If your company has a TPA, enter the TPA’s ID no. In case you have another health insurance policy As on the health ID card issued to you Type of hospitalization Details If it was a medico legal case. Page 1 Enter your policy number As on policy document Can be you or your family member Your employee code no. Allopathy? Ayurveda? Homeopathy? Etc.
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If your company has
a TPA, enter the
TPA’s ID no.
In case you
have another
health
insurance
policy
As on the health
ID card issued to
you
Type of
hospitalization
Details
If it was a
medico legal
case.
Page 1
Enter your
policy number
As on policy
document
Can be you or
your family
member
Your employee
code no.
Allopathy?
Ayurveda?
Homeopathy?
Etc.
In case medical
treatment taken
at home
In case you
have benefit
based plan
Enter all the
bills incurred
before, during
& after
hospitalization
Very
important
payment
details
Page 2
Expenses
incurred before
and after
Hospitalization
List of documents
to be attached
with this claim
form
Total
hospitalization
bill
Signature of the
policyholder
To be filled
by the
hospital in
concern
Page 3
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