CLAIM FORM - PART A

TO BE FILLED IN BY THE INSURED

UNITED INDIA INSURANCE COMPANY LIMITED
REGISTERED & HEAD OFFICE: 24, WHITES ROAD, CHENNAI-600014

The issue of theis form is not to be taken as admission of liability

(To be filled in block letters)

DETAILS OF PRIMARY INSURED

a) Policy no:

b) Sl. No/ Certificate No:

c) Company/ TPA ID No:

SECTION

d) Name:
SECTION A

e) Address:

City:

State:

Pin Code:

Phone No:

Email ID:

DETAILS OF INSURANCE HISTORY

Yes

a) Currently covered by any other Mediclaim/ Health Insurance:

No

b) Date of commencement of first insurance without break:

Policy No:

Sum Insured (`):

d) Have you been hospitalized in the last four years since inception of the contract?

Diagnosis:

Yes

No

Date:

e) Previously covered by any other Mediclaim/ Health Insurance :

Yes

No

SECTION B

c) If yes, company name:

f) If yes, Company Name :

DETAILS OF INSURED PERSON HOSPITALIZED
a) Name :
b) Gender :

Male

Female

e) Relatuionship to Primary Insured:

Self

Service

Self Employed

months
Child

Homemaker

d) Date of Birth:

Father

Mother

Other

(Please specify)

Student

Retired

Other

(Please specify)

SECTION C

f) Occupation:

c) Age: years
Spouse

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
Injury

Single occupancy

Illness

e) Date of Admission:
i) If injury, give cause:
ii. Reported to police:

Yes

g) Date of Discharge:

Road Traffic Accident

No

3 or more beds per room

d) Date of injury/ Date Disease first detected/ Date of Delivery:

f) Time:
Self inflicted

Twin sharing

Maternity

Substance abuse / Alcohol Consumption

iii. MLC Report & Police FIR attached:

Yes

No

h) Time:
i. If Medico Legal:

Yes

No

SECTION D

c) Hospitalization due to:

j) System of medicine:

DETAILS OF CLAIM
a) Details of treatment expenses claimed

Claim Documents Submitted- Check List:

i. Pre Hospitalization Expenses

ii. Hospitalization Expenses

Claim FormDuly signed

iii. Post Hospitalization Expenses

iv. Health Check up Cost

Copy of the claim intimation, if any

v. Ambulance Charges

vi. Others (code):

Hospital Main bill

Total

days

b) Claim for Domiciliary Hospitalization:

Yes

No

Hospital Break-up bill

days

vii. Pre hospitalization period:

(if yes, provide details in annexure)

Hospital Discharge Summary

Pharmacy Bill

c) Details of Lump sum / cash benefit claimed:

Operation Theatre Notes

`

i. Hospital Daily Cash:

ii. Surgical Cash:

SECTION E

vi. Pre hospitalization period:

ECG

iii. Critical Illness Benefit:

iv. Convalescence:

Doctor's request for investigation

v. Pre/Post hosp. Lump sum benefit:

vi. Others:

Investigation Reports (including CT /

Total

MRI / USG / HPE)

Doctor's Prescription
Others
DETAILS OF BILLS ENCLOSED

Sl. No.

Bill No.

Date

Issued By

Towards

Hospital Main Bill

Pre hospitalisation Bills: ___ Nos

Post hospitalisation Bills: ___ Nos

Pharmacy Bills:

5
6

SECTION F

Amount (`)

7
8
9
10
DETAILS OF PRIMARY INSURED'S BANK ACCOUNT

c) Bank Name and Branch

b) Account Number:

SECTION

a) PAN:

ION G

d) Cheque/ DD Payable details:

e) IFSC Code:

DECLARATION BY THE INSURED

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

a) Policy No.

Enter the policy number

As allotted by the insurance company

b) SI. No/ Certificate No.

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

As allotted by the organization

c) Company TPA ID No.

Enter the TPA ID No

License number as allotted by IRDA and printed in TPA

documents.

d) Name

Enter the full name of the policyholder

Surname, First name, Middle name

e) Address

Enter the full postal address

Include Street, City and Pin Code

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 first Insurance without break

Enter the date of commencement of first 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 4 years since inception of the contract?

Indicate whether hospitalized in the last 4 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 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

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

SECTION D - DETAILS OF HOSPITALIZATION

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 first 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 time 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 filed

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

b) Claim for Domiciliary Hospitalization

Indicate whether claim is for domiciliary hospitalization

Tick Yes or No

c) Details of Lump sum/ cash benefit claimed

Enter the amount claimed as lump sum/ cash benefit

In rupees (Do not enter paise values)

d) Claim Documents Submitted-Check List

Indicate which supporting documents are submitted

Tick the right option

In rupees (Do not enter paise values)

SECTION F - DETAILS OF BILLS ENCLOSED

Indicate which bills are enclosed with the amounts in rupees
SECTION G - DETAILS OF PRIMARY INSUREDS 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 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.

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.

CLAIM FORM - PART B

TO BE FILLED IN BY THE HOSPITAL
UNITED INDIA INSURANCE COMPANY LIMITED
REGISTERED & HEAD OFFICE: 24, WHITES ROAD, CHENNAI-600014

The issue of theis form is not to be taken as admission of liability

Please include the original preauthorization request form in lieu of PART A
(To be filled in block letters)

DETAILS OF HOSPITAL
a) Name of the Hospital:
c) Type of Hospital:

Network

Non Network

(if non network, fill Section E)

SECTION A

c) Hospital ID:
d) Name of the treating doctor:
e) Qualification:

f) Registration No. with state code:

g) Phone No.

DETAILS OF PATIENT ADMITTED

a) Name of Patient:
c) Gender :

f) Date of Admission:

g) Time:

j) Type of Admission:

Emergency

Planned

l) Status at time of discharge:

Discharged to home

Day Care

Male

Female

d) Age: years

months

e) Date of Birth:

h) Date of Discharge:

Maternity

k) If Maternity:

Discharged to another hospital

i) Time:

i. Date of Delivery:

SECTION B

b) IP Registration No.:

ii. Gravida Status:

Deceased

m) Total claimed amount

DETAILS OF AILMENT DIAGNOSED (PRIMARY)

a)

ICD 10 Codes

Description

b)

ICD 10 PCS
i. Procedure 1 :

ii. Additional Diagnosis :

ii. Procedure 2 :

iii. Co-morbidities :

iii. Procedure 3 :

iv. Co-morbidities :

iv. Details of Procedure :

Yes

c) Pre authorization obtained:

No

Description

SECTION C

i. Primary Diagnosis :

d) Pre-authorization number:

e) If authorization by network hospital not obtained, give reason:

f) Hospitalization due to injury:

Yes

No

i. If yes, give cause

Self inflicted
Yes

ii. If injurydue to Substance abuse / alcohol consumption, Test Conducted to establish this:
v. FIR No.

Road Traffic Accident

No

Substance abuse / alcohol consumption

(if yes, attach reports)

iii. If Medico Legal:

Yes

No

iv. Reported to Police:

Yes

No

Yes

No

vi. If not reported to police, give reason:

CLAIM DOCUMENTS SUBMITTED - CHECKLIST

Claim Form duly signed

Investigation reports
CT/ MRI/ USG/ HPE/ Investigation reports

Copy of the Pre-authorization approval letter

Doctor's referance slip

SECTION D

Original Pre-authorization request

Copy of photo ID card of patient verified by hospital

ECG

Hospital discharge summary

Pharmacy bills

Oparation Theatre Notes

MLC report & Police FIR

Hospital main bill

Original death summary from hospital, where applicable

Hospital break-up bill

Any other, please specify

DETAILS IN CASE OF NON NETWORK HOSPITAL (ONLY FILL IN CASE OF NON NETWORK HOSPITAL)
a) Address of the hospital:
SECTION E

City:

State:

Pin Code:

b) Phone No:

d) Hospital PAN

c) Registration No. with State Code:

e) Number of inpatient beds

f) Facilities available in the hospital:

i. OT:

Yes

No

ii. ICU:

iii. Others:
DECLARATION BY THE HOSPITAL

(Please read very carefully)

Date:

Place:

Signature of the insured:

GUIDANCE FOR FILLING CLAIM FORM PART B (To be filled in by the hospital)
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 nospital

Tick the right option

d) Name of treating doctor

Enter the name of the treating doctor

Name of doctor in full

e) Qualification

Enter the qualifications of the treating doctor

Abbreviations of educational qualifications

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

a) Name of Patient

Enter the name of hospital

SECTION B DETAILS OF THE PATIENT ADMITTED

Name of hospital in full

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.

b) IP Registration Number

Enter insurance provider registration number

As allotted by the insurance provider

c) Gender

Indicate Gender of the patient

Tick Male or Female

d) Age

Enter age of the patient

Number of years and months

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 time of discharge

Use hh:mm format

i) Type of Admission

Indicate type of admission of patient

Tick the right option

Date of Delivery

Enter Date of Delivery if maternity

Use dd-mm-yy format

Gravida Status

Enter Gravida status if maternity

Use standard format

Indicate status of patient at time of discharge

Tick the right option

j) If Maternity

k) Status at time of discharge

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

Standard Format and Open text

b) ICD 10 PCS
Procedure 1

Enter the ICD 10 PCS and description of the first procedure

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

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 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

Indicate cause of injury

Tick the right option

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 filed

Tick Yes or No

FIR No.

Enter first information report number

As issued by police authorities

If not reported to police, give reason

Enter reason for not reporting to police

Open Text

Cause
If injury due to substance abuse/alcohol consumption, test conducted to establish this

SECTION D CLAIM DOCUMENTS SUBMITTED-CHECK LIST

Indicate which supporting documents are submitted
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 F - DECLARATION BY THE INSURED

Read declaration carefully and mention date (in dd:mm:yy format), place (open text) and sign.