CLAIM ACKNOWLEDGMENT SHEET CLAIM … Bupa/Reimburse… · C(ai) For) CLAIM FORM The issue of this For) is not to be taken as an ad)ission of (iabi(ity PART A TO BE FILLED IN BY THE

Name of Insurer : Policy No :

Insured Name : Patient Name :

PHS ID : Employee No :

Mobile No : Phone (STD) :

E-Mail ID : Type of Claim :

Main Hospitalisation / Pre-Post

Hospitalisation / OPD Claim /

Deficiency Retrieval / Critical Illness /

Cash Benefit

Sr. No Description

Document

Status Remarks

1 IRDA Claim Form duly signed by the Insured

2 Policy Copy

3 64VB Compliance Certificate

4

Original Cancelled Cheque copy of Employee/Proposer with the name of the Account

Holder Printed on the Cheque Leaf.

5 Photo Identity & Address Proof of Insured (In case claim amount is 1 lac & above)

6

Original detailed Discharge Summary / Day care summary from the hospital in case of

Day Care Treatment / Death Summary in Case of Death Claim

a) Copy of the Legal heir certificate, if the claim is for the death of the principle insured.

b) Copy of Post Mortem Report & Death Certificate (In Accidental Death cases)

PARAMOUNT HEALTH SERVICES & INSURANCE TPA PRIVATE LIMITED (IRDA License No. 006)

[formerly known as PARAMOUNT HEALTH SERVICES (TPA) PVT.LTD]

Plot no.A-442, Road No-28,M.I.D.C Industrial Area, Wagale Estate, Ram Nagar, Vitthal Rukmani Mandir, Thane (W), Mumbai, Pin Code 400 604

CLAIM ACKNOWLEDGMENT SHEET

CLAIM DOCUMENT CHECK LIST

Name of Corporate:

b) Copy of Post Mortem Report & Death Certificate (In Accidental Death cases)

7 Original Final Hospital bill with breakup of each Item

8 Original Payment Receipt of Main Hospital bill ( both Deposit / Refund)

a) Receipt Of Payments made at the Hospital by Credit Card : Please attach the Xerox

Copy of the Credit Card Payment Slip as received from the Vendor

9

Original copy of Implant Invoice along with Payment Receipts & Implant Labels /

Stickers for Stents/Mesh/IOL

10 Original bills, original Payment Receipts and investigation / Laboratory Reports

11

Original medicine bills specifying Patient Name and date of purchase along with

supporting Prescriptions.

12 Original copy of First Consultation letter and subsequent Prescriptions.

13

In case of No / Delay Intimation & Delay in submission of claim, a letter from insured is

required stating reason for the same

14 OTHER DOCUMENTS

a

Original copy of Obstetric history (Gravida, Para, Living children, Abortions) from

treating doctor. (Maternity Claim)

b Original Sonography Report in case of Maternity Claim

c

Original A-Scan Report along with IOL Sticker and Tax paid invoice in case of Cataract

Claim

d

Copy of the First Information Report (FIR) from Police Department / Copy of the

Medico-Legal Certificate (MLC) in case of Road Traffic Accident (RTA)

e

A medical certificate from a doctor not less qualified than MD/MS confirming the

diagnosis of critical illness along with the Investigation reports/Other related

documents reflecting the critical illness diagnosis. (Critical Illness Cases)

f

In case of claims where the insured has submitted documents to another insurance co.

/TPA, he needs to submit attested Photocopies of all the documents along with

detailed claim settlement letter from the TPA and any unpaid bills and receipt for the

same in originals.

Claims Submitted by : Insured / Corporate / Agent / Broker / Insurer / Hopsital

Claim Submitted by: Mobile No.Claim Submitted by: Mobile No.

