National Insurance - ClaimForm
National Insurance - ClaimForm
National Insurance - ClaimForm
Regd. Office 3, Middleton Street, Post Box 9229, Kolkata 700 071
b) Gender :
Male
Female
10
11
12
13
14
15
c) Age: years
16
17
18
19
20
21
22
months
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
d) Date of Birth:
e) Contact number:
h) Employee ID:
Yes
No
Company Name:
Give details:
j) Do you have a family physician?
Yes
No
b) Contact number:
Days
f) Provisional diagnosis:
i. ICD 10 Code
g) Proposed line of treatment:
Medical Management
Surgical Management
Intensive Care
Investigation
details
l) In case of accident:
i. Is it RTA?
Yes
No
Yes
L
No
a) Date of admission:
b) Time:
Emergency
Days
No
Date of Delivery:
Yes
Yes
Planned
Diabetes
Heart Disease
e) Room Type:
Hypertension
f) Per Day Room Rent + Nursing & Service Charges + Patient's Diet:
Hyperlipidemia
Osteoarthritis
h) ICU Charges:
i) OT Charges:
Cancer
`
(PLEASE READ VERY CAREFULLY)
DECLARATION
We confirm having read, understood and agreed to the Declaration on the reverse of this form
a) Name of the treating doctor:
b) Qualification:
1. I agree to allow the hospital to submit all original documents pertaining to hospitalization to the Insurer/T.P.A after the discharge. I agree to sign on the Final Bill & the Discharge Summary, before my discharge.
2. 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.
3. All non-medical expenses and expenses not relevant to current hospitalization and the amounts over & above the limit authorized by the Insurer/T.P.A not governed by the terms and conditions of the policy will be paid by me. In case any clarification is needed on admissibility of a particular item I shall contact
T.P.A at the Toll Free Number on the reverse of this form.
4. 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
5. 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.
6. 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, my right to claim reimbursement of the said expenses shall be absolutely forfeited. I further declare that, in respect of the above
treatment, no benefits are admissible under any other Medical Scheme or Insurance
7. I agree to indemnify the hospital against all expenses incurred on my behalf, which are not reimbursed by the Insurer / TPA.
b) Contact number:
HOSPITAL DECLARATION
1. We have no objection to any authorized TPA / Insurance Company official verifying documents pertaining to hospitalization.
2. 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.
3. All non medical expenses , OR expenses not relevant to hospitalization or illness, OR expenses disallowed in the Authorization Letter of the TPA / Insurance Co, OR arising out of incorrect information in the pre-authorisation form will be collected from the patient.
4. 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.
5. The patient declaration has been signed by the patient or by his representative in our presence.
6. We agree to provide clarifications for the queries raised regarding this hospitalization and we take the sole responsibility for any delay in offering clarifications.
7. We will abide by the terms and conditions agreed in the MOU.
Hospital Seal
Doctor's Signature
SECTION A
d) Name:
SECTION A
e) Address:
City:
State:
Pin Code:
Phone No:
Email ID:
Yes
No
d) Have you been hospitalized in the last four years since inception of the contract?
Diagnosis:
Yes
No
Date:
Yes
No
SECTION B
Male
Female
d) Date of Birth:
Self
Spouse
Service
Self Employed
Homemaker
i) CB (if any)
Father
Mother
Other
(Please specify)
Student
Retired
Other
(Please specify)
SECTION C
g) Occupation:
e) Sum insured:
Child
City:
State:
Pin Code:
Phone No:
Email ID:
DETAILS OF HOSPITALIZATION
a) Name of Hospital where Admitted:
b) Room category occupied:
Day Care
Injury
Single occupancy
Illness
e) Date of Admission:
i) If injury, give cause:
ii. Reported to police:
Yes
g) Date of Discharge:
f) Time:
Self inflicted
Twin sharing
Maternity
Yes
No
h) Time:
i. If Medico Legal:
Yes
No
SECTION D
j) System of medicine:
DETAILS OF CLAIM
a) Details of treatment expenses claimed
days @ `
per day
days @ `
per day
days
Maximum limit of 25% of SI for any one
illness
Pharmacy Bill
vi. Dialysis
vii. Chemotherapy
Investigation
Reports (including CT /
MRI / USG / HPE)
Doctor's Prescription
viii. Radiotherapy
Others
x. Ambulance Charges
ECG
Doctor's request for investigation
SECTION E
days
Date
Issued By
Towards
Hospital Main Bill
Pre hospitalisation Bills: ___ Nos
Post hospitalisation Bills: ___ Nos
Pharmacy Bills:
Amount (`)
SECTION F
Sl. No.
1
2
3
4
5
6
7
8
9
10
e) IFSC Code:
SECTION G
a) PAN:
Date:
Place:
SECTION H
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.
GUIDANCE FOR FILLING CLAIM FORM PART A (To be filled in by the insured)
DATA ELEMENT
DESCRIPTION
FORMAT
d) Name
e) Address
Tick Yes or No
c) Company Name
Policy No.
d) Have you been Hospitalized in the last 4 years since inception of the contract?
Date
Diagnosis
Open Text
Tick Yes or No
f) Company Name
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
Sum Insured
c) Hospitalization due to
f) Time
g) Date of discharge
Reported to Police
Tick Yes or No
j) System of Medicine
Open Text
h) Time
i) If Injury give cause
If Medico legal
Tick Yes or No
In rupees (Do not enter paise values)
b) Account Number
c) Bank Name and Branch
Enter the name of the beneficiary the cheque/ DD should be made out to
e) IFSC Code
Network
Non Network
SECTION A
c) Hospital ID:
d) Name of the treating doctor:
e) Qualification:
g) Phone No.
f) Date of Admission:
g) Time:
j) Type of Admission:
Emergency
Planned
Discharged to home
Day Care
Male
Female
d) Age: years
months
e) Date of Birth:
h) Date of Discharge:
Maternity
k) If Maternity:
i) Time:
i. Date of Delivery:
SECTION B
b) IP Registration No.:
Deceased
ICD 10 Codes
Description
b)
ICD 10 PCS
i. Procedure 1 :
ii. Procedure 2 :
iii. Co-morbidities :
iii. Procedure 3 :
iv. Co-morbidities :
Yes
No
Description
SECTION C
i. Primary Diagnosis :
d) Pre-authorization number:
Yes
No
Self inflicted
ii. If injurydue to Substance abuse / alcohol consumption, Test Conducted to establish this:
v. FIR No.
Yes
Yes
No
Yes
No
Yes
No
ECG
Pharmacy bills
SECTION D
DETAILS IN CASE OF NON NETWORK HOSPITAL (ONLY FILL IN CASE OF NON NETWORK HOSPITAL)
a) Address of the hospital:
Pin Code:
d) Hospital PAN
SECTION E
City:
State:
b) Phone No:
i. OT:
Yes
No
ii. ICU:
iii. Others:
DECLARATION BY THE HOSPITAL
Date:
Place:
SECTION F
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, suppress or concealment of anu material fact, our right to claim under this claim shall be
forfeited.
GUIDANCE FOR FILLING CLAIM FORM PART B (To be filled in by the hospital)
DESCRIPTION
DATA ELEMENT
FORMAT
b) Hospital ID
c) Type of Hospital
e) Qualification
Enter the registration number of the doctor along with the state code
g) Phone No.
b) IP Registration Number
c) Gender
d) Age
e) Date of Admission
f) Time
g) Date of Discharge
h) Time
i) Type of Admission
Date of Delivery
Gravida Status
j) If Maternity
Additional Diagnosis
Co-morbidities
Procedure 1
Procedure 2
Procedure 3
Details of Procedure
Open text
c) Pre-authorization obtained
Tick Yes or No
d) Pre-authorization Number
As allotted by TPA
Open text
Tick Yes or No
Cause
Tick Yes or No
Medico Legal
Tick Yes or No
Reported To Police
Tick Yes or No
FIR No.
Open Text
b) ICD 10 PCS
b) Phone No.
Enter the registration number of the doctor along with the state code
d) Hospital PAN
Digits