Heritage Health Tpa Claim Form – Fill Out and Use This PDF

The Heritage Health TPA Claim Form is a comprehensive document designed for insured individuals to report their healthcare claims for processing and reimbursement. This form captures detailed information regarding the policyholder, their insurance history, details of the hospitalized person, and the specifics of their hospitalization and claim. It's crucial for ensuring that all necessary data is provided to facilitate a smooth and efficient claim process. To submit your claim effortlessly, click the button below.

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Heritage Health Tpa Claim Form PDF Details

Filing a claim for health insurance benefits can seem daunting, but the Heritage Health TPA Claim Form simplifies this process, guiding insured individuals through each necessary step to ensure precise and comprehensive submissions. This form is meticulously designed to capture all essential information, starting from the primary insured's details such as policy number, personal identification, and address, to a detailed account of any hospitalization event. It includes sections for documenting insurance history, providing an intricate look into any prior coverages and medical conditions. Additionally, it caters to the hospitalized person's specifics, encompassing demographics, relationship to the insured, and the nature of their hospital stay or treatment received. What sets this form apart is its ability to accommodate a wide range of claims, from pre and post-hospitalization expenses to domiciliary hospitalization and even lump sum or cash benefits under various scenarios. Equally important, the form includes a segment for submitting detailed bills and receipts, ensuring that all financial aspects of the claim are transparent and accountable. Lastly, a declaration by the insured underscores the importance of truthfulness and consent for the necessary medical information exchange, encapsulating the mutual trust and responsibilities in the insurer-insured relationship. This comprehensive approach not only aids in expediting the claim process but also serves to minimize discrepancies, making it a vital tool for individuals navigating their health insurance benefits.

Question	Answer
Form Name	Heritage Health Tpa Claim Form
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	heritage tpa claim form part a pdf, heritage claim form, heritagehealthtpa claim form, heritage health tpa

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CLAIM FORM - PART A

TO BE FILLED BY THE INSURED

(To be Filled in block letters)

The issue of this Form is not to be taken as an admission of liablity

DETAILS OF PRIMARY INSURED:

a) Policy No.:

b) Sl. No/ Certificate no.

c) Company/ TPA ID No:

d) Name:

e) Address:

City:

State:

Pin Code

Phone No:

Email ID:

DETAILS OF INSURANCE HISTORY:

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

Yes

b) Date of

commencement of first Insurance without break:

c) If yes, company name:

Policy No.

Sum insured (Rs.)

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

Yes

Date:

Diagnosis:

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

Yes

f) If yes, company name:

DETAILS OF INSURED PERSON HOSPITALIZED: :

a) Name:

b) Gender

Male

Female

c) Age years

Months

d) Date of Birth

e) Relationship to Primary insured:

Self

Spouse

Child

Father

Mother

Other

(Please Specify)

f) Occupation

Service

Self Employed

Home Maker

Student

Retired

Other

(Please Specify)

g) Address (if different from above) :

City:

State:

Pin Code

Phone No:

Email ID:

DETAILS OF HOSPITALIZATION: :

a) Name of Hospital where Admited:

b) Room Category occupied:

Day care

Single occupancy

Twin sharing

3 or more beds per room

c) Hospitalization due to:

Injury

Illness

Maternity

d) Date of injury / Date Disease first detected

/Date of Delivery:

e) Date of Admission:

h) Time:

f) Time

g) Date of Discharge:

I) If injury give cause:

Self inflicted

Road Traffic Accident

Substance Abuse / Alcohol Consumption

I) If Medico l e g a l

Yes

ii) Reported to Police

iii. MLC Report & Police FIR attached

Yes

j) System of Medicine:

DETAILS OF CLAIM:

SECTION A

SECTION B

SECTION C

SECTION D

a) Details of the Treatment expenses claimed

I. Pre -hospitalization expenses	Rs.
iii. Post-hospitalization expenses	Rs.
v. Ambulance Charges:	Rs.
vii. Pre -hospitalization period:	days

b)Claim for Domiciliary Hospitalization:

c)Details of Lump sum / cash benefit claimed:

i. Hospital Daily cash:	Rs.
iii. Critical Illness benefit:	Rs.

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

DETAILS OF BILLS ENCLOSED:

Yes

ii. Hospitalization expenses

iv. Health-Check up cost:

vi. Others (code):

Total

viii. Post -hospitalization period:

(If yes, provide details in annexure)

ii. Surgical Cash: iv. Convalescence: vi. Others:

Total

Rs.

days

Rs.

Claim Documents Submitted - Check List:

Claim form duly signed

Copy of the claim intimation, if any

Hospital Main Bill

Hospital Break-up Bill

Hospital Bill Payment Receipt

Hospital Discharge Summary

Pharmacy Bill

Operation Theater Notes

ECG

Doctor’s request for investigation Investigation Reports (Including CT / MRI / USG / HPE)

Doctor’s Prescriptions

Others

SECTION E

Sl. No.

Bill No.

Date

Issued by

Towards

Amount (Rs)

Hospital main Bill

Pre-hospitalization Bills:

Nos

Post-hospitalization Bills:

Nos

Pharmacy Bills

10.

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:

SECTION F

SECTION G

(IMPORTANT: PLEASE TURN OVER)

Heritage Health Tpa Claim Form – Fill Out and Use This PDF

Heritage Health Tpa Claim Form PDF Details

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