REQUEST FOR CASHLESS HOSPITALISATION FOR HEALTH INSURANCE

POLICY PART - C (Revised)

(TO BE FILLED IN BLOCK LETTERS)

DETAILS OF THE THIRD PARTY ADMINISTRATOR/ INSURER/ HOSPITAL:

a. Name of TPA/ lnsurance company: MDIndia Health Insurance TPA Pvt. Ltd. (IRDA LICENCENO. 005)

b. Toll free phone number: 1800-233-4505

1800-233-4449
c. Toll free fax:
d. Name of Hospital:

i. Address
ii. Rohini ID
iii. e-mail id

TO BE FILLED BY INSURED/PATIENT

A. Name of the Patient

B. Gender: Male Female Third Gender
C. Age: (Years) / (Month)

D. Date of Birth: DD/MM/YYYY

E. Contact number:

F. Contact number of attending Relative:

G. lnsured Card ID number:

H. Policy number/Name of Corporate:

I. Employee ID:

J. Currently do you have any other mediclaim /health insurance: Yes No

i. Company Name
ii.Give Details:

K: Do you have a family Physician: Yes No

L: Name of the Family Physician:
M: Contact number, if any:
N: Current Address of lnsured patient:
O: Occupation of Insured patient:

(PLEASE COMPLETE DECLARATION OF THIS FORM)

 TO BE FILLED BY TREATING DOCTOR/HOSPITAL

A: Name of the treating Doctor:

B: Contact number:
C: Nature of illness/Disease with presenting complaint
D: Relevant Critical Findings:
E: Duration of the present ailment Days

i. Date of First consultation DD/MM/Y'YYY

ll. Past history of present ailment, if any

F: Provisional diagnosis:
i. ICD l0 code
G: Proposed line of treatment:

i. Medical Management ( )
ii. Surgical Management ( )
iii. Intensive care ( )
iv. Investigation ( )
v. Non-allopathic treatment ( )

H: If investigation and,/or Medical Management, provide

i. Route of Drug Administration

I: lf surgical, name of surgery

i. ICD l0 PCS code

J: If other treatment, provide details

K: How did injury occur

L: ln case of accident

i. Is it RTA Yes No
ii. Date of injury (DD/MM/YYYY)
iii. Report to Police Yes No
iv. FIR NO
v. Injury /Disease caused due to substance abuse/alcohol consumption Yes No

vi. Test conducted to establish this (if yes, attach report) Yes No

M. In case of Maternity G P L A

i. Expected date of Delivery DD/MM/YYYY

 DETAILS OF PATIENT ADMITTED

A: Date of admission (DD/MM/YYYY)

B: Time of admission ( HH : MM )
C: Is this an emergency/planned hospitalization event Emergency Planned
D: Mandatory Past History of any chronic illness If yes (Since month/year)

i. Diabetes
ll. Heart disease
iii. Hypertension
iv. Hyperlipidemias
v. Osteoarthritis
vi. Asthma./COPD/Bronchitis
vii. Cancer
viii . Alcohol/Drug abuse
ix. Any HIV/ or STD Related ailment
x. Any other ailment, give details

E. Expected number of Days/stay in hospital provide details Days

F. Days in ICU Days

G. Room Type
H. Per day room rent+ nursing and service charges+ patients diet
I. Expected cost of investigation + diagnostic
J. ICU charges
K. OT charges
L. Professional fees Surgeon + Anesthetist Fees + consultation Charges
M. Medicines+ Consumables+ Cost of Implants (if applicable please specify)

N. Other hospital expenses if any

O. All-inclusive package charges if any applicable

P. Sum Total expected cost of hospitalization

 DECLARATION
(Please read very carefully)
We confirm having read understood and agreed to the Declarations of this form

a. Name of the treating doctor

b. Qualification:

c. Registration number with State code

Hospital Seal Patient / lnsured Name

(Must Include Hospital ID)

DECLARATION BY THE PATIENT / REPRESENTATIVE

a. 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.

b. Payment to hospital is governed by the terms and conditions of the policy. In case the lnsurer / TPA is not
liable to settle the hospital bill, I undertake to settle the bill as per the terms and conditions of the policy.

c. 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.

d. 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

e. 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.

f. 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 with respect to the claim, my right to claim
reimbursement of the said expenses shall be absolutely forfeited.

g. I agree to indemnify the hospital against all expenses incurred on my behalf, which are not reimbursed by
the Insurer/ TPA.

h. "I/We authorize Insurance Company/TPA to contact me/us through mobile/email for any update on this
claim"
a) Patient's / Insured's Name:

b) Contact Number: e-mail Id(optional)

d) Patient's / Insured's Signature:

Date: Time:_

HOSPITAL DECLARATION

a. We have no objection to any authorized TPA / Insurance Company official verifying documents pertaining
to hospitalization.

b. All valid original documents duly countersigned by the insured / patient as per the checklist below will be
sent to TPA/ lnsurance Company within 7 days of the patient’s discharge.

c. 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.

d. The patient declaration has been signed by the patient or by his representative in our presence.

e. We agree to provide clarifications for the queries raised regarding this hospitalization and we take
responsibility the sole for any delay in offering clarifications

f. We will abide by the terms and conditions agreed in the MOU.

 g. We confirm that no additional amount would be collected from the insured in excess of Agreed Package
Rates except costs towards non-admissible amounts (including additional charges due to opting higher
room rent than eligibility choosing separate line of treatment which is not envisaged/considered in
package).

h. We confirm that no recoveries would be made from the deposit amount collected from the lnsured except
for costs towards non-admissible amounts (including additional charges due to opting higher room rent
than eligibility/choosing separate line of treatment which is not envisaged/considered in package).

i. In the event of unauthorized recovery of any additional amount from the Insured in excess of Agreed
Package Rates, the authorized TPA / Insurance Company reserves the right to recover the same from us
(the Network Provider) and/or take necessary action, as provided under the MoU or applicable laws.
.

Hospital Seal Doctors Signature

Date: Time: