m/s.natco pharma ltd.ess.natcopharma.co.in/files/scanco.pdfunited india insurance company limited...
TRANSCRIPT
2/18/2016 1MDIndia Health Care Services ( TPA ) Pvt Ltd
M/S.NATCO PHARMA LTD.
UNITED INDIA INSURANCE COMPANY LIMITED
Policy No : 052100/28/15/P112796862 Policy Start Date-21/01/2016 Policy End Date –20/01/2017
Contents of Presentation
• Parties to Group Medi-claim Policy.
• Functions of MDIndia
• Scope of Mediclaim
• Terms & Condition for M/S.Natco Pharma Ltd
• Permanent policy exclusion
• How to avail Cashless Facility
• How to avail Re-imbursement Facility
• Checklist - Documents to be submitted for Re-imbursement
• Network of Hospitals for Cashless
• Website Access Navigation for Individual Employee
• Aneroid Mobile App Navigation – HAWK APP
• Toll free No. and mail ids –MDIndia Health Care Services (TPA) Pvt. Ltd.
MDIndia Health Care Services ( TPA ) Pvt Ltd2/18/2016 2
Group Mediclaim Policy In
sura
nce
Co
mp
any
• United IndiaInsuranceCompanyLimited.
Co
rpo
rate
Gro
up
Med
icla
im
• NatcoPharma Ltd.
Thir
d P
arty
Ad
min
istr
ato
rs
• MDIndiaHealthcareServices(TPA) Pvt.Ltd
MDIndia Health Care Services ( TPA ) Pvt Ltd2/18/2016 3
MD India Healthcare Services Pvt Ltd
• MDIndia Healthcare Service (TPA) Pvt. Ltd. was formed in November 2000, a licensed third Party Administrator (License No. 005) and were very soon a leading company in the insurance sector. The success of the Company has been built year on year by an ability to anticipate the future requirements of the Health insurance industry.
• Awarded : 2013 – The Indian Insurance Awards: Best TPA Award
• 2014 – The Indian Insurance Awards: Best TPA Award
• 2014 - 18th Asia Insurance Industry Awards: Service Provider of the Year
• 2015 – The Indian Insurance Awards: Innovative TPA of the Year
MDIndia Health Care Services ( TPA ) Pvt Ltd2/18/2016 4
5
Transparent communication
Reliable processing TATs
Error free processing
Response timeframes & quality
Accessibility
Reach
Claim Cost Control
Coordination with Insurance company & Broker
Exceptional calls to be taken
Hassle free hospitalization
Policy understanding
Strategic Guidance
Value adds
What would you look for in a service provider
Founded in November 2000
IRDA License no 005
Headquartered in Pune, Maharashtra
One of the leading companies in the Health
Insurance sector of India
The Largest TPA in India by Revenue, Lives
Serviced, Claims Settled & Headcount
FYE 2013 Projected : 1st TPA to breach 100
Cr Revenue Mark
Pan India footprint with 115 Servicing
locations
In-House Developed Software deployed with
54 member strong team
3500+ Employees strong consisting of 500+
Medico’s on pay roll as full-time employees
with core team of MBBS, MD/MS
Specialists & MCh Surgeons
ISO, CRISIL & QCI certified
24x7 Customer Care and Support and
Website Services
6000+ Net work Hospitals
MDINDIA AT A GLANCE…..2016
MDIndia Health Care Services ( TPA ) Pvt Ltd2/18/2016
To work as a Nodal agency between Insurance Company, Natco Pharma Ltd, and the
Hospitals.
To issue ID Cards to all the members covered under the policy.
To administer Cashless Facility in network hospitals & reimbursement claims settlement as
per the policy terms and conditions.
To negotiate & procure comprehensive schedule of charges from empanelled hospitals.
Functions of MD India (TPA)
MDIndia Health Care Services ( TPA ) Pvt Ltd2/18/2016 6
Scope of Mediclaim
• COVERAGE - Any Insured Person who shall contract any disease /illness or sustainany bodily injury through accident and upon the advice of a duly qualified doctorfor Hospitalisation in any Hospital in India .