Date of Claim

Submission: DD/MM/YYYY HH:MM

PHS Executive

Name:

Claim Submitted at: PHS - (Location) / Help Desk Signature:

Important Points to Remember:-

6. Member is advised to keep photocopies of all the papers since Insurer requires all the above documents in original. Documents once submitted will not returned

unless approved & agreed by Insurer

7. Corrections in any documents are not allowed

5. Please visit us at www.paramounttpa.com to check Online Claim Status or download Paramount Mobile App

3. Claim Need to be Submitted within 7 Working Days from Date of Discharge from Hospital

4. The above list of documents is indicative. In case of any other document requirement as specified by the Insurance Company, our document recovery team will

contact you on receipt of your claim documents by us

2. Date of File Received will be considered as next working day for Claim Files picked up at Help Desk

1. Please mark either or against respective check box

C(ai) For)CLAIM FORM

The issue of this For) is not to be taken as an ad)ission of (iabi(ity

PART A

TO BE FILLED IN BY THE INSURED TO BE FILLED IN BLOCK LETTERS

SECTIONA - DETAILS OF PRIMARY INSURED

a Po(icy No. : b S(. No/ 3ertificate No. :

c 3o)pany/ TP1 ID No :

d Na)e :

SECTION B - DETAILS OF INSURANCE HISTORY

a 3urrent(y covered by any other )edic(ai) hea(th insurance Yes / No

b Date of co))ence)ent of first Insurance for the person without break : DD/MM/YYYY :

c If Yes, 3o)pany Na)e :

Po(icy No. : Su) Insured :

d 7ave you been hospita(ized in the (ast four years since inception of the contract? Yes / No DD/MM/YYYY :

e Previous(y covered by any other Medic(ai)/7ea(th insurance Yes / No

f If Yes, 3o)pany Na)e :

SECTION C - DETAILS OF THE INSURED PERSON HOSPITALISED :

a Na)e :

b Re(ationship : Se(f / Spouse / 3hi(d / 5ather / Mother / Other

e 6ender: Ma(e / 5e)a(e

g Occupation : Service / Se(f e)p(oyed / 7o)e)aker / Student / Retired / Others

SECTION D - DETAILS OF HOSPITALISATION :

a Na)e of the 7ospita( where ad)itted :

b Roo) 3ategory occupied : Day care / Sing(e occupancy / Twin sharing / or )ore beds per roo)

c 7ospita((isation due to I((ness / Injury / Maternity : Detai(s :

d Date of Injury/ Date of disease first detected/ Date of de(ivery : DD/MM/YYYY :

e Date of ad)ission : DD/MM/YYYY : f Ti)e : 77/MM :

g Date of discharge : DD/MM/YYYY : h Ti)e : 77/MM :

i If injury, give cause : Se(f Inf(icted / Road Traffic 1ccident / Substance 1buse / 1(coho( 3onsu)ption

i If Medico (ega( Yes / No ii Reported to po(ice? Yes / No iii ML3 Report, & Po(ice 5IR attached? Yes / No

j Syste) of )edicine : 1((opathic / Other syste)s of )edicine

SECTION E - DETAILS OF CLAIM :

a Detai(s of the treat)ent expenses c(ai)ed :

i Pre-hospita(isation 4xpenses Rs. ii 7ospita(isation 4xpenses Rs.

iii Post-hospita(isation 4xpenses Rs. iv 7ea(th-3heck up 3ost Rs.

D D M M Y Y Y Y

D D M M Y Y Y Y

c Date of 2irth : 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 1ge YY/MM : M MY Y

7 7 M M

7 7 M M

Non-sub)ission of origina( bi((s and receipts is the )ain reason for de(ay in c(ai) sett(e)ents. P(ease provide the origina(s

Provide your bank detai(s for direct/ E(ectronic Fund Transfer EFT for faster c(ai) sett(e)ent. Refer Part A - Section G

To receive updates on your c(ai) status, p(ease provide your )obi(e no. & E-)ai( ID

You can check your c(ai) status at: www.)axbupa.co) C(ai)s C(ai)s statusLogin to check status

Do You Know

Diagnosis :

P(ease Specify :

P(ease Specify :

e 1ddress :

3ity : State :

Pin 3ode : 4)ai( ID :Phone No. :

f 1ddress :

3ity : State :3ity : State :


P(ease dispatch your c(ai) docu)ent to: Max 2upa 3orporate Office: 2(oc 2 /I- , Mohan 3ooperative Industria( 4state, Mathura Road, New De(hi - .

v 1)bu(ance 3harges Rs. vi Others code Rs.

Tota( Rs.

C(ai) For)

vii Pre-hospita(isation Period Days viii Post -hospita(isation Period Days

b 3(ai) for Do)ici(iary 7ospita(ization : Yes / No if yes, p(ease provide detai(s in annexure

c Detai(s of Lu)psu) / cash benefit c(ai)ed :

i 7ospita( Dai(y 3ash Rs. ii Surgica( 3ash Rs.

iii 3ritica( I(Iness 2enefit Rs. iv 3onva(escence Rs.

v Pre/Post hospita(isation (u) psu) benefit: Rs. vi Others Rs.

3(ai) Docu)ents Sub)itted- 3heckList:

Du(y fi((ed and signed 3(ai) 5or) 3opy of inti)ation (etter, if any

7ospita( Main 2i(( 7ospita( 2reak Up bi((

7ospita( 2i(( Pay)ent Receipt 7ospita( Discharge Su))ary

Phar)acy 2i(( Operation Threater Notes

436 Doctors Request for Investigation

Investigation Reports Inc(uding 3T, MRI/US6/7P4 Doctors Prescription

Others


SECTION H - DECLARATION BY THE INSURED

Date : P(ace :

D D M M Y Y Y Y Signature of Insured :

I hereby dec(are that the infor)ation furnished in this c(ai) for) is true & correct to the best of )y know(edge and be(ief. If I have )ade any fa(se or untrue state)ent,

suppression or concea()ent of any )ateria( fact with respect to questions asked in re(ation to this c(ai), )y right to c(ai) rei)burse)ent sha(( be forfeited. I a(so consent

& authorize TP1 / insurance co)pany, to seek necessary )edica( infor)ation / docu)ents fro) any hospita( / Medica( Practitioner who has attended on the person against

who) this c(ai) is )ade. I hereby dec(are that I have inc(uded a(( the bi((s / receipts for the purpose of this c(ai) & that I wi(( not be )aking any supp(e)entary c(ai) except

the pre/post-hospita(isation c(ai), if any.

SECTION - F DETAILS OF BILLS ENCLOSED :

S(. No. Bi(( No. Date Issued by TowardsS(. No. Bi(( No. Date Towards A)ount Rs.

D D M M Y Y

D D M M Y Y

D D M M Y Y

D D M M Y Y

D D M M Y Y

D D M M Y Y

D D M M Y Y

D D M M Y Y

D D M M Y Y

D D M M Y Y

D D M M Y Y

7ospita( Main 2i((

Pre-hospita(isation 2i((s:___Nos

Post-hospita(isation 2i((s:___Nos

Phar)acy 2i((s

SECTION - G DETAILS OF PRIMARY INSUREDS BANK ACCOUNT :

a 1ccount 7o(ders Na)e:

d 2ank Na)e : 2ranch :

g MI3R No :

e I5S3 3ode :

b P1N No : c 1ccount No :

f Pay)ent option: 3heque / DD / N45T

Note: P(ease sub)it a cance((ed cheque (eaf or a copy of (atest bank state)ent or passbook with a/c ho(ders na)e, account no. and I5S3 code )entioned on it.

C(ai) For)

In-patient Treat)ent /Day Care Procedures

q Du(y fi((ed and signed 3(ai) 5or).

q Photocopy of ID card / Photocopy of current year po(icy.

q Origina( Detai(ed Discharge Su))ary / Day care su))ary fro) the hospita(.

q Origina( conso(idated hospita( bi(( with break up of each Ite), du(y signed by the insured.

q Origina( pay)ent Receipt of the hospita( bi((.

q 5irst 3onsu(tation (etter and subsequent Prescriptions.

q Origina( bi((s, origina( pay)ent receipts and Reports for investigation.

q Origina( )edicine bi((s and receipts with corresponding Prescriptions.

q Origina( invoice/bi((s for I)p(ants viz. Stent /P7S Mesh / IOL etc. with origina( pay)ent receipts.

Road Traffic Accident

In addition to the In-patient Treat)ent docu)ents:

q 3opy of the 5irst Infor)ation Report fro) Po(ice Depart)ent / 3opy of the Medico-Lega( 3ertificate.

In Non Medico (ega( cases

q Treating Doctors 3ertificate giving detai(s of injuries 7ow, when and where injury sustained

In 1ccidenta( Death cases

q 3opy of Post Morte) Report & Death 3ertificate

For Death Cases


q Origina( Death Su))ary fro) the hospita(.

q 3opy of the Death certificate fro) treating doctor or the hospita( authority.

q 3opy of the Lega( heir certificate, if the c(ai) is for the death of the princip(e insured.

