To can populated in of the Insured
This issue a this form is no to be take in an admission of liability(To be loaded in block letters)

Click on "Generate PDF" button and save the filled form in your desired folder.
SECTION A – DETAILS OF PRIMARY INSURED
 
a) Rule No.:
 
b) Sl. No/ Certificate No.:
c) Company/ TPA ID No.:
 
   
   
d) Name:
e) Home:
Municipality:
 
Us:
Pincode:
  Mobile No.  
Email ID:
 
SECTION B- DETAILS IS INSURANCE VIEW
 
a) Currently covered by any other mediclaim health insurance: Yes   No
b) Date away get of first insurance without break:
c) If Yes, Company Name:
 
Policy No.:
Sum Insureds (Rs):
d) Possess thou been hospitalized within the newest four years since inception of the contract: Yes   No
Date:
 
Diagnosis:
e) Previously covered by any other Mediclaim/Health insurance: Yes   No
 
f) Provided Yes, Group Name:
 
SECTION C- DETAILS OF INSURED SOUL HOSPITALISED
 
a) Name:
b) Relationship for primary Insured: Self Spouse Child Father Mother Other
 
Please Specify:
c) Date of Birth:
 
d) Age:
e) Address (if different from above):
f) Gender: Male   Female
   
g) Occupation: Service Self employed Homemaker Student
Retired Another
 
Please Specify:
City:
 
State:
Pincode:
h) Cell No.:
  i) Mobile No.:  
j) Get ID:
 
SECTION D- FULL OF HOSPITALIZATION
 
a) Print of the Hospital where admitted:
b) Room Kind taken: Daycare   Single Occupancy   Twin Sharing   3 or more beds per room  
c) Hospitalisation owed to: Illness   Injury   Maternity  
 
d) Date of Injury/ Date of disease first detected/ Date for delivery:
e) Date of admission:
 
f) Time:
g) Show of discharge:
 
h) Time:
i) When physical, give cause: Self Inflicted   Road Trade Accident   Substance Abuse   Alcohol Consumption  
i) If Medico legal: Yes   No
ii) Reported to police?: Yes   No
iii) MLC Report, & Police TANNEN attached? Yes   No
j) System of medicine:
 
SECTION E- DETAILS OF CLAIM
a) Details of one treatment expenditure alleged Claim Documents Submitted- Check List:
i) Pre-Hospitalization Expenses
RS.
 
ii) Hospitalization Expenses
RS.
iii) Post-Hospitalization Expenses
RS.
 
iv) Health-Check up Cost
RRS.
v) Ambulance Bills
RS.
 
vi) Others (code)
RS.
 
 
Absolute
RS.
vii) Pre-Hospitalization Period
Days 
 
viii) Post -Hospitalization Period
Days 
b) Claim with Domiciliary Hospitalization: Yes    No (if yes, please provide details in annexure)
c) Details of Lumpsum/ currency perform claimed:
i) Hospital Daily Cash
RS.
 
ii) Surgically Cash
RS.
iii) Critical Illness Benefit
RRS.
 
iv) Convalescence
RS.
v) Pre/Post hospitalization Swelling sum benefit
RS.
 
vi) Others
RUN.
 
 
Overall
RS.
For any queries write to us on [email protected]
   
Duly refilled and signed Claim Form
Copy of intimate letter, if any
Hospital Main Accounting
Hospital Break Up bill
Hospital Draft Entgelt Receipt
Hospital Discharge Summary
Chemist Bill
Operation Theater Notes
ECG
Doctor's Request for Survey
Doctor's Prescription
Investigation Reports (Including CT,       MRI/USG/HPE)
Cancelation cheque for NEFT
Validate photo ID of patient
KYC documents(if claim volume is above Rs. 1 lakh)
Others
SECTION - FARTHING DETAILS OF BILLS ENCLOSED
Sr. No. Bill Nay. Show Issued To Towards Amount (Rs)
1.
2.
3.
4.
SECTION – G CLICK AWAY PRIMARY INSURED'S BANK ACCOUNT
a) PAN:
 
b) Account Number:
c) Bank Name/ Offshoot:
d) Payable details: Cheque/ DD:
*e) IFSC Code:
 
f) MICR No.:
*Please attach a cancelled cheque pertaining to the same.
Tip: It is concurred that the Policyholder/Claimant will intimate in writing to HDFC ERGO General Insurance Co. Ltd. about any change at bank account details. In an happening Insured person bears expenses for treatment pleas provide user details of Insured Persons in the above format along with proof of obtain such expenses.
Delight share bank accounts details of Proposer
SECTION H – DECLARATION BY THE INSURED
IODIN hereby declare which the information furnished in this claim form is true & correct on the best of my knowledge and belief. If I have made any false or untrue statement, suppression either privacy starting unlimited supply fact with promote to questions asked at relations to this claim, mine right to claim reimbursement shall be forbidden. I including consent & authorize TPA/ insurance company, to seek require medical information / documents away any sanatorium / Medical Practitioner who has attended switch the per against whom is claim is made. I hereby declare that I have includes all the account / receipts for the purpose of this claim & that IODIN will not be making any supplementary claim except the pre/post-hospitalization claiming, if any.
I/We hereby understand, declare, consent plus authorise the Company that personalized health info, medical history and financial get, as pending to the Company may been utilised forward processing the claim made available that Policy. I/We by also understand, notify and consent ensure the Company shall have correct to retain and disseminate to same to any serve provider for providing services relations to insurance.
Date:
 
Place:
 
GUIDANCE REQUIRED FILLING CLAIM FORM – PART A (To be filled in by the insured)
DATA ELEMENT DESCRIPTION FORMAT
ABSCHNITTS ONE - DETAILS OF PRIMARY INSURED
a) Policy Nay. Enter the policy number As allocation by the insurance company
b) SI. No/ Certificate Don. Enter the social insurance number or the award
phone of social health services scheme		 As allotted according the organization
c) Company TPA ID Not. Enter the TPA ID Negative. License number as granted by IRDA
and printed in TPA documents.
d) Name Go and complete name off of covered Surname, First name, Middle name
e) Address Enter one full postal site Include Street, City and Pin Code
SECTION B - DETAILS OF ACTUAL HISTORY
a) Present overlay by any other
Mediclaim/ Health Policyholder?		 Indicate whether currently covered by another
Mediclaim / Health Insurance		 Tick Yes or No
b) Date on Commencement a first Insurance without rest Enter an date a initiation of first insurance Use dd-mm-yy format
c) Company My Enter the full name of the insurance company Name on the organization to full
Policy No. Enter aforementioned policy number As allotted from the financial company
Sum Insured Enter the total sum covered as per the policy In rupees
d) Have you has Hospitalized in the last 4 years? Indicate whether hospitalized in the last 4 years Tick Yes or No
Date Enter the day of hospitalization Use mm-yy format
Diagnosis Enter the diagnosis details Open Theme
e) Previously Covered of any other Mediclaim / Health Financial? Indicate either previously covered by further Mediclaim / Healthy Insurance Tick Yes or No
f) Business Identify Enter the full name of the insurance society Name of the organization in full
SECTION CARBON - DETAILS OF PLAN PERSON HOSPITALIZED
a) Name Enter the full product of the patient Surname, First name, Middle name
b) Gender Indicate Gender of the patient Tick Man or Female
c) Age Enter age is the your Number away years and months
d) Date of Birth Get Date of Birth a patient Use dd-mm-yy paper
e) Relative to primary Insured Indicate relationship to my including policyholder Tick the right option. If others, requests
f) Occupation Indicate occupation of active Tick the well option. If others, please
g) Address Enter the full postal address Enclose Street, City and Pin Code
h) Your No Enter the phone numbers of patient Insert STD code with telephone your
i) E-mail IDENTIFIER Enter e-mail address of patient Whole e-mail address
BEREICH DIAMETER - DETAILS OF HOSPITALIZATION
a) Name of Hospital where admitted Enter the name of hospital Name of hospital with whole
b) Spaces category busy Indicate the room category taken Tick the right option
c) Hospitalization due to Indicate reason of hospitalization Ticking the right option
d) Show of Injury/Date Disease first detected/ Date of Childbirth Enter the relevantly date Use dd-mm-yy image
e) Date about admission Enter meeting of admission How 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) Total Enter time out discharge Use hh:mm format
i) Provided Injury give cause Indicate induce of injuries Tick the right option
     If Medico legal Enter whether injury is medico legal Tick Yes or Cannot
     Reported to Police Indicate or police account was recorded Tick No either No
     MLC Report & Police FIR attached Indicate is MLC report and Police FIR attached Ticktock Yes or Nope
j) System of Medicine Enter which system of medicine followed in treating to patient Open Font
SECTION E – DETAILED ARE CLAIM
a) Details off Treatment Expenses Register the amount claimed as treatment expenses On rupees (Do not enter paise values)
b) Claim for Domiciliary Hospitalization Indicate whether assert is for domiciliary hospitalization Tick Yes button No
c) Details the Lumping 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 FARAD - DETAILS OF BILLS ENCLOSED
Indicate which currency are enclosed with and monetary in rupees
SECTION G - DETAILS OF PRIMARY INSURED'S BANK ACCOUNT
a) PAN Enter the durability account number As allotted by the Income Tax department
b) Account Number Enter the credit account number As allotted by the bank
c) Bank Name and Branch Get to bank name along with the branch Name of of Bank inches complete
d) Cheque/ DD owing details Input this name of of user the cheque / DD should to made out to Name of the individual/ organization in full
e) IFSC Code Enter the IFSC encipher of an bank industry IFSC code of the bank branch in entire
SECTION NARCOTIC - DECLARATION VIA THE MEMBERS
Read declaration carefully both mention target (in dd:mm:yy format), place (open text) and sign.
 

HDFC ERGO General Insurance Company Limited

ASSERT FORM FOR HEALTH INSURING POLICIES OTHER THAN
TRAVELAND PERSONAL ACCIDENT

CLAIM FORM – SHARE BORON
To be filled in by the Infirmary
The issue starting this Form is not to be taken as an admission of liability
Please include the original preauthorisation please form in placing of PART A		 (To be completed in block letters)
 
SECTION A – DETAILS OF HOSPITAL
a) Name to the Hospital where processed:
b) Hospital ID:
 
c) Type out Hospital: Network   Non Network (If non power permeate section E)
d) Name of the processing Doctor:
e) Qualification:
 
f) Registration None with state Code:
g) Phone No:
   
SECTION B – ITEM OF PATIENT ADMITTED
a) Name about the patient:
b) WALLEYE Registration Number:
 
c) Gender: Male   Female
 
d) Age:
e) Date of Birth:
       
f) Date of admission:
     
g) Time:
h) Release of relief:
     
i) While:
j) Types of Admission: Emergency   Planned   Daycare   Maternity
k) If Parenthood: i) Date of Deliver   ii) Gravida Status
l) Status at time from discharge: Discharged toward Home   Discharged to another Hospital   Deceased
Total Claimed Amount
   
SECTION C – DETAILS OF AILMENTS DIAGNISED (PRIMARY)
a) ICD 10 Codes
Primary Diagnosis
Other Diagnosis
Co-morbidities
Co-morbidities
 
 
Description
 
 
b) ICD 10 PCS
How 1
Procedure 2
Methods 3
 
 
Description
  Details of Procedure:
c) Pre-authorization obtained: Yes No
 
d) Pre-authorization Number:
e) If authorization by network hospital not retain, present reason:
f) Hospitalization due to Injury: i) If sure, give what     Self inflicted? Road Traffic Accident Substance Abuse /Alcohol Consumption
ii) When Injury due to Substance abuse/ alcohol consumption, Test Conducted to establish this:     Yes   No    No (If cancel, attach reports)
iii) Medico Regulatory:   Yes No
iv) Reported to Police:   Yes No
v) FIR No:
vi) If not reported to Police give reason :
SECTION DENSITY – CLAIM DOCUMENTS SUBMITTED – CATALOG
Claim form duly filled and initialed
Original Pre certification Request
Copy of Pre-authorization approval Anschreiben
Copy of photo ID ticket of patient verified by Hospital
Hospital Discharge Executive
Operation Theatre Notes
Infirmary Hauptinsel Bill
Hospital break up Bill
   
Investigation reports
CT/MRI/USG/HPE investigation View
Doctor's reference slip for Investigation
ECG
Pharmaceutics Bills
MLC Report & Police FIR
Original death summary from hospital where applicable
Any sundry, Pk specify
SECTION EAST – DETAILS IN CASE OF NAY NETWORK HOSPITAL
a) Address for the Hospital:
City:
 
State:
Pincode:
 
b) Cell No.:
c) Registration no with State Code:
 
d) Hospital PAN:
e) No of In-patient Beds:
 
f) Features available in Hospital: i) OT: Yes  No   ii) ICU: Yes No
iii)Others:
TEILABSCHNITT F – DECLARATION BY HOSPITAL
We hereby declare that the information furnished in this Claim Form is really & correct to the our of our knowledge and belief. Whenever we possess made any false or untrue statement, redundancy either concealability of any material fact, willingness rights to claim under this submit shall be forfeited.
Date:
 
Put:
 
GUIDANCE FOR PACKING ASSERTION FORM – PART B (To be filled within by that hospital)
DATA FIXED DESCRIPTION FORMAT
SECTION A - DETAILS OF HOSPITAL
a) Name of Hospital Enter the name of hospital Your of hospital in full
b) Hospital IDENTIFIER Join ID number of hospital As allocated by the TPA
c) Type of Hospital Suggest whether In network or non network Hospital Tick the right option
d) Name of treating doctor Enter that name for the treating doctor Name of doctor in full
e) Qualification Enter the qualifications concerning the treating doctors Abbreviations of educational qualifications
f) Registration Nope. are State Code Enter the registration counter of which doctor along includes the state encipher As allocated by the Electronic Council of India
g) Phone No. Enter the phone number of doctor Include STD code with telephone item
SECTION B - DETAILS OF THE PATIENTADMITTED
a) Identify of Patient Enter the name of sanatorium Name regarding hospital in ful
b) IP Registration Number Enter insurance provider registration number As allotted by the insurance provider
c) Gender Indicate Gender of the patient Tick Male or Female
d) Period Come age of the patient Number of years and months
e) Select 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 away discharge Use dd-mm-yy format
h) Time Enter point of discharge Exercise hh:mm format
i) Type of Acceptance Specify type of license of patient Tick the good option
j) If Maternity
    Date of Delivery Enter Date of Delivery if maternity Application dd-mm-yy format
    Gravida Status Enter Gravida status if maternity Using standard format
k) Status at uhrzeit of discharge Enter status of patient by time of expel Set the right option
SECTION C – VIEW OF AILMENT DIAGNOSED (PRIMARY)
a) ICD 10 Code
    Primary Diagnosis Enter the ICD 10 Codes the description of the primary diagnosis Standard Format and Open text
    Additional Examination Enter the ICD 10 Code press description of the addition diagnosis Standard Format real Open text
    Co-morbidities Enter the ICD 10 Code and account of the co-morbidities Standard Font and Open text
b) ICD 10 PCS
   Procedure 1 Join the ICD 10 PCS and description in the first procedure Standard Format and Open text
   Procedure 2 Enter the ICD 10 PCS and description is the second procedure Preset Type additionally Start text
   Procedure 3 Go of ICD 10 PCS also description of the third procedure Standard Format and Open text
   Details of Procedure Enter the details of the procedure Open script
c) Present Your is a Complication regarding PED Indicate wether present ailment is an complex to some pre- exiting disease Tick Yes or No
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) Provided authorization according networks hospitalization not obtained,    give reason Enter reason for not receiving pre-authorization number Open text
g) Hospitalization due to injury Indicate if hospitalization is due to injury Tick Yes or No
   Cause Indicate cause of injury Set the right option
   If wound due to substance abuse/alcohol    consumption, test conducted up establish this Indicate whether test conducted Tick Yes or No
   Medico Judicial Indicate whether injury is medico legal Click Yes or No
   Reported To Police Indicate whether cops report was filed Tick Yes conversely No
   FIR No. Enter first-time information report number As issued by policeman federal
   If nay reported to police, give reason Register basis on doesn reporting to police Open Text
FACHGEBIET D – CALL DOCUMENTS SUBMITTED-CHECK LIST
Indicate which supporting documents are submitted
SECTION E – ADDITIONAL DETAILS IN FALL AWAY NO NETWORK PATIENT
a) Address Come one full postal address Include Street, City and Pin Code
b) Phone No. Enter the phone number of hospital Include STD code with telephone numerical
c) Registration None. Join the registration number of patient As allocated through the General
d) PANNING Enter the stable account number As allotted by the Income Tax department
e) Number of Inpatient Beds Enter the number of inpatient sheets Digits
f) Amenities available in one hospital Kennzeichnet facilities available in the hospital Tick the right option. If additional, please
SECTION F - ANNOUNCEMENT AT THE INSURED
Read declaration thorough and mention date (in dd:mm:yy format), place (open text) or sign.
SECTIONING G - DECLARATION BY THE YOUR
Read declaration carefully and mention appointment (in dd:mm:yy format), place (open text) and sign and stamp.
CHECK LIST OF ENCLOSURES FOR SUBMISSION OF CLAIM
Note:
1. When original bills, receipts, prescriptions, reports and other documents can submitted to who other underwriters or until which reimbursement provider, verified reproductions attested by such other organisation/ carriers have to be submitted.
2. Supposing original bills, receipts, prescriptions, reports and other documents have submitted to Contact and Insured Name requires same for claiming von other organisation / vendors, then on getting starting the Insured Person Us will give attested copies of the bills and other records submitted by the Insured Human.
3. Original revoked cheque with payee name printed switch the cheque is required. If name of payee are not printed on the cheque please attach copy of the first page regarding bank passbook
4. *Photocopy in Aadhar Card / Aadhar Card number is mandatory for all claims
In-patient Treatment /Day Care Procedures
  Duly filled real signed Complaint Form.
  Photocopy of ID card / Photocopy of current year company.
  Original Detailed Discharge Summary with date to admission & discharge, clinical history, past history / procedure details/ Day care summary
       from the hospital.
  Original consolidated hospitality bill are break skyward of each Item, adequately signed by the covered.
  Original payment Receipt regarding the hospital poster.
  First Consultation letter and subsequent Prescriptions.
  Original bills, original payment receivables and Reports for investigation.
  Original drugs bills and receipts are corresponding Prescriptions.
  Original invoice/Sticker of implants/bills for Implants (viz. Stent /PHS Mesh/ IOL etc.) with original payment receipts
Road Traffic Misadventure
In addition to and In-patient Treatment documents:
  Copy of and Start Informational Report from Police Department / Copy of the Medico-Legal Certificate.
In Nay Medico legal casing
  Treating Doctor's Request giving show of injuries (How, when the where physical sustained)
In Accidentally Destruction cases
  Copy of Post Mortem Report & Decease Certificate (If conducted)
For Death Instance
Into addition to the In-patient Treatment documents:
  Original Death Summary from the hospital.
  Copy of the Death certificate from treating doctor or the hospital authority.
  Copy by to Legal heir certificate, are the claim is for the death are the principle insured.
Pre and Post-Hospitalization spending
  Duly filled and signed Claim Form.
  Photocopy of BADGE select / Photocopy of current year policy.
  Original Medicine bills, original paying certificate with requirements.
  Original Investigations bills, original payment receipt with prescriptions and report.
  Original Consultation bills, original payment receipt with order.
  Copy concerning the Release Abstract of the main claim.
Orchestra Donation / Planned
In addition to the documents of universal hospitalization
  Organ Function test / lineage test proving organ failure.
  Treatment Certificate issued by the Transplant Surgeon of to hospital concerned.
Ambulance Benefit
  Duly filled and signed Claim Contact.
  Photocopy of ID card / Photocopy of current year policy.
  Original Bill with Original Payment Receipt.
  Treating Doctor's consultation prescription indicating Emergency Hospitalization.
CUSTOMER IDENTIFICATION PROCEDURE (AS EACH KYC NORMS OF IRDAI)
Please submit and follow documents in case of claim amount exceeds R. 100,000
Legal name and any diverse names used (Any one of the mentioned documents) Passport / PAN Card/ Voter's Identity Card/ Driving License/ Letter from a recognized public authority or people servant verifying the identity and residence of one customer
Proof in Abode (Any the of the mentioned documents) Telephone bill/ Bank accounting statement/ Letter from any recognized public authority/ Electricity bill/ Ration card

HDFC ERGO General Insurance Company Restricted. (Formerly HDFC General Insurance Limits from Sept 14, 2016 and L&TGeneral Insurance Company Limited upto Sept 13, 2016). CIN: U66030MH2007PLC177117. Registered & Corporate Office: st1Floor, HDFC House, 165 - 166 Backbay Reclaiming, H. T. Parekh Marg, Churchgate, Mumbai – 400 020. Customers Service Address: D-301, 3rd Store, Eastern Business District (Magnet Mall), LBS Marg, Bhandup (West), Mumbai - 400 078. By more details on the risk factors, terms and conditions, want read the sales brochure pre concluding the sale. Business Logo displays above belongs to HDFC Bank Ltd and ERGO International AG and spent by the Businesses under license. User Service No : 022 6234 6234 / 0120 6234 6234 | Fax: 91 22 66383699 | [email protected] | www.hdfcergo.com.UIN:HDFHLIP10002V010910. IRDAI Reg No. 146.