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 admission of liability

(To be filled in block letters)

DETAILS OF PRIMARY INSURED:
b) Sl. No./Certificate No:

a) Policy No:

SECTION A

c) Company/TPA ID No:

Ericssons Employee Code:

S

d) Name :

No

Date: M

e) Address :

State:

City:
Pin Code:

Phone No:

Email ID:

DETAILS OF INSURANCE HISTORY:

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

Yes

No

b) Date of commencement of first insurance without break:

Policy No.
d) Have you been hospitalized in the last four years since inception of the contract?

Sum Insured (Rs.)

Yes

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

Diagnosis : ___________________________________________________________________

Yes

Y
No

SECTION B

c) If yes, company name:

f) If yes, Company Name:

DETAILS OF INSURED PERSON HOSPITALIZED:
a) Name:

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

e) Relationship to Primary Insured:

f) Occupation:

Female

g) Address (if different from above):

City:

State:

Pin Code:

Phone No:

Email ID:

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

b) Room Category occupied:

Single occupancy

e) Date of Addmission:

Illness

Self inflicted

i) If injury give cause:

ii) Reported to police:

Twin sharing

Maternity
Y

f) Time:

Road Traffic Accident

Yes

g) Date of Discharge:

Substance Abude / Alcohol Comsumption

iii) MLC Report & Police FIR attached

No

3 or more beds per room

d) Date of injury/Date Disease first detected/Date of Delivery

Yes

h) Time:

i) If Medico legal:

Yes

No

SECTION D

Injury

c) Hospitalization due to:

j) System of Medicine

No

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

vii. Pre-Hospitalization period:

Days

Rs.

viii. Post-Hospitalization period:

Hospital Break-up Bill

Days

SECTION E

Total

Hospital Bill Payment Receipt

Hospital Discharge Summary

b) Claim for Domiciliary Hospitalization:

Yes

No

(If yes, provide details in annexure)

Pharmacy Bill
Operation Theatre Notes

c) Details of Lump sum / cash benefit claimed:

ECG

i. Hospital Daily Cash

Rs.

ii. Surgical Cash:

Rs.

Doctor's request for investigation

iiii. Critical illness Benefit:

Rs.

iv. Convalescene:

Rs.

Investigation Reports (including CT/MRI/USG/HPE)

vi. Others:

Rs.

Doctor's Prescriptions

Total

Rs.

Others

v. Pre/Post Hospitlaization
Lump sum benefit

Rs.

DETAILS OF BILLS ENCLOSED:

SL. No.

Bill No.

Date

Issued by

Towards

Amount (Rs)

Hospital Main Bill

Pre-hospitalization Bill:

Post-hospitalization Bill: Nos.

Pharmacy Bills

10

Nos.

SECTION F

DETAILS OF PRIMARY INSURED'S BANK ACCOUNT:

SECTION G

a) PAN:

b) Account Number:

c) Bank Name and Branch:

d) Cheque/DD Payable details:

e) IFSC Code:

(IMPORTANT:PLEASE TURN OVER)

DECLARATION BY THE INSURED:

Date:

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.

Enter the policy number

As allotted by the insurance company

b) Sl. No./Certificate No.

Enter the social insurance number of the certificate number of

social health insurance scheme

As allotted by the organization

c) Company TPA ID No.

Enter the TPA ID No.

License number as allotted by IRDA and printed 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 Insurance?

Indicate whether currently covered by another Medicliam /

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

Tick Yes or No

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

Indicate whether hospitalized in the last four years

Tick Yes or No

d) Have you been Hospitalized in the last four years since

inception of the contract?
Date

Enter the date of hospitalization

User mm-yy format

Diagnosis

Enter the diagnosis details

Open Text

e) Previously Covered by any other Mediclaim / Health

Insurance?

Indicate whether previously covered by another mediclaim /

Health Insurance

Tick Yes or No

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

i) E-mail ID

Enter e-mail address of patient

Complete e-mail address

a) Name of Hospital where Insured

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

Delivery

Enter the relevant date

Use dd-mm-yy format

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 in 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

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

SECTION F - DETAILS OF BILLS ENCLOSED

Tick the right option

SECTION D - DETAILS OF HOSPITALIZATION

SECTION E - DETAILS OF CLAIM

Indicate which bills are enclosed with the amounts in rupees

a) PAN

SECTION G - DETAILS OF PRIMARY INSURED'S BANK ACCOUNT

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 bank name along with the branch

Name of the bank in full

d) Cheque/DD payable details

Enter the name of beneficiary the cheque/DD should be

made out to

Name of the individual/organization in full

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.

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