united india insur health_claim_form

7/26/2019 United India Insur Health_claim_form

1/6

CLAIM FORM - PART A

TO BE FILLED IN BY THE INSURED

(To be filled in block lee!"#

DETAILS OF PRIMARY INSURED

a) Policy no:

c) Company/ TPA ID No:

d) Name:SEC

TION

A

e) Address:

City: State:

Pin Code: Phone No: Email ID:

DETAILS OF INSURANCE HISTORY

Yes No b) Date o commencement o irst ins!rance "itho!t brea#:

SECTION

B

c) I yes$ company name: Policy No:

d) %a&e yo! been hospi ta li 'ed i n the l as t o!r years s ince i ncepti on o the contrac t( Yes No Date:

Dianosis: Yes No

) I yes$ Company Name :

DETAILS OF INSURED PERSON HOSPITALI$ED

a) Name :

b) *ender : +ale ,emale c) Ae: years months d) Date o -irth:

Sel Spo!se Child ,ather +other Other .Please speciy)

SECTION

C

) Occ!pation: Ser&ice Sel Employed %omema#er St!dent etired Other .Please speciy)

) Address .i dierent rom abo&e):

City: State:

Pin Code: Phone No: Email ID:

DETAILS OF HOSPITALI$ATION

a) Name o %ospital "here Admitted:

b) oom cateory occ!pied: Day Car e Sinle occ!pancy T"in shar in 0 or mor e beds per room

SECTION

D

c) %ospi tali'ation d!e to: In1!ry Illness +aternity d) Date o in1!ry/ Date Disease irst detected/ Date o Del i&ery:

e) Date o Admission: ) Time: : ) Date o Dischare: h) Time: :

i ) I in1!ry$ i&e ca!se: Sel inlicted oad Traic Accident S!bstance ab!se / Alcohol Cons!mption i 2 I +edico 3eal : Yes No

ii2 eported to police: Yes No iii2 +3C eport 4 Police ,I attached: Yes No 1) System o medicine:

DETAILS OF CLAIM

a) Details o treatment e5penses claimed Cl%i& Doc'&en" S'b&ied- Ceck Li")

` ii2 %ospitali'ation E5penses `

iii2 Post %ospitali'ation E5penses ` i&2 %ealth Chec# !p Cost ` Copy o the claim intimation$ i any

&2 Amb!lance Chares ` &i2 Others .code): ` %ospital +ain bill

To%l ` %ospital -rea#6!p bill

SECTION

E

days days %ospital Dischare S!mmary

b) Claim or Domiciliary %ospitali'ation: Yes No Pharmacy -ill

c) Details o 3!mp s!m / cash beneit claimed:

i2 %ospital Daily Cash: ` ii2 S!rical Cash: ` EC*

iii2 Critical Illness -eneit: ` i&2 Con&alescence: ` Doctor7s re8!est or in&estiation

` &i2 Others: ` In&estiation eports .incl!din CT /

+I / 9S* / %PE)

To%l ` Doctor7s Prescription

Others

DETAILS OF BILLS ENCLOSED

Bill No* D%e I""'ed B+ To,%!d"

%ospital +ain -ill

.

/

0 Pharmacy -ills: SECTION

F

1

2

3

4

5

6

DETAILS OF PRIMARY INSURED7S BAN8 ACCOUNT

a) PAN: b) Acco!nt N!mber:SECTION

c) -an# Name and -ranch

The iss!e o theis orm is not to be ta#en as admission o liability

b) Sl2 No/ Certiicate No:

a) C!rrently co&ered by any other +ediclaim/ %ealth Ins!rance:

S!m Ins!red .`):

e) Pre&io!sly co&ered by any other +ediclaim/ %ealth Ins!rance :

e) elat!ionship to Primary Ins!red:

i2 Pre %ospitali'ation E5penses Claim ,ormD!ly sined

&i2 Pre hospitali'ation period: &ii2 Pre hospitali'ation period:

.i yes$ pro&ide details in anne5!re)

Operation Theatre Notes

&2 Pre/Post hosp2 3!mp s!m beneit:

Sl* No* A&o'n ( #

Pre hospitalisation -ills: Nos

Post hospitalisation -ills: Nos

UNITED INDIA INSURANCE COMPANY LIMITED

REGISTERED & HEAD OFFICE: 24, WHITES ROAD, CHENNAI-600014


2/6

e) I,SC Code:9

DECLARATION BY THE INSURED

SECTION

H

Date: Place: Sinat!re o the ins!red:

GUIDANCE FOR FILLING CLAIM FORM PART A (To be filled in by the insued!

