CLAIM FORM - PART A' to 'CLAIM FORM FOR HEALTH INSURANCE POLICIES OTHER

THAN TRAVEL AND PERSONAL ACCIDENT - PART A TO BE FILLED BY THE

INSURED

DETAILS OF PRIMARY INSURED:

Sl. No/
Policy No.: 251100502510000125_IBA Certificate
no.
Company/
TPA ID No:
Name: MANI MURUGESAN P EmpID: 839596 MAID: 4052320230
Address:
City: State:
Pin Code: Phone No:
Email ID:

DETAILS OF INSURANCE HISTORY:

Currently covered by any other Yes No Date of commencement of first Insurance

Mediclaim / Health Insurance: without break:

If yes, company 251100502510000125_IBA

Policy No.:
name:

Have you been hospitalized in the

Sum insured Yes No
last four years since inception of the Date:
(Rs.):
contract?

Previously covered by any other Mediclaim Yes No

Diagnosis:
/Health insurance:

DETAILS OF INSURED PERSON HOSPITALIZED:

Name: PAPPU LAKSHMI P Gender: Male Female

Age years: 24 Date of Birth:
Relationship to SELF SPOUSE CHILD FATHER MOTHER OTHER(PLEASE SPECIFY)
Primary insured:
SERVICE SELF EMPLOYED HOME MAKER STUDENT RETIRED
Occupation:
OTHER(PLEASE SPECIFY)
Address(if diffrent
from above):
City: State:
Pin Code: Phone No:
Email ID:

DETAILS OF HOSPITALIZATION:

Name of Hospital where COORG HEALTH CARE CENTER

amited:

Room Category DAY CARE SINGLE OCCUPANCY TWIN SHARING 3 OR MORE BEDS PER ROOM
occupied:

Hospitalization Date of injury / Date Disease first 4TH-JUN-

INJURY ILLNESS MATERNITY
due to: detected /Date of Delivery: 2026

Date of Admission: 4TH-JUN-2026 Time: Date of Discharge: 5TH-JUN-2026 Time:

 If injury give SELF INFLICTED ROAD TRAFFIC ACCIDENT SUBSTANCE If Medico YES
cause: ABUSE / ALCOHOL CONSUMPTION legal: NO

Reported to YES MLC Report & Police FIR YES NO System of

Police: NO attached: Medicine:

DETAILS OF CLAIM:
a) Details of the Treatment expenses claimed:

Pre -hospitalization expenses INR Hospitalization expenses INR 8765

Post-hospitalization expenses INR Health-Check up cost: INR
Ambulance Charges: INR Others (code): INR
Pre -hospitalization period: Post -hospitalization period:

Total: INR 8765

b) Claim for Domiciliary YES NO (IF YES, PROVIDE DETAILS IN ANNEXURE)
Hospitalization:

c) Details of Lump sum / cash

benefit claimed:
Hospital Daily cash: INR Surgical Cash: INR
Critical Illness benefit: INR Convalescence: INR

Total: INR 8765

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
DETAILS OF BILLS ENCLOSED:
Amount
SI No. Bill No. Date Remarks
(Rs)
5th-Jun- Investigation & Lab
1 102860 1100
2026 Charges
5th-Jun- Investigation & Lab
2 103959 1200
2026 Charges
5th-Jun- Investigation & Lab
3 CG089743/56272 3850
2026 Charges
5th-Jun- Pharmacy &
4 5511 1500
2026 Medicine Charges
5th-Jun-
5 5875 1000 Consultant Charges
2026
4th-Jun- Pharmacy &
6 5985 115
2026 Medicine Charges

DETAILS OF PRIMARY INSURED’S BANK ACCOUNT:

PAN: Account Number:

Bank Name: CANARA BANK Branch: UNDEFINED
Cheque / DD Payable C********22
IFSC Code:
details:

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, suppression or 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-hospitalization
claim, if any.

Date: 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
As allotted by the Insurance
a) Policy No. Enter the policy number
Company
Enter the social insurance number or the
As allotted by the
b) Sl. No/ Certificate No. certificate number of social health
oraganization
insurance scheme
Licence number as allotted by
c) Company TPA ID No. Enter the TPA ID No. IRDA and printed in TPA
documents.
Surname, First name, Middle
d) Name Enter the full name of the policyholder
name
Include Street, City and Pin
e) Address Enter the full postal address
code
SECTION B - DETAILS OF INSURANCE HISTORY
a) Currently covered by any other Mediclaim / Indicate whether currently covered by
Tick Yes or No
Health Insurance? another Mediclaim / Health Insurance
b) Date of commencement of first Insurance Enter the date of commencement of first
Use dd-mm-yy-forrmat
without break Insurance
Enter the full name of the Insurance Name of the organization in
c) Company Name
Company full
As allotted by the Insurance
Policy No. Enter the policy number
Company
Enter the total sum insured as per the
Sum insured In rupees
policy
d) Have you been Hospitalized in the last four Indicate whether hospitalized in the last
Tick Yes or No
years since Inception of the contract? four years
Date Enter the date of Hospitalization Use mm-yy format
Diagnosis Enter the diagnosis details Open Text
e) Previously covered by any other Mediclaim / Indicate whether previously covered by
Tick Yes or No
Health Tick Yes or No Insurance? another mediclaim / Health Insurance
Enter the full name of the Insurance Name of the organization in
f) Company Name
Company full
SECTION C - DETAILS OF INSURED PERSON HOSPITALIZED
Surname, First name, Middle
a) Name Enter the full name of the patient
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
Indicate relationship of patient with Tick the right option, if
e) Relationship to primary Insured
policyholder others, please specify
Tick the right option. If
f) Occupation indicate occupation of patient
others, please specify.
Include Street, City and Pin
g) Address Enter the full postal address
code
Include STD code with
h) Phone No Enter the phone number of patient
telephone number
1) E-mail ID Enter e-mail address of patient Complete e-mail address
SECTION D - DETAILS OF HOSPITALIZATION
a) Name of Hospital where admited 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 first detected /
Enter the relevant date Use dd-mm-yy format
Date of Delivery

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) 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 filed Tick Yes or No
indicate whether MLC report and Police
MLC Report & Police FIR attached Tick Yes or No
FIR attached
Enter the system of medicine followed in
i) System of Medicene Open Text
treating the patient
SECTION E - DETAILS OF CLAIM
Enter the amount claimed as treatment In rupees (Do not enter paise
a) Details of Treatment Expences expences values)

indicate whether claim is for domiciliary

b) Claim for Domiciliary Hospitalization Tick Yes or No
hospitalization
Enter the amount claimed as lump sum / In rupees (Do not enter paise
c) Details of Lump sum/ Cash benifit claimed
cash benefit values)
indicate which supporting documents are
d) Claim documents Submitted-Check List Tick the right option
submitted
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
As allotted by the Income Tax
a) PAN Enter the permanent account number
Department
b) Account Number Enter the Bank account number As allotted by the Bank
Enter the Bank name along with the
c) Bank Name and Branch Name of the Bank in full
branch
Enter the name of the beneficiary the Name of the individual /
d) Cheque/ DD payable details
cheque / DD should be made out to organization in full
IFSC code of the Bank branch
e) IFSC Code Enter the 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.

CLAIM FORM - PART B TO BE FILLED IN BY THE HOSPITAL 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

DETAILS OF HOSPITAL:

a) Name of the COORG HEALTH CARE CENTER

hospital:

b) Hospital ID: c) Type of Network Non Network (if non network fill section E)
Hospital:

d) Name of the treating e) Qualification:

doctor:
f) Registration No. with g) Phone No.:
State Code:

DETAILS OF THE PATIENT ADMITTED:

a) Name of the PAPPU LAKSHMI P

Patient:

b) IP Registration c) Gender: Male d) Date of

Number: Female birth:

4TH-JUN- 5TH-JUN-
e) Date of Admission: Time: f) Date of Discharge: Time:
2026 2026

g) Type of Emergency Planned Day h) If 1) Date of 2) Gravida

Admission: Care Maternity Maternity: Delivery: Status:

i) Status at time of Discharge to home Discharge to another j) Total claimed

discharge: hospital Deceased amount:

DETAILS OF AILMENT DIAGNOSED (PRIMARY):

a) ICD 10 Codes Description

I. Primary Diagnosis
ii. Additional Diagnosis:
iii. Co-morbidities:
iv. Co-morbidities:
b) ICD 10 Codes Description
i. Procedure 1:
ii. Procedure 2:
iii. Procedure 3:
iv. Details of Procedure

Yes No d) Pre-authorization
c) Pre-authorization obtained:
Number:

e) If authorization by network hospital not

obtained, give reason:

f) Hospitalization due to Yes No

injury:

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 Yes No (If Yes, attach reports)
establish this:
iii) If Medico legal: Yes No
iv) Reported to Police: Yes No
v) FIR No.:
vi) If not reported to police give reason:

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 Investigation reports Hospital main bill Hospital break-up bill
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):

a) Address of the Hospital

City: State:
Pin Code: Phone No: Registration No. with State
Code:
Hospital PAN: Number of inpatient beds
Facilities available in the hospital i. OT YES NO ii. ICU YES NO

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.

Signature and Seal of the Hospital

Date: Place: Authority:

GUIDANCE FOR FILLING CLAIM FORM - PART B (To be filled in by

the hospital)
DATA ELEMENT DESCRIPTION FORMAT
SECTION A - DETAILS OF HOSPITAL
Name of the hospital in
a) Name of the hospital: Enter the name of hospital
full
As allocated by the
b) Hospital ID Enter ID number of hospital
TPA
c) Type of Hospital Enter the name of the treating doctor Name of doctor in full
Abbreviations of
e) Qualification Enter the qualification of the treating doctor educational
 qualifications
As allocated by the
Enter the registration number of the doctor along
f) Registration No. with State Code Medical Council of
with the state code
India
Include STD code with
g) Phone No. Enter the phone number of doctor
telephone number
SECTION B - DETAILS OF THE PATIENT ADMITTED
a) Name of Patient Enter the name of patient Name of patient in full
As allotted by the
b) IP registration Number Enter insurance provider registration number
insurance provider
c) Gender Indicate Gender of the patient Tick Male or Female
Number of years and
d) Age Enter age of the patient
months
e) Date of Birth Enter date of birth Use dd-mm-yy format
f) Date of Admission Enter date of admission Use dd-mm-yy format
g) Time Enter Time of admission Use hh:mm format
h) Date of Discharge Enter date 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
i) Date of Delivery Enter Date of Delivery if maternity Use dd-mm-yy format
ii) Gravida Status Enter Gravida status if maternity Use standard format
l) Status at time of discharge Indicate status of patient at time of discharge Tick the right option
In rupees (Do not enter
M) Total claimed amount Indicate the total claimed amount
paise values)
SECTION C - DETAILS OF AILMENT DIAGNOSED (PRIMARY)
a) ICD 10 Code
b) Gender Indicate Gender of the patient Tick Male or Female
Enter the ICD 10 Code and description of the Standard Format and
Primary Diagnosis
primary diagnosis Open text
Enter the ICD 10 Code and description of the Standard Format and
Additional Diagnosis
additional diagnosis Open text
Enter the ICD 10 Code and description of the Co- Standard Format and
Co-morbidities
morbidities Open text
b) ICD 10 PCS
Enter the ICD 10 Code and description of the Standard Format and
Procedure 1
first procedure Open text
Enter the ICD 10 Code and description of the Standard Format and
Procedure 2 second procedure Open text

Enter the ICD 10 Code and description of the Standard Format and
Procedure 3
third procedure Open text
Details of Procedure Enter the details of the procedure Open text
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 Enter reason for not obtaining pre-authorization
Open text
obtained, give reason number
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
Indicate whether test conducted Tick Yes or No
consumption test conducted to establish this
Medico Legal Indicate whether injury is medico legal Tick Yes or No
Reported to Police Indicate whether police report was filed Tick Yes or Not
As issued by police
FIR No. Enter first information report number
authrities
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
Include Street, City
a) Address Enter the full postal address
and Pin Code
Include STD code with
b) Phone No. Enter the phone number of hospital
telephone number
Enter the registration number of the Hospital As allocated by the
c) Registration No. with State Code obtained from local body like City Corporation / City Corporation /
 Municipality Municipality
As allocated by the
d) Hospital PAN Enter the permanent account number Income Tax
Department
e) Number of Inpatient beds Enter the number of inpatient beds Digits
Tick the right option. If
f) Facilities available in the hospital Indicate facilities available in the hospital
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

DECLARATION:

Date Employee Signature

Date of Submission Generated On :- 6/6/2026