• ROOM RENT ELIGILIBITY – Includes Room, boarding and nursing expenses
• Normal Room Max Limit–1.5% Per day.
• ICU Room Max Limit – 3% Per day.
• (This also includes Nursing Care, RMO & DMO Charges, IV Fluids/ BloodTransfusion Charges /Injection Administration Charges and similar expenses)
• HOSPITALISATION - Means admission in any Hospital/Nursing Home in India uponthe written advice of a Medical Practitioner for a minimum period of 24consecutive hours.
• PRE HOSPITALISATION medical charges up to 30 days period immediately beforethe Insured’s admission to hospital for that illness or injury.
• POST HOSPITALISATION medical charges up to 60 days period immediately afterthe Insured’s discharge from the hospital for that illness or injury.
MDIndia Health Care Services ( TPA ) Pvt Ltd2/18/2016 7
Terms & Conditions for Natco Pharma Policy.
• POLICY COVERS: 1+5 (Self, Spouse, 2 Dependent Childrens and 2 parents or In-laws)
• SUM INSURED –Rs:200000/- per family.
• PRE-EXISTING DISEASES COVERAGE: Waived Off
4.1: Pre-Existing Illness/ Ailments are waived Off.
4.2: 30 Days lock in period waived off for any claim.
4.3: 1Yr/2Yr/3Yr/4Yr Exclusion waiting period waived Off.
• AMBULANCE CHARGES:1% of SI
MDIndia Health Care Services ( TPA ) Pvt Ltd2/18/2016 8
Terms & Conditions for Natco Pharma Ltd.
• Cataract, Hernia, Hysterctomy Limits: Actual expenses incurred or 25% of the Sum insured whichever is less.
• Major Surgeries: Actual expenses incurred or 70% of the sum insured whichever is less.
• Claim intimation to be given within 48 Hrs. from date of admission
• Claim submission to be done within 15 days from date of discharge.
• Cheque in Favour of:• Reimbursement claim payment should be in favour of Employee.
MDIndia Health Care Services ( TPA ) Pvt Ltd2/18/2016 9
The Insurance Company shall not be liable to make any payment under this Policy in respect ofany expenses whatsoever incurred by any Insured Person in connection with or in respect of:
1. Any Out Patient Charges/ OPD Treatment.
2. The cost of spectacles, contact lenses and hearing aids, external durable items.
3. Dental treatment or surgery of any kind unless requiring hospitalization.
4. Convalescence, general debility, a ‘run-down’ condition or rest cure, external congenitaldisease, defects or anomalies, sterility, venereal disease or intentional self injury.
5. All expenses arising out of any condition directly or indirectly caused by or associated withHuman T-Cell Lymphotropic Virus Type III (HTLB-III) or Lymphadenopathy Associated Virus(LAV) or the Mutants Derivative or variations of Deficiency Syndrome or any syndrome orcondition of a similar kind commonly referred to as AIDS. (Information available in the PolicySummary booklet)
6. Sex change or any treatment which results from, or is in any way related to, sex change.Hormone replacement therapy.
7. The treatment of psychiatric, mental or nervous conditions and insanity.
8. Any cosmetic, plastic surgery, aesthetic or related treatment of any description, whether ornot for psychological reasons, unless medically necessary as a result of an accident.
POLICY EXCLUSIONS
MDIndia Health Care Services ( TPA ) Pvt Ltd2/18/2016 10
9. Any treatment received in convalescent homes, convalescent hospitals, health - hydros, Nature Cure clinics or similar establishments.
10. Any stay in hospital for any domestic reason or where there is no active, regular treatment by a specialist.
11. Any treatment received outside India.
12. Complication of surgery, therapy or treatment administered on the Insured Person which isnot prescribed or required by a Registered Medical Practitioner/ Registered MedicalInstitution in their professional capacity.
13. Taking of drugs unless it is taken on proper medical advice and is not for the treatment ofdrug addiction.
14. Any fertility, sub-fertility or assisted conception operation.
15. Any person whilst engaging in speed contest or racing of any kind (other than on foot),bungee jumping, parasailing, ballooning, parachuting, skydiving, paragliding, hang gliding,mountain or rock climbing necessitating the use of guides and ropes, pot holing, abseiling,deep sea diving using hard helmet and breathing apparatus, polo, snow and ice sports andactivities and similar hazards.
