Reimbursement Form A 2013 - Bajaj Allianz

Bajaj Allianz General Insurance Company Limited.Regd. & Head Office : GE Plaza, Airport Road, Yerawada, Pune 411 006Email id:-customercare@bajajallianz.co.inToll free no:1800-209-5858020-30305858(To be filled in block letters)CLAIM FORM FOR HEALTH INSURANCE POLICIES OTHER THAN TRAVEL AND PERSONAL ACCIDENT – PART ADETAILS OF PRIMARY INSUREDTO BE FILLED IN BY THE INSUREDThe issue of this form is not to be taken as an admission of liabilitya) Policy No: b) Sl. No/Certificate No:c) Company TPA ID No:e) Company Name:__________________________________________________________f) Employee No:___________________________g) Name:h) Address:d) Customer ID:City: State: Pin Code:Phone No: Email ID:__________________________________________________________DETAILS OF INSURANCE HISTORYa) Currently covered by any other Mediclaim / Health Insurance Yes Nob) date of commencement of first insurance without breakc) 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:Diagnosise) Previously covered by any other Mediclaim / Health Insurance: Yes Nof) If yes, Company NameDETAILS OF INSURED PERSON HOSPITALIZEDa) Name of the Patient: _______________________________________________________________________________________________b) Health ID card no of the Patient:______________________________________________________________________________________c) Gender: Male Female d) Age: years months e) Date of Birthf) Relationship of Primary insured: Self Spouse Child Father Mother Other (Please Specify)g) Occupation: Service Self Employed Homemaker Student Retired Other (Please Specify)h) Address (if different from above) _____________________________________________________________________________________City: State: Pin Code:I) Phone No: J) Email ID: ________________________________________________________DETAILS OF HOSPITALIZATIONa) Name of Hospital where Admitted: ____________________________________________________________________________________b) Room Category occupied: Day Care Single occupancy Twin sharing 3 or more beds per roomc) Hospitalisation due to: Injury Illness Maternityd) Date of Injury/Date Disease first detected/Date of Delivery:D D M M Y Y Y Ye) Date of admission D D M M Y Y Y Y f) Time: H H : M M g) Date of Discharge D D M M Y Y Y Y h)Time: H HI) Name of treating doctor_____________________________________Diagnosis________________________________________________j) If injury give cause: Self inflicted Road Traffic Accident Substance Abuse /Alcohol Consumptioni) If Medico legal: Yes No ii) Reported to police: Yes Noiii) MLC report and Police FIR attached: Yes No j) System of MedicineD D M M Y Y Y YD D M M Y Y Y YM MSECTION A SECTION B SECTION C SECTION D

DETAILS OF CLAIMa) Details of the treatment expenses claimedI. Pre-Hospitalisation Expenses: Rs. ii. Hospitalisation Expenses Rs.iii. Post-Hospitalisation Expenses: Rs. iv. Health checkup cost Rs.v. Ambulance Charges: Rs. vi. Others (code) Rs.vii. Pre-Hospitalisation period: days viii. Post Hospitalisation period: daysb) Claim for Domiciliary Hospitalisation: Yes No (If yes, provide details in annexure)c) Details of Lump sum / cash benefit claimed:i. Hospital Daily Cash Rs. ii. Surgical Cash Rs.iii. Critical illness Benefit Rs. iv. Convalescence Rs.v. Pre/Post hospitalisation Rs. vi. Others Rs.lump sum benefitClaim Documents Submitted – Check ListClaim Form Duly Signed Copy of claim intimation if any Original Hospital Main BillOriginal Hospital Breakup Bill Original Hospital Bill Payment Receipt Original Hospital Discharge SummaryPharmacy BillOperation Theater Notes ECG Original Doctor's PrescriptionsDECLARATIONI 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 falseor untrue statement, suppression or concealment of any material fact with respect to questions asked in relation to this claim, my right to claimreimbursement shall be forfeited. I also consent & authorize Bajaj Allianz General Insurance Company Limited, to seek necessary medicalinformation / documents from any hospital / Medical Practitioner who ha s attended on the person against whom this claim is made. I herebydeclare that I have included all the bills / receipts for the purpose of this claim & that I will not be making any supplementary claim except thepre/post-hospitalization claim, if any.TotalTotalOriginal Doctors request for investigation reports (including CT/MRI/USG/HPE)Cancelled blank cheque leaf with payee name printed. If name of the payee is not printed on the cheque leaf please attach copy of the firstpage of the bank passbook.DETAILS OF BILLS ENCLOSEDSr.No Bill No Date Issued by Towards Amount (Rs)1 D D M M Y YHospitalisation Main Bill2 D D M M Y YPre-Hospitalisation Bills:__Nos3 D D M M Y YPost-Hospitalisation Bills:__Nos4 D D M M Y YPharmacy Bills5678910D D M M Y YD D M M Y YD D M M Y YD D M M Y YD D M M Y YD D M M Y YDETAILS OF PRIMARY INSURED'S BANK ACCOUNTa) Name of the Account Holder ( As per Bank Account):______________________________________________________________________b) Account no ( As appearing in the cheque book) :c) Bank Name :_____________________________________________________________________________________________________d) Branch Name & Address:___________________________________________________________________________________________:e) Account Type : Saving Current Cash CreditOthersf) MICR No. g)IFSC Code:h) PAN: i) Cheque / DD Payable Details:Rs.Rs.SECTION E SECTION F SECTION G SECTION HDate: D D M M Y Y Y Y Place: Signature of the Insured

Bajaj Allianz General Insurance Company Limited.Regd. & Head Office : GE Plaza, Airport Road, Yerawada, Pune 411 006Email id: customercare@bajajallianz.co.in, Toll free no. 1800-209-5858, 020-30305858DETAILS OF HOSPITALCLAIM FORM- PART BTO BE FILLED IN BY THE HOSPITALThe issue of this form is not to be taken as admission of liabilityPlease include the original preauthorization request form in lieu of PART-A(To be filled in block letters)a) Name of the hospital : ___________________________________________________________________________________________________________b) Hospital ID :________________________________________c) Type of hospital : Network Non-Network (If non-network fill section E)d) Name of treating doctor: _________________________________________________________________________________________________________e) Qualification: ________________________ f) Registration No with State Code_________________ g) Phone No:___________________________________DETAILS OF THE PATIENT ADMITTEDa) Name of the patient :____________________________________________________________________________________________________________b) IP registration Number : _________________c) Gender: Male Female d) Age : Years Months: e) Date of birth: D D M M Y Yf) Date of admission: D D M M Y Y g) Time : H H M M h) Date of discharge : D D M M Y Y i) Time: H H M Mj) Type of Admission : Emergency Planned Day Care Maternity k) If Maternity i) Date of delivery D D M M Y Y ii)Gravida Status:l) Status at time of discharge: Discharge to home Discharge to another hospital Deceased: m) Total claimed Amount:DETAILS OF AILMENT DIAGNOSED (PRIMARY)a) ICD 10 Codes Descriptionb) ICD 10 PCS Descriptioni) Primary Diagnosis:i) Procedure 1:ii) Additional Diagnosis:ii) Procedure 2:iii) Co-morbidities :iii) Procedure 3:SECTION A SECTION B SECTION Civ) Co-morbidities :iv) Details ofProcedure:d) Pre-Authorization Obtained: Yes No e) Pre-Authorization Number:f) If authorization by network hospital no obtained, give reason: _____________________________________________________________________________g) 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)Medico Legal: Yes Noiv)Reported to Police: Yes No v) FIR no: __________vi) if not reported to police give reason: ___________________________________________CLAIM DOCUMENTS -CHECK LISTClaim form duly signedOriginal Pre-Authorization requestCopy of Pre-Authorization letterCopy of photo ID card of patient verified by hospitalHospital discharge summaryOperation theatre notesHospital main billHospital break up billIngestion reportsCT/MR/USG/HPE investigation reportDoctor's reference slip for investigationECGPharmacy billsMLC report & Police FIROriginal death summary from hospital where applicableAny other, please specifyADDITIONAL DETAILS IN CASE OF NON NETWORK HOSPITAL (ONLY FILL IN CASE OF NON NETWORK HOSPITAL)a) Address of hospital______________________________________________________________________________________________________________City:_____________ State: _______________ Pin Code: _________Phone No: ___________________ c) Registration no with State Code: ________________d) Hospital PAN:_____________________e) Number of Inpatient beds: Facilities available in hospital: i) OT: Yes No ii) ICU: Yes Noiii) Others: _____________________________________________________________________________________________________________________DECLARATION BY THE HOSPITAL: (PLEASE READ VERY CAREFULLY)We hereby declare that the information furnished in the Claim Form is true and correct to the best of our knowledge and belief. If we have made any false and untruestatement, suppression or concealment of any material fact, our right to claim under this claim shall be forfeited.Date : D D M M Y YPlace : _____________________Signature and Seal of the Hospital AuthoritySECTION D SECTION E SECTION F

GUIDANCE FOR FILLING CLAIM FORM - PART B (To be filled in by the hospital)DATA ELEMENT DESCRIPTION FORMATSECTION A - DETAILS OF HOSPITALa) Name of Hospital Enter the name of hospital Name of hospital in fullb) Hospital ID Enter ID number of the hospital As allocated by TPAc) Type of Hospital Indicate whether in network or non network hospital Tick the right optiond) Name of Treating doctor Enter the name of treating doctor Name of doctor in fulle) Qualification Enter the qualification of treating doctor abbreviations of educationalqualificationsf) Registration No with state code Enter the registration no of treating doctor As allocated by the medicalalong with state codecouncil of Indiag) Phone No Enter the phone no of doctor Include STD code with telephone numberSECTION B - DETAILS OF THE PATIENT ADMITTEDa) Name of the patient Enter the name of hospital Name of hospital in fullb) IP Registration number Enter the insurance provide registration number As allocated by the insurance providec) Gender Indicate Gender of the patient Tick Male or Femaled) Age Enter age of the patient Number of years and monthse) Date of Birth Enter date of admission Use dd-mm-yy formatf) Date of Admission Enter date of admission Use dd-mm-yy formatg) Time Enter date of admission Use hh:mm formath) Date of Discharge Enter date of discharge Use dd-mm-yy formati) Time Enter time of discharge Use hh:mm formatj) Type of Admission Indicate type of admission of patient Tick the right optionk) If MaternityDate of Delivery Enter Date of Delivery if maternity Use dd-mm-yy formatGravida Status Enter Gravida status if maternity Use standard formatl) Status at time of discharge Indicate status of patient at time of discharge Tick the right optionm)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 CodePrimary Diagnosis Enter the ICD 10 Code and description of the primary diagnosis Standard Format and Open textAdditional Diagnosis Enter the ICD 10 Code and description of the additional diagnosis Standard Format and Open textCo-morbidities Enter the ICD 10 Code and description of the co-morbidities Standard Format and Open textb) ICD 10 PCSProcedure 1 Enter the ICD 10 PCS and description of the first procedure Standard Format and Open textProcedure 2 Enter the ICD 10 PCS and description of the second procedure Standard Format and Open texProcedure 3 Enter the ICD 10 PCS and description of the third procedure Standard Format and Open textDetails of Procedure Enter the details of the procedure Open textc) Pre-authorization obtained Indicate whether pre-authorization obtained Tick Yes or Nod) Pre-authorization Number Enter pre-authorization number As allotted by TPAe) If authorization by network Enter reason for not obtaining pre-authorization number Open texthospital not obtained, give reasonf) Hospitalization due to injury Indicate if hospitalization is due to injury Tick Yes or NoCause Indicate cause of injury Tick the right optionIf injury due to substance abuse/ Indicate whether test conducted Tick Yes or Noalcohol consumption, testconducted to establish thisMedico Legal Indicate whether injury is medico legal Tick Yes or NoReported To Police Indicate whether police report was filed Tick Yes or NoFIR No. Enter first information report number As issued by police authoritiesIf not reported to police, give reason Enter reason for not reporting to police Open TextIndicate which supporting documents are submittedSECTION D - CLAIM DOCUMENTS SUBMITTED-CHECK LISTSECTION E - DETAILS IN CASE OF NON NETWORK HOSPITALa) Address Enter the full postal address Include Street, City and Pin Codeb) Phone No. Enter the phone number of hospital Include STD code with telephonenumberc) Registration No. with State Code Enter the registration number of the doctor along with As allocated by the Medicalthe state codeCouncil of Indiad) Hospital PAN Enter the permanent account number As allotted by the Income Taxdepartmente) Number of Inpatient beds Enter the number of inpatient beds Digitsf) Facilities available in the hospital Indicate facilities available in the hospital Tick the right option. If others,please specifySECTION F - DECLARATION BY THE HOSPITALRead declaration carefully and mention date (in dd:mm:yy format), place (open text) and sign and stamp