Claim Form Dhs Reimbursement 2d6sh

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

Name of Insurance Company: _______________________________________________________

(To be filled in block letters)

DETAILS OF PRIMARY INSURED: a) Policy No:

b) Sl. No/ Certificate No:

c) Company/ TPA ID No: S

U

R

N

A

M

E

F

I

R

S

N

T

A

M

E

M

I

D

D

L

M

M

N

E

A

M

SECTION A

d) Name :

E

e) Address :

City:

State:

Pin Code:

Phone No:

Email ID :

DETAILS OF INSURANCE HISTORY: Yes

No

b) Date of commencement of first Insurance without break:

c) If yes, company name:

D

D

Y

Y

Date:

M

Policy No.

Sum Insured (Rs.)

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

Diagnosis:

Yes

No

M

Y

Y

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

Yes

No

SECTION B

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

f) If yes, Company Name DETAILS OF INSURED PERSON HOSPITALIZED: S

a) Name: b) Gender:

U

R

Male

N

A

M

E

Female

c) Age: years Y

Self

Spouse

f) Occupation:

Self Employed

Y

Child

Homemaker

I

R

S

T

months M M

N

A

M

d) Date of Birth:

D

E

M M M

D

Father

Mother

Other

(Please Specify)

Student

Retired

Other

(Please Specify)

I

D

Y

Y

D

L

N

E

A

M

Y

Y

H

H

E

SECTION C

e) Relationship to Primary insured: Service

F

g) Address (if different from above):

City:

State:

Pin Code:

Phone No:

E-mail ID:

DETAILS OF HOSPITALIZATION: a) Name of Hospital where itted: Day care

c) Hospitalization due to:

Injury

e) Date of ission:

D

i) If Injury give cause:

Self inflicted

ii. Reported to police:

Illness

D

M

Yes

Maternity Y

M

Y

3 or more beds per room

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

f) Time:

H

Road Traffic Accident No

Twin sharing

Single occupancy

H

:

M

M

g) Date of Discharge: D

Substance Abuse / Alcohol Consumption

iii. MLC Report & Police FIR attached:

Yes

No

D

M

D

M

i. If Medico legal:

D Y

M M

h) Time:

Y

Yes

:

M

M

No

SECTION D

b) Room Category occupied:

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.

Claim Form Duly signed

iii. Post-hospitalization Expenses:

Rs.

iv. Health-Check up Cost:

Rs.

Copy of the claim intimation, if any

v. Ambulance Charges:

Rs.

vi. Others (code):

Rs.

Hospital Main Bill

Total vii. Pre-hospitalization period:

days

viii. Post-hospitalization period:

b) Claim for Domiciliary Hospitalization:

Yes

No

Rs. days

(If yes, provide details in annexure)

Hospital Bill Payment Receipt Hospital Discharge Summary Pharmacy Bill

c) Details of Lump sum / cash benefit claimed:

Operation Theatre Notes

i. Hospital Daily Cash:

Rs.

ii. Surgical Cash:

Rs.

iii. Critical Illness Benefit:

Rs.

iv. Convalescence:

Rs.

vi. Others:

Rs.

Total

Rs.

v. Pre/Post hospitalization Lump sum benefit: Rs.

SECTION E

Hospital Break-up Bill

ECG Doctor's request for investigation Investigation Reports (Including CT / MRI / USG / HPE) Doctor's Prescriptions Others

DETAILS OF BILLS ENCLOSED: Sl. No

Bill No

Issued by

Date D

D

M

M

Y

Y

D

D

M

M

Y

Y

3. 4.

D

D

M

M

Y

Y

D

D

M

M

Y

Y

5. 6.

D

D

M

M

Y

Y

D

D

M

M

Y

Y

7. 8.

D

D

M

M

Y

Y

D

D

M

M

Y

Y

9. 10

D

D

M

M

Y

Y

D

D

M

M

Y

Y

Towards Hospital Main Bill Pre-hospitalization Bills: Post-hospitalization Bills: Pharmacy Bills

Amount (Rs)

SECTION F

1. 2.

Nos Nos

DETAILS OF PRIMARY INSURED'S BANK :

d) Cheque/ DD Payable details:

SECTION G

a) PAN: c) Bank Name and Branch:

b) Number:

e) IFSC Code:

(IMPORTANT: PLEASE TURN OVER)

DECLARATION BY THE INSURED:

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.

b)

SI. No/ Certificate No.

c)

Company TPA ID No.

Enter the TPA ID No

d)

Name

Enter the full name of the policyholder

License number as allotted by IRDA and printed in TPA documents. Surname, First name, Middle name

e)

Address

Enter the full postal address

Include Street, City and Pin Code

a)

Enter the policy number Enter the social insurance number or the certificate number of social health insurance scheme

SECTION B - DETAILS OF INSURANCE HISTORY Indicate whether currently covered by another Mediclaim / Health Insurance Enter the date of commencement of first insurance

As allotted by the insurance company As allotted by the organization

b)

Currently covered by any other Mediclaim / Health Insurance? Date of Commencement of first Insurance without break

c)

Company Name

Enter the full name of the insurance company

Name of the organization in full

Policy No.

