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)

Click on "Generate PDF" button and save the filled form in your desired folder.
SECTION A – DETAILS OF PRIMARY INSURED
 
a) Policy No.:
 
b) Sl. No/ Certificate No.:
c) Company/ TPA ID No.:
 
   
   
d) Name:
e) Address:
City:
 
State:
Pincode:
  Mobile No.  
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:
 
Policy No.:
Sum Insured (Rs):
d) Have you been hospitalized in the last four years since inception of the contract: Yes   No
Date:
 
Diagnosis:
e) Previously covered by any other Mediclaim/Health insurance: Yes   No
 
f) If Yes, Company Name:
 
SECTION C- DETAILS OF INSURED PERSON HOSPITALISED
 
a) Name:
b) Relationship to primary Insured: Self Spouse Child Father Mother Other
 
Please Specify:
c) Date of Birth:
 
d) Age:
e) Address (if different from above):
f) Gender: Male   Female
   
g) Occupation: Service Self employed Homemaker Student
Retired Other
 
Please Specify:
City:
 
State:
Pincode:
h) Phone No.:
  i) Mobile No.:  
j) Email ID:
 
SECTION D- DETAILS OF HOSPITALIZATION
 
a) Name of the Hospital where admitted:
b) Room Category occupied: Daycare   Single Occupancy   Twin Sharing   3 or more beds per room  
c) Hospitalisation due to: Illness   Injury   Maternity  
 
d) Date of Injury/ Date of disease first detected/ Date of delivery:
e) Date of admission:
 
f) Time:
g) Date of discharge:
 
h) Time:
i) 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, & Police FIR attached? Yes   No
j) System of medicine:
 
SECTION E- DETAILS OF CLAIM
a) Details of the treatment expenses claimed Claim Documents Submitted- Check List:
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.
 
 
Total
RS.
vii) Pre-Hospitalization Period
Days 
 
viii) Post -Hospitalization Period
Days 
b) Claim for Domiciliary Hospitalization: Yes    No (if yes, please provide details in annexure)
c) Details of Lumpsum/ 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.
 
 
Total
RS.
For any queries write to us on healthclaims@hdfcergo.com
   
Duly filled and signed Claim Form
Copy of intimation letter, if any
Hospital Main Bill
Hospital Break Up bill
Hospital Bill Payment Receipt
Hospital Discharge Summary
Pharmacy Bill
Operation Theater Notes
ECG
Doctor's Request for Investigation
Doctor's Prescription
Investigation Reports (Including CT,       MRI/USG/HPE)
Cancelled cheque for NEFT
Valid photo ID of patient
KYC documents(if claim amount is above Rs. 1 lakh)
Others
SECTION - F DETAILS OF BILLS ENCLOSED
Sr. No. Bill No. Date Issued By Towards Amount (Rs)
1.
2.
3.
4.
SECTION – G DETAILS OF PRIMARY INSURED'S BANK ACCOUNT
a) PAN:
 
b) Account Number:
c) Bank Name/ Branch:
d) Payable details: Cheque/ DD:
*e) IFSC Code:
 
f) MICR No.:
*Please attach a cancelled cheque pertaining to the same.
Note: It is agreed that the Policyholder/Claimant will intimate in writing to HDFC ERGO General Insurance Co. Ltd. about any change in bank account details. In an event Insured person bears expenses for treatment please provide account details of Insured Persons in the above format along with proof of incurring such expenses.
Please share bank account details of Proposer
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 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.
I/We hereby understand, declare, consent and authorise the Company that personal health details, medical history and financial information, as provided to the Company may be utilised for processing the claim made under the Policy. I/We hereby also understand, declare and consent that the Company shall have right to retain and disseminate the same to any service provider for providing services related to insurance.
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) SI. No/ Certificate No. Enter the social insurance number or the certificate
number of social health insurance scheme		 As allotted by the organization
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/ Health Insurance?		 Indicate whether currently covered by another
Mediclaim / Health Insurance		 Tick Yes or No
b) Date of Commencement of first Insurance without break Enter the date of commencement of first insurance Use dd-mm-yy format
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 the last 4 years? Indicate whether hospitalized in the last 4 years Tick Yes or No
Date Enter the date of hospitalization Use mm-yy format
Diagnosis Enter the diagnosis details Open Text
e) Previously Covered by any other Mediclaim / Health Insurance? Indicate whether previously covered by another Mediclaim / Health Insurance Tick Yes or No
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
f) Occupation Indicate occupation of patient Tick the right option. If others, please
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 of Delivery Enter the relevant date Use dd-mm-yy format
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 attached Tick Yes or No
j) System of Medicine Enter the system of medicine followed in treating the patient Open Text
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 hospitalization Tick Yes or No
c) Details of Lump sum/ cash benefit claimed Enter the amount claimed as lump sum/ cash benefit In rupees (Do not enter paise values)
d) Claim Documents Submitted-Check List Indicate which supporting documents are submitted Tick the right option
SECTION F - DETAILS OF BILLS ENCLOSED
Indicate which bills are enclosed with the amounts 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 should be made out to Name of the individual/ organization in full
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.
 

