Group MediPrime Claim Form

PART A
TO BE FILLED IN BY THE INSURED
The issue of this Form is not to be taken as an admission of liability

SECTION A – DETAILS OF PRIMARY INSURED

a) Policy No b) Sl. No/ Certificate No:

c) Company / TPA ID No

d) Name

e) Address

Phone no Code Mobile

Email ID

SECTION B - DETAILS OF INSURANCE HISTORY

a) Currently covered by any other mediclaim health insurance YES NO

b) Date of commencement of first insurance without break D D M M Y Y Y Y

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 NO D D M M Y Y Y Y

Diagnosis

e) Previously covered by any other Mediclaim/Health insurance YES NO

f) If yes, Company Name

SECTION C - DETAILS OF INSURED PERSON HOSPITALISED

a) Name

b) Relationship (Self/spouse/Child/Father/Mother/Other)

c) Date of Birth D D M M Y Y Y Y d) Age mths/yrs

e) Address (If different than above)

Phone no Code Mobile

Email ID

f) Gender Male Female g) Occupation Service/Self employed/Homemaker/Student/Retired/Others

h)Telephone i) Mobile No

j) E-mail ID, if any

SECTION D - DETAILS OF HOSPITALISATION

a) Name of the Hospital where admitted

b) Room Category occupied Daycare/Single Occupancy/Twin Sharing/ 3 or more beds per room

c) Hospitallisation due to Illness / Injury / Maternity

d) Date of Injury/ Date of disease first detected/ D D M M Y Y Y Y

Date of delivery

e) Date of admission D D M M Y Y Y Y

f) Time H H M M

g) Date of discharge D D M M Y Y Y Y

h) Time H H M M

i) If injury, give cause Self Inflicted/Road Traffic Accident/Substance Abuse/Alcohol Consumption

ii) If Medico legal YES NO ii) Reported to police? YES NO

iii) MLC Report, & Police FIR attached? YES NO j) System of medicine Allopathic/Other
systems of medicine

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 SECTION E - DETAILS OF CLAIM
a)Details of the treatment expenses claimed

i) Pre-hospitalisation Expenses Rs. ii) Hospitalisation Expenses Rs.

iii) Post-hospitalisation Expenses Rs. iv) Health-Check up Cost Rs.

v) Ambulance Charges Rs. vi) Others (code) Rs

Total Rs.

vii) Pre-hospitalisation Period Days viii) Post -hospitalisation Period

a) Claim for Domiciliary Hospitalization YES NO (if yes, please provide details i9n annexure)

b) Details of Lumpsum / cash benefit claimed:

i) Hospital Daily Cash Rs. ii) Surgical Cash Rs.

iii) Critical Illness Benefit Rs. iv) Convalescence Rs.

v) Pre/Post hospitalisation Rs. vi) Others Rs.

lumpsum benefit:

Claim Documents Submitted - Check List:

• Duly filled and signed Claim Form • Operation Threater Notes
• Copy of intimation letter, if any • ECG
• Hospital Main Bill • Doctor's Request for Investigation
• Hospital Break Up bill • Investigation Reports ( Including CT, MRI/USG/HPE)
• Hospital Bill Payment Receipt • Doctor's Prescription.
• Hospital Discharge Summary • Others
• Pharmacy Bill

SECTION – F DETAILS OF BILLS ENCLOSED

Sno Bill No Date Issued By Towards Amount (Rs)
D D M M Y Y Y Y
D D M M Y Y Y Y
D D M M Y Y Y Y
D D M M Y Y Y Y
D D M M Y Y Y Y
D D M M Y Y Y Y
D D M M Y Y Y Y
D D M M Y Y Y Y
D D M M Y Y Y Y
D D M M Y Y Y Y
D D M M Y Y Y Y

SECTION – G DETAILS OF PRIMARY INSURED’S BANK ACCOUNT

a) PAN b) Account Number

c) Bank Name/ Branch d) Payable details: Cheque/ DD
e) IFSC Code e) *please attach a cancelled cheque pertaining to the same
f) MICR No *please attach a cancelled cheque pertaining to the same
Note:
It is agreed that the Policyholder/Claimant will intimate in writing to Tata-AIG General Insurance Co. Ltd. about any change in bank
account details. In an event Insured person bears expenses for treatment please provide account details of Insured Persons in the
above format along with proof of incurring such expenses.

