CLAIM FORM FOR HEALTH INSURANCE POLICIES OTHER THAN

TRAVEL AND PERSONAL ACCIDENT - PART A

TO BE FILLED IN BY THE INSURED

Vipul MedCorp TPA Pvt Ltd.

Redefining Healthcare Services.

The issue of this Form is not to be taken a s an admission of liability

(To be illed in block letters)

DETAILS OF PRIMARY INSURED:

a) PolicyNo:

b) SI. No/ Certiicate No:

c) Company/ TPA ID No:

d)Name
e)Address:

City:

State:

Pin Code:

Phone No:

Email lD

DETAILS OF INSURANCE HISTORY:

a) Currently covered by any other Mediclaim / Health Insurance:

Yes

c) If yes, company name

Sum Insured (Rs.)

b) Date of commencement of irst Insurance without break:

No

PolicyNo:

d) Have you been hospitalized in the last four years since inception of the contract?

Diagnosis

Yes

Date

No

e) Previously covered by any other Mediclaim / Health insurance:

f) If yes, company name

Yes

No

DETAILS OF INSURED PERSON HOSPITALIZED:

a)Name
b) Gender:

Male

e) Relationship to Primary insured:

f) Occupation:

Service

g)Address:

Female

Self

Self Employed

c)Age:
Spouse

Years

Child

Homemake

Months

Father

Student

d) Date of birth:
Mother

Other

Other

Retired

City:

(Please Specify)

(Please Specify)

State:

Pin Code:

Email lD

Phone No:

DETAILS OF HOSPITALIZATION:
a) Name ol Hospital where Admitted:
b) Room Category occupied:
c) Hospitalization due to:

Injury

e) Dated of Admission:
i) If Injury give cause
ii. Reported to police:

Day care

Illness

Self inlicted

DETAILS OF CLAIM:

Yes

Single occupancy

Maternity

Twin sharing

d) Date of Injury / Date Disease irst detected /Date of Delivery:

f)Time:

Road Trafic Accident

g) Date ol Discharge
Substance Abuse/Alcohol Consumption

iii. MLC Report & Police FIR attached:

No

3 or more beds per room

Yes

Rs

ii. Hospitalization Expenses:

Rs

iii. Post-hospitalization Expenses:

Rs

iv. Health-Check up Cost:

Rs

v. Ambulance Charges:

Rs

vi. Others (code)

Rs

Total

Rs

Days
Yes

c) Details of Lump sum / cash beneit claimed:

viii. Post-hospitalization period

No

(If yes, provide details in annexure)

i. Hospital Daily Cash:

Rs

ii. Surgical Cash:

Rs

iii. Critical Illness Beneit:

Rs

iv. Convalescence:

Rs

v. Pre/Post hospitalization Lump

sum beneit:

Rs

vi. Others (code)

Rs

Total

Rs

DETAILS OF BILLS ENCLOSED:

S.No
1.
2.
3.
4.
5.
6.
7.
8.
9.

10.

Bill No

Yes

No

Claim Documents Submitted- Check List:

i. Pre-hospitalization Expenses:

b) Claim for Domiciliary Hospitalization:

i. If Medico legal:

j) System of Medicine:

No

a) Details of the treatment expenses claimed:

vii. Pre-hospitalization period:

h)Time:

Date

Issued By

Towards

Claim Form Duly signed

Copy of the claim intimation, if any

Hospital Main Bill

Hospital Break-up Bill

Days

Hospital Bill Payment Receipt

Hospital Discharge Summary
Operation Theatre Notes
ECG

Doctor's request for investigation

Investigation Reports (Including CT

MRI / USG / HPE)
Doctors Prescriptions
Others

Amount (Rs)

DETAILS OF PRIMARY INSURED'S BANK ACCOUNT:

a) PAN:

b) Account Number:

c) Bank Name and Branch:

d) Cheque/ DD Payable details:

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-hospitalization claim, if any.
Place:

Date:

Signature of the Insured

GUIDANCE FOR FILLING CLAIM FORM - PART A (To be illed in by the insured)
DATA ELEMENT

DESCRIPTION
SECTION A - DETAILS OF PRIMARY INSURED

FORMAT

a) Policy No.

Enter the policy number

As allotted by the insurance company

c) Company TPA ID No.

Enter the TPA ID No

License number a s allotted by IRDA and

printed in TPA documents.

Enter the social insurance number or the certiicate number

of social health insurance scheme

b) SI. No/ Certiicate No.

As allotted by the organization

d) Name

Enter the full name of the policyholder

Surname, First name, Middle name

a) Currently covered by any other Mediclaim

/ Health Insurance?

Indicate whether currently covered by another Mediclaim /

Health Insurance

Tick Yes or No

c) Company Name

Enter the full name of the insurance company

Name of the organization in full

Enter the full postal address

e) Address

SECTION B - DETAILS OF INSURANCE HISTORY

b) Date of Commencement of irst Insurance

without break
Policy No.

Enter the date of commencement of irst insurance

Enter the policy number

Include Street, City and Pin Code

Use dd-mm-yy format

As allotted by the insurance company

Sum Insured

Enter the total sum insured a s per the policy

In rupees

Date

Enter the date of hospitalization

Use mm-yy format

d) Have you been Hospitalized in the last four

years since inception of the contract?
Diagnosis

e) Previously Covered by any other Mediclaim

/ Health Insurance?
f) Company Name

Indicate whether hospitalized in the last four years

Enter the diagnosis details

Indicate whether previously covered by another Mediclaim /

Health Insurance
Enter the full name of the insurance company

Tick Yes or No
Open Text

Tick Yes or No

Name of the organization in full

SECTION C - DETAILS OF INSURED PERSON HOSPITALIZED

a) Name
b) Gender

Enter the full name of the policyholder

Indicate Gender of the patient

Surname, First name, Middle name

Tick Male or Female

e) Relationship to primary Insured

Indicate relationship of patient with policyholder

Tick the right option. If others, please specify.

c) Age

d) Date of Birth
f) Occupation
g) Address

h) Phone No
i) E-mail ID

a) Name of Hospital where admitted

b) Room category occupied
c) Hospitalization due to

d) Date of Injury/Date Disease irst detected/

Date of Delivery
e) Date of admission
f) Time

g) Date of discharge
h) Time

i) If Injury give cause

If Medico legal

Reported to Police

MLC Report & Police FIR attached

j) System of Medicine

Enter age of the patient

Enter Date of Birth of patient

Indicate occupation of patient

Enter the full postal address

Enter the phone number of patient

Enter e-mail address of patient

SECTION D - DETAILS OF HOSPITALIZATION

Number of years and months

Use dd-mm-yy format

Tick the right option. If others, please specify.

Include Street, City and Pin Code

Include STD code with telephone number

Complete e-mail address

Enter the name of hospital

Indicate the room category occupied

Name of hospital in full

Tick the right option

Enter the relevant date

Use dd-mm-yy format

Indicate reason of hospitalization

Enter date of admission

Enter time of admission

Enter date of discharge

Enter time of discharge

Indicate cause of injury

Tick the right option

Use dd-mm-yy format

Use hh:mm format

Enter date of discharge

Use hh:mm format

Tick the right option

Indicate whether injury is medico legal

Tick Yes or No

Enter the system of medicine followed in treating the patient

Open Text

Indicate whether police report was iled

Indicate whether MLC report and Police FIR attached

SECTION E - DETAILS OF CLAIM

Tick Yes or No
Tick Yes or No

a) Details of Treatment Expenses

Enter the amount claimed a s treatment expenses

In rupees (Do not enter paise values)

c) Details of Lump sum/ cash beneit claimed

Enter the amount claimed a s lump sum/ cash beneit

In rupees (Do not enter paise values)

b) Claim for Domiciliary Hospitalization

d) Claim Documents Submitted-Check List

Indicate whether claim is for domiciliary hospitalization

Indicate which supporting documents are submitted

SECTION F - DETAILS OF BILLS ENCLOSED

Indicate which bills are enclosed with the amounts in rupees

Tick Yes or No

Tick the right option

CLAIM FORM - PART B

TO BE FILLED IN BY THE HOSPITAL

Vipul MedCorp TPA Pvt Ltd.