DATA ELEMENT DE"CRIPTION FORMAT

"ECTION A # DETAIL" OF PRIMAR$ IN"URED

a) Policy No.Enter the policy number As allotted by the insurance company

b) SI. No/ Certificate No. As allotted by the organization

c) Company PA I! No. Enter the PA I! No

d) Name Enter the full name of the policyholder Surname" #irst name" $iddle name

e) Address Enter the full postal address Include Street" City and Pin Code

"ECTION % # DETAIL" OF IN"URANCE &I"TOR$

ic% &es or No

b) !ate of Commencement of first Insurance 'ithout brea%Enter the date of commencement of first insurance

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 companySum Insured

Enter the total sum insured as per the policy In rupees

d) (ae you been (ospitalized in the last * years since inception of the contract+ Indicate 'hether hospitalized in the last * years ic% &es or No

!ateEnter the date of hospitalization

!iagnosisEnter the diagnosis details ,pen e-t

ic% &es or No

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

"ECTION C # DETAIL" OF IN"URED PER"ON &O"PITALI'ED

a) NameEnter the full name of the patient Surname" #irst name" $iddle name

b) ender Indicate ender of the patient ic% $ale or #emale

c) AgeEnter age of the patient Number of years and months

d) !ate of irthEnter !ate of irth of patient

e) 0elationship to primary Insured Indicate relationship of patient 'ith policyholder ic% the right option. If others" please specify.

f) ,ccupationIndicate occupation of patient ic% the right option. If others" please specify.

g) AddressEnter the full postal address Include Street" City and Pin Code

h) Phone No

Enter the phone number of patient Include S! code 'ith telephone number i) E1mail I!

Enter e1mail address of patient Complete e1mail address

"ECTION D # DETAIL" OF &O"PITALI'ATION

a) Name of (ospital 'here admittedEnter the name of hospital Name of hospital in full

b) 0oom category occupiedIndicate the room category occupied ic% the right option

c) (ospitalization due toIndicate reason of hospitalization ic% the right option

d) !ate of In2ury/!ate !isease first detected/ !ate of !elieryEnter the releant date

e) !ate of admission Enter date of admission

f) ime Enter time of admission

g) !ate of dischargeEnter date of discharge

h) ime Enter time of discharge

i) If In2ury gie cause Indicate cause of in2ury ic% the right option

If $edico legalIndicate 'hether in2ury is medico legal ic% &es or No

0eported to Police Indicate 'hether police report 'as filed ic% &es or No

$3C 0eport 4 Police #I0 attached Indicate 'hether $3C report and Police #I0 attached ic% &es or No

2) System of $edicine Enter the system of medi ci ne foll o'ed i n treating the pati ent ,pen e-t

"ECTION E # DETAIL" OF CLAIMa) !etails of reatment E-penses Enter the amount claimed as treatment e-penses

b) Claim for !omiciliary (ospitalization Indicate 'hether claim is for domiciliary hospitalization ic% &es or No

c) !etails of 3ump sum/ cash benefit claimed Enter the amount claimed as lump sum/ cash benefit

d) Claim !ocuments Submitted1Chec% 3ist Indicate 'hich supporting documents are submitted ic% the right option

"ECTION F # DETAIL" OF %ILL" ENCLO"ED

Indicate 'hich bills are enclosed 'ith the amounts in rupees

"ECTION G # DETAIL" OF PRIMAR$ IN"URED" %AN) ACCOUNT

a) PAN Enter the permanent account number As allotted by the Income a- department

b) Account NumberEnter the ban% account number As allotted by the ban%

c) an% Name and ranch Enter the ban% name along 'ith the branch Name of the an% in full

Name of the indiidual/ organization in full

e) I#SC CodeEnter the I#SC code of the ban% branch I#SC code of the ban% branch in full

"ECTION & # DECLARATION %$ T&E IN"URED

d) Che8!e/ DD Payable details:

I hereby declare that the inormation !rnished in this claim orm is tr!e 4 correct to the best o my #no"lede and belie2 I I ha&e made any alse or !ntr!e statement$ s!ppression or concealment o any material act "ith respect to 8!estions as#ed in relation to thisclaim$ my riht to claim reimb!rsement shall be oreited2 I also consent 4 a!thori'e TPA / ins!rance company$ to see# necessary medical inormation / doc!ments rom any hospital / +edical Practitioner "ho has attended on the person aainst "hom this claim ismade2 I hereby declare that I ha&e incl!ded all the bills / receipts or the p!rpose o this claim 4 that I "ill not be ma#in any s!pplementary claim e5cept the pre/post6hospitali'ation claim$ i any2

Enter the social insurance number or the certificate number of social healthinsurance scheme

3icense number as allotted by I0!A and printed in PAdocuments.

a) Currently coered by any other $ediclaim / (ealth Insurance+ Indicate 'hether currently coered by another $ediclaim / (ealth Insurance

5se dd1mm1yy format

5se mm1yy format

e) Preiously Coered by any other $ediclaim/ (ealth Insurance+ Indicate 'hether preiously coered by another $ediclaim / (ealth Insurance

5se dd1mm1yy format

5se dd1mm1yy format

5se dd1mm1yy format

5se hh6mm format

5se dd1mm1yy format

5se hh6mm format

In rupees 7!o not enter paise alues)

In rupees 7!o not enter paise alues)

d) Che8ue/ !! payable detailsEnter the name of the beneficiary the che8ue/ !! should be made out to

0ead declaration carefully and mention date 7in dd6mm6yy format)" place 7open te-t) and sign.


3/6


4/6


5/6

CLAIM FORM - PART B

TO BE FILLED IN BY THE HOSPITAL

(To be filled in block lee!"#

DETAILS OF HOSPITAL

a) Name o the %ospital:

SECTION

A

c) %ospital ID: c) Type o %ospital: Net"or# Non Net"or# .i non net"or#$ ill Section E)

d) Name o the treatin doctor:

e) ;!aliication: ) eistration No2 "ith state code: ) Phone No2

DETAILS OF PATIENT ADMITTED

a) Name o Patient:

b) IP eistration No2: c) *ender : +ale ,emale d) Ae: years months e) Date o -irth:SECTION

B

) Date o Admission: ) Time: : h) Date o Dischare: i) Time: :

1) Type o Admission: Emerency Planned Day Care +aternity #) I +aternity: i2 Date o Deli&ery:

l) Stat!s at time o dischare: Dischared to home Dischared to another hospital Deceased m) Total claimed amo!nt

DETAILS OF AILMENT DIA9NOSED (PRIMARY#

a) ICD


6/6

b) IP 0egistration Number Enter ins!rance pro&ider reistration n!mber As allotted by the ins!rance pro&ider

c) ender Indicate *ender o the patient Tic# +ale or ,emale

d) Age Enter ae o the patient N!mber o years and months

e) !ate of Admission Enter date o admission

f) ime Enter time o admission

g) !ate of !ischarge Enter date o dischare

h) ime Enter time o dischare

i) ype of Admission Indicate type o admission o patient Tic# the riht option

2) If $aternity

!ate of !eliery Enter Date o Deli&ery i maternity

9se standard ormat%) Status at time of discharge Indicate stat!s o patient at time o dischare Tic# the riht option

"ECTION C DETAIL" OF AILMENT DIAGNO"ED (PRIMAR$!

a) IC! :; Code

Primary !iagnosis Enter the ICD

united india insur health_claim_form

Documents