SAMPLE CLAIM FORM PART A – REIMBURSEMENT

(Please fill in the highlighted mandatory details)

Enter Raksha
C L A IM F O R M - P A R T A
member id T O BE F IL L E D IN BY TH E IN S U R E D
The issue of this F o r m is no t to be t aken as an admis s io n of liability

DETAILS OF PRIMARY INSURED: ( To be f i l led in b lo c k letters)

a) Po lic y N o : b) SI. N o / Certificate N o :

c) C o m p a n y / T PA ID N o :
d) N a m e SURNAM E F IR S T NAM E M I D D L E NAM E
Enter employee details:

SECTION A
e) Ad d res s :
Name, Address, Mobile
No., Email Id
C ity: State:
Pin Code: PhoneNo: To be filled in case you
have EmailID:
another health insurance (Optional)
D E T A I L S O F I N S UR A NC E H I S T O R Y:

a) Currently covered by any other Mediclaim / Health Insurance: Ye s No b) Date of commencement of first Insurance without break: D D M M Y Y

SECTIONB
c) I f yes, co mp an y n ame Po lic y N o :

S u m Insur ed ( Rs.) d ) Ha ve yo u bee n ho sp it alize d in the last fo u r year s since incep t io n o f the c o ntract? Yes No Date:M M Y Y

Diagnosis: e) Previo usly c o ve r e d by a ny o t her Me d ic la im / H e a lt h insur ance: Yes No

f) If yes, C o mp an y N ame Patient’s details (Can be

DET AIL S OF I N SUR E D PE R SO N HO SP IT AL IZ E D: employee or his dependent)
a) N a me : S U R N A M E F IR S T N A M E L E A M E
M I D D N

b) Gend er : Male Female c)Age: years Y Y Months M M Da t e o f Birth: D D M M Y Y

e) Relat io nship t o P r ima r y insur ed: Self Spouse Child Father Mother O th er ( Please Specify)

SECTIONC
f) Occupat io n: Ser vice Self E mp lo ye d H o m em ak er S tud e nt R et ired Ot her ( Please Specify)

e)Address(if different from above)

City: State:
Pin Code: PhoneNo: Email ID:
DET AIL S O F H O SPIT AL IZ AT IO N:

a) N a m e o f Ho spit al w he r e Admit t ed :

SECTIOND
b) R o o m C at ego r y o ccup ied : D a y car e Single o cc u p anc y Twin shar ing 3 or mo r e be d s per r o o m
D D M M Y If itYwas a
c) Ho spit alizat io n d u e to: I njur y I lln ess M a t ern it y d) D a t e o f Inju r y / D a t e D is ea s e first d et e cte d / D a t e o f De live r y:
medico legal
e) Da te d
D D M M Y Y f) H H : M M g) Dat e of D D M M Y Y
h)
H H : M M

Time: Di scharge: Time:

Admission:
i) If I njur y give cause : Self inflicted R o a d Traffic Accid ent Subst ance Abu s e / Alc o ho l C o ns u mp t io n i. I f M e d ic o legal: Yes No

ii. R e p o rt e d t o police: Yes No iii. M L C R e p o r t & Po lice F I R a tt ached: Yes N o j) S ys t em o f M e d ic in e :

D E T A I L S OF C L A I M : Expenses incurred before & Total hospitalization bill
a) Det a ils o f t he t reatment expenses c la ime d after hospitalization Claim Documents Submitted- Check List:

i. Pre- ho spit a lizat io n E xpens es : Rs. ii. Ho spit a lizat io n E xpenses : Rs. C l ai m F o r m D u l y si gned
C o p y of the cl aim i n t ima t ion, if a n y
iii. Po s t - ho spit a lizat io n E xp ens e s : Rs. iv. He a lth- C hec k u p C o st: Rs.
Hospi t al Ma i n Bi l l

v. Amb u la n c e Char ges : Rs. vi.Ot hers ( cod e) : Rs. Hospi t al Br e a k- up Bi l l Refer Claim SECTIONE
To tal Rs. Hospi t a l Bi l l P a ym e n t Rece su bmission
Hospi t a l Di sch a r ge Summacrhecklist on
vii. Pr e- ho spit a lizat io n period: days viii. Po s t - ho spit alizat io n per io d: d ays
Phar m a c y Bi l l
b) C la im fo r Do miciliar y Ho spit a lizat io n : Yes N o ( I f yes, pro vide details in annexur e) Oper a t i on Theat r e N ot es

c) Deta ils of L u m p s u m / cash benefit c la imed: ECG

Doctor' s r equest for investi s
i. H o sp it al Da ily C ash: Rs. ii. Surgical C a s h: Rs.
In vest i ga t i on Repor t s ( In cl udi ng C T
iii. C rit ical Illness B enefit: Rs. iv. Co nvale sce nce: Rs. MR I / U SG / H P E )
Doct or ’ s Pr escr i pt i ons
v. Pre/ Po s t hospitalizat io n L u m p s u m benefit: Rs. vi. Ot hers: Rs. Ot h er s

T otal Rs.
D E T AI L S O F B I L L S E NC L O S E D :

Sl. N o Bill No D at e I s s ue d b y T o wa r d s A m o un t ( R s )

1. D D M M Y Y Ho s pi t a l M a i n B i l l
2. D D M M Y Y P r e- ho s pi t a l i z a t i o n Bi l l s: Nos
3. D D M M Y Y P o s t - ho s pi t a l i z a t i o n Bi l l s :
S EC IO F

4. D D M M Y Y P h a r m a c y Bi l l s :
5. D D M M Y Y Enter all the bills
6. D D M M Y Y incurred befo re, during
7. D D M M Y Y
8. D D M M Y Y
& after hospi talization Empl oyee acc oun deta ils in whi ch
9. D D M M Y Y claim amo unt i s to be credited
10. D D M M Y Y

DET A I L S OF PRI MA RY NS URE D'S B A N K A C C O U N T :

TIO N G

I
a)PA N : b) Ac c o u nt N u mb e r :

c) B a n k N a me a nd B r a nc h
d) C he q u e / D D Payab le details: e) IFS C C o d e:
 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 Signature of
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
the employee

SECTION H
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.

Date: D D M M Y Y Place: Signature of the Insured

GUIDANCE FOR FILLING CLAIM F O R M - PART A (To be f illed in b y t h e i nsure d)

DATA EL EMEN T DESCRIPTION FORMAT

SECTION A - DETAILS OF PRIMARY INSURED
a ) P o l ic y N o . Enter the policy number As allotted by the insurance company
Enter the social insurance number or the certificate number of As allotted by the organization
b) SI. No/ Certificate No. social health insurance scheme
c) Comp a n y TPA ID No. License number as allotted by IRDA and printed
Enter the TPA ID No
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

S E C T IO N 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
b) Date of Commencement of first Insurance without break Enter the date of commencement of first insurance Use dd-mm-yy format

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?
Date Enter the date of hospitalization Use mm-yy format

Diagnosis Enter the diagnosis details Open Text

e) Previously Covered by any other Mediclaim/ Health Indicate whether previously covered by another Mediclaim / Tick Yes or No
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 ST D 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 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 Use dd-mm-yy format
Delivery Enter the relevant date

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 amounts in rupees

SECTION G - DETAILS OF PRIMARY INSURED’ S BAN K AC CO U NT

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