Redefining Healthcare Services.

DETAILS OF HOSPITAL

The issue of this Form is not to be taken a s an admission of liability

Please indude the original preauthorization request form in lieu of PART A
(To be illed in block letters)

a) Name of the hospital:

b) Hospital ID:

c) Type of Hospital:

Network

d) Name of the treating doctor:

e) Qualiication:

(If non network ill section E)

Non Network

f) Registration No. with State Code:

g) Phone No.

DETAILS OF THE PATIENT ADMITTED

a) Name of the Patient:
c) Gender:

b) IP Registration Number
f) Dated of Admission:

g)Time:

j) Type of Admission: Emergency

Planned

I) Status at time of discharge: Discharge to home

Day Care

Maternity

Male
:

Female d)Age: Years

Discharge to another hospital

Deceased

Description

b)

ICD10 Codes

Description

ICD 10 PCS

i. Procedure1

ii. Additional Diagnosis:

ii. Procedure2:

iii. Co-morbidities:

iii. Procedure3:

iv. Co-morbidities:

iv. Details of Procedure:

Yes

ii. Gravida Status:

m) Total claimed amount

i. Primary Diagnosis

c) Pre-authorization obtained:

i)Time:

k) If Maternity i. Date of Delivery

DETAILS OF AILMENT DIAGNOSED (PRIMARY)

a)

h) Date ol Discharge

e) Date of birth:

Months

d) Pre-authorization Number:

No

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

f) Hospitalization due to Injury:

Yes

No

i. If Yes, give cause

ii. If Injury due to Substance abuse / alcohol consumption,

Test Conducted to establish this:
v. FIR no.

Yes

No

Self-inlicted

(If Yes, attach reports)

Road Trafic Accident

iii. If Medico legal

Yes

Substance abuse / alcohol consumption

No

iv. Reported to Police:

Yes

No

vi. If not reported to police give reason

CLAIM DOCUMENTS SUBMITTED - CHECK LIST

Claim Form duly signed

Investigation reports

Copy of the Pre-authorization approval letter

Doctors reference slip for investigation

CT/MR/USG/HPE investigation reports

Original Pre-authorization request

Copy of photo ID card of patient veriied by hospital

ECG

Operation Theatre notes

MLC report & Police FIR

Hospital break-up bill

Any other, please specify

Pharmacy bills

Hospital Discharge summary

Original death summary from hospital where applicable

Hospital main bill

ADDITIONAL DETAILS IN CASE OF NON NETWORK HOSPITAL (ONLY FILL IN CASE OF NON-NETWORK HOSPITAL)
a) Address of the Hospital

City:
Pin Code:
d) Hospital PAN:

State:
c) Registration No. with State Code

b) Phone No:
e) Number of inpatient beds:

d) Facilities available in the Hospital : i) OT:

iii) Others:

DECLARATION BY THE HOSPITAL

Yes

No ii) ICU:

Yes

No

(PLEASE READ VERY CAREFULLY)

We hereby declare that the information furnished in this Claim Form is true & correct to the best of our knowledge and belief. If we have made any false or untrue statement,
suppression or concealment of any material fad, our right to claim under this claim shall be forfeited.
Date :
Place :

Signature and Seal of the Hospital Authority

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

DESCRIPTION
SECTION A - DETAILS OF HOSPITAL

FORMAT

Enter the name of hospital

Name of hospital in full

d) Name of treating doctor

Enter the name of the treating doctor

Name of doctor in full

f) Registration No. with State Code

Enter the registration number of the doctor along with the

state code
Enter the phone number of doctor

a) Name of Hospital
b) Hospital ID

Enter ID number of hospital

Indicate whether In network or non network hospital

c) Type of Hospital

Enter the qualiications of the treating doctor

e) Qualiication
g) Phone No.