SECTION H – 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 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.

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

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 GUIDANCE FOR FILLING CLAIM FORM – PART A (To be filled in by the insured)
DATA ELEMENT DESCRIPTION FORMAT
SECTION A - DETAILS OF PRMARY INSURED
a) Policy No. Enter the policy number As allotted by the insurance company
b) SI. No/ Certificate No. Enter the social insurance number or the As allotted by the organizationcertificate
number of social health insurance scheme
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 Indicate whether currently covered by Tick Yes or No
Mediclaim / Health Insurance? another Mediclaim / Health Insurance
b) Date of Commencement of first Enter the date of commencement of Use dd-mm-yy format
Insurance without break first insurance
c) Company Name Enter the full name of the insurance Name of the organization in full
company
Policy No. Enter the policy number As allotted by the insurance company
Sum Insured Enter the total sum insured as per In rupees
the policy
d) Have you been Hospitalized in Indicate whether hospitalized in Tick Yes or No
the last 4 years the last 4 years
Date Enter the date of hospitalization Use mm-yy format
Diagnosis Enter the diagnosis details Open Text
e) Previously Covered by any other Indicate whether previously covered by Tick Yes or No
Mediclaim/ Health Insurance? another Mediclaim / Health Insurance
f) Company Name Enter the full name of the insurance Name of the organization in full
company\
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 Tick the right option. If others, please
policyholder 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 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/ Enter the relevant date Use dd-mm-yy format
Date of 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 Tick Yes or No
Police FIR attached
j) System of Medicine Enter the system of medicine followed Open Text
in treating the patient
SECTION E - DETAILS OF CLIAM
a) Details of Treatment Expenses Enter the amount claimed as In rupees (Do not enter paise values)
treatment expenses
b) Claim for Domiciliary Hospitalization Indicate whether claim is for Tick Yes or No
domiciliary hospitalization
c) Details of Lump sum / Enter the amount claimed as lump sum / In rupees (Do not enter paise values)
cash benefit claimed cash benefit
d) Claim Documents Submitted-Check List Indicate which supporting documents Tick the right option
are submitted
SECTION F - DETAILS OF BILLS ENCLOSED
Indicate which bills are enclosed with the amounts 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
d) Cheque/ DD payable details Enter the name of the beneficiary the Name of the individual/ organization in full
cheque / DD should be 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.
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 PART B
TO BE FILLED IN BY THE HOSPITAL
The issue of this Form is not to be taken as an admission of liability
Please include the original preauthorisation request form in lieu of PART A
SECTION A – DETAILS OF HOSPITAL
a) Name of the Hospital where treated b) Hospital ID
c) Type of Hospital Network Non Network
(If non network fill form section E)
d) Name of the treating Doctor
e) Qualification f) Registration No with state Code
g) Phone No:

SECTION B – DETAILS OF PATIENT ADMITTED

a) Name of the patient

b) IP Registration Number
c) Gender Male Female d) Age Y Y M M e)Date of Birth D D M M Y Y Y Y
f) Date of Admission D D M M Y Y Y Y g) Time of Admission H H M M
h) Date of Discharge D D M M Y Y Y Y i) Time of Discharge H H M M
j) Type of Admission Emergency/Planned/Daycare/Maternity k) If Maternity
i) Date of Delivery D D M M Y Y Y Y ii) Gravida Status
l) Status at time of discharge Discharged to Home,
Discharged to another Hospital, Deceased Total Claimed Amount Rs H H M M

SECTION C – DETAILS OF AILMENTS DIAGNISED (PRIMARY)

a) ICD 10 Code Primary Additional
Diagnosis Diagnosis Co-morbidities
Details of
Procedure/s done
b) ICD 10 PCS Procedure 1 Procedure 2 Procedure 3
d) Pre-authorization Y N e) Pre-authorization No
obtained
f) If authorization by
network hospital not
obtained, give reason
g) Hospitalisation Y N i) If yes, give cause
due to Injury
Self inflicted? Y N Road Traffic Accident Y N
Substance Abuse / Alcohol Consumption Y N
ii) If Injury due to Substance abuse / alcohol consumption, Test Conducted to establish this: Y N
(If yes, attach reports Y N v) FIR No
iii) Medico Legal Y N vi) If not reported to Policy give reasons
iv) Reported to Policy Y N
SECTION D – CLAIM DOCUMENTS SUBMITTED - CHECKLIST

Claim form duly filled and signed Investigation reports

Original Pre authorization Request CT/MRI/USG/HPE investigation Report
Copy of Pre-authorization approval Letter Doctor's reference slip for Investigation
Copy of photo ID card of patient verified by Hospital ECG
Hospital Discharge Summary Pharmacy Bills
Operation Theatre Notes MLC Report & Police FIR
Hospital Main Bill Original death summary from hospital where applicable
Hospital break up Bill Any other, Pl specify

SECTION E –ADDITIONAL DETAILS IN CASE OF NON NETWORK HOSPITAL

a) Address of the Hospital

b) Phone NO: c) Registration no with State Code

d) Hospital PAN e) No of In-patient Beds

f) Facilities available in Hospital:

i) OT Y N ii) ICU Y N

iii) Others

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 SECTION F – DECLARATION BY HOSPITAL
We hereby declare that the information furnished in this Claim Form is true & correct to the best of our knowledge and belief. If we
have made any false or untrue statement, suppression or concealment of any material fact, our right to claim under this claim shall
be forfeited.

Date D D M M Y Y Y Y Place
Signature and seal of the Hospital Authority

GUIDANCE FOR FILLING CLAIM FORM – PART B (To be filled in by the hospital)
DATA 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 Tick the right option
network Hospital
d) Name of treating doctor Enter the name of the treating doctor Name of doctor in full
e) Qualification Enter the qualifications of the treating doctor Abbreviations of educational qualifications
f) Registration No. with State Code Enter the registration number of the doctor As allocated by the Medical Council
along with the state code of India
g) Phone No. Enter the phone number of doctor Include STD code with telephone number
SECTION B - DETAILS OF THE PATIENT ADMITTED
a) Name of Patient Enter the name of hospital Name of hospital in full
b) IP Registration Number Enter insurance provider registration As allotted by the insurance provider
number
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 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) Type of Admission Indicate type of admission 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
k) Status at time of discharge Indicate status of patient at time of discharge Tick the right option
SECTION C - DETAILS OF AILMENT DIAGNOSED (PRIMARY)
a) ICD 10 Code
Primary Diagnosis Enter the ICD 10 Code and description Standard Format and Open text
of the primary diagnosis
Additional Diagnosis Enter the ICD 10 Code and description Standard Format and Open text
of the additional diagnosis
Co-morbidities Enter the ICD 10 Code and description Standard Format and Open text
of the co-morbidities
b) ICD 10 PCS
Procedure 1 Enter the ICD 10 PCS and description Standard Format and Open text
of the first procedure
Procedure 2 Enter the ICD 10 PCS and description Standard Format and Open text
of the second procedure
Procedure 3 Enter the ICD 10 PCS and description Standard Format and Open text
of the third procedure
Details of Procedure Enter the details of the procedure Open text
c) Present Ailment is a Complication Indicate whether present ailment is a Tick Yes or No
of PED complication of some pre- existing disease
d) Pre-authorization obtained Indicate whether pre-authorization obtained Tick Yes or No
e) Pre-authorization Number Enter pre-authorization number As allotted by TPA
f) If authorization by network hospital Enter reason for not obtaining Open text
not obtained, give reason pre-authorization number
g) Hospitalization due to injury Indicate if hospitalization is due to injury Tick Yes or No
Cause Indicate cause of injury Tick the right option
If injury due to substance Indicate whether test conducted Tick Yes or No
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
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
SECTION D - CLAIM DOCUMENTS SUBMITTED-CHECK LIST
Indicate which supporting 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 account 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

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 PART C
(To be filled ONLY for re-imbursement under wellness benefit of Product Name policy)

SECTION A – DETAILS OF PRIMARY INSURED

Policy No

Member ID Company/ TPA ID No

Name

Address

Telephone No Mobile

Email ID

Policyholder's Bank Account particulars

Policyholders PAN Account Number

Payable details: Cheque/ DD/NEFT* Payable to

Bank Name/ Branch

IFSC Code MICR No

*please attach a cancelled cheque pertaining to the same

Note:
It is agreed that the Policyholder/Claimant will intimate in writing to Tata-AIG General Insurance Co. Ltd. about any change in
bank account details.
Sl. No. Bill No. Date Issued by Towards Amount

Total

DECLARATION BY THE INSURED

l I confirm that the expenses for which claim is being lodged have been incurred in respect of the insured.
l 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 for this policy year.

Date:
Signature of the Policyholder

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CHECK LIST OF ENCLOSURES FOR SUBMISSION OF CLAIM
l Duly filled and signed Re-imbursement Form.
l Original payment Receipt of the hospital bill.

CHECK LIST OF ENCLOSURES FOR SUBMISSION OF CLAIM

Note:
1. When original bills, receipts, prescriptions, reports and other documents are submitted to the other insurer or to the
reimbursement provider, verified photocopies attested by such other organisation/provider have to be submitted.
2. If original bills, receipts, prescriptions, reports and other documents are submitted to Us and Insured Person requires
same for claiming from other organisation/provider, then on request from the Insured Person We will provide attested
copies of the bills and other documents submitted by the Insured Person.
In-patient Treatment /Day Care Procedures
l Duly filled and signed Claim Form.
l Photocopy of ID card / Photocopy of current year policy.
l Original Detailed Discharge Summary with date of admission & discharge, clinical history, past history / procedure
details/ Day care summary from the hospital.
l Original consolidated hospital bill with break up of each Item, duly signed by the insured.
l Original payment Receipt of the hospital bill.
l First Consultation letter and subsequent Prescriptions.
l Original bills, original payment receipts and Reports for investigation.
l Original medicine bills and receipts with corresponding Prescriptions.
l Original invoice/Sticker of implants/bills for Implants (viz. Stent /PHS Mesh/ IOL etc.) with original payment receipts.
Road Traffic Accident
In addition to the In-patient Treatment documents:
l Copy of the First Information Report from Police Department / Copy of the Medico-Legal Certificate.
In Non Medico legal cases
l Treating Doctor's Certificate giving details of injuries (How, when and where injury sustained)
In Accidental Death cases
l Copy of Post Mortem Report & Death Certificate ( If conducted)
For Death Cases
In addition to the In-patient Treatment documents:
l Original Death Summary from the hospital.
l Copy of the Death certificate from treating doctor or the hospital authority.
l Copy of the Legal heir certificate, if the claim is for the death of the principle insured.
Pre and Post-hospitalisation expenses
l Duly filled and signed Claim Form.
l Photocopy of ID card / Photocopy of current year policy.
l Original Medicine bills, original payment receipt with prescriptions.
l Original Investigations bills, original payment receipt with prescriptions and report.
l Original Consultation bills, original payment receipt with prescription.
l Copy of the Discharge Summary of the main claim.
Organ Donation/Transplantation
In addition to the documents of general hospitalization
l Organ Function test / blood test proving organ failure.
l Treatment Certificate issued by the Transplant Surgeon of the hospital concerned.
Ambulance Benefit
l Duly filled and signed Claim Form.
l Photocopy of ID card / Photocopy of current year policy.
l Original Bill with Original Payment Receipt.
l Treating Doctor's consultation prescription indicating Emergency Hospitalization.

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Customer Identification Procedure (as per KYC norms of IRDA)
Please submit the following documents in case of claim amount exceeds Rs. 100,000
Legal name and any other names used Passport/ PAN Card/ Voter’s Identity Card/ Driving License/
(Any one of the mentioned documents) Letter from a recognized public authority or public servant
verifying the identity and residence of the customer
Proof of Residence Telephone bill/ Bank account statement/ Letter from any
(Any one of the mentioned documents) recognized public authority/ Electricity bill/ Ration card

For more information; Email us at [email protected] or visit www.tataaiginsurance.in

Contact us on our 24 hour Toll Free Helpline at 1800 266 7780 or 1800 22 9966
(only for senior citizen policy holders) Insurance is the subject matter of the solicitation

Tata AIG General Insurance Company Limited

Registered Office: Peninsula Business Park, Tower A, 15th Floor, G.K. Marg, Lower Parel, Mumbai – 400013
24X7 Toll Free No: 1800 266 7780 or 1800 22 9966 (For Senior Citizens) Fax: 022 6693 8170 Email: [email protected]
Website: www.tataaiginsurance.in IRDA of India Registration No: 108 CIN:U85110MH2000PLC128425