Beruflich Dokumente
Kultur Dokumente
a) Policy No:
SECTION A
c) Company/TPA ID No:
d) Name :
No
Date: M
e) Address :
State:
City:
Pin Code:
Phone No:
Email ID:
Yes
No
Policy No.
d) Have you been hospitalized in the last four years since inception of the contract?
Yes
Diagnosis : ___________________________________________________________________
Yes
Y
No
SECTION B
Male
b) Gender:
E
c) Age: years
Service
Spouse
Self Employed
d) Date of Birth:
Child
Father
Mother
Other
(Please Specify)
Homemaker
Student
Retired
Other
(Please Specify)
SECTION C
Self
Female
City:
State:
Pin Code:
Phone No:
Email ID:
DETAILS OF HOSPITALIZATION:
a) Name of Hospital where Admitted:
Day care
Single occupancy
e) Date of Addmission:
Illness
Self inflicted
Twin sharing
Maternity
Y
f) Time:
Yes
g) Date of Discharge:
No
Yes
h) Time:
i) If Medico legal:
Yes
No
SECTION D
Injury
j) System of Medicine
No
DETAILS OF CLAIM
a) Details of the treatment expenses claimed:
i. Pre-Hospitalization Expenses:
Rs.
Rs.
Rs.
Rs.
v. Ambulance Charges:
Rs.
Rs.
Days
Rs.
SECTION E
Total
Yes
No
Pharmacy Bill
Operation Theatre Notes
ECG
Rs.
Rs.
Rs.
iv. Convalescene:
Rs.
vi. Others:
Rs.
Doctor's Prescriptions
Total
Rs.
Others
v. Pre/Post Hospitlaization
Lump sum benefit
Rs.
Bill No.
Date
Issued by
Towards
Amount (Rs)
Pre-hospitalization Bill:
Pharmacy Bills
10
Nos.
SECTION F
a) PAN:
b) Account Number:
e) IFSC Code:
Date:
Place
GUIDANCE FOR FILLING CLAIM FORM - PART A (To be filled in by the insured)
DATA ELEMENT
DESCRIPTION
FORMAT
d) Name
e) Address
c) Company Name
Tick Yes or No
Policy No
Sum Insured
In rupees
Tick Yes or No
Diagnosis
Open Text
Tick Yes or No
f) Company Name
b) Gender
c) Age
d) Date of Birth
f) Occupation
g) Address
h) Phone No
i) E-mail ID
c) Hospitalization due to
e) Date of admission
f) Time
g) Date of discharge
h) Time
If Medico legal
Tick Yes or No
Reported to Police
Tick Yes or No
Tick Yes or No
j) System of Medicine
Open Text
Tick Yes or No
b) Account Number
e) IFSC Code
SECTION H
I hereby declare that the information furnished in this claim 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 forfieted. 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 this claim & that will not be making any suplementary claim except the pre/post-hospitalization claim, if
any