16. Any person whilst engaging in aviation, whilst mounting into or demounting from ortraveling in any aircraft other than as a passenger (fare paying or otherwise) in any dulylicensed standard type of aircraft anywhere in the world*.
POLICY EXCLUSIONS
MDIndia Health Care Services ( TPA ) Pvt Ltd2/18/2016 11
• Cashless Facility is available at Network Hospitals, provided the purpose of Hospitalisation iswithin the scope of cover and adherence to protocol.
The patient need to bring Mediclaim ID card along with any valid Photo ID card (e.g.-Voter ID, Passport, PAN card, Driving Licence, School or College ID card etc.), during admission to Hospitalisation.
Hospital will send RAL & related documents to TPA (MD India)
If Cashless is accorded, TPA will inform the member and the hospital on the same & will send a letter of approval (Authorisation Letter) to Hospital, for CASHLESS facility. Similar Procedure is followed after Discharge is confirmed.
In case of further clarifications, MD India will contact employee/HR.
TPA will examine the documents, if the ailment is covered under the policy, they will ACCORD a Cashless facility to the member.
Claim Process – CASHLESS
MDIndia Health Care Services ( TPA ) Pvt Ltd2/18/2016 12
In case of a medical claim where the member has already paid or intends to pay the
hospital bill, then the following process should be followed –
Intimate to TPA 48 hrs. prior to admissionPay the Hospital bill
Complete the claim form. Attach all the original documents & submit the same to MD India Helpdesk / respective HR Person.
The complete set is forwarded to TPA (MD India) within 15 days from the Date of Discharge from the Hospital.
If the claim is payable, payment will be forwarded to the respective Employee Account.
In case of further clarifications, MD India will contact employee/HR
TPA will lodge a claim with the Insurance Company after verifying the documents.
Claim Process – REIMBURSEMENT
MDIndia Health Care Services ( TPA ) Pvt Ltd2/18/2016 13
1. Duly filled & signed Claim form by the employee with the seal & signature of the concerned authority in the organization.
2. Photocopy of Cashless card.3. Original Discharge card / Discharge summary.4. Original Hospital bill with the seal & signature of the Hospital along with the Bill No. Printed5. Detailed Hospital bill break-up for the expenses incurred.6. All original prescriptions & consultation papers of the Doctor.7. All original Medical bills with the name of the Patient duly endorsed by the treating Doctor.8. All original cash paid receipts supporting the bills in the name of patient vide receipt No:s.9. All original Medical reports certified by the Doctor (Pathology, X-Ray, CT-Scan, ECG, MRI,
etc.)10. Summary of all Expenses.11. Medico Legal Certificate (MLC) / FIR in case of accident cases.12. Medico Legal Certificate (MLC) & FIR both are mandatory in case of road traffic accident.13. All Indoor Case Papers (ICP).14. Cancelled cheque of the Employee along with Employee Name printed on Cheque leaf or
Bank Pass Book.
Checklist - Documents to be submitted for Re-imbursement
MDIndia Health Care Services ( TPA ) Pvt Ltd2/18/2016 14
• Visit us at www.mdindiaonline.com
• Click on Login -- My Account Corporate Employee and
Click
15
Website Access - Online
MDIndia Health Care Services ( TPA ) Pvt Ltd2/18/2016 15
2/18/2016MDI Confidential Proprietary Information
Please provide your complete policy number / MD ID as on policy schedule
16
Login to your account
MDIndia Health Care Services ( TPA ) Pvt Ltd2/18/2016 16
2/18/2016
Click on E card to download E card or on claims to see details of claims.
MDI Confidential Proprietary Information17
Welcome to primary information screen
MDIndia Health Care Services ( TPA ) Pvt Ltd2/18/2016 17
Print E card as per your convenience if you require to give it to someone and
during claims submission .
18
E - Cards
MDIndia Health Care Services ( TPA ) Pvt Ltd2/18/2016 18
2/18/2016 19
Android Phones – Mobile App
MDIndia Health Care Services ( TPA ) Pvt Ltd
2/18/2016 20
First Screen of the App –Click/Tap Corporate Policy Holder
MDIndia Health Care Services ( TPA ) Pvt Ltd
2/18/2016 21
Enter the Valid Mobile Number, Verification code shall be sent to the Mobile number entered. This is one time registration process.
MDIndia Health Care Services ( TPA ) Pvt Ltd
2/18/2016 22
Below details can be validated or obtained from employee individual login:1. E-Cards of Self &
Dependents.2. Claims Status –
Cashless &Reimbursement.
3. Policy Features andeligibility Criteria.
4. Network List ofHospitals for CashlessFacility across PanIndia.
5. Various formsavailable online
MDIndia Health Care Services ( TPA ) Pvt Ltd
23
Provider Network – Our Network of Hospitals across Pan India
3Himachal Pradesh
Assam
Bihar
Andhra Pradesh
4
7
11
168
7
302
Haryana 100Punjab
Chandigarh
35
Uttarakhand 10
Uttar Pradesh
West BengalOrissa
Maharashtra
Gujarat
Rajasthan
Delhi
Madhya Pradesh
Goa
Karnataka
Kerala
Tamil Nadu
180
Chattisgarh
40
469
261
92
325
140
11
103
857
42
Daman & Diu 2
Jharkhand4
Meghalaya
16000+ HOSPITALS
EMPANELED &
GROWING.
*Visit website for latest list
MDIndia Health Care Services ( TPA ) Pvt Ltd2/18/2016 23
Employee may contact MD India @ Toll Free & UAN Numbers –
• Cashless Hospitalization:
The Request for authorization(Cashless) form can be sent with the help of
network Hospital to the following No. or mail id.
1. Toll free Fax No -1860-233-4449.
2. Email - [email protected]
• Customer Care:
The Employee can contact the Customer Care on :-
1.Toll free No.- 1800-233-1166 or 1800-233-4505
2. Email - [email protected]
3. Online - www.mdindiaonline.com
Toll free No. and E-Mail ids –MDIndia Health Care Services (TPA) Pvt Ltd.
• 24 x 7 for 365
days at your
services
• Toll free numbers
for cashless
services and
customer queries.
• Supported with
Medical Query
Assistance round
the clock.
MDIndia Health Care Services ( TPA ) Pvt Ltd2/18/2016 24
• Contact Details:
Ms. Navara Renuka - 9391427060
Landline – : 040-23414121/ 040-23414125
Email - [email protected]
Point Of Contacts and Escalation Matrix –MDIndia Health Care Services (TPA) Pvt Ltd.
MDIndia Health Care Services ( TPA ) Pvt Ltd2/18/2016 25
Escalation Level Name Contact No Mail ID
Level1 Ms. Navara Renuka 9391427060 [email protected]
Level2 Ms. Sangeetha Tammali 9390838023 [email protected]
Level3 Mr.Somasekhar Reddy 9347129606 [email protected]
Level4 Mr.Anand Rao Dasagiri 8886644260 [email protected];
MDIndia Health Care Services ( TPA ) Pvt Ltd 14 Jun’2015MDIndia Health Care Services ( TPA ) Pvt Ltd
��������������� ��������������������
�
�
�� �������������������������� � �
�
����������������� ������������������ ��������������������������������� ������������
����� ��������� ����� �� ��������������
���� ����������������������������������� ������������������ !�����������������
����������������"�� �����������������������#�$���� ����
������������ ����������������������������� ������ ��������������� ������
� � � ��� ��� �� ��������
��������������������������� ���� ����������� ������������������� !"#��
�
�
$� ��������� �������������������
����������������� ������������������ �������%���������� ��� ����� ��������
�����������������
��������� ������ ��� �� ���������������������������� ���
&� ������� ����� ���������� ������ ����������'�������(��� �����)�����
�����������* �� ����������������������* �� ������"���������������������
������ &+,,�-..�/0,01�&+,,�-..�&&&2"��
-� $������������������������������ ������������������������������ ��� ������
����� ��� �� ���� ���������� ������� ���������!��$�3�� ���� ��� �.,�
����������������������������
�" �����������������������
�" �������������������� ������������������ ������������������������
�������"�
�" 4 ���� ����������������
" 4 ���� �����������������
�" 4 ���� ��������������������� ��������
�" 4 ���� ���� �������� �������� ���� �"��
�" $������������� ��������� ���
�" �����������)�5������
�" 4 ���� ����� ���������6���
�
�
�
�
�
�
�������������
�� ��������
�� ���������
������������
�� ����������
����������
����������
������� ����
������� ������
�����������������
�������������������
�� ������������������
�� �������� ����
����� �������
���������������
CLAIM FORM - PART A' to 'CLAIM FORM FOR HEALTH INSURANCE POLICIES OTHER THAN TRAVEL AND PERSONAL ACCIDENT - PART ATO BE FILLED BY THE INSURED
The issue of this Form is not to be taken as an admission of liablity
DETAILS OF PRIMARY INSURED:
a) Policy No.:
(To be Filled in block letters)S
EC
TIO
N A
SE
CT
ION
B
b) Sl. No/ Certificate no.
c) Company/ TPA ID No:
e) Address:
DETAILS OF INSURANCE HISTORY:
a) Currently covered by any other Mediclaim / Health Insurance: 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?
Diagnosis: e) Previously covered by any other Mediclaim /Health insurance : :
Date: M M
Y
Y
Y
Y
f) If yes, company name:
DETAILS OF INSURED PERSON HOSPITALIZED: :
DETAILS OF HOSPITALIZATION: :
DETAILS OF CLAIM:
DETAILS OF BILLS ENCLOSED:
Sl. No. Bill No. Date Issued by Towards Amount (Rs)
DETAILS OF PRIMARY INSURED’S BANK ACCOUNT::
SE
CT
ION
CS
EC
TIO
N D
SE
CT
ION
ES
EC
TIO
N F
SE
CT
ION
G
D YMD YM1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
D YMD YM
D YMD YM
D YMD YM
D YMD YM
D YMD YM
D YMD YM
D YMD YM
D YMD YM
D YMD YM
City: State:
Pin Code Phone No: Email ID:
City: State:
Pin Code Phone No: Email ID:
D D
D D
M M
M M
Y Y
Y Y
Yes No
Yes No
Yes No
d) Name: S U R N A M E F I R S T N A M E M I D D L E N A M E
a) Name: S U R N A M E F I R S T N A M E M I D D L E N A M E
b) Gender Male Female c) Age years M M Y Y Y YMonths d) Date of Birth
e) Relationship to Primary insured: Self Spouse Child Father Mother Other (Please Specify)
(Please Specify)OtherRetiredStudentHome MakerSelf EmployedServicef) Occupation
g) Address (if diffrent from above) :
a) Name of Hospital where Admited:
b) Room Category occupied: Day care
D D M M Y Y H H H HM H M H
D D M M Y Y Y Y
D D M M Y Y
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) Date of Admission: f) Time g) Date of Discharge: h) Time: :
NoYesI) If Medico legal
j) System of Medicine:
Substance Abuse / Alcohol ConsumptionI) If injury give cause: Self inflicted Road Traffic Accident
iii. MLC Report & Police FIR attachedii) Reported to Police NoYes
a) Details of the Treatment expenses claimed
I. Pre -hospitalization expenses
iii. Post-hospitalization expenses
v. Ambulance Charges:
Rs.
Rs.
Rs.
ii. Hospitalization expenses Rs.
iv. Health-Check up cost:
vi. Others (code):
Rs.
Rs.
Rs.Total
vii. Pre -hospitalization period: days viii. Post -hospitalization period: days
b) Claim for Domiciliary Hospitalization: NoYes (If yes, provide details in annexure)
c) Details of Lump sum / cash benefit claimed:
i. Hospital Daily cash: Rs.
Rs.
Rs.
iii. Critical Illness benefit:
v. Pre/Post hospitalization Lump sum benefit:
ii. Surgical Cash:
iv. Convalescence:
vi. Others:
Rs.
Rs.
Rs.