Pre and Post-hospita(isation expenses



q Origina( Medicine bi((s, origina( pay)ent receipt with prescriptions.

q Origina( Investigations bi((s, origina( pay)ent receipt with prescriptions and report.

q Origina( 3onsu(tation bi((s, origina( pay)ent receipt with prescription.

q 3opy of the Discharge Su))ary of the )ain c(ai).

Outpatient Benefit/Denta(



q Origina( Medicine bi((s, origina( pay)ent receipt.

q Origina( Investigations bi((s, origina( pay)ent receipt with report.

q Origina( 3onsu(tation bi((s, origina( pay)ent receipt with prescription.

q Detai(s of any Outpatient Procedures, If any

q Denta( X-ray fi().

Dai(y Cash Benefit



Organ Donation/Transp(antation

In addition to the docu)ents of genera( hospita(isation

q Organ 5unction test / b(ood test proving organ fai(ure.

q Treat)ent 3ertificate issued by the Transp(ant Surgeon of the hospita(

concerned.

A)bu(ance Benefit



q Origina( 2i(( with Origina( Pay)ent Receipt.

q Treating Doctors consu(tation prescription indicating 4)ergency

7ospita(ization.

Maternity Expenses


q Obstetric history 6ravida, Para, Living chi(dren, 1bortions fro)

treating doctor.

Critica( I((ness Benefit



q 1 )edica( certificate confir)ing the diagnosis of critica( i((ness fro) a

doctor not (ess qua(ified than MD/MS.

q Investigation reports / other re(ated docu)ents ref(ecting the critica(

i((ness diagnosis.

Hea(th Check up



q Origina( Investigation bi((s, origina( pay)ent receipts with Reports.

q Origina( 3onsu(tation bi((s and origina( pay)ent receipts with prescription.

Expenses for spectac(es/contact (enses, hearing aids



q Prescription of the Treating Doctor.

q Origina( Invoice/bi((s, origina( pay)ent receipt of the device, app(iances, (ens etc.

CHECK LIST OF ENCLOSURES FOR SUBMISSION OF CLAIM


q Du(y fi((ed and signed 3onsent 5or).

GUIDANCE FOR FILLING CLAIM FORM - PART A :

D1T1 4L4M4NT D4S3RIPTION 5ORM1T

S43TION 1 - D4T1ILS O5 PRIM1RY INSUR4D

a Po(icy No. 4nter the po(icy nu)ber 1s a((otted by the insurance co)pany

b SI. No/ 3ertificate No. 4nter the socia( insurance nu)ber or the 3ertificate nu)ber of socia(

hea(th insurance sche)e

1s a((otted by the organization

c 3o)pany TP1 ID No. 4nter the TP1 ID No License nu)ber as a((otted by IRD1 and

printed in TP1 docu)ents

d Na)e 4nter the fu(( na)e of the po(icyho(der Surna)e, 5irst na)e, Midd(e na)e

e 1ddress 4nter the fu(( posta( address Inc(ude Street, 3ity and Pin 3ode

S43TION 2 - D4T1ILS O5 INSUR1N34 7ISTORY

a 3urrent(y covered by any other

Medic(ai) / 7ea(th Insurance?

Indicate whether current(y covered by another Medic(ai) / 7ea(th

Insurance

Tick Yes or No

b Date of 3o))ence)ent of first

Insurance without break

4nter the date of co))ence)ent of first insurance Use dd-))-yy for)at

c 3o)pany Na)e 4nter the fu(( na)e of the insurance co)pany Na)e of the organization in fu((

Po(icy No. 4nter the po(icy nu)ber 1s a((otted by the insurance co)pany

Su) Insured 4nter the tota( su) insured as per the po(icy In rupees

d 7ave you been 7ospita(ized in the

(ast years

Indicate whether hospita(ized in the (ast years Tick Yes or No

Date 4nter the date of hospita(isation Use ))-yy for)at

Diagnosis 4nter the diagnosis detai(s Open Text

e Previous(y 3overed by any other

Medic(ai)/ 7ea(th Insurance?

