Claim form for health insurance policies other than
travel and personal accident - PART A
TO BE FILLED IN BY THE INSURED
(TO BE FILLED IN BLOCK LETTERS)
The issue of this Form is not to be taken as an admission of liability
DETAILS OF PRIMARY INSURED:
a) Policy No:
c) Company/TPA ID No:
d) Name:
b) Sl. No/Certicate No
e) Address:
Pin Code Phone No: Email ID:
City State:
DETAILS OF INSURED PERSON HOSPITALIZED:
DETAILS OF HOSPITALIZATION:
a) Name:
f) Occupation: Service Self Employed Homemaker Student Retired Other
c) Hospitalization due to: Injury Illness Maternity
b) Room Category occupied: Day Care Single occupancy Twin sharing 3 or more beds per room
Road Trafc Accident Substance Abuse / Alcohol Consumption i. If Medico legal: YES NO
e) Relationship to Primary insured: Self Spouse Child Father Mother Other
b) Gender: Male Female Third Gender c) Age: Years Month d) Date of Birth:
(Please Specify)
(Please Specify)
g) Address (if different from above):
City State:
Pin Code: Phone No: Email ID:
ii. Reported to police: YES NO iii. MLC Report & Police FIR attached: YES NO j) System of Medicine:
f) Time: g) Date of Discharge: h) Time: i) If Injury give cause: Self inicted
d) Date of Injury / Date Disease rst detected /Date of Delivery: e) Date of Admission:
a) Name of Hospital where Admitted:
SECTION A
DETAILS OF INSURANCE HISTORY:
a) Currently covered by any other Mediclaim / Health Insurance: YES NO
b) Date of commencement of rst 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? YES NO Date
Diagnosis:
e) Previously covered by any other Mediclaim / Health insurance : YES NO
f) If yes, Company Name
SECTION B
SECTION D
SECTION C
DETAILS OF CLAIM:
a) Details of the treatment expenses claimed
c) Details of Lump sum / cash benet claimed:
Claim Documents Submitted- Check List:
Sl. No. Bill No. Date Issued by
Towards
Amount (Rs)
Hospital Main Bill
Pre-hospitalization Bills: Nos
Post-hospitalization Bills: Nos
Pharmacy Bills
Claim Form Duly signed
Hospital Discharge Summary
Copy of the Claim intimation if any
Pharmacy Bill
Hospital Main Bill
Operation Theatre Notes
Hospital Break-up Bill
ECG
Hospital Bill Payment Receipt
Doctor’s request for investigation
Investigation Reports (Including CT
MRI / USG / HPE)
Doctor's Prescriptions
Others
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/posthospitalization claim, if any
DETAILS OF BILLS ENCLOSED:
YES NO (If yes, provide details in annexure)b) Claim for Domiciliary Hospitalization:
i. Pre-hospitalization Expenses:
ii. Hospitalization Expenses:Rs Rs
i. Hospital Daily Cash: ii. Surgical Cash:Rs Rs
iii. Post-hospitalization Expenses: iv. Health-Check up Cost: RsRs
iii. Critical Illness Benet:
iv. Convalescence:Rs Rs
v. Ambulance Charges:
vi. Others (code): RsRs
v. Pre/Post hospitalization Lump sum benet: vi. OthersRs Rs
Total
Rs
Total
Rs
a) PAN b) Account Number:
c) Bank Name and Branch:
d) Cheque/ DD Payable details: e) IFSC Code:
SECTION E
SECTION F
SECTION H
SECTION G
vii. Pre-hospitalization period: viii. Post-hospitalization period:Days Days
DETAILS OF PRIMARY INSURED'S BANK ACCOUNT:
DECLARATION BY THE INSURED:
Date Place
Signature of the Insured
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 rst
Insurance without break
Enter the date of commencement of rst
insurance
Use dd-mm-yy format
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
Sum Insured Enter the total sum insured as per the policy In rupees
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
e) Previously Covered by any other
Mediclaim/ Health Insurance?
Indicate whether previously covered by
another Mediclaim / Health Insurance
Tick Yes or No
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, Female or Third Gender
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
h) Phone No Enter the phone number of patient Include STD code with telephone number
i) E-mail ID Enter e-mail address of patient Complete e-mail address
DATA ELEMENT DESCRIPTION FORMAT
SECTION A - DETAILS OF PRIMARY INSURED
a) Policy No. Enter the policy number As allotted by the insurance company
b) SI. No/ Certicate No. Enter the social insurance number or the
certicate number of social health insurance
scheme
As allotted by the organization
c) Company TPA ID No.
Enter the TPA ID No Surname, First name, Middle name
d) Name Enter the full name of the policyholderr Surname, First name, Middle name
e) Address
Enter the full postal address Include Street, City and Pin Code
GUIDANCE FOR FILLING CLAIM FORM - PART A
(To be filled in by the insured)
SECTION B - DETAILS OF INSURANCE HISTORY
a) Name of Hospital where admitted Enter the name of hospital Name of hospital in full
b) Room category occupied Indicate the room category occupied Tick the right option
c) Hospitalization due to Indicate reason of hospitalization Tick the right option
d) Date of Injury/Date Disease rst
detected/ Date of Delivery
Enter the relevant date Use dd-mm-yy format
e) Date 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 of discharge Use dd-mm-yy format
h) Time Enter date of discharge Use hh:mm format
i) If Injury give cause Indicate cause of injury Tick the right option
If Medico legal Indicate whether injury is medico legal Tick Yes or No
Reported to Police Indicate whether police report was led Tick Yes or No
MLC Report & Police FIR attached Indicate whether MLC report and Police FIR
attached
Tick Yes or No
j) System of Medicine Enter the system of medicine followed in
treating the patient
Open Text
SECTION E - DETAILS OF CLAIM
a) Details of Treatment Expenses Enter the amount claimed as treatment
expenses
In rupees (Do not enter paise values)
b) Claim for Domiciliary
Hospitalization
Indicate whether claim is for domiciliary
hospitalization
Tick Yes or No
c) Details of Lump sum/ cash
benet claimed
Enter the amount claimed as lump sum/
cash benet
In rupees (Do not enter paise values)
d) Claim Documents Submitted
Check List
Indicate which supporting documents are
submitted
Tick the right option
SECTION G - DETAILS OF PRIMARY INSURED’S BANK ACCOUNT
a) PAN Enter the permanent account number As allotted by the Income Tax department
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 beneciary 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 F - DETAILS OF BILLS ENCLOSED
Indicate which bills are enclosed with the amounts in rupees
SECTION H - DECLARATION BY THE INSURED
Read declaration carefully and mention date (in dd:mm:yy format), place (open text) and sign.
Niva Bupa Health Insurance Company Limited; Registered oce:- C-98, First Floor, Lajpat Nagar, Part 1, New Delhi-110024
Disclaimer: Insurance is a subject maer of solicitaon. Niva Bupa Health Insurance Company Limited (formerly known as Max Bupa Health Insurance Company
Limited) (IRDAI Registraon No. 145). ‘Bupa’ and ‘HEARTBEAT’ logo are registered trademarks of their respecve owners and are being used by Niva Bupa Health
Insurance Company Limited under license. Customer Helpline: 1860-500-8888. Website: www.nivabupa.com. CIN: U66000DL2008PLC182918. For more details on
terms and condions, exclusions, risk factors, waing period & benets, please read sales brochure carefully before concluding a sale.
DETAILS OF AILMENT DIAGNOSED (PRIMARY)
a) ICD 10 Codes Description b) I CD 10 PCS Description
Substance abuse / alcohol consumption
f) Hospitalization due to Injury: YES NO I. If Yes, give cause Self-inicted Road Trafc Accident
ii. If Injury due to Substance abuse / alcohol consumption, Test Conducted to establish this: YES NO (If Yes, attach reports)
l) Status at time of discharge: Discharge to home Discharge to another hospital Deceased
d) Age: Years e) Date of birth:Months
m)Total claimed amount
i. Procedure 1:
i. Primary
Diagnosis
ii. Procedure 2:
ii. Additional
Diagnosis
iii. Procedure 3:iii. Co_morbidities
iv. Details of
Procedure:
iv. Co_morbidities
e) If authorization by network hospital not obtained, give reason:
vi. If not reported to police give reason:
c) Pre-authorization obtained: YES NO d) Pre-authorization Number:
a) Name of the Patient:
k) If Maternity i. Date of Delivery: ii. Gravida Status:
f) Date of Admission: g) Time: h) Date of Discharge:
i) Time: j) Type of Admission: Emergency Planned Day Care Maternity
b) IP Registration Number: c) Gender: Male Female Third Gender
DETAILS OF HOSPITAL
d) Name of the treating doctor:
g) Phone No.
e) Qualication: f) Registration No. with State Code:
a) Name of the hospital:
b) Hospital ID: c) Type of Hospital: Network Non Network
(If non network
ll section E)
SECTION A
SECTION B SECTION C
CLAIM FORM - PART B
DETAILS OF THE PATIENT ADMITTED
iii. If Medico legal: YES NO iv. Reported to Police: YES NO v. FIR no
TO BE FILLED IN BY THE HOSPITAL
(TO BE FILLED IN BLOCK LETTERS)
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 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 veried 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 report & Police FIR
Original death summary from hospital where
applicable
Any other, please specify
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.
DECLARATION BY THE HOSPITAL
(PLEASE READ VERY CAREFULLY)
Signature and Seal of the Hospital Authority:
Date:
Place:
f) Facilities available in the hospital:
i. OT : YES NO ii. ICU : YES NO
iii. Others :
a) Address of the Hospital:
City
State:
Pin Code: b) Phone No: d) Hospital PAN:
e) Number of Inpatient bedsc) Registration No. with State Code:
SECTION D
SECTION D SECTION E
ADDITIONAL DETAILS IN CASE OF NON NETWORK HOSPITAL (ONLY FILL IN CASE OF NON-NETWORK HOSPITAL)
SECTION B - DETAILS OF THE PATIENT ADMITTED
a) Name of Patient Enter the name of hospital Name of hospital in full
b) IP Registration Number Enter insurance provider registration number As allotted by the insurance provider
c) Gender Indicate Gender of the patient Tick Male, Female or Third Gender
d) Age Enter age of the patient Number of years and months
e) Date of Birth Enter time of admission Use dd-mm-yy format
f) Date of Admission Enter time of admission Use dd-mm-yy format
g) Time Enter time of admission Use hh:mm format
h) Date of Discharge Enter time of discharge Use dd-mm-yy format
I) Time Enter time of discharge Use hh:mm format
j) Type of Admission Indicate type of admission of patient Tick the right option
k) If Maternity
Date of Delivery Enter Date of Delivery if maternity Use dd-mm-yy format
Gravida Status Enter Gravida status if maternity Use standard format
l) Status at me of discharge
Indicate status of patient at time of discharge Tick the right option
m) Total claimed amount
Indicate the total claimed amount In rupees (Do not enter paise values)
SECTION C - DETAILS OF AILMENT DIAGNOSED (PRIMARY)
a) ICD 10 Code
Primary Diagnosis Enter the ICD 10 Code and description of the
primary diagnosis
Standard Format and Open text
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
rst procedure
Standard Format and Open text
Procedure 2 Enter the ICD 10 PCS and description of the
second procedure
Enter the ICD 10 PCS and description of the
second procedure
DATA ELEMENT DESCRIPTION FORMAT
SECTION A - DETAILS OF HOSPITAL
a) Name of Hospital Enter the name of hospital Name of hospital in full
b) Hospital ID Enter ID number of hospital As allocated by the TPA
c) Type of Hospital
Indicate whether In network or non network
hospital
Tick the right option
d) Name of treating doctor Enter the name of the treating doctor Name of doctor in full
e) Qualication Enter the qualications of the treating doctor Abbreviations of educational qualications
f) 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
g) Phone No. Enter the phone number of doctor Include STD code with telephone number
GUIDANCE FOR FILLING CLAIM FORM - PART B
(To be filled in by the insured)
Product Name: Max Bupa Health Recharge | Product UIN: MAXHLIP20140V021920
SECTION C - DETAILS OF AILMENT DIAGNOSED (PRIMARY)
Procedure 3 Enter the ICD 10 PCS and description of the
third procedure
Standard Format and Open text
Details of Procedure Enter the details of the procedure Standard Format and Open text
Details of Procedure 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 consumpon, test
conducted to establish this
Indicate whether test conducted Tick Yes or No
Medico Legal
Indicate whether injury is medico legal Tick Yes or No
Reported To Police
Indicate whether police report was led Tick Yes or No
FIR No.
Enter rst information report number As issued by police authorities
If not reported to police, give reason
Enter reason for not reporting to police Open Text
SECTION E - DETAILS IN CASE OF NON NETWORK HOSPITAL
a) Address Enter the full postal address Include Street, City and Pin Code
b) Phone No. Enter the phone number of hospital 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 D - CLAIM DOCUMENTS SUBMITTED-CHECK LIST
Indicate which supporting documents are submitted
SECTION F - DECLARATION BY THE HOSPITAL
Read declaration carefully and mention date (in dd:mm:yy format), place (open text) and sign and stamp
Niva Bupa Health Insurance Company Limited; Registered oce:- C-98, First Floor, Lajpat Nagar, Part 1, New Delhi-110024
Disclaimer: Insurance is a subject maer of solicitaon. Niva Bupa Health Insurance Company Limited (formerly known as Max Bupa Health Insurance Company
Limited) (IRDAI Registraon No. 145). ‘Bupa’ and ‘HEARTBEAT’ logo are registered trademarks of their respecve owners and are being used by Niva Bupa Health
Insurance Company Limited under license. Customer Helpline: 1860-500-8888. Website: www.nivabupa.com. CIN: U66000DL2008PLC182918. For more details on
terms and condions, exclusions, risk factors, waing period & benets, please read sales brochure carefully before concluding a sale.
