Bajaj Allianz General Insurance Company Limited.

Regd. & Head Office : GE Plaza, Airport Road, Yerawada, Pune 411 006
(To be filled in block letters)
Email id:[email protected]
Toll free no:1800-209-5858
020-30305858

CLAIM FORM FOR HEALTH INSURANCE POLICIES OTHER THAN TRAVEL AND PERSONAL ACCIDENT – PART A
TO BE FILLED IN BY THE INSURED
The issue of this form is not to be taken as an admission of liability
DETAILS OF PRIMARY INSURED
a) Policy No: O G - 2 3 - 1 9 1 9 - 8 4 0 3 - 0 0 0 0 0 0 9 9 b) Sl. No/Certificate No:
c) Company TPA ID No: d) Customer ID:
DELOITTE CONSULTING INDIA PRIVATE LIMITED
e) Company Name:__________________________________________________________f) 607043
Employee No:___________________________

SECTION A
g) Name: K A N D U K U R I S U P R I Y A

h) Address: H . N o : 1 1 - 1 4 - 3 9 4 / 1 , p l o t n o : 3 , s i r i
n a g a r c o l o n y , L . B . N a g a r
City: H y d e r a b a d State: T e l a n g a n a Pin Code: 5 0 0 0 7 4
Phone No: 9 8 6 6 5 0 9 1 2 0 [email protected]
Email ID:__________________________________________________________
DETAILS OF INSURANCE HISTORY
a) Currently covered by any other Mediclaim / Health Insurance Yes N No
b) date of commencement of first insurance without break
c) If yes, company name: Policy No:

SECTION B
Sum Insured (Rs.):
d) Have you been hospitalized in the last four years since inception of the contract? Yes No Date: D D M M Y Y Y Y
Diagnosis
e) Previously covered by any other Mediclaim / Health Insurance: Yes No
f) If yes, Company Name

DETAILS OF INSURED PERSON HOSPITALIZED

KANDUKURI ANURADHA
a) Name of the Patient: _______________________________________________________________________________________________
DTT-23-607043E
b) Health ID card no of the Patient:______________________________________________________________________________________
c) Gender: Male Female y d) Age: years 5 1 months 1 1 e) Date of Birth 28/11/1970
D D M M Y Y Y Y

SECTION C
f) Relationship of Primary insured: Self Spouse Child Father Mother Y Other (Please Specify)
g) Occupation: Service Self Employed Homemaker Y Student Retired Other (Please Specify)
h) Address (if different from above) _____________________________________________________________________________________
City: State: Pin Code:
I) Phone No: J) Email ID: ________________________________________________________

DETAILS OF HOSPITALIZATION
SRIKARA HOSPITALS
a) Name of Hospital where Admitted: ____________________________________________________________________________________
b) Room Category occupied: Day Care Single occupancy Twin sharing Y 3 or more beds per room
c) Hospitalisation due to: Injury Illness Y Maternity
SECTION D

d) Date of Injury/Date Disease first detected/Date of Delivery: 08/10/2022

D D M M Y Y Y Y
e) Date of admission 09/10/2022
D D M M Y Y Y Y f) Time: 1006 H H : M M g) Date of Discharge 13/10/2022
D D M M Y Y Y Y h)Time: 1147H H M M
Dr. KARTHIK MERUVA
I) Name of treating doctor_____________________________________Diagnosis________________________________________________
j) If injury give cause: Self inflicted Road Traffic Accident Substance Abuse /Alcohol Consumption
i) If Medico legal: Yes No ii) Reported to police: Yes No
iii) MLC report and Police FIR attached: Yes No j) System of Medicine
DETAILS OF CLAIM
a) Details of the treatment expenses claimed
I. Pre-Hospitalisation Expenses: Rs. 3 7 8 0 ii. Hospitalisation Expenses Rs.
iii. Post-Hospitalisation Expenses: Rs. 2 0 1 5 iv. Health checkup cost Rs.
v. Ambulance Charges: Rs. vi. Others (code) Rs.
Total Rs.

SECTION E
vii. Pre-Hospitalisation period: days 0 0 1 viii. Post Hospitalisation period: days 0 0 7
b) 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 benefit
Total Rs.
Claim Documents Submitted – Check List
Claim Form Duly Signed Copy of claim intimation if any Original Hospital Main Bill
Original Hospital Breakup Bill Original Hospital Bill Payment Receipt Original Hospital Discharge SummaryPharmacy Bill
Operation Theater Notes ECG Original Doctor's Prescriptions
Original Doctors request for investigation reports (including CT/MRI/USG/HPE) Others
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 first
page of the bank passbook.
DETAILS OF BILLS ENCLOSED
Sr.No Bill No Date Issued by Towards Amount (Rs)
1 D D M M Y Y Hospitalisation Main Bill
2 140780 08/10/2022
D D M M Y Y Pre-Hospitalisation Bills:__Nos 5 0 0

SECTION F
3 BIL35934
08/10/2022
D D M M Y Y Post-Hospitalisation Bills:__Nos 2 4 0 0
4 BIL35940
08/10/2022
D D M M Y Y Pharmacy Bills 8 8 0
5 OPO68168
13/10/2022
D D M M Y Y 1 2 1 5
6 BIL36222
19/10/2022
D D M M Y Y 8 0 0
7 D D M M Y Y
8 D D M M Y Y
9 D D M M Y Y
10 D D M M Y Y

DETAILS OF PRIMARY INSURED'S BANK ACCOUNT

SECTION G
KANDUKURI SUPRIYA
a) Name of the Account Holder ( As per Bank Account):______________________________________________________________________
b) Account no ( As appearing in the cheque book): 5 2 1 3 5 6 4 8 7 5
Kotak Mahindra Bank
c) Bank Name :_____________________________________________________________________________________________________
1-1-584, Kausthubh Towers, CTO Colony, Kothapet, Hyderabad
d) Branch Name & Address:___________________________________________________________________________________________:
e) Account Type : Saving Y Current Cash Credit
f) MICR No. 5 0 0 4 8 5 0 2 5 g)IFSC Code: K K B K 0 0 0 7 4 6 2
h) PAN: H Z D P K 1 7 4 5 R i) Cheque / DD Payable Details:
SECTION H

DECLARATION
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 Bajaj Allianz General Insurance Company Limited, to seek necessary medical
information / documents from any hospital / Medical Practitioner who ha s 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: 09/11/2022
D D M M Y Y Y Y Place: HYDERABAD Signature of the Insured
Bajaj Allianz General Insurance Company Limited.
Regd. & Head Office : GE Plaza, Airport Road, Yerawada, Pune 411 006
Email id: [email protected], Toll free no. 1800-209-5858, 020-30305858

CLAIM FORM- PART B

TO BE FILLED IN BY THE HOSPITAL
The issue of this 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
SRIKARA HOSPITALS
a) Name of the hospital : ___________________________________________________________________________________________________________

SECTION A
b) Hospital ID :________________________________________c) Type of hospital : Network Y Non-Network (If non-network fill section E)
DR. KARTHIK MERUVA
d) Name of treating doctor:_________________________________________________________________________________________________________

e) Qualification: ________________________ f) Registration No with State Code_________________ g) Phone No:___________________________________

DETAILS OF THE PATIENT ADMITTED

a) Name of the patient :____________________________________________________________________________________________________________
KANDUKURI ANURADHA

b) IP registration Number : _________________c) Gender: Male Female Y d) Age : Years 5 1 Months: 1 1 e) Date of birth: 28/11/1970
D D M M Y Y

SECTION B
f) Date of admission: 09/10/2022
D D M M Y Y g) Time : 1 H0 0M 6
H M h) Date of discharge : 13/10/2022
D D M M Y Y i) Time: 1 H1 4M 7M
H
j) Type of Admission : Emergency Y 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 Y Discharge to another hospital Deceased: m) Total claimed Amount: 0 0 0 5 7 9 5

DETAILS OF AILMENT DIAGNOSED (PRIMARY)

a) ICD 10 Codes Description b) ICD 10 PCS Description

i) Primary Diagnosis: i) Procedure 1:

ii) Additional Diagnosis: ii) Procedure 2:

SECTION C
iii) Co-morbidities : iii) Procedure 3:

iv) Co-morbidities : iv) Details of

Procedure:

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 No

iv)Reported to Police: Yes No v) FIR no: __________vi) if not reported to police give reason: ___________________________________________

CLAIM DOCUMENTS -CHECK LIST

Claim form duly signed Ingestion reports
Original Pre-Authorization request CT/MR/USG/HPE investigation report
SECTION D

Copy of Pre-Authorization letter Doctor's reference slip for investigation

Y Copy of photo ID card of patient verified by hospital ECG
Y Hospital discharge summary Y Pharmacy bills
Operation theatre notes MLC report & Police FIR
Hospital main bill Original death summary from hospital where applicable
Hospital break up bill Any other, please specify
ADDITIONAL DETAILS IN CASE OF NON NETWORK HOSPITAL (ONLY FILL IN CASE OF NON NETWORK HOSPITAL)
SECTION E

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 No
iii) 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 untrue
SECTION F

statement, suppression or concealment of any material fact, our right to claim under this claim shall be forfeited.

Date : D D M M Y Y
Place : _____________________
Signature and Seal of the Hospital Authority
 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 the hospital As allocated by TPA
c) Type of Hospital Indicate whether in network or non network hospital Tick the right option
d) Name of Treating doctor Enter the name of treating doctor Name of doctor in full
e) Qualification Enter the qualification of treating doctor abbreviations of educational
qualifications
f) Registration No with state code Enter the registration no of treating doctor As allocated by the medical
along with state code council of India
g) Phone No Enter the phone no of doctor Include STD code with telephone number
SECTION B - DETAILS OF THE PATIENT ADMITTED
a) Name of the patient Enter the name of hospital Name of hospital in full
b) IP Registration number Enter the insurance provide registration number As allocated by the insurance provide
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 Birth Enter date of admission Use dd-mm-yy format
f) Date of Admission Enter date of admission Use dd-mm-yy format
g) Time Enter date 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
Date of Delivery Enter Date of Delivery if maternity Use dd-mm-yy format
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
m)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 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
b) ICD 10 PCS
Procedure 1 Enter the ICD 10 PCS and description of the first procedure Standard Format and Open text
Procedure 2 Enter the ICD 10 PCS and description of the second procedure Standard Format and Open tex
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 Enter reason for not obtaining pre-authorization number Open text
hospital not obtained, give reason
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/ Indicate whether test conducted Tick Yes or No
alcohol 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 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
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 As allocated by the Medical
the state code 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 HOSPITAL
Read declaration carefully and mention date (in dd:mm:yy format), place (open text) and sign and stamp