Indicate whether previous(y covered by another Medic(ai) / 7ea(th

Insurance

Tick Yes or No

f 3o)pany Na)e 4nter the fu(( na)e of the insurance co)pany Na)e of the organization in fu((

S43TION 3 - D4T1ILS O5 INSUR4D P4RSON 7OSPIT1LIZ4D

a Na)e 4nter the fu(( na)e of the patient Surna)e, 5irst na)e, Midd(e na)e

b Re(ationship to pri)ary Insured Indicate re(ationship of patient with po(icyho(der Tick the right option. If others, p(ease specify

c Date of 2irth 4nter Date of 2irth of patient Use dd-))-yy for)at

d 1ge 4nter age of the patient Nu)ber of years and )onths

e 1ddress 4nter the fu(( posta( address Inc(ude Street, 3ity and Pin 3ode

f 6ender Indicate 6ender of the patient Tick Ma(e or 5e)a(e

g Occupation Indicate occupation of patient Tick the right option. If others, p(ease specify

h Phone No 4nter the phone nu)ber of patient Inc(ude STD code with te(ephone

i 4-)ai( ID 4nter e-)ai( address of patient 3o)p(ete e-)ai( address

S43TION D - D4T1ILS O5 7OSPIT1LIZ1TION

a Na)e of 7ospita( where ad)itted 4nter the na)e of hospita( Na)e of hospita( in fu((

b Roo) category occupied Indicate the roo) category occupied Tick the right option

c 7ospita(ization due to Indicate reason of hospita(isation Tick the right option

d Date of Injury/Date Disease first

detected/ Date of De(ivery

4nter the re(evant date Use dd-))-yy for)at

e Date of ad)ission 4nter date of ad)ission Use dd-))-yy for)at

f Ti)e 4nter ti)e of ad)ission Use hh:)) for)at

g Date of discharge 4nter date of discharge Use dd-))-yy for)at

h Ti)e 4nter ti)e of discharge Use hh:)) for)at

i If Injury give cause Indicate cause of injury Tick the right option

If Medico (ega( Indicate whether injury is )edico (ega( Tick Yes or No

Reported to Po(ice Indicate whether po(ice report wasfi(ed Tick Yes or No

ML3 Report & Po(ice 5IR attached Indicate whether ML3 report and Po(ice 5IR attached Tick Yes or No

j Syste) of Medicine 4nter the syste) of )edicine fo((owed in treating the patient Open Text


S43TION 4 - D4T1ILS O5 3L1IM

a Detai(s of Treat)ent 4xpenses 4nter the a)ount c(ai)ed as treat)ent expenses In rupees Do not enter paise va(ues

b 3(ai) for Do)ici(iary

7ospita(ization

Indicate whether c(ai) is for do)ici(iary hospita(isation Tick Yes or No

c Detai(s of Lu)p su)/ cash benefit

c(ai)ed

4nter the a)ount c(ai)ed as (u)p su)/ cash benefit In rupees Do not enter paise va(ues

d 3(ai) Docu)ents Sub)itted-

3heck List

Indicate which supporting docu)ents are sub)itted Tick the right option

S43TION 5 - D4T1ILS O5 2ILLS 4N3LOS4D

Indicate which bi((s are enc(osed with the a)ounts in rupees

S43TION 6 - D4T1ILS O5 PRIM1RY INSUR4DS 21NK 133OUNT

PART B

TO 24 5ILL4D IN 2Y T74 7OSPIT1L IN 31S4 O5 31S7L4SS 3L1IMS

The issue of this 5or) is not to be taken as an ad)ission of (iabi(ity. P(ease inc(ude the origina( preauthorisation request for) in (ieu of P1RT 1

SECTION A - DETAILS OF HOSPITAL

a Na)e of the 7ospita( where treated :

b 7ospita( ID : c Type of 7ospita( : Network / Non-Network

If non network fi(( for) section 4 .

d Na)e of the treating Doctor :

e Qua(ification :

f Registration No with state code : g Phone No :

SECTION B - DETAILS OF PATIENT ADMITTED

a Na)e of the patient :

b IP Registration Nu)ber : c 6ender: Ma(e / 5e)a(e

d 1ge YY/MM : Date of 2irth DD/MM/YYYY :

e Date of 1d)ission DD/MM/YYYY : f Ti)e of 1d)ission 77/MM :

g Date of Discharge DD/MM/YYYY : h Ti)e of Discharge 77/MM :

i Type of 1d)ission : 4)ergency / P(anned / Day-care / Maternity

j If Maternity

i Date of de(ivery DD/MM/YYYY : ii 6ravida Status :

k Status at ti)e of discharge : Discharged to 7o)e / Discharged to another 7ospita( / Deceased

Tota( 3(ai)ed 1)ount Rs.

