CLAIM FORM FOR HEALTH INSURANCE POLICIES OTHER THAN

Vipul Medcorp lnsurance TPA Pvt Ltd. TRAVEL AND PERSONAL ACCIDENT - PART A
Redefining Healthcare Services... TO BE FILLED IN BY THE INSURED
The issue of this Form is not to be taken aass an admission of liability
DETAILS OF PRIMARY INSURED: (To be filled in block letters)

a) PolicyNo: b) SI. No/ Certificate No:

c) Company/ TPA ID No:

d)Name

e)Address:

City: State:

Pin Code: Phone No: Email lD

DETAILS OF INSURANCE HISTORY:

a) Currently covered by any other Mediclaim / Health Insurance: Yes No 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 No Date

Diagnosis e) Previously covered by any other Mediclaim / Health insurance: Yes No

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 Homemake Student Retired Other (Please Specify)

g)Address:

City: State:

Pin Code: Phone No: Email lD

DETAILS OF HOSPITALIZATION:

a) Name ol Hospital where Admitted:

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) Dated of Admission: f) Time: : g) Date ol Discharge h)Time: :

i) If Injury give cause Self inflicted Road Traffic Accident Substance Abuse/Alcohol Consumption i. If Medico legal: Yes No

ii. Reported to police: Yes No iii. MLC Report & Police FIR attached: Yes No j) System of Medicine:

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-Checkup Cost: Rs Copy of the claim intimation, if any

v. Ambulance Charges: Rs vi. Others (code) Rs Hospital Main Bill

Hospital Break-up Bill
Total Rs
Hospital Bill Payment Receipt
vii. Pre-hospitalization period: Days viii. Post-hospitalization period Days Hospital Discharge Summary

b) Claim for Domiciliary Hospitalization: Yes No (If yes, provide details in annexure) Operation Theatre Notes

c) Details of Lump sum / cash benefit claimed: ECG

Doctor's request for investigation
i. Hospital Daily Cash: Rs ii. Surgical Cash: Rs
Investigation Reports (Including CT
iii. Critical Illness Benefit: Rs iv. Convalescence: Rs MRI / USG / HPE)

v. Pre/Post hospitalization Lump Rs vi. Others (code) Rs Doctor’s Prescriptions

sum benefit:
Rs Others
Total
DETAILS OF BILLS ENCLOSED:

S.No Bill No Date Issued By Towards Amount (Rs)

1.
2.
3.
4.
5.
6.
7.
8.
9.
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:

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: 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
Enter the social insurance number or the certificate number
b) SI. No/ Certificate No. of social health insurance scheme As allotted by the organization

c) Company TPA ID No. Enter the TPA ID No License number a s 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 Indicate whether currently covered by another Mediclaim /
/ Health Insurance? Health Insurance Tick Yes or No

b) Date of Commencement of first Insurance Enter the date of commencement of first insurance Use dd-mm-yy format
without break
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 a s per the policy In rupees
d) Have you been Hospitalized in the last four
years since inception of the contract? Indicate whether hospitalized in the last four years Tick Yes or No

Date Enter the date of hospitalization Use mm-yy format

Diagnosis Enter the diagnosis details Open Text
e) Previously Covered by any other Mediclaim Indicate whether previously covered by another Mediclaim /
/ Health Insurance? 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 policyholder 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
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 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 Enter date of discharge
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 a s 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 a s 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
 CLAIM FORM - PART B
Vipul Medcorp lnsurance TPA Pvt Ltd. TO BE FILLED IN BY THE HOSPITAL
Redefining Healthcare Services...
The issue of this Form is not to be taken aass an admission of liability
Please indude the original preauthorization request form in lieu of PART A
DETAILS OF HOSPITAL (To be filled in block letters)

a) Name of the hospital:

b) Hospital ID: c) Type of Hospital: Network Non Network (If non network fill section E)

d) Name of the treating doctor:

e) Qualification: f) Registration No. with State Code: g) Phone No.

DETAILS OF THE PATIENT ADMITTED

a) Name of the Patient:

b) IP Registration Number c) Gender: Male Female d)Age: Years Months e) Date of birth:

f) Dated of Admission: g)Time: : h) Date ol Discharge i)Time: :

j) Type of Admission: Emergency Planned Day Care Maternity k) If Maternity i. Date of Delivery ii. Gravida Status:

I) Status at time of discharge: Discharge to home Discharge to another hospital Deceased m) Total claimed amount

DETAILS OF AILMENT DIAGNOSED (PRIMARY)

Description
a) ICD10 Codes Description b) ICD 10 PCS

i. Primary Diagnosis i. Procedure1

ii. Additional Diagnosis: ii. Procedure2:

iii. Co-morbidities: iii. Procedure3:

iv. Co-morbidities: iv. Details of Procedure:

c) Pre-authorization obtained: Yes No d) Pre-authorization Number:

e) If authorization by network hospital not obtained, give reason:

f) Hospitalization due to Injury: Yes No i. If Yes, give cause Self-inflicted Road Traffic Accident Substance abuse / alcohol consumption

ii.If Injury due to Substance abuse / alcohol consumption, Yes No (If Yes, attach reports) iii. If Medico legal Yes No iv. Reported to Police: Yes No
Test Conducted to establish this:

v. FIR no. vi. If not reported to police give reason

CLAIM DOCUMENTS SUBMITTED - CHECK LIST

Claim Form duly signed Investigation reports

Original Pre-authorization request CT/MR/USG/HPE investigation reports

Copy of the 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, please specify

ADDITIONAL DETAILS IN CASE OF NON NETWORK HOSPITAL (ONLY FILL IN CASE OF NON-NETWORK HOSPITAL)

a) Address of the Hospital

City: State:

Pin Code: b) Phone No: c) Registration No. with State Code

d) Hospital PAN: e) Number of inpatient beds: d) Facilities available in the Hospital : i) OT: Yes No ii) ICU: Yes No

iii) Others:

DECLARATION BY THE HOSPITAL (PLEASE READ VERY CAREFULLY)

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 fad, our right to claim under this claim shall be forfeited.

Date : Signature and Seal of the Hospital Authority

Place :