SECTION B - DETAILS OF THE PATIENT ADMITTED

As allocated by the TPA

Tick the right option

Abbreviations of educational qualiications

As allocated by the Medical Council of India

Include STD code with telephone number

Enter the name of hospital

Name of hospital in full

d) Age

Enter age of the patient

Number of years and months

f) Date of Admission

Enter date of admission

a) Name of Patient
b) IP Registration Number

Enter insurance provider registration number

Indicate Gender of the patient

c) Gender

e) Date of Birth
g) Time

Enter time of admission

Use hh:mm format

Enter Date of Delivery if maternity

Date of Delivery

Gravida Status
l) Status at time of discharge
m) Total claimed amount

Use dd-mm-yy format

Enter time of discharge

Indicate type of admission of patient

i) Time
j) Type of Admission
k) If Maternity

Tick Male or Female

Enter date of admission

Enter date of discharge

h) Date of Discharge

As allotted by the insurance provider

Enter Gravida status if maternity

Indicate status of patient at time of discharge
Indicate the total claimed amount

Use dd-mm-yy format

Use dd-mm-yy format
Use hh:mm format
Tick the right option

Use dd-mm-yy format

Use standard format

Tick the right option
In rupees (Do not enter paise values)

SECTION C - DETAILS OF AILMENT DIAGNOSED (PRIMARY)

a) ICD 10 Code

Primary Diagnosis

Additional Diagnosis

Co-morbidities

b) ICD 10 PCS

Enter the ICD 10 Code and description of the primary

diagnosis
Enter the ICD 10 Code and description of the additional
diagnosis
Enter the ICD 10 Code and description of the co-morbidities

Standard Format and Open text

Standard Format and Open text

Standard Format and Open text

Procedure 1

Enter the ICD 10 PCS and description of the irst procedure

Standard Format and Open text

Details of Procedure

Enter the details of the procedure

Open text

Procedure 2
Procedure 3

c) Pre-authorization obtained
d) Pre-authorization Number

e) If authorization by network hospital not

obtained, give reason
f) Hospitalization due to injury
Cause

Enter the ICD 10 PCS and description of the second procedure Standard Format and Open text
Enter the ICD 10 PCS and description of the third procedure
Indicate whether pre-authorization obtained
Enter pre-authorization number

Enter reason for not obtaining pre-authorization number

Indicate if hospitalization is due to injury
Indicate cause of injury

Standard Format and Open text

Tick Yes or No

As allotted by TPA
Open text

Tick Yes o r No

Tick the right option

If injury due to substance abuse/alcohol

consumption, test conducted to establish
this

Indicate whether test conducted

Tick Yes or No

FIR No.

Indicate whether police report was iled

Enter irst information report number

Tick Yes o r No

Medico Legal

Reported To Police

If not reported to police, give reason

Indicate whether injury is medico legal

Enter reason for not reporting to police

Tick Yes o r No
As issued by police authorities

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

b) Phone No.

c) Registration No. with State Code

d) Hospital PAN

e) Number of Inpatient beds

f) Facilities available in the hospital

Enter the full postal address

Enter the phone number of hospital

Enter the registration number of the doctor along with the

state code
Enter the permanent account number
Enter the number of inpatient beds

Indicate facilities available in the hospital

SECTION F - DECLARATION BY THE HOSPITAL

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

Include Street, City and Pin Code

Include STD code with telephone number

As allocated by the Medical Council of India

As allotted by the Income Tax department
Digits

Tick the right option. If others, please specify