S U R N 1 M 4 5 I R S T N 1 M 4 M I D D L 4 N 1 M 4

S U R N 1 M 4 5 I R S T N 1 M 4 M I D D L 4 N 1 M 4

7 7 M M

7 7 M M

7 7 M M

D D M M Y Y Y Y

D D M M Y Y Y Y

D D M M Y Y Y Y

M MY Y


b P1N 4nter the per)anent account nu)ber 1s a((otted by the Inco)e Tax

c 1ccount Nu)ber 4nter the bank account nu)ber 1s a((otted by the bank

d 2ank Na)e and 2ranch 4nter the bank na)e a(ong with the branch Na)e of the 2ank in fu((

f 3heque/ DD payab(e detai(s 4nter the na)e of the beneficiary the cheque/DD shou(d be )ade out to Na)e of the individua(/ organization in fu((

e I5S3 3ode 4nter the I5S3 code of the bank branch I5S3 code of the bank branch in fu((

S43TION 7 - D43L1R1TION 2Y T74 INSUR4D

Read dec(aration carefu((y and )ention date in dd:)):yy for)at , p(ace open text and sign.

a 1ccount 7o(ders Na)e 4nter the fu(( na)e 1s )entioned in the bank docu)ents

SECTION C - DETAILS OF AILMENTS DIAGNOSED PRIMARY

a I3D 3odes Description

i Pri)ary Diagnosis :

ii 1dditiona( Diagnosis :

iii 3o-)orbidities :

iv 3o-)orbidities :

b I3D P3S Description

i Procedure :

ii Procedure :

iii Procedure :

iv Detai(s of Procedure :

c Pre-authorization obtained : Yes / No d Pre-authorization No. :

e If authorization by network hospita( not obtained, give reason :

f 7ospita(isation due to Injury ? Yes / No

i If Yes, give cause

SECTION D - CLAIM DOCUMENTS SUBMITTED - CHECKLIST

3(ai) for) du(y fi((ed and signed Investigation reports

Origina( Pre authorization Request 3T/MRI/US6/7P4 investigation Report

3opy of Pre-authorization approva( Letter Doctors reference s(ip for Investigation

3opy of photo ID card of patient verified by 7ospita( 436

7ospita( Discharge Su))ary Phar)acy 2i((s

Operation Theatre Notes ML3 Report & Po(ice 5IR

7ospita( Main 2i(( Origina( death su))ary fro) hospita( where app(icab(e

7ospita( break up 2i(( 1ny other, P(s specify

SECTION E - ADITIONAL DETAILS IN CASE OF NON NETWORK HOSPITAL

SECTION F - DECLARATION BY HOSPITAL

We hereby dec(are that the infor)ation furnished in this 3(ai) 5or) is true & correct to the best of our know(edge and be(ief. If we have )ade any fa(se or untrue

state)ent, suppression or concea()ent of any )ateria( fact, our right to c(ai) under this c(ai) sha(( be forfeited.

Se(f inf(icted? Yes / No Road Traffic 1ccident Yes / No

ii If Injury due to Substance abuse / a(coho( consu)ption, Test 3onducted to estab(ish this: Yes

iii Medico Lega( Yes / No iv Reported to Po(icy Yes / No

vi If not reported to Po(icy give reasons

Substance 1buse /1(coho( 3onsu)ption Yes / No

/ No If yes, attach reports

v 5IR No :

c Registration no with State 3ode :

e No of In-patient 2eds :

d 7ospita( P1N :

f 5aci(ities avai(ab(e in 7ospita( :

i OT : Yes / No

ii I3U : Yes / No iii Others :

Date : P(ace : Signature and sea( of the 7ospita( 1uthority : D D M M Y Y Y Y

e 1ddress :

3ity : State :3ity : State :



GUIDANCE FOR FILLING CLAIM FORM - PART B :

D1T1 4L4M4NT D4S3RIPTION 5ORM1T

S43TION 1 - D4T1ILS O5 7OSPIT1L

a Na)e of 7ospita( 4nter the na)e of hospita( Na)e of hospita( in fu((

b 7ospita( ID 4nter ID nu)ber of hospita( 1s a((ocated by the TP1

c Type of 7ospita( Indicate whether In network or non network 7ospita( Tick the right option

d Na)e of treating doctor 4nter the na)e of the treating doctor Na)e of doctor in fu((

e Qua(ification 4nter the qua(ifications of the treating doctor 1bbreviations of educationa( qua(ification

f Registration No. with State 3ode 4nter the registration nu)ber of the doctor a(ong with the state code 1s a((ocated by the Medica( 3ounci( of India

g Phone No. 4nter the phone nu)ber of doctor Inc(ude STD code with te(ephone nu)ber

S43TION 2 - D4T1ILS O5 T74 P1TI4NT

a Na)e of Patient 4nter the na)e of hospita( Na)e of hospita( in fu((

b IP Registration Nu)ber 4nter insurance provider registration nu)ber 1s a((otted by the insurance provider

c 6ender Indicate 6ender of the patient Tick Ma(e or 5e)a(e

d 1ge 4nter age of the patient Nu)ber of years and )onths

e Date of 2irth 4nter date of ad)ission Use dd-))-yy for)at

f Date of 1d)ission 4nter date of ad)ission Use dd-))-yy for)at

g Ti)e 4nter ti)e of ad)ission Use hh:)) for)at

h Date of Discharge 4nter date of discharge Use dd-))-yy for)at

i Ti)e 4nter ti)e of discharge Use hh:)) for)at

j Type of 1d)ission Indicate type of ad)ission of patient Tick the right option

k If Maternity

Date of De(ivery 4nter Date of De(ivery if )aternity Use dd-))-yy for)at

6ravida Status 4nter 6ravida status if )aternity Use standard for)at

( Status at ti)e of discharge Indicate status of patient at ti)e of discharge Tick the right option

) Tota( c(ai)ed a)ount Indicate the tota( c(ai)ed a)ount In rupees Do not enter pa(se va(ues

SECTION C - DETAILS OF AILMENT DIAGNOSED (PRIMARY)

a I3D 3ode

Pri)ary Diagnosis 4nter the I3D 3ode and description of the pri)ary diagnosis Standard 5or)at and Open text

1dditiona( Diagnosis 4nter the I3D 3ode and description of the additiona( diagnosis Standard 5or)at and Open text

3o-)orbidities 4nter the I3D 3ode and description of the co-)orbidities Standard 5or)at and Open text

b I3D P3S Standard 5or)at and Open text

Procedure 4nter the I3D P3S and description of the first procedure Standard 5or)at and Open text

Procedure 4nter the I3D P3S and description of the second procedure Standard 5or)at and Open text

Procedure 4nter the I3D P3S and description of the third procedure

Detai(s of Procedure 4nter the detai(s of the procedure Open text

c Present 1i()ent is a 3o)p(ication

of P4D

Indicate whether present ai()ent is a co)p(ication of so)e pre-

existing disease

Tick Yes or No

d Pre-authorization obtained Indicate whether pre-authorization obtained Tick Yes or No

e Pre-authorization Nu)ber 4nter pre-authorization nu)ber 1s a((otted by TP1

f If authorization by network hospita(

not obtained, give reason

4nter reason for not obtaining pre-authorization nu)ber Open text


8

CUSTOMER IDENTIFICATION PROCEDURE AS PER KYC NORMS OF IRDA

Part AProof of (ega( na)e andany other na)es used

i. Pan Card

ii. If Pan Card is not available please submit any of the documents mentioned below stating reason for

not having Pan Card.

a) Passport

b) Voters Identity Card

c) Driving License

d) Personal Identification and Certification of the employees for your identity.

e) Letter issued by Unique identification 1uthority of India containing details of name address and

1adhar ;umber

f) Job Card issued by ;REG1 duly signed by an officer of the State Government

Photograph

P(ease sub)it c(ear and (egib(e copy of one docu)ent va(id and effective as on date of c(ai) sub)ission each fro) Part 1 and Part B and your

recent passport size photograph not )ore than 6 )onths o(d incase c(ai) a)ount exceeds Rs , .

Please dispatch your claim document to :ax 2upa Corporate Office 2loc 2 /I- , :ohan Cooperative Industrial Estate, :athura Road, ;ew Delhi - 44.

g 7ospita(ization due to injury Indicate if hospita(isation is due to injury Tick Yes or No

3ause Indicate cause of injury Tick the right option

If injury due to substance abuse/

a(coho( consu)ption, test

conducted to estab(ish this

Indicate whether test conducted Tick Yes or No

Medico Lega( Indicate whether injury is )edico (ega( Tick Yes or No

Reported To Po(ice Indicate whether po(ice report was fi(ed Tick Yes or No

5IR No. 4nter first infor)ation report nu)ber 1s issued by po(ice authorities

If not reported to po(ice, give reason 4nter reason for not reporting to po(ice Open Text

S43TION D - 3L1IM DO3UM4NTS SU2MITT4D-3743K LIST

Indicate which supporting docu)ents are sub)itted

S43TION 4 - D4T1ILS IN 31S4 O5 NON N4TWORK 7OSPIT1L

a 1ddress 4nter the fu(( posta( address Inc(ude Street, 3ity and Pin 3ode

b Phone No. 4nter the phone nu)ber of hospita( Inc(ude STD code with te(ephone nu)ber

c Registration No. 4nter the registration nu)ber of patient 1s a((ocated by the 7ospita(

d 7ospita( P1N 4nter the per)anent account nu)ber 1s a((otted by the Inco)e Tax depart)ent

e Nu)ber of Inpatient 2eds 4nter the nu)ber of inpatient beds Digits

f 5aci(ities avai(ab(e in the hospita( Indicate faci(ities avai(ab(e in the hospita( Tick the right option. If others, p(ease

S43TION 5 - D43L1R1TION 2Y T74 INSUR4D

Read dec(aration carefu((y and )ention date in dd:)):yy for)at , p(ace open text and sign.

S43TION 6 - D43L1R1TION 2Y T74 7OSPIT1L

Read dec(aration carefu((y and )ention date in dd:)):yy for)at , p(ace open text and sign and sta)p

Corporate Oce: Block B1/I-2, Mohan Cooperative Industrial Estate, Mathura Road,

New Delhi -110044. CIN: U66000DL2008PHC182918, Fax: 011-30902010, www.maxbupa.comToll free: 1800 3010 3333 Insurance is the subject matter of solicitation.

Registered oce: Max House, 1 Dr. Jha Marg, Okhla, New Delhi - 110020

(Pleaseattachcopyofacancelledblankchequeofyourbankforensuringaccuracyofnameofthebank,branchname,AccountnumberandIFSCcode.Ifnameofthepayeeisnotprintedonthechequeleafpleaseattachcopyofthefirstpageofthebankpassbookalso)

I hereby declare that I have submitted above mentioned documents and recent photograph (not more than 6 months old) for the purpose of claim and the said documents are valid and eective.

Date : Signature of Policyholder :

Part BProof of Residence

i. Electricity Bill not older than 6 months from the date of Insurance Contract

ii. Telephone Bill pertaining to any kind of telephone connection like mobile, landline, wireless etc.

Provided it is not older than 6 months from the date of claim submission

iii. Ration Card

iv. Valid lease agreement along with rent receipts which is not more than 3 months old as a residence

proof

v. Saving Bank Passbook with details of permanent/ present residence address ( updated upto 1 month

prior to claim submission document)

vi. Statement of saving bank account with details of present/ present address ( updated upto 1 month

prior to claim submission document)

D D M M Y Y Y Y

Max Bupa Health Insurance Co. Ltd. (IRDA Registration no. 145). Max, Max logo, Bupa and HEARTBEATlogo are trademarks of their respective owners and are being used by Max Bupa Health Insurance Company Limited under license.

To Date ___/____/____

Medical Superintendent

___________________

___________________

___________________

Consent Letter

I, :r/:s age resident

of state hereby

give my willful consent to :r/Dr of :ax 2upa Health

Insurance Company Limited to verify and collect necessary documents/statements including but not limited to certified copies of medical records from your esteemed hospital for the purpose of

settlement of my insurance claim.

:y other relevant details are provided below

Detai( of Insured:-

DOA:

DOD:

MRD/Indoor/IP No:

Po(icy No:

I request you to provide all the information/documents as required by :ax 2upa Health Insurance Company Ltd.

Na)e:

Signature/ Thu)b I)pression Witness na)e & Signature