10.
Note: If there are more bills, please attach additional sheets with this claim form giving the bill details in same format as below.
Hospital Main Bill Payment Receipts only
Receipt No. Date Amount (Rs) Please (P
) Tick Relevant Box
Advance Receipt Final Receipt
Advance Receipt Final Receipt
Advance Receipt Final Receipt
Advance Receipt Final Receipt
Note: Please attach separate sheet if necessary
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CLAIM FORM FOR HEALTH INSURANCE POLICIES OTHER THAN TRAVEL
AND PERSONAL ACCIDENT - PART A TO BE FILLED IN BY THE INSURED
The issuance of this Form is not to be taken as an admission of liability

IF THE CLAIM IS FOR ACCIDENTAL INJURIES, PLEASE PROVIDE DETAILS OF DATE, TIME AND CIRCUMSTANCES OF ACCIDENT EVENT
AND OTHER DETAILS AS RELEVANT:
Date: D D M M Y Y Y Y Time: H H :M M
Circumstances of Accident
event and other details:

SECTION G - DETAILS OF PRIMARY INSURED's BANK ACCOUNT:

PLEASE PROVIDE YOUR BANK DETAILS: (PLEASE ATTACH CANCELLED CHEQUE LEAF OF BANK ACCOUNT IN THE NAME OF PRIMARY
INSURED WITHOUT FAIL)
a) PAN: b) Account Number:
c) Bank Name and Branch:
d) IFSC Code:
e) Cheque/ DD
Payable Details:

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, suppressed or concealed 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 the person for 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 pre/post hospitalization claim and for additional covers, 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) SI. No/ Certificate No. Enter the social insurance number or the certificate As allotted by the organisation
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 Mediclaim / Indicate whether currently covered by another Tick Yes or No
Health Insurance? Mediclaim / Health Insurance
b) i. Company Name Enter the full name of the insurance company Name of the organisation in full
b) ii. Policy No. Enter the policy number As allotted by the insurance company
c) Date of Commencement of first Insurance Enter the date of commencement of first Use dd-mm-yy format
without break insurance
d) Sum Insured Enter the total sum insured as per the policy In rupees
Have you been Hospitalised in the last four years Indicate whether hospitalised in the last four years Tick Yes or No
since inception of the contract?
f) Date Enter the date of hospitalisation Use mm-yy format
g) Diagnosis Enter the diagnosis details Open Text
h) Previously Covered by any other Mediclaim/ Indicate whether previously covered by another Tick Yes or No
Health Insurance? Mediclaim / Health Insurance
i) Company Name Enter the full name of the insurance company Name of the organisation in full

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CLAIM FORM FOR HEALTH INSURANCE POLICIES OTHER THAN TRAVEL
AND PERSONAL ACCIDENT - PART A TO BE FILLED IN BY THE INSURED
The issuance of this Form is not to be taken as an admission of liability

GUIDANCE FOR FILLING CLAIM FORM - PART A (To be filled in by the insured)
DATA ELEMENT DESCRIPTION FORMAT
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
e) Relationship to primary Insured Indicate relationship of patient with policyholder Tick the right option. If others, please specify
f) Address Enter the full postal address Include Street, City and Pin Code
Phone No. Enter the phone number of patient Include STD code with telephone number
E-mail ID Enter e-mail address of patient Complete e-mail address
g) Occupation Indicate occupation of patient Tick the right option. If others, please specify
i) Address of the Employer Complete address of the employer of the Insured Include Street, City and Pin Code

SECTION D - DETAILS OF HOSPITALISATION FOR CLAIM BEING FILED

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) Hospitalisation due to Indicate reason of hospitalisation Tick the right option
d) Date of injury / Date disease first detected/ Enter the relevant date Use dd-mm-yy format
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 ) In case of maternity
I. Date of delivery Enter date of delivery Use dd-mm-yy format
ii. Gravida Status Enter Gravida Status Use standard format
j) If Injury give cause Indicate cause of injury Tick the right option
i. If Medico Legal Indicate whether injury is Medico Legal Tick Yes or No
ii. Reported to Police Indicate whether police report was filed Tick Yes or No
iii. MLC Report & Police FIR attached Indicate whether MLC report and Police FIR attached Tick Yes or No
k) 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 Hospitalisation Indicate whether claim is for domiciliary Tick Yes or No
hospitalization
c) Details of Lump sum/ Cash Benefit claimed Enter the amount claimed as lump sum/ cash In rupees (Do not enter paise values)
benefit
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 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) 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
The issuance of this Form is not to be taken as an admission of liability
Please include the original pre-authorisation request form in lieu of PART A

SECTION A - DETAILS OF HOSPITAL (To be filled in block letters)

a) Name of the hospital:
b) Hospital ID: c) Type of Hospital: Network Non-Network (For office use only)
d) Name of the treating doctor:
e) Qualification:
f) Registration No. with State Code: g) Phone No.:

SECTION B - DETAILS OF THE PATIENT ADMITTED

a) Name of the Patient:
b) IP Registration Number: c) Gender: Male Female
d) Age: Years Months e) Date of birth: D D M M Y Y Y Y
f) Date of Admission: D D M M Y Y Y Y g) Time: H H :M M
h) Date of Discharge: D D M M Y Y Y Y i ) Time: H H :M M
j) Type of Admission: Emergency Planned Day Care Maternity
k) If Maternity: i. Date of Delivery: D D M M Y Y Y Y ii. Gravida Status:
l) Status at time of discharge: Discharge to home Discharge to another hospital Deceased
m) Total amount claimed:

SECTION C - DETAILS OF AILMENT DIAGNOSED (PRIMARY)

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

1 Primary Diagnosis: 1 Procedure 1:

2 Additional Diagnosis: 2 Procedure 2:

3 Co-morbidities: 3 Procedure 3:

4 Co-morbidities: 4 Details of Procedure:

c) Whether pre-authorisation obtained: Yes No d) If Yes, pre-authorisation Number:

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

f) Hospitalisation due to injury: Yes No If Yes, give cause:

i. Self-inflicted Road Traffic Accident Substance abuse / alcohol consumption Other
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 the police: Yes No
v. FIR No.: vi. If not reported to the police, give reason:

g) When did the patient start suffering of the complaint:

Date of first consultation: D D M M Y Y Y Y
h) Please give previous medical history of the patient:
I) Is the patient suffering from any of the following diseases? If "Yes" Please mention the duration below.

Yes / No Duration in year & months

1 High or low blood pressure, chest pain, or any other cardiac
disorder
2 Tuberculosis, asthma, bronchitis or any other lung / respiratory
disorder
3 Ulcer (stomach / duodenal), liver or gall bladder disorder or
any other digestive tract disorder
4 Kidney failure, stone in kidney or urinary tract, prostate
disorder or any other kidney / urinary tract disorder
5 Stroke, epilepsy (fits), paralysis or any other nervous system
(brain, spinal cord, etc) disorder

1
CLAIM FORM - PART B TO BE FILLED IN BY THE HOSPITAL
The issuance of this Form is not to be taken as an admission of liability
Please include the original pre-authorisation request form in lieu of PART A

Yes / No Duration in year & months

6 Diabetes, Impaired glucose tolerance (Pre-diabetes),
Thyroid/Pituitary Disorder or any other endocrine disorder
7 Tumor (swelling)-benign or malignant, any external ulcer /
growth / cyst / mass anywhere in the body
8 Arthritis, spondylosis or any other disorder of the muscle /
bone / joint
9 Diseases of the ear / nose / throat / teeth / eye (please
mention dioptres in case of refractory error)
10 HIV / AIDS or sexually transmitted diseases or any immune
system disorder
11 Anaemia, leukaemia, lymphoma or any other blood /
lymphatic system disorder
12 Psychiatric / mental illnesses or sleep disorder
13 Uterine fibroid, fibroadenoma breast or any other
gynaecological (female reproductive system) / breast disorder
14 Any other illness or injury not mentioned above (other than
common cold)

g) Is the ailment a complication / sequel of a pre-existing disease or condition? Yes No

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

SECTION D - CLAIM DOCUMENTS SUBMITTED - CHECK LIST

Claim Form duly signed Investigation reports
Original pre-authorisation request CT/MR/USG/HPE investigation reports
Copy of the pre-authorisation 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 Other, please specify

SECTION E - ADDITIONAL DETAILS IN CASE OF NON-NETWORK HOSPITAL (ONLY FILL IN CASE OF NON-NETWORK HOSPITAL)
a) Address of the hospital:
City: State:
Pincode: b) Phone No:
c) Registration No. with State Code: d) Hospital PAN:
e) Number of Inpatient beds:
f) Facilities available in the hospital: i. OT: Yes No ii. ICU: Yes No iii. Round the clock Doctor / Nurses: Yes No
iv. Maintains daily record of patients: Yes No v. Others:

SECTION F - 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, suppressed or concealed 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:

2
CLAIM FORM - PART B TO BE FILLED IN BY THE HOSPITAL
The issuance of this Form is not to be taken as an admission of liability
Please include the original pre-authorisation request form in lieu of PART A

Authorisation Letter (Mandatory) Date: D D M M Y Y Y Y

From:

To:
The Manager / Medical Superintendent, Medical Records

Dear Sir
Reg: Authorisation 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 authorise M/s Magma HDI General Insurance Co. Limited and their Authorised 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 hospitalisation dated ......................................... to ..............................................

Thanking you,

Yours sincerely,

Signature of the Proposer Signature of the Patient

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 Tick the right option
hospital

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 As allocated by the Medical Council of India
with the state code
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 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 Birth Enter date of admission 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 Tick the right option Tick the right option
Date of Delivery Enter Date of Delivery if maternity Use dd-mm-yy format
Gravida Status Enter Gravida Status if maternity Use standard format
l) Status at time of discharge Indicate status of patient at time of discharge Tick the right option
m) Total amount claimed Indicate the total amount claimed In rupees (Do not enter paise values)

3
CLAIM FORM - PART B TO BE FILLED IN BY THE HOSPITAL
The issuance of this Form is not to be taken as an admission of liability
Please include the original pre-authorisation request form in lieu of PART A

GUIDANCE FOR FILLING CLAIM FORM - PART A (To be filled in by the Insured)
DATA ELEMENT DESCRIPTION FORMAT
SECTION C - DETAILS OF 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- Standard format and open text
morbidities
b) ICD 10 PCS
Procedure 1 Enter the ICD 10 PCS and description of the first Standard format and open text
procedure
Procedure 2 Enter the ICD 10 PCS and description of the Standard format and open text
second procedure
Procedure 3 Enter the ICD 10 PCS and description of the third Standard format and open text
procedure
Details of Procedure Enter the details of the procedure Open text
c) Whether pre-authorisation obtained Indicate whether pre-authorisation obtained Tick Yes or No
d) Pre-authorisation Number Enter pre-authorisation number As allotted by TPA
e) If authorization by network hospital not Enter reason for not obtainingpre-authorisation Open text
obtained, give reason number
f) Hospitalization due to injury Indicate if hospitalisation 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 the police, give reason Enter reason for not reporting to the police Open text
g) Complaints / Symptoms Indicate the date when the symptom / complaint Use dd-mm-yy format
h) Previous medical history Enter the medical history Open text
.i.) Specific diseases State Yes or No Duration should be in years and months
j) Complication of pre-existing diseases Indicate whether present ailment is a Open text
complication that existed prior to policy inception
k) Alcoholism Indicate Yes or No. If ‘yes’ state quantity consumed Open text

l) Smoking of tobacco Indicate Yes or No. If ‘yes’ state units consumed 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 As allocated by the Medical Council of India
with 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 at the hospital Indicate facilities available at the hospital Tick the right option. If others, please specify

SECTION F - DECLARATION BY THE HOSPITAL

Read the declaration carefully and mention date (in dd:mm:yy format), place (open text) and sign and stamp

4
 POLICY DECLARATION FORM

Date:…………………….
Name of the Hospital :……………………………………………………………………………………………………………………………….
Address:…………………………………………………………………………………………………………………………………………………….
PATIENT NAME (BLOCK LETTERS):…………………………………………………………………… AGE/SEX :……………………….
Mobile No of Patient:…..........................
Date of Admission:………………………………………….. Date of Discharge:……………………………………………

Undertaking by the Patient regarding Heath Insurance Policy

(स्वास्थ्य बीमा पॉलिसी के संबंध में रोगी द्वारा शपथ-पत्र))

I have not declared about any health insurance policy, at the time of Hospital admission.
( मैं सुचित करता हूं चक अस्पताल में उपिार के दौरान मेरे पास कोई भी स्वास्थ्य बीमा पॉचलसी नहीूं है ।

Signature: ………………………………………… (हस्ताक्षर)

Name of the Patient/Patient’s attendant (मरीज का नाम)

I have declared about the health insurance policy, at the time of Hospital admission.
(मैं सुचित करता हूं चक अस्पताल में उपिार के दौरान मेरे पास स्वास्थ्य बीमा पॉचलसी है,

Signature: ………………………………………… (हस्ताक्षर)

Name of the Patient/Patient’s attendant (मरीज का नाम)

Undertaking by the Hospital

Based on patient undertaking hospital declare that patient: (रोगी के उपक्रम के आधार पर हम उस रोगी की घोषणा करते हैं)

 Patient did not declare any health insurance coverage, at the time of hospital admission. Hence we will bill
the patient as per our rack rates. We may or may not consider discount for all such undertakings . (स्वास्थ्य बीमा
कवरे ज नही ूं है , अस्पताल में भती के समय । इसचलए हम मरीज को अपनी रै क दरोूं के अनुसार चबल दें गे। हम ऐसे सभी उपक्रमोूं के चलए छूट पर
चविार कर भी सकते हैं और नही ूं भी।)

 Patient declared health insurance coverage, at the time of hospital admission. But out of own free will is
opting for reimbursement/ cash paying mode. . As insured is already covered under TPA servicing for which
we are network provider, hence we agree to bill this patient as per PHS or insurer agreed rate list
(whichever is less). The benefit of discount as per MOU will also be given to this patient. (रोगी के पास स्वास्थ्य
बीमा कवरे ज है , अस्पताल में भती के समय । लेचकन वह अपनी मजी से रीइूूंबससमेंट/नकद भुगतान मोड का चवकल्प िुन रहा है । . िूूँचक बीचमत
व्यक्ति पहले से ही टीपीए सचविचसूंग के अूंतगित कवर है चजसके चलए हम नेटवकि प्रदाता हैं , इसचलए हम इस मरीज को पीएिएस या बीमाकताि द्वारा
सहमत दर सूिी (जो भी कम हो) के अनुसार चबल दे ने के चलए सहमत हैं । एमओयू के अनुसार छूट का लाभ भी इस मरीज को चदया जायेगा.)

Signature: …………………………………………

Name of the Hospital Representative & Hospital Seal