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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)

DECLARATION BY THE INSURED:

I hereby declare that the information furnished in the 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:

Signature of the Insured

Date

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

SECTION H

	DATA ELEMENT		DESCRIPTION	FORMAT

			SECTION A - DETAILS OF PRIMARY INSURED

a)	Policy No.		Enter the policy number	As allotted by the Insurance Company
b)	Sl. No/ Certificate No.		Enter the social Insurance number or the certificate number of	As allotted by the organization
b)	Sl. No/ Certificate No.		social health insurance scheme	As allotted by the organization
			social health insurance scheme
c)	Company TPA ID No.		Enter the TPA ID No.	License number as allotted by IRDA and printed
c)	Company TPA ID No.		Enter the TPA ID No.	in TPA documents.
				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 / Health		Indicate whether currently covered by another Mediclaim /	Tick Yes or No
	Insurance?		Health Insurance	Tick Yes or No
	Insurance?		Health Insurance
b)	Date of commencement of first Insurance without break		Enter the date of commencement of first Insurance	Use dd-mm-yy-forrmat
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		Enter the total sum insured as per the policy	In rupees

d)	Have you been Hospitalized in the last four years since		Indicate whether hospitalized in the last four years	Tick Yes or No
	Inception of the contract?		Indicate whether hospitalized in the last four years	Tick Yes or No
	Inception of the contract?
	Date		Enter the date of Hospitalization	Use mm-yy format

	Diagnosis		Enter the diagnosis details	Open Text
	Diagnosis		Enter the diagnosis details

e)	Previously covered by any other Mediclaim / Health		Indicate whether previously covered by another mediclaim /	Tick Yes or No
	Insurance?		Health Insurance	Tick Yes or No
	Insurance?		Health Insurance
f)	Company Name		Enter the full name of the Insurance Company	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

1)	E-mail ID		Enter e-mail address of patient	Complete e-mail address

			SECTION D - DETAILS OF HOSPITALIZATION

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)	Hospitalization due to		indicate reason of hospitalization	Tick the right option

d)	Date of injury/Date Disease first detected / Date of		Enter the relevant date	Use dd-mm-yy format
	Delivery		Enter the relevant date	Use dd-mm-yy format
	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)	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

j)	System of Medicine		Enter the system of medicine followed in treating the patient	Open Text

			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 supporting documents are submitted	Tick the right option

			SECTION F - DETAILS OF BILLS ENCLOSED

Indicate which bills are enclosed with the amount 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

c)	Cheque/ DD payable details		Enter the name of the beneficiary the cheque / DD should be	Name of the individual / organization in full
c)	Cheque/ DD payable details		made out to	Name of the individual / organization in full
			made out to
c)	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.

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

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

Heritage Health Tpa Claim Form PDF Details

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