Please return your completed claim form to:

ManipalCigna Health Insurance Company Limited (Formerly known as CignaTTK Health Insurance Company Limited)
Registered & Corporate Office: 401/402, Raheja Titanium, Western Express Highway, Goregaon (East), Mumbai - 400063.
IRDAI Registration No. 151. Call (Toll Free): 1800-102-4462 Visit: www.manipalcigna.com
E-mail: [email protected] | OR Nearest ManipalCigna Branch.
CIN: U66000MH2012PLC227948
The issue of this Form is not to be taken as an admission of liability
(To be filled in Block Letters) - PARTA - To be filled by Insured

5 easy ways to speed up the claims process

1 2 3 4 5
Submit all original Make sure the form Provide correct For any assistance, Do not conceal
documents as per the is complete and and accurate bank please reach out to or withhold any
checklist within 15 don't forget to sign. details with your health advisor information with
days of discharge Cancelled cheque or connect with our respect to your
from the hospital. Health Relationship claim.
Manager.

MANIPALCIGNA PROHEALTH INSURANCE

CLAIM FORM A
SECTION I - TO BE COMPLETED BY INSURED PERSON/ CLAIMANT
A. DETAILS OF PRIMARY INSURED:

a. Policy Number:

b. Sl. No/Certificate No:

c. Company/ TPA ID No

d. Name: F I R S T N A M E M I D D L E N A M E L A S T N A M E
e. Address:

City: State: Pin Code:

Phone No: Email ID:

B: DETAILS OF INSURANCE HISTORY:

a) Currently covered by any 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 (`):

d) Have you been hospitalised in the last four years since inception of the contract? Yes No Date: D D M M Y Y Y Y

Diagnosis:

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

ManipalCigna ProHealth Insurance | UIN: MCIHLIP24011V072324 | April 2023

f) If yes, Company Name:

C. DETAILS OF INSURED PERSON HOSPITALISED:

a. Name:

b. Gender: Male Female Others

c. Age: Years Months d. Date of Birth D D M M Y Y Y Y

e. Relationship to Primary Insured: Self Spouse Child Father Mother Other (Please specify)

f. Occupation: Service Self Employed Homemaker Student Retired Other (Please specify)

g. Address(If different from above):

City: State: Pin Code:

Phone No: Email ID:

D: DETAILS OF HOSPITALIZATION:

a) Name of the Hospital where admitted:

City: State: Pin Code:

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: D D M M Y Y Y Y

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

a. If Medico Legal: Yes No b. Reported to Police: Yes No c. MLC Report & Police FIR attached: Yes No
j) System of Medicine (Allopathic/ AYUSH):

E. DETAILS OF CLAIM:

a. Details of Treatment Expenses Claimed: Amount (Rs.)

i. Pre-Hospitalization Expenses: b. Claim for Domiciliary Hospitalization: Yes No

ii. Hospitalization Expenses: c. Details of Lump sum/ Cash Benefit Claimed:

iii. Post-Hospitalization Expenses: i. Hospital Daily Cash:
iv. Health Check up Cost: ii. Surgical Cash:
v. Ambulance Charges: iii. Critical illness Benefit:
vi. Others: iv. Convalescence:
Total: v. Pre/Post-Hospitalization
Lump sum Benefit:
vii. Pre-Hospitalization Period: Days
vi. Others (code):
viii. Post-Hospitalization Period: Days
Total:

Claim Documents Submitted Check List: Pharmacy Bill

Claim Form Duly Signed Operation Theatre Notes
Copy of the Claim Intimation, 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 Doctors Prescriptions
Hospital Discharge Summary Others ManipalCigna ProHealth Insurance | UIN: MCIHLIP24011V072324 | April 2023

F. DETAILS OF BILLS ENCLOSED:

Sl. No. Bill No. Date Issued By Towards Nos. Amount (`)

1. D D M M Y Y Y Y Hospital Main Bill

2. D D M M Y Y Y Y Pre-hospitalization Bills: Nos
3. D D M M Y Y Y Y Post-hospitalization Bills: Nos

4. D D M M Y Y Y Y Pharmacy Bills
5. D D M M Y Y Y Y

6. D D M M Y Y Y Y

7. D D M M Y Y Y Y

8. D D M M Y Y Y Y

9. D D M M Y Y Y Y

10. D D M M Y Y Y Y

Total Claimed Amount

G. 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:

Please attach original cancelled Cheque of your bank account, with your name pre-printed on the cheque, for ensuring accuracy of name of the
Bank, Branch name, Account number and IFSC code.