Enter the policy number

As allotted by the insurance company

Sum Insured Have you been Hospitalized in the last four years since inception of the contract? Date

Enter the total sum insured as per the policy

In rupees

Indicate whether hospitalized in the last four years

Tick Yes or No

Enter the date of hospitalization

Use mm-yy format

Diagnosis Previously Covered by any other Mediclaim/ Health Insurance? Company Name

Enter the diagnosis details Indicate whether previously covered by another Mediclaim / Health Insurance Enter the full name of the insurance company

Open Text

d)

e) f)

Tick Yes or No Use dd-mm-yy format

Tick Yes or No 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 the patient

Number of years and months

d)

Date of Birth

Enter Date of Birth of patient

Use dd-mm-yy format

e)

Relationship to primary Insured

Indicate relationship of patient with policyholder

Tick the right option. If others, please specify.

f)

Occupation

Indicate occupation of patient

Tick the right option. If others, please specify.

g)

Address

Enter the full postal address

Include Street, City and Pin Code

h)

Phone No

Enter the phone number of patient

Include STD code with telephone number

i)

E-mail ID

Enter e-mail address of patient

Complete e-mail address

SECTION D - DETAILS OF HOSPITALIZATION a)

Name of Hospital where itted

Enter the name of hospital

Name of hospital in full

b)

Room category occupied

Indicate the room category occupied

Tick the right option

c) d)

Indicate reason of hospitalization

Tick the right option

Enter the relevant date

Use dd-mm-yy format

e)

Hospitalization due to Date of Injury/Date Disease first detected/ Date of Delivery Date of ission

Enter date of ission

Use dd-mm-yy format

f)

Time

Enter time of ission

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)

If Injury give cause

Indicate cause of injury

Tick the right option

If Medico legal

Indicate whether injury is medico legal

Tick Yes or No

Reported to Police

Indicate whether police report was filed

Tick Yes or No

MLC Report & Police FIR attached

Indicate whether MLC report and Police FIR attached

Tick Yes or No

System of Medicine

Enter the system of medicine followed in treating the patient

Open Text

j)

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 ing 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 a)

PAN

Enter the permanent number

As allotted by the Income Tax department

b)

Number

Enter the bank number

As allotted by the bank

c)

Bank Name and Branch

Name of the Bank in full

d)

Cheque/ DD payable details

e)

IFSC Code

Enter the bank name along with the branch Enter the name of the beneficiary the cheque/ DD should be made out to Enter the IFSC code of the bank branch SECTION H - DECLARATION BY THE INSURED

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

Name of the individual/ organization in full IFSC code of the bank branch in full

SECTION H

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.

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Annexure - III

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 nospital

Tick the right option

d)

Name of treating doctor

Enter the name of the treating doctor

Name of doctor in full

e)

Qualification

Abbreviations of educational qualifications

f)

Registration No. with State Code

g)

Phone No.

Enter the qualifications of the treating doctor Enter the registration number of the doctor along with the state code Enter the phone number of doctor

As allocated by the Medical Council of India Include STD code with telephone number

SECTION B – DETAILS OF THE PATIENT ITTED 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 ission

Enter date of ission

Use dd-mm-yy format

f)

Time

Enter time of ission

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)

Type of ission

Indicate type of ission of patient

Tick the right option

j)

If Maternity Date of Delivery

Enter Date of Delivery if maternity

Use dd-mm-yy format

Gravida Status

Enter Gravida status if maternity

Use standard format

Status at time of discharge

Indicate status of patient at time of discharge

Tick the right option

k)

SECTION C – DETAILS OF AILMENT DIAGNOSED (PRIMARY) a)

ICD 10 Code 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

Primary Diagnosis Additional Diagnosis Co-morbidities b)

Standard Format and Open text Standard Format and Open text Standard Format and Open text

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 Indicate whether present ailment is a complication of some preexisting disease Indicate whether pre-authorization obtained

Open text

c)

Present Ailment is a Complication of PED

d)

Pre-authorization obtained

e) f)

Pre-authorization Number If authorization by network hospital not obtained, give reason Hospitalization due to injury

Enter pre-authorization number

As allotted by TPA

Enter reason for not obtaining pre-authorization number

Open text

Indicate if hospitalization is due to injury

Tick Yes or No

Cause If injury due to substance abuse/alcohol consumption, test conducted to establish this Medico Legal

Indicate cause of injury

Tick the right option

Indicate whether test conducted

Tick Yes or No

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

g)

Tick Yes or No Tick Yes or No

SECTION D – CLAIM DOCUMENTS SUBMITTED-CHECK LIST Indicate which ing 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.

Enter the registration number of patient

As allocated by the Hospital

d)

PAN

Enter the permanent 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 INSURED Read declaration carefully and mention date (in dd:mm:yy format), place (open text) and sign. SECTION G - DECLARATION BY THE HOSPITAL Read declaration carefully and mention date (in dd:mm:yy format), place (open text) and sign and stamp