HDFC ERGO General Insurance Company Limited

CLAIM FORM FOR HEALTH INSURANCE POLICIES OTHER THAN
TRAVELAND PERSONAL ACCIDENT

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 preauthorisation request form in lieu of PART A		 (To be filled in block letters)
 
SECTION A – DETAILS OF HOSPITAL
a) Name of the Hospital where treated:
b) Hospital ID:
 
c) Type of Hospital: Network   Non Network (If non network fill section E)
d) Name of the treating Doctor:
e) Qualification:
 
f) Registration No with state Code:
g) Phone No:
   
SECTION B – DETAILS OF PATIENT ADMITTED
a) Name of the patient:
b) IP Registration Number:
 
c) Gender: Male   Female
 
d) Age:
e) Date of Birth:
       
f) Date of admission:
     
g) Time:
h) Date of discharge:
     
i) Time:
j) Type of Admission: Emergency   Planned   Daycare   Maternity
k) If Maternity: i) Date of Delivery   ii) Gravida Status
l) Status at time of discharge: Discharged to Home   Discharged to another Hospital   Deceased
Total Claimed Amount
   
SECTION C – DETAILS OF AILMENTS DIAGNISED (PRIMARY)
a) ICD 10 Codes
Primary Diagnosis
Additional Diagnosis
Co-morbidities
Co-morbidities
 
 
Description
 
 
b) ICD 10 PCS
Procedure 1
Procedure 2
Procedure 3
 
 
Description
  Details of Procedure:
c) Pre-authorization obtained: Yes No
 
d) Pre-authorization Number:
e) If authorization by network hospital not obtained, give reason:
f) Hospitalization due to Injury: 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    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 reasons :
SECTION D – CLAIM DOCUMENTS SUBMITTED – CHECKLIST
Claim form duly filled and signed
Original Pre authorization Request
Copy of Pre-authorization approval Letter
Copy of photo ID card of patient verified by Hospital
Hospital Discharge Summary
Operation Theatre Notes
Hospital Main Bill
Hospital break up Bill
   
Investigation reports
CT/MRI/USG/HPE investigation Report
Doctor's reference slip for Investigation
ECG
Pharmacy Bills
MLC Report & Police FIR
Original death summary from hospital where applicable
Any other, Pl specify
SECTION E – DETAILS IN CASE OF NON NETWORK HOSPITAL
a) Address of the Hospital:
City:
 
State:
Pincode:
 
b) Phone No.:
c) Registration no with State Code:
 
d) Hospital PAN:
e) No of In-patient Beds:
 
f) Facilities available in Hospital: i) OT: Yes  No   ii) ICU: Yes No
iii)Others:
SECTION F – DECLARATION BY HOSPITAL
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:
 
Place:
 
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 Hospital Tick the right option
d) Name of treating doctor Enter the name of the treating doctor Name of doctor in full
e) Qualification Enter the qualifications of the treating doctor Abbreviations of educational qualifications
f) Registration No. with State Code Enter the registration number of the doctor along with the state code As allocated by the Medical Council of India
g) Phone No. Enter the phone number of doctor Include STD code with telephone number
SECTION B - DETAILS OF THE PATIENTADMITTED
a) Name of Patient Enter the name of hospital Name of hospital in ful
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 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) Type of Admission Indicate type of admission of patient Tick the right option
j) 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
k) Status at time of discharge Indicate status of patient at time of discharge Tick the right option
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 text
   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) Present Ailment is a Complication of PED Indicate whether present ailment is a complication of some pre- existing disease Tick Yes or No
d) Pre-authorization obtained Indicate whether pre-authorization obtained Tick Yes or No
e) Pre-authorization Number Enter pre-authorization number As allotted by TPA
f) If authorization by network hospital not obtained,    give reason Enter reason for not obtaining pre-authorization number Open text
g) 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    consumption, test conducted to establish this Indicate whether test conducted Tick Yes or No
   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 – ADDITIONAL 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. Enter the registration number of patient As allocated by the Hospital
d) 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
SECTION F - DECLARATION BY THE INSURED
Read declaration carefully and mention date (in dd:mm:yy format), place (open text) and sign.
SECTION G - DECLARATION BY THE HOSPITAL
Read declaration carefully and mention date (in dd:mm:yy format), place (open text) and sign and stamp.
CHECK LIST OF ENCLOSURES FOR SUBMISSