Claim Form - Part A

For Health Insurance Policies Other than Travel & Personal Accident
TO BE FILLED IN BY THE INSURED
The issue of this Form is not to be taken as an admission of liability (To be filled in block letters)
All the fields in the Claim Form are mandatory.
SECTION A - DETAILS OF PRIMARY INSURED:
a) Policy No: b) SI No / Certificate No. c) Company/ TPA ID No:
d) Name:
e) Address:

City: State: Pin Code:

f) Phone No: g) Email ID:

SECTION B - DETAILS OF INSURANCE HISTORY:

a) Currently covered by any other Mediclaim / Health Insurance: Yes No b) Date of commencement of first Insurance without break:
c) If Yes, Company Name:
i) Insurer’s Email ID: ii) Insurer’s Phone No:

iii) Policy No. iv) Sum Insured (Rs.)

d) Have you been hospitalized in the last four years since inception of the contract? Yes No i) Date:
ii) Diagnosis:
e) Previously covered by any other Mediclaim /Health insurance: Yes No

f) If yes, Company Name:

SECTION C - DETAILS OF INSURED PERSON HOSPITALIZED:

a) Name:
b) Relationship to Primary insured:: Self Spouse Child Father Mother Other
c) Date of Birth:

d) Address:
(if different from above)

e) Gender: Male: Female: f) Age: years months

Occupation: Service Self Employed Homemaker Student Retired Other

City: State: Pin Code:

g) Phone No: h) Email ID:

SECTION D - DETAILS OF HOSPITALIZATION:

a) Name of Hospital where Admitted:
b) Hospital’s Email ID:

c) Room Category Occupied: Day care Twin sharing Single Occupancy 3 or more beds per room
d) Hospitalization due to: Injury Illness Maternity
e) Date of injury / Date Disease first detected / Date of Delivery: f) Date of Admission: g) Time:
h) Date of Discharge: i) Time:

j) If Injury give cause: Self inflicted Road Traffic Accident Substance Abuse / Alcohol Consumption
k) If Medico Legal: Yes No l) Reported to police: Yes No m) MLC Report & Police FIR attached: Yes No
n) System of Medicine:

SECTION E - DETAILS OF CLAIM:

a. Details of the treatment expenses claimed:
i. Pre -hospitalization Expenses: Rs. ii. Hospitalization Expenses: Rs.
iii. Post-hospitalization Expenses: Rs. iv. Health-Check up Cost:Rs.
v. Ambulance Charges: Rs. vi. Others (code): Rs.
vii. Total: Rs.

b. Claim for Domiciliary Hospitalization: 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 hospitalization Lump sum benefit: Rs. vi. Others: Rs.
vii. Total Rs.

Claim Documents Submitted - Check List:

Duly filled and signed Claim Form Part A All previous consultation papers (prior to hospitalization)

Duly filled and signed Claim Form Part B for a Hospitalization Claim Proposer’s Bank Account Details-Cancelled Cheque Leaf with Proposer name
pre-printed OR Bank Passbook 1st page

Hospital Final Bill with breakup Legal Heir / Succession Certificate in case of Proposer’s Death

Discharge Summary / Day-care Summary Affidavit - NOC from other Legal Heirs on a Stamp Paper certified by a Public
Notary (In case of settlement to one Legal Heir)

In case of Death: Death Summary and Death Certificate Nominee / Legal Heir Bank Account Details-Cancelled Cheque Leaf /
Passbook / Bank Statement (in case of Proposer’s Death)

Indoor Case papers (Hospital progress notes and nursing charts) Pharmacy / Investigation / Diagnostic Bills with Prescriptions / Diagnostic

All investigation reports Including CT / MRI / USG / HPE / ECG / X-Ray / MRI / Reason for delayed submission of claim (if submission is beyond 30 days
CT Reports and Films from date of discharge/event/last treatment date)

Doctor Consultation Bills and Papers Invoice / Sticker for the implants used in the treatment

All Bill Payment Receipts ID Card issued by Employer (in case of Group Policy)

Proposer’s ID Proof : In case of Accident:

PAN Card & Aadhaar Card (If CKYC not registered). Medico Legal Case (MLC) / Accident Report (AR)
If CKYC registered: CKYC form and CKYC number First Information Report (FIR)
Police Final Report

SECTION F - DETAILS OF BILLS ENCLOSED:

S. No Bill No. Date Issued by Towards Amount (Rs)
D D M M Y Y

SECTION G - DETAILS OF PRIMARY INSURED’S BANK ACCOUNT:

a) Pan No: b) Account No:
c) Bank Name and Branch: d) Cheque / DD Payable details:
e) IFSC Code:

SECTION H - DECLARATION BY THE INSURED:

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 confirm 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. In addition, I have submitted all previous consultation papers to the Company and I further declare that there are no additional
consultation papers, apart from the ones submitted, relating to my claim. In the event of false or inaccurate statements found to be untrue, or if any material facts have
been deliberately supressed / concealed, I agree that the Company reserves the right to repudiate my claim. I authorize the Company to send my claim documents to
other insurer/s. It is expressly agreed and understood by Me that the Company is merely acting as a conduit between Me and other Insurer(s) and shall coordinate with
the other Insurer(s) for settlement of the balance amount, in case of insufficient coverage under the current policy with our Company.

Under no circumstances, the Company be liable to you or to other Insurer(s) for any direct, indirect, special, incidental, exemplary, consequential or other damages under
any legal theory, including, without limitation, tort, contract, strict liability or otherwise, towards any non-settlement and partial settlement, as the case may be or rejection
of your claim by other insurer(s). Without limiting the generality of the foregoing, the Company shall have absolutely no liability in connection with other Insurer(s) for:
1. damages as a result of failure of performance, delays in operation or transmission;
2. any loss or injury caused, in whole or in part, by the actions, omissions, or negligence, of other Insurer(s);

The liability of the Company under this contract is several and not joint with other insurer(s). The company shall be liable only to the extent of the Sum Assured provided
under the policy and subject to other policy terms and conditions as may be applicable under the Policy Schedule opted by Me. The company is not jointly liable for the
proportion of liability underwritten by any other Insurer(s).

Date:
Place:
 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) Sl. No/ Certificate No. Enter the social insurance number or the certificate As allotted by the organization
number of social health insurance scheme
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 / Indicate whether currently covered by another Tick Yes or No
Health Insurance? Mediclaim / Health Insurance
b) Date of Commencement of first Insurance Enter the date of commencement of first Insurance Use dd-mm-yyformat
without break
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 th e last four years Indicate whether hospitalized in the last four years Tick Yes or No
since inception of the contract?
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 another Tick Yes or No
Health Insurance? Mediclaim / Health Insurance
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 Enter the relevant date Use dd-mm-yy format
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) 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 Tick Yes or No
attached
j) System of Medicine Enter the system of medicine followed in treating Open Text
the patient
 SECTION E - DETAILS OF CLAIM
a) Details of Treatment Expenses Enter the amount claimed as treatment expenses In rupees (Do not enter paise values)
b) Claim for Domiciliary Hospitalization Indicate whether claim is for domiciliary Tick Yes or No
hospitalization
c) Details of Lump sum/ cash benefit claimed Enter the amount claimed as lump sum / cash In rupees (Do not enter paise values)
benefit
d) Claim Documents Submitted-Check List Indicate which supporting documents are 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
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 Name of the individual / organization in full
should be made out to
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.

Aditya Birla Health Insurance Co. Limited Registered Office:

Product Name: Group Activ Secure, UIN: ADIHLGP22155V032223. 9th Floor, Tower1, One World Centre, Jupiter Mills Compound,
1800 270 7000 | [email protected] | www.adityabirlahealthinsurance.com
Trademark/Logo Aditya Birla Capital is owned by Aditya Birla Management Corporation Private Limited and 841, Senapati Bapat Marg, Elphinstone Road, Mumbai 400013.
Trademark/logo HealthReturns, Healthy Heart Score and Active Day are owned by Momentum Metropolitan Life Limited CIN:U66000MH2015PLC263677
(Formerly known as MMI Group Limited). These trademark/Logos are being used by Aditya Birla Health Insurance Co. Limited
under licensed user agreement(s). IRDA Registration No. 153
 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 (To be filled in block letters)
All the fields in the Claim Form are mandatory

1. DETAILS OF HOSPITAL

a. Name of the hospital:

b. Hospital ID:

c. Hospital Email ID:

d. Type of Hospital: Network Non Network (if non network fill section E)
e. Name of the treating f. Qualification:
doctor:
g. Registration No. with h. Phone No.:
State Code.:

2. DETAILS OF THE PATIENT ADMITTED

a. Name of the Patient:

b. IP Registration Number: c. Gender: Male Female

d. Age: Y Y Years M M Months e. Date of Birth: D D M M Y Y Y Y

f. Date of Admission: D D M M Y Y Y Y g. Time :

h. Date of Discharge: D D M M Y Y Y Y i. Time :

j. Type of Admission: Emergency Planned Day Care Maternity

k. If Maternity i) Date of Delivery: D D M M Y Y Y Y ii) Gravida Status:

l. Status at time of Discharge to home Discharge to another hospital Deceased

discharge
m. Total claimed amount: Rs.

3. 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:
iii. Co-morbidities: iii. Procedure 3:
iv. Co-morbidities: iv. Details of Procedure:

a) Pre-authorization obtained: Yes No b) Pre-authorization Number:

c) ___ ___________________________________________________________________________
If authorization by network hospital not obtained, give reason:

_________________________________________________________________________________________________________________________

d) Hospitalization due to injury: Yes No

i. If Yes, give cause Self-inflicted 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. If Medico legal: Yes No iv. Reported to Police: Yes No v. FIR no.

iv. If not reported to police give reason: ___________________________________________________________________________________________

____

_________________________________________________________________________________________________________________________
 4. CLAIM DOCUMENTS SUBMITTED - CHECK LIST:

Duly filled and signed Claim Form Part A All previous consultation papers (prior to hospitalization)

Duly filled and signed Claim Form Part B for a Hospitalization Claim Proposer’s Bank Account Details-Cancelled Cheque Leaf with Proposer name
pre-printed OR Bank Passbook 1st page

Hospital Final Bill with breakup Legal Heir / Succession Certificate in case of Proposer’s Death

Discharge Summary / Day-care Summary Affidavit - NOC from other Legal Heirs on a Stamp Paper certified by a Public
Notary (In case of settlement to one Legal Heir)

In case of Death: Death Summary and Death Certificate Nominee / Legal Heir Bank Account Details-Cancelled Cheque Leaf /
Passbook / Bank Statement (in case of Proposer’s Death)

Indoor Case papers (Hospital progress notes and nursing charts) Pharmacy / Investigation / Diagnostic Bills with Prescriptions / Diagnostic

All investigation reports Including CT / MRI / USG / HPE / ECG / X-Ray / MRI / Reason for delayed submission of claim (if submission is beyond 30 days
CT Reports and Films from date of discharge/event/last treatment date)

Doctor Consultation Bills and Papers Invoice / Sticker for the implants used in the treatment

All Bill Payment Receipts ID Card issued by Employer (in case of Group Policy)

Proposer’s ID Proof : In case of Accident:

PAN Card & Aadhaar Card (If CKYC not registered). Medico Legal Case (MLC) / Accident Report (AR)
If CKYC registered: CKYC form and CKYC number First Information Report (FIR)
Police Final Report

5. 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:

b. Phone No.: c. Registration No. with State Code:

d. Hospital PAN: e. Number of Inpatient beds:

f. Facilities available in the hospital: OT: Yes No ICU: Yes No

g. Others:

6. DECLARATION BY THE HOSPITAL (PLEASE READ VERY CAREFULLY)

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.

Date: D D M M Y Y 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 hospital As allocated by the TPA
c) Type of Hospital Indicate whether In network or non network Tick the right option
Hospital

d) Name of treating doctor Enter the name of the treating doctor Name of doctor in full
e) Qualification Enter the qualification of the treating doctor Abbreviations of educational qualifications
f) Registration No. with State Code Enter the registration number of the doctor along As allocated by the Medical Council of India
with the state code

g) Phone No. Enter the phone number of doctor Include STD code with telephone number
SECTION B - DETAILS OF THE PATIENT ADMITTED
a) Name of Patient Enter the name of hospital Name of hospital in full
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 Birth Enter date of birth of the patient 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
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 Standard Format and Open text
primary diagnosis

Additional Diagnosis Enter the ICD 10 Code and description of the Standard Format and Open text
additional diagnosis

Co-morbidities Enter the ICD 10 Code and description of the Standard Format and Open text
co-morbidities

b) ICD 10 PCS
Procedure 1 Enter the ICD 10 PCS and description of the first Standard Format and Open text
procedure

Procedure 2 Enter the ICD 10 PCS and description of the second Standard Format and Open text
procedure

Procedure 3 Enter the ICD 10 PCS and description of the third Standard Format and Open text
procedure

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 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 As allocated by the Medical Council of India
with the state code

d) Hospital PAN Enter the permanent account number As allocated 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

Aditya Birla Health Insurance Co. Limited

Registered Office:
1800 270 7000 | [email protected] | www.adityabirlahealthinsurance.com 9th Floor, Tower1, One World Centre, Jupiter Mills Compound,
Trademark/Logo Aditya Birla Capital is owned by Aditya Birla Management Corporation Private Limited and 841, Senapati Bapat Marg, Elphinstone Road, Mumbai 400013.
Trademark/logo HealthReturns, Healthy Heart Score and Active Day are owned by Momentum Metropolitan Life Limited
(Formerly known as MMI Group Limited). These trademark/Logos are being used by Aditya Birla Health Insurance Co. Limited CIN:U66000MH2015PLC263677
under licensed user agreement(s). IRDA Registration No. 153