H: DECLARATION BY 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 the Insured:

ManipalCigna ProHealth Insurance | UIN: MCIHLIP24011V072324 | April 2023

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

b) SI. No/ Certificate No. As allotted by the organisation
number of social health insurance scheme
License number as allotted by IRDAI and printed in
c) Company TPA ID No. Enter the TPA ID No
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
Tick Yes or No
Health Insurance? Mediclaim / Health Insurance
b) Date of Commencement of first Insurance without
Enter the date of commencement of first insurance Use dd-mm-yy format
break

c) Company Name Enter the full name of the insurance company Name of the organisation 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 Hospitalised in the last four years

Indicate whether hospitalised in the last four years Tick Yes or No
since 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/ Indicate whether previously covered by another
Tick Yes or No
Health Insurance? Mediclaim / Health Insurance

f) Company Name Enter the full name of the insurance company Name of the organisation in full

SECTION C - DETAILS OF INSURED PERSON HOSPITALISED

a) Name Enter the full name of the patient Surname, First name, Middle name

b) Gender Indicate Gender of the patient Tick Male, Female or Others

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 ManipalCigna ProHealth Insurance | UIN: MCIHLIP24011V072324 | April 2023

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

Enter the relevant date Use dd-mm-yy format
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 Police FIR attached Tick Yes or No

Enter the system of medicine followed in treating the

j) System of Medicine Open Text
patient

SECTION E - DETAILS OF CLAIM

a) Details of Treatment Expenses Enter the amount claimed as treatment expenses In rupees (Do not enter paise values)

Indicate whether claim is for domiciliary

b) Claim for Domiciliary Hospitalization Tick Yes or No
hospitalization

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 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

Enter the name of the beneficiary the cheque/ DD

d) Cheque/ DD payable details Name of the individual/ organisation in full
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.

ManipalCigna ProHealth Insurance | UIN: MCIHLIP24011V072324 | April 2023

CONSENT & AUTHORIZATION LETTER

This consent is being taken in order to expedite the claim adjudication process by the insurer/TPA

Date: - ________________
To,
The Medical Superintendent / Insurance department
Name of Hospital: - ________________________________
Address: - _________________________________________
___________________________________________________

I Mr/Ms ___________________________________was under treatment at your esteemed hospital from DOA_______________ to DOD_________________ under

IP No________________

I hereby consent & authorize ManipalCigna Health Insurance Company Limited / Authorized TPA and their authorized agencies, to seek necessary medical
information / documents from the Hospital / Diagnostic Center/ Chemist / Medical Practitioner and obtain below mentioned documents

1. Indoor case papers

2. Discharge Summary
3. Previous & Follow-Up Consultation Notes
4. Treating doctor’s statement
5. Tariff card
6. Final bill
7. Investigation reports
8. Any other information, if required

We look forward to your prompt action and kind co-operation.

The execution of this consent is of free and voluntary act, without any duress, coercion or undue influence exerted by or on behalf of ManipalCigna Health Insurance
Company Limited.

Yours Sincerely

Signature of Insured/ Proposer

ManipalCigna ProHealth Insurance | UIN: MCIHLIP24011V072324 | April 2023

Know Your Customer
Processing your claim smoothly and quickly is of importance
to you as well as us. Help us remain as your trusted service
partner by ensuring we have a copy of all your documents.

Mandatory KYC documents required

• Original cancelled Cheque with pre-printed
name of the proposer
• For claims over 1 lakh
- Color passport size photograph not older
than 6 months
- Copy of PAN card
- Copy of address proof

Proof of Residence (Any one of below mentioned documents required)

• Driving license / Adhaar card
• Electricity bill / Ration card*
• Letter from any recognised public authority
• Current statement of bank account with details of permanent/ present residence address as
stamped by bank* ManipalCigna ProHealth Insurance | UIN: MCIHLIP24011V072324 | April 2023

• Current passbook with details of permanent/ present residence address (updated up to the
previous month)*
• Valid lease agreement along with rent receipt, which is not more than three months old as a
residence proof
• Telephone bill pertaining to any kind of telephone connection like, mobile, landline,
wireless, etc. provided it is not older than six months from the date of insurance contract
• Employer's certificate as a proof of residence (Certificates of employers who have in place
systematic procedures for recruitment along with maintenance of mandatory records of its
employees are generally reliable)

*Acceptable as Address proof and Identity proof if photograph of applicant is affixed