Rs.Total
Claim Documents Submitted - Check List:
Claim form duly signed
Copy of the claim intimation, if any
Hospital Main Bill
Hospital Break-up Bill
Hospital Bill Payment Receipt
Hospital Discharge Summary
Pharmacy Bill
Operation Theater Notes
ECG
Doctor’s request for investigation
Investigation Reports (Including CT/ MRI / USG / HPE)Doctor’s Prescriptions
Others
Hospital main Bill
Pharmacy Bills
Post-hospitalization Bills: Nos
Pre-hospitalization Bills: Nos
a) PAN:
c) Bank Name and Branch:
d) Cheque / DD Payable details:
b) Account Number:
e) IFSC Code:
(IMPORTANT: PLEASE TURN OVER)
DECLARATION BY THE INSURED:
I hereby declare that the information furnished in the claim form is true & correct to the best of my knowledge and belief. If I have made any false or untrue statement, suppressionor concealent of any material fact with respect to questions asked in relation to this claim, my right to claim reimbrusement 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-hospitalizationclaim, if any.
Date Y YD D M M Y Y 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
b) Sl. No/ Certificate No.Enter the social Insurance number or the certificate number of
As allotted by the oraganizationsocial health insurance scheme
c) Company TPA ID No. Enter the TPA ID No.Licence number as allotted by IRDA and printedin TPA documents.
d) Name Enter the full name of the policyholder Surname, First name, Middle name
Include Street, City and Pin codeEnter the full postal addresse) Address
SECTION B -DETAILS OF INSURANCE HISTORY
a) Currently covered by any other Mediclaim / Health Insurance?
Indicate whether currently covered by another Mediclaim /Health Insurance
Tick Yes or No
b) Date of commencement of first Insurance without break Enter the date of commencement of first Insurance Use dd-mm-yy-forrmat
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
In rupeesEnter the total sum insured as per the policySum insured
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
Tick Yes or Noe) Previously covered by any other Mediclaim / Health Insurance?
Indicate whether previously covered by another mediclaim / Health Insurance
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 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 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
Include STD code with telephone number
Complete e-mail address
h) Phone No
1) E-mail ID
Enter the phone number of patient
Enter e-mail address of patient
SECTION D - DETAILS OF HOSPITALIZATION
a) Name of Hospital where admited Enter the name of hospital Name of hospital in full
Tick the right option
Tick the right option
Use dd-mm-yy format
Use dd-mm-yy format
Use hh-mm- format
Use dd-mm-yy format
Use hh-mm- format
Tick the right option
Tick Yes or No
Tick Yes or No
Tick Yes or No
Open Text
b) Room category occupied
c) Hospitalization due to
d) Date of injury/Date Disease first detected / Date of Delivery
e) Date of admission
f) Time
g) Date of discharge
h) Time
I) If injury give cause
If Medico legal
Reported to Police
MLC Report & Police FIR attached
j) System of Medicene
indicate the room category occupied
indicate reason of hospitalization
Enter the relevant date
Enter date of admission
Enter time of admission
Enter date of discharge
Enter time of discharge
indicate cause of injury
indicate whether injury is medico legal
indicate whether police report was filed
indicate whether MLC report and Police FIR attached
Enter the system of medicine followed in treating the patient
SECTION E - DETAILS OF CLAIM
a) Details of Treatment Expences
b) Claim for Domiciliary Hospitalization
c) Details of Lump sum/ Cash benifit claimed
d) Claim documents Submitted-Check List
Enter the amount claimed as treatment expences
indicate whether claim is for domiciliary hospitalization
Enter the amount claimed as lump sum / cash benefit
indicate which supporting documents are submitted
Tick Yes or No
Tick the right option
In rupees (Do not enter paise values)
In rupees (Do not enter paise values)
SECTION F - DETAILS OF BILLS ENCLOSED
Indicate which bills are enclosed with the amount in rupees
SECTION G - DETAILS OF PRIMARY INSURED’s BANK ACCOUNT
a) PAN
b) Account Number
c) Bank Name and Branch
c) Cheque/ DD payable details
c) IFSC Code
Enter the permanent account number
Enter the Bank account number
Enter the Bank name along with the branch
Enter the name of the beneficiary the cheque / DD should bemade out to
Enter the IFSC code of the Bank branch
As allotted by the Income Tax Department
As allotted by the Bank
Name of the Bank in full
Name of the individual / organization in full
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.
SE
CT
ION
H
CLAIM FORM - PART BTO BE FILLED IN BY THE HOSPITAL
The issue of this Form is not to be taken as an admission of liabilityPlease include the original preauthorization request form in lieu of PART A
(To be Filled in block letters)
DETAILS OF HOSPITAL
a) Name of the hospital:
a) Hospital ID:
c) Name of the treating doctor:
e) Qualification:
DETAILS OF THE PATIENT ADMITTED
c) Type of Hospital: Network : Non Network : (if non network fill section E)
f) Registration No. with State Code: g) Phone No.
a) Name of the Patient:
b) IP Registration Number: c) Gender: Male Female d) Age: Years Months e) Date of birth:
ii) Gravida Status: :
m) Total claimed amount
h) Date of Discharge:
i) Date of Delivery: k) If MaternityMaternityDay CarePlannedEmergency
f) Date of Admission:
j) Type of Admission:
I) Status at time of discharge: Discharge to home Discharge to another hospital Deceased
DETAILS OF AILMENT DIAGNOSED (PRIMARY)
a) ICD 10 Codes
I. Primary Diagnosis
ii. Additional Diagnosis:
iii. Co-morbidities:
iv. Co-morbidities:
vi. If not reported to police give reason:
Description b)
i. Procedure 1:
ii. Procedure 2:
iii. Procedure 3:
iv. Details of Procedure:
ICD 10 PCS Description
c) Pre-authorization obtained: Yes
Yes
Yes Yes
No
No
No No
d) Pre-authorization Number:
e) If authorization by network hospital not obtained, give reason:
f) Hospitalization due to injury: I. If Yes, give cause Self-inflicted Road Traffic Accident Substance abuse / alcohol consumption
iv. Reported to Policeiii. If Medico legal:(If Yes, attach reports)ii) If injury due to substance abuse / alcohol consumption, Test conducted to establish this:
v. FIR No.
CLAIM DOCUMENTS SUBMITTED - CHECK LIST
Claim Form duly signed
Original Pre-authorization request
Copy of the Pre-authorization approval letter
Copy of Photo ID Card of patient Verified by hospital
Hospital Discharge summary
Operation Theatre Notes
Hospital main bill
Hospital break-up bill
Investigation reports
CT/MR/USG/HPE investigation reports
Doctor’s reference slip for investigation
ECG
Pharmacy bills
MLC reports & Police FIR
Original death summary from hospital where applicable
Any other, please specify
ADDITIONAL DETAILS IN CASE OF NON NETWORK HOSPITAL (ONLY FILL IN CASE OF NON-NETWORK HOSPITAL)
(PLEASE READ VERY CAREFULLY)
a) Address of the Hospital
d) Hospital PAN:
iii. Others:
DECLARATION BY THE 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:
Place: Signature and Seal of the Hospital Authority:
SE
CT
ION
AS
EC
TIO
N B
SE
CT
ION
CS
EC
TIO
N D
SE
CT
ION
ES
EC
TIO
N F
Yes No
Yes No
City: State:
Pin Code: b) Phone No. c) Registration No. with State Code:
e) Number of inpatient beds f) Facilities available in the hospital i. OT ii. ICU Yes No
S U R N A M E F I R S T N A M E M I D D L E N A M E
S U R N A M E F I R S T N A M E M I D D L E N A M E
D D M M Y Y H H M M
Y Y M M
M M
M M
D D
D D
H MH MY
Y
D D M M Y Y
D D M M Y Y
Y
Y
g) Time:
GUIDANCE FOR FILLING CLAIM FORM - PART B (To be filled in by the hospital)
DATA ELEMENT DESCRIPTION FORMAT
a) Name of the hospital:
b) Hospital ID
c) Type of Hospital
c) Name of treating doctor
SECTION A - DETAILS OF HOSPITAL
e) Qualification
f) Registration No. with State Code
g) Phone No.
Enter the name of hospital
Enter ID number of hospital
Indicate whether in network or non network hospital
Enter the name of the treating doctor
Enter the qualification of the treating doctor
Enter the registration number of the doctor along with the state code
Enter the phone number of doctor
SECTION B - DETAILS OF THE PATIENT ADMITTED
a) Name of Patient
b) IP registration Number
c) Gender
d) Age
e) Date of Birth
f) Date of Admission
g) Time
h) Date of Discharge
i) Time
j) Type of Admission
k) If Maternity
Date of Delivery
Gravida Status
l) Status at time of discharge
M) Total claimed amount
Enter the name of patient
Enter insurance provider registration number
Indicate Gender of the patient
Enter age of the patient
Enter date of birth
Enter date of admission
Enter Time of admission
Enter date of Discharge
Enter time of Discharge
Indicate type of admission of patient
Enter Date of Delivery if maternity
Enter Gravida status if maternity
Indicate status of patient at time of discharge
Indicate the total claimed amount
SECTION C - DETAILS OF AILMENT DIAGNOSED (PRIMARY)
a) ICD 10 Code
Primary Diagnosis
Additional Diagnosis
Co-morbidities
b) ICD 10 PCS
Procedure 1
Procedure 2
Procedure 3
Details of Procedure
c) Pre-authorization obtained
d) Pre-authorization Number
e) If authorization by network hospital not obtained, give reason
f) Hospitalization due to injury
Cause
If injury due to substance abuse/alcohol consumption test conducted to establish this
Medico Legal
Reported to Police
FIR No.
If not reported to police, give reason
Indicate which supporting documents are submitted
SECTION D - CLAIM DOCUMENTS SUBMITTED-CHECK LIST
SECTION E - DETAILS IN CASE OF NON NETWORK HOSPITAL
a) Address
b) Phone No.
c) Registration No. with State Code
d) Hospital PAN
e) Number of Inpatient beds
f) Facilities available in the hospital
Read declaration carefully and mention date (in dd:mm:yy format), place (open text) and sign. and stamp
Enter the ICD 10 Code and description of the primary diagnosis
Enter the ICD 10 Code and description of the additional diagnosis
Enter the ICD 10 Code and description of the Co-morbidities
Enter the ICD 10 Code and description of the first procedure
Enter the ICD 10 Code and description of the second procedure
Enter the ICD 10 Code and description of the third procedure
Enter the details of the procedure
Enter pre-authorization number
Indicate whether pre-authorization obtained
Enter reason for not obtaining pre-authorization number
Indicate if hospitalization is due to injury
Indicate cause of injury
Indicate whether test conducted
Indicate whether injury is medico legal
Indicate whether police report was filed
Enter first information report number
Enter reason for not reporting to police
Enter the full postal address
Enter the phone number of hospital
Enter the permanent account number
Enter the number of inpatient beds
Indicate facilities available in the hospital
SECTION F - DECLARATION BY THE HOSPITAL
Name of the hospital in full
As allocated by the TPA
Tick the right option
Name of doctor in full
Abbreviations of educational qualifications
As allocated by the Medical Council of India
Include STD code with telephone number
Name of patient in full
As allotted by the insurance provider
Tick Male or Female
Number of years and months
Use dd-mm-yy format
Use dd-mm-yy format
Use hh:mm format
Use dd-mm-yy format
Use hh:mm format
Tick the right option
Use dd-mm-yy format
Use standard format
Tick the right option
In rupees (Do not enter paise values)
Include Street, City and Pin Code
Include STD code with telephone number
As allocated by the City Corporation / Municipality
As allocated by the Income Tax Department
Digits
Tick the right option. If others, please specify
Standard Format and Open text
Standard Format and Open text
Standard Format and Open text
Standard Format and Open text
Standard Format and Open text
Standard Format and Open text
Open text
Tick Yes or No
As allotted by TPA
Open text
Tick Yes or No
Tick Yes or No
Tick the right option
Tick Yes or No
Tick Yes or No
As issued by police authrities
Open text
Enter the registration number of the Hospital obtained from local bodylike City Corporation / Municipality