SECTION A
TO BE FILLED IN BY THE INSURED
The issue of this Form is not to be taken as an admission of liability
DETAILS OF PRIMARY INSURED
a) Policy No:
b) Sl. No/Certificate No
c) Company/TPA ID No:
d) Name:
S
U
R N
A
M E
M I D D L E
N
A
M EF I R S T N
A
M E
e
) Address:
City
State:
Pin Code Phone No:
Email ID:
DETAILS OF INSURANCE HISTORY:
a) Currently covered by any other Mediclaim / Health Insurance:
b) Date of commencement of first Insurance without break:
YES
NO
D D M M Y Y
c) If yes, company name:
Policy No.
SECTION B
Sum Insured (Rs.)
d) Have you been hospitalized in the last four years since inception of the contract?
YES NO
D D M M Y Y
Diagnosis:
e) Previously covered by any other Mediclaim / Health insurance :
YES NO
f) If yes, Company Name
Date
DETAILS OF INSURED PERSON HOSPITALIZED:
a) Name:
b
) Gender:
Male Female
c) Age: Years
Y Y
Month
M M
d) Date of Birth:
D D
M M
Y Y
SECTION C
e) Relationship to Primary insured:
Self
Spouse
Child
Father Mother Other
f) Occupation:
Service
Self Employed
Homemaker Student
Retired Other
(Please Specify)
g) Address (if different from above):
City
State:
Pin Code: Phone No:
Email ID:
DETAILS OF HOSPITALIZATION:
a) Name of Hospital where Admitted:
b) Room Category occupied:
Day Care
Single occupancy
Twin sharing 3 or more beds per room
c) Hospitalization due to:
Injury
Illness
Maternity
d) Date of Injury / Date Disease first detected /Date of Delivery:
D D
M M
Y Y
e) Date of Admission:
D D
M M
Y Y
f) Time:
H H M M
g) Date of Discharge:
D D
M M
Y Y
h) Time:
H H M M
i) If Injury give cause:
Self inflicted
Road Traffic Accident
Substance Abuse / Alcohol Consumption
i. If Medico legal:
YES NO
ii. Reported to police:
YES NO
iii. MLC Report & Police FIR attached:
YES NO
j) System of Medicine:
SECTION D
Y Y
Claim form for health insurance policies other than
travel and personal accident - PART A
(Please Specify)
(TO BE FILLED IN BLOCK LETTERS)
S
U
R N
A
M E
M I D D L E
N
A
M EF I R S T N
A
M E
Third Gender
Ver-2/Claim_Reimb/April20/Form
Amount (Rs)
b) Account Number:
e) IFSC Code:
D D
M M
Y Y
DETAILS OF CLAIM:
a) Details of the treatment expenses claimed
i. Pre-hospitalization Expenses:
iii. Post-hospitalization Expenses:
Rs.
Claim Documents Submitted- Check List:
Rs.
v
. Ambulance Charges:
Rs.
vii. Pre-hospitalization period:
Days
b
) Claim for Domiciliary Hospitalization:
ii. Hospitalization Expenses:
Rs.
iv
. Health-Check up Cost:
Rs.
vi. Others (c
ode):
Rs.
T
otal
Rs.
viii. Post-hospitalization period:
Days
YES NO
(If yes, provide details in annexur
e)
c
) Details of Lump sum / cash benefit claimed:
i. Hospital Daily Cash:
iii. Critical Illness Benefit:
v
. Pre/Post hospitalization Lump sum benefit:
ii. Surgical Cash:
iv.
Convalescence:
Rs.
Rs.
vi. Others
Rs.
T
otal
Rs.
Claim Form Duly signed
Hospital Main Bill
Hospital Break-up Bill
Hospital Bill Payment Receipt
Hospital Discharge Summary
Pharmacy Bill
Operation T
heatre Notes
Copy of the Claim intimation if any
ECG
Doctor's request for investigation
Investigation Reports (Including CT
MRI / USG / HPE)
/
Doctor's Prescriptions
Others
SECTION E
DETAILS OF BILLS ENCLOSED:
Sl. No. Bill No.
Date
Issued by
Towards
Hospital Main Bill
Pre-hospitalization Bills: Nos
Post-hospitalization Bills: Nos
Pharmacy Bills
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
1
2
3
4
5
6
7
8
9
10
DETAILS OF PRIMARY INSURED'S BANK ACCOUNT:
SECTION F
c) Bank Name and Branch:
d) Cheque/ DD Payable details:
SECTION G
DECLARATION BY THE INSURED:
I hereby declare that the information furnished in this claim form is true & correct to the best of my knowledge and belief. If I have made any
false or untrue statement, suppression or concealment of any material fact with respect to questions asked in relation to this claim, my right
to claim reimbursement shall be forfeited. I also consent & authorize TPA / insurance company, to seek necessary medical information /
documents from any hospital / Medical Practitioner who has attended on the person against whom this claim is made. I hereby declare that
I have included all the bills / receipts for the purpose of this claim & that I will not be making any supplementary claim except the pre/post-
hospitalization claim, if any.
SECTION H
Date Place
Signature of the Insured
Rs.
Rs.
Rs.
a) PAN
DATA ELEMENT
DESCRIPTION FORMAT
SECTION A - DETAILS OF PRIMARY INSURED
a) Policy No.
b) SI. No/ Certificate No.
c) Company TPA ID No.
d) Name
e) Address
Enter the policy number
Enter the social insurance number or the
certificate number of social health insurance
scheme
Enter the TPA ID No
Enter the full name of the policyholder
Enter the full postal address
As allotted by the insurance company
As allotted by the organization
License number as allotted by IRDAI
and printed in TPA documents.
Surname, First name, Middle name
Include Street, City and Pin Code
a) Currently covered by any other
Mediclaim / Health Insurance?
b) Date of Commencement of first
Insurance without break
c) Company Name
Policy No.
Sum Insured
d) Have you been Hospitalized in
the last four years since
inception of the contract?
Date
Diagnosis
e) Previously Covered by any other
Mediclaim/ Health Insurance?
f) Company Name
Indicate whether currently covered by another
Mediclaim / Health Insurance
Enter the date of commencement of first
insurance
Enter the full name of the insurance company
Enter the policy number
Enter the total sum insured as per the policy
Indicate whether hospitalized in the last four
years
Enter the date of hospitalization
Enter the diagnosis details
Indicate whether previously covered by
another Mediclaim / Health Insurance
Enter the full name of the insurance company
Tick Yes or No
Use dd-mm-yy format
Name of the organization in full
As allotted by the insurance company
In rupees
Tick Yes or No
Use mm-yy format
Open Text
Tick Yes or No
Name of the organization in full
a) Name
b) Gender
c) Age
d) Date of Birth
e) Relationship to primary Insured
f) Occupation
g) Address
h) Phone No
i) E-mail ID
Enter the full name of the patient
Indicate Gender of the patient
Enter age of the patient
Enter Date of Birth of patient
Indicate relationship of patient with
policyholder
Indicate occupation of patient
Enter the full postal address
Enter the phone number of patient
Enter e-mail address of patient
Surname, First name, Middle name
Tick Male, Female or Third Gender
Number of years and months
Use dd-mm-yy format
Tick the right option. If others, please specify.
Tick the right option. If others, please specify.
Include Street, City and Pin Code
Include STD code with telephone number
Complete e-mail address
SECTION B - DETAILS OF INSURANCE HISTORY
SECTION C - DETAILS OF INSURED PERSON HOSPITALIZED
GUIDANCE FOR FILLING CLAIM FORM - PART A
(To be filled in by the insured)
a) Name of Hospital where admitted
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 Medicine
Enter the name of hospital
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
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
SECTION D - DETAILS OF HOSPITALIZATION
a) Details of Treatment Expenses
b) Claim for Domiciliary
Hospitalization
c) Details of Lump sum/ cash
benefit claimed
d) Claim Documents Submitted
Check List
Enter the amount claimed as treatment
expenses
Indicate whether claim is for domiciliary
hospitalization
Enter the amount claimed as lump sum/
cash benefit
Indicate which supporting documents are
submitted
In rupees (Do not enter paise values)
Tick Yes or No
In rupees (Do not enter paise values)
Tick the right option
SECTION E - DETAILS OF CLAIM
Indicate which bills are enclosed with the amounts in rupees
SECTION F - DETAILS OF BILLS ENCLOSED
a) PAN
Enter the permanent account number
As allotted by the Income Tax department
SECTION G - DETAILS OF PRIMARY INSURED'S BANK ACCOUNT
b) Account Number
Enter the bank account number
As allotted by the bank
c) Bank Name and Branch
Enter the bank name along with the branch
Name of the Bank in full
d) Cheque/ DD payable details
Enter the name of the beneficiary the cheque/
DD should be made out to
Name of the individual/ organization in full
e) IFSC Code
Enter the IFSC code of the bank branch IFSC code of the bank branch in full
SECTION H - DECLARATION BY THE INSURED
Read declaration carefully and mention date (in dd:mm:yy format), place (open text) and sign.
Disclaimer: Max Bupa Health Insurance Company Limited, Registered Office: B-1/I-2, Mohan Cooperative Industrial Estate, Mathura
Road, New Delhi – 110044. Website: www.maxbupa. com, Fax: 011-30902010, Customer Helpline No.: 1860 500 8888. CIN:
U66000DL2008PLC182918, IRDAI Registration No. 145. ‘Max’, Max logo, ‘Bupa’ and Heartbeat logo are registered trademarks of their
respective owners and are being used by Max Bupa Health Insurance Company Limited under license. Insurance is the subject matter of
solicitation. Please read sales brochure carefully before concluding a sale.
DETAILS OF HOSPITAL
a) Name of the hospital:
b) Hospital ID:
c) Type of Hospital: Network
Non Network
(If non network
fill section E)
d) Name of the treating doctor:
S
U
R N
A
M E M I D D L E N
A
M EF I R S T N
A
M E
e
) Qualification:
f) Registration No. with State Code:
g) Phone No.
SECTION A
DETAILS OF THE PATIENT ADMITTED
a) Name of the Patient:
S
U
R N
A
M E M I D D L E N
A
M EF I R S T N
A
M E
b) IP Registration Number:
c) Gender: Male
Female
d) Age: Years
Y Y
Months
M M
e) Date of birth:
D D M M Y Y
Y Y
f) Date of Admission:
D D M M Y Y
Y Y
g) Time:
H H M M
h) Date of Discharge:
D D M M Y Y
Y Y
i) Time:
H H M M
j) Type of Admission: Emergency
Planned
Day Care
Maternity
k) If Maternity i. Date of Delivery:
D D M M Y Y
Y Y
ii. Gravida Status:
l) Status at time of discharge: Discharge to home
Discharge to another hospital Deceased
m)Total claimed amount
SECTION B
a)
ICD 10 Codes
Description
Primary
Diagnosis:
ii. Procedure 2:
iii. Procedure 3:
Additional
Diagnosis:
Co-morbidities:
Co-morbidities:
iv
. Details of
Procedure:
c) Pre-authorization obtained: d) Pre-authorization Number:
YES
NO
e) If authorization by network hospital not obtained, give reason:
f) Hospitalization due to Injury:
YES
NO
I. If Yes, give cause Self-inflicted
Road Traffic Accident
Substance abuse / alcohol consumption
ii. If Injury due to Substance abuse / alcohol consumption, Test Conducted to establish this:
YES
NO
(If Yes, attach reports)
iii. If Medico legal:
YES
NO
iv. Reported to Police:
YES
NO
v. FIR no.
vi. If not reported to police give reason:
SECTION C
DETAILS OF AILMENT DIAGNOSED (PRIMARY)
The issue of this Form is not to be taken as an admission of liability
Please include the original preauthorization request form in lieu of PART A
CLAIM FORM - PART B
TO BE FILLED IN BY THE HOSPITAL
i.
ii.
iii.
iv.
b)
ICD 10 PCS
Description
Procedure 1:
i.
(TO BE FILLED IN BLOCK LETTERS)
Third Gender
2 1 0 1 8 3
SECTION D
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
ADDITIONAL DETAILS IN CASE OF NON NETWORK HOSPITAL (ONLY FILL IN CASE OF NON-NETWORK HOSPITAL)
a) Address of the Hospital:
SECTION E
State:
b) Phone No:
d) Hospital PAN:
e) Number of Inpatient beds
i. OT : YES
NO
ii. ICU :
YES
NO
City
Pin Code:
c) Registration No. with State Code:
f) Facilities available in the hospital:
iii. Others :
DECLARATION BY THE HOSPITAL
(PLEASE READ VERY CAREFULLY)
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.
D D M M Y Y
Y Y
Date:
Place:
Signature and Seal of the Hospital Authority:
SECTION F
Investigation reports
CT/MR/USG/HPE investigation reports
Doctor's reference slip for investigation
ECG
Pharmacy bills
MLC report & Police FIR
Original death summary from hospital where
applicable
Any other, please specify
DATA ELEMENT
DESCRIPTION FORMAT
GUIDANCE FOR FILLING CLAIM FORM - PART B
(To be filled in by the hospital)
SECTION A - DETAILS OF HOSPITAL
a) Name of Hospital
b) Hospital ID
c) Type of Hospital
d) Name of treating doctor
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 qualifications of the treating doctor
Enter the registration number of the doctor
along with the state code
Enter the phone number of doctor
Name of 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
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
Indicate the total claimed amount
Indicate status of patient at time of discharge
Enter Gravida status if maternity
Enter Date of Delivery if maternity
Indicate type of admission of patient
Enter time of discharge
Enter date of discharge
Enter time of admission
Enter date of admission
Enter date of admission
Enter age of the patient
Indicate Gender of the patient
Enter insurance provider registration number
Enter the name of hospital
In rupees (Do not enter paise values)
Tick the right option
Use standard format
Use dd-mm-yy format
Tick the right option
Use hh:mm format
Use dd-mm-yy format
Use hh:mm format
Use dd-mm-yy format
Use dd-mm-yy format
Number of years and months
Tick Male, Female or Third Gender
As allotted by the insurance provider
Name of hospital in full
SECTION C - DETAILS OF AILMENT DIAGNOSED (PRIMARY)
a) ICD 10 Code
Standard Format and Open text
Enter the ICD 10 Code and description of the
primary diagnosis
Primary Diagnosis
Additional Diagnosis
Enter the ICD 10 Code and description of the
additional diagnosis
Standard Format and Open text
Co-morbidities
Enter the ICD 10 Code and description of the
co-morbidities
Standard Format and Open text
b) ICD 10 PCS
Procedure 1
Enter the ICD 10 PCS and description of the
first procedure
Standard Format and Open text
Procedure 2
Enter the ICD 10 PCS and description of the
second procedure
Standard Format and Open text
Procedure 3
Enter the ICD 10 PCS and description of the
third procedure
Standard Format and Open text
Open text
Enter the details of the procedure
Details of Procedure
c) Pre-authorization obtained
Indicate whether pre-authorization obtained
Tick Yes or No
d) Pre-authorization Number
Enter pre-authorization number
As allotted by TPA
e) If authorization by network
hospital not obtained, give reason
Enter reason for not obtaining pre
authorization number
Open text
f) Hospitalization due to injury Indicate if hospitalization is due to injury
Tick Yes or No
Cause
Indicate cause of injury
Tick the right option
If injury due to substance abuse/
alcohol consumption, test
conducted to establish this
Indicate whether test conducted Tick Yes or No
Medico Legal
Reported To Police
FIR No.
Indicate whether injury is medico legal
Indicate whether police report was filed
Enter first information report number
Tick Yes or No
Tick Yes or No
As issued by police authorities
If not reported to police, give
reason
Enter reason for not reporting to police
Open Text
SECTION D - CLAIM DOCUMENTS SUBMITTED-CHECK LIST
Indicate which supporting documents are submitted
SECTION E - DETAILS IN CASE OF NON NETWORK HOSPITAL
a) Address
b) Phone No.
Enter the full postal address
Enter the phone number of hospital
Include Street, City and Pin Code
Include STD code with telephone number
c) Registration No. with State
Code
Enter the registration number of the doctor
along with the state code
As allocated by the Medical Council of India
d) Hospital PAN Enter the permanent account number
As allotted by the Income Tax department
e) Number of Inpatient beds Enter the number of inpatient beds
Digits
f) Facilities available in the
hospital
Indicate facilities available in the hospital
Tick the right option. If others, please specify
SECTION F - DECLARATION BY THE HOSPITAL
Read declaration carefully and mention date (in dd:mm:yy format), place (open text) and sign and stamp
Disclaimer: Max Bupa Health Insurance Company Limited, Registered Office: B-1/I-2, Mohan Cooperative Industrial Estate, Mathura
Road, New Delhi – 110044. Website: www.maxbupa. com, Fax: 011-30902010, Customer Helpline No.: 1860 500 8888. CIN:
U66000DL2008PLC182918, IRDAI Registration No. 145. ‘Max’, Max logo, ‘Bupa’ and Heartbeat logo are registered trademarks of their
respective owners and are being used by Max Bupa Health Insurance Company Limited under license. Insurance is the subject matter of
solicitation. Please read sales brochure carefully before concluding a sale.
DETAILS OF PRIMARY INSURED'S BANK ACCOUNT
Name of Accountholder:
Bank Name:
Branch:
City:
IFSC Code:
Payment option:
Cheque
DD
NEFT
*Note: Please submit a cancelled cheque leaf or a copy of latest bank statement or passbook with accountholder's name, account no., and
IFSC code mentioned on it.
• Non-submission of original bills and receipts is the main reason for delay in claim settlements.
Please provide the originals
• Provide your bank details for direct/ Electronic Fund Transfer (EFT) for faster claim settlement.
• To receive updates on your claim status, please provide your mobile no. & E-mail ID
• You can check your claim status at: www.maxbupa.com 2 Claims 2 Claims status 2 Login to check status.
Dear Policyholder,
Please fill the following information along with the reimbursement claim form for your medical insurance policy.
Policy No.
Membership No.
CUSTOMER IDENTIFICATION PROCEDURE (AS PER KYC NORMS OF IRDAI)
Please submit clear and legible copy of one document (valid and effective as on date of claim submission) each from Part A and Part B and your
recent passport size photograph (not more than 6 months old) incase claim amount exceeds Rs 100,000
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) Voter's Identity Card
c) Driving License
d) Personal Identification and Certification of the employees for your identity.
e) Letter issued by Unique identification Authority of India containing details of
name address and Aadhar Number
f) Job Card issued by NREGA duly signed by an officer of the State Government
Part A
Proof of legal name and any
other names used
Annexure - Claim Form for reimbursement
Do You Know?
Photo
Ver-2/Claim_Reimb/April20/add_info
Part B
Proof of Residence
i. Electricity Bill not older than 6 months from the date of claim submission
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 permanent/ present address
(updated upto 1 month prior to claim submission document)
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 effective.
Date
Signature of Policyholder:
(Please attach copy of a cancelled cheque of your bank for ensuring accuracy of name of the bank, branch name, Account number and
IFSC code. If name of the payee is not printed on the cheque leaf please attach copy of the first page of the bank passbook also)
Disclaimer: Max Bupa Health Insurance Company Limited, Registered Office: B-1/I-2, Mohan Cooperative Industrial Estate,
Mathura Road, New Delhi – 110044. Website: www.maxbupa. com, Fax: 011-30902010, Customer Helpline No.: 1860 500 8888.
CIN: U66000DL2008PLC182918, IRDAI Registration No. 145. ‘Max’, Max logo, ‘Bupa’ and Heartbeat logo are registered trademarks of
their respective owners and are being used by Max Bupa Health Insurance Company Limited under license. Insurance is the subject
matter of solicitation. Please read sales brochure carefully before concluding a sale.
D D M M Y Y
Y Y
To,
Medical Superintendent
My other relevant details are provided below;
Detail of Insured:-
DOA:-
DOD:-
MRD/ Indoor/ IP No:-
Policy No:-
I request you to provide all the information/ documents as required by Max Bupa Health Insurance Company Ltd.
Name:-
Signature/ Thumb Impression
Witness Name & Signature
I, Mr./Ms
Age
Resident
of
State
Hereby
give my willful consent to Mr/ Dr
of Max Bupa 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.
Consent Letter
Disclaimer: Max Bupa Health Insurance Company Limited, Registered Office: B-1/I-2, Mohan Cooperative Industrial Estate,
Mathura Road, New Delhi – 110044. Website: www.maxbupa. com, Fax: 011-30902010, Customer Helpline No.: 1860 500 8888.
CIN: U66000DL2008PLC182918, IRDAI Registration No. 145. ‘Max’, Max logo, ‘Bupa’ and Heartbeat logo are registered trademarks of
their respective owners and are being used by Max Bupa Health Insurance Company Limited under license. Insurance is the subject
matter of solicitation. Please read sales brochure carefully before concluding a sale.
Date
D D M M Y Y
A. Name of the treating Doctor:
B. Contact number:
C. Nature of Illness/Disease with presenting complaint:
D. Relevant critical findings:
E. Duration of the present ailment Days (i) Date of first consultation:
(ii) Past history of present ailment, if any
F. Provisional diagnosis:
(i) ICD 10 code:
G. Proposed line
of treatment:
H. If investigation &/or Medical Management, provide details
TO BE FILLED BY INSURED/PATIENT
Request for Cashless Hospitalisation for
Health Insurance Policy Part - C
Details of the Third Party Administrator/ Insurer/ hospital: (To be filled in block letters)
A. Name of the Patient:
B. Gender: Male Female Third Gender C. Age: Year Month
D. Date of Birth: E. Contact number:
F. Contact number & name of attending relative:
G. Insured Card ID number:
H. Current Address of Insured Patient
I. Occupation of Insured Patient
J. Policy number/Name of Corporate:
K. Employee ID:
L. Currently do you have any other mediclaim /health insurance: Yes No
Company Name:
Give Details:
M. Do you have a family Physician: Yes No
N. Name of the Family Physician:
O. Contact number, if any: (Please complete declaration of this form)
TO BE FILLED BY TREATING DOCTOR/HOSPITAL
Surgical
Management
Intensive
care
Investigation
Medical
Management
Non-allopathic
treatment
M A X B U P A
1 88 86 80 85 0 0
H E A L T H I N NS U R A C E
a) Name of lnsurance company:
b) Customer helpline number:
c) Fax no./email Id:
d) Name of Hospital:
i. Address
ii. ROHINI ID
iii. E-mail Id
We confirm having read understood and agreed to the Declarations of this form
a. Name of the treating Doctor
b. Qualification: c. Registration number with State code
Hospital Seal
(Must include Hospital ID)
Patient/Insured Name and Sign
DECLARATION
I. If Surgical, name of surgery
(i) ICD 10 code:
J. If other treatment, provide details
K. How did injury occur
L. In case of accident (i) Is it RTA: Yes NO (ii) Date of lnjury:
(iii) Report to Police Yes NO (iv) FIR No.
(v) Injury /Disease caused due to substance abuse/alcohol consumption Yes NO
(vi) Test conducted to establish this Yes NO (if yes, attach report)
M. In case of Maternity G P L A (i) Expected date of Delivery
Details of patient admitted
A. Date of admission
B. Time of admission
C. Is this an emergency/planned hospitalization
event: Emergency Planned
E. Expected number of days stay
in hospital: (Days)
F. Days in ICU
G. Room Type
H. Per Day Room Rent + Nursing
and Service Charges +
Patients Diet: (INR)
I. Expected cost of investigation +
diagnostic: (INR)
J. ICU Charges (INR)
K. OT charges (INR)
L. Professional fees Surgeon + Anesthetist Fees +
Consultation Charges: (INR)
M. Medicines+ Consumables+
Cost of Implants
(if applicable please specify)
N. Other hospital expenses if any
O. All-inclusive package charges
if any applicable
P. Sum Total expected cost
of hospitalization
Any other ailment, give details
Diabetes
Heart disease
Hypertension
Hyperlipidemias
Osteoarthritis
Asthma/COPD/Bronchitis
Cancer
Alcohol/Drug abuse
Any HIV/ or STD
Related ailment
D. Mandatory Past History of any chronic illness
If yes (Since month/year)
(i) Route of Drug Administration
a. We have no objection to any authorized TPA / Insurance Company ocial verifying documents pertaining to
hospitalization.
b. All valid original documents duly countersigned by the insured/patient as per the checklist below will be sent
to TPA / Insurance Company within 7 days of the patient’s discharge.
c. We agree that TPA / Insurance Company will not be liable to make the payment in the event of any discrepancy
between the facts in this form and discharge summary or other documents.
d. The patient declaration has been signed by the patient or by his representative in our presence.
e. We agree to provide clarifications for the queries raised regarding this hospitalization and we take the sole
respons1b1hty for any delay in oering clarifications.
f. We will abide by the terms and conditions agreed in the MOU.
g. We confirm that no additional amount would be collected from the insured in excess of Agreed Package Rates
except costs towards non-admissible amounts (including additional charges due to opting higher room rent
than eligibility/choosing separate line of treatment which is not envisaged/considered in package).
h. We confirm that no recoveries would be made from the deposit amount collected from the Insured except
for costs towards non-admissible amounts (including additional charges due to opting higher room rent than
eligibility/choosing separate line of treatment which is not envisaged/considered in package).
i. In the event of unauthorized recovery of any additional amount from the Insured in excess of Agreed Package
Rates, the authorized TPA/ Insurance Company reserves the right to recover the same from us (the Network
Provider) and/or take necessary action, as provided under the MoU or applicable laws.
Hospital Seal Doctor’s Signature
DECLARATION BY THE PATIENT/REPRESENTATIVE
HOSPITAL DECLARATION
Date Time
a. I agree to allow the hospital to submit all original documents pertaining to hospitalization to the lnsurer/ T.P.A
after the discharge. I agree to sign on the Final Bill & the Discharge Summary, before my discharge.
b. Payment to hospital is governed by the terms and conditions of the policy. In case the Insurer/ TPA is not liable
to settle the hospital bill, I undertake to settle the bill as per the terms and conditions of the policy.
c. All non-medical expenses and expenses not relevant to current hospitalization and the amounts over & above
the limit authorized by the lnsurer/ T.P.A not governed by the terms and conditions of the policy will be paid
by me.
d. I hereby declare to abide by the terms and conditions of the policy and if at any time the facts disclosed by me
are found to be false or incorrect I forfeit my claim and agree to indemnify the Insurer/ T.P.A
e. I agree and understand that T.P.A is in no way warranting the service of the hospital & that the Insurer/ TPA is
in no way guaranteeing that the services provided by the hospital will be of a particular quality or standard.
f. I hereby warrant the truth of the forgoing particulars in every respect and I agree that if I have made or shall
make any false or untrue statement, suppression or concealment with respect to the claim, my right to claim
reimbursement of the said expenses shall be absolutely forfeited.
g. I agree to indemnify the hospital against all expenses incurred on my behalf, which are not reimbursed by the
Insurer/TPA.
h. “I/We authorize Insurance Company TPA to contact me/us through mobile/email for any update on this claim”.
1. Patient’s/Insured’s Name:
2. Contact number:
3. e-mail Id (optional)
4. Patient’s / lnsured’s Signature:
Date Time
Max Bupa Health Insurance Co. Ltd.. ‘Max’, ‘Max logo’ and ‘Bupa’ logo are trademarks of their respective owners
and are being used by Max Bupa Health Insurance Company Limited under license. Registered Oce: Max House,
1 Dr. Jha Marg, Okhla, New Delhi - 110020. IRDAI Registration No. 145. CIN No. is U66000DL2008PLC182918. Fax
Number: + 91 11 30902010. Website: www.maxbupa.com. Customer Helpline No.: 1860-500-8888.
ANNEXURE FOR PREAUTH CLAIMS
Dear Policyholder,
Please fill the following information along with the cashless form for your medical insurance policy.
Policy No.
Membership Number
Hospital Id
(To be filled by hospital)
DOCUMENT CHECKLIST:
I. Copy of Photo ID, address proof and recent photo of patient. (for Valid proof of documents kindly
refer KYC documents list) KYC documents list includes PAN Card/Driving License/Voter Id. Card/
Aadhar Card
II. Past illness records (With duration of symptoms) if any
III. First and subsequent consultation paper along with admission note.
IV. Complete medical history along with supporting investigation reports.
V. In case of accident, MLC/FIR copy (if applicable)
VI. Claim consent letter
All documents mentioned above to be submitted along with the completed filled cashless form. Insurer may
require further documents to process the request.
Name of the Proposer/insured
Contact No.
D D M M Y Y Y Y
Signature
Name of the TPA coordinator
Signature
Date:
Place:
S U R N A M E M I DDLE NA ME
F I R S T N A M E
S U R N A M E M I DDLE NA ME
F I R S T N A M E
Max Bupa Health Insurance Co. Ltd.. ‘Max’, ‘Max logo’ and ‘Bupa’ logo are trademarks of their respective owners
and are being used by Max Bupa Health Insurance Company Limited under license. Registered Oce: Max House,
1 Dr. Jha Marg, Okhla, New Delhi - 110020. IRDAI Registration No. 145. CIN No. is U66000DL2008PLC182918. Fax
Number: + 91 11 30902010. Website: www.maxbupa.com. Customer Helpline No.: 1860-500-8888.
To,
Medical Superintendent
My other relevant details are provided below;
Detail of Insured:-
DOA:-
DOD:-
MRD/ Indoor/ IP No:-
Policy No:-
I request you to provide all the information/ documents as required by Max Bupa Health Insurance Company Ltd.
Name:-
Signature/ Thumb Impression
Witness Name & Signature
Date
I, Mr./Ms
Age
Resident
of
State
Hereby
give my willful consent to Mr/ Dr
of Max Bupa 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.
Consent Letter
Max Bupa Health Insurance Co. Ltd.. 'Max', 'Max logo' and 'Bupa' logo are trademarks of their respective owners and are being used by Max Bupa Health Insurance
Company Limited under license. Registered Office: Max House, 1 Dr. Jha Marg, Okhla, New Delhi - 110020. IRDAI Registration No. 145. CIN No. is
U66000DL2008PLC182918. Fax Number: 1800 3070 3333. Website: www.maxbupa.com. Customer Helpline No.: 1860-3010-3333.
TM
Product Name: GoActive , Product UIN No.: MAXHLIP18109V011718
Consent Letter
To, Date___/___/____
Medical Superintendent
–––––––––––––––––––––––––––
–––––––––––––––––––––––––––
–––––––––––––––––––––––––––
I, Mr./Ms ___________________________________________________ Age ____________________ Resident
of ______________________________________________________________ State _______________ Hereby
give my willful consent to Mr/ Dr _______________________________________________ of Max Bupa 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.
My other relevant details are provided below;
Detail of Insured:-
DOA:-
DOD:-
MRD/ Indoor/ IP No:-
Policy No:-
I request you to provide all the information/documents as required by Max Bupa Health Insurance Company Ltd.
Name
Signature/ Thumb Impression Witness Name & Signature
Max Bupa Health Insurance Co. Ltd.. ‘Max’, ‘Max logo’ and ‘Bupa’ logo are trademarks of their respective owners
and are being used by Max Bupa Health Insurance Company Limited under license. Registered Oce: Max House,
1 Dr. Jha Marg, Okhla, New Delhi - 110020. IRDAI Registration No. 145. CIN No. is U66000DL2008PLC182918. Fax
Number: + 91 11 30902010. Website: www.maxbupa.com. Customer Helpline No.: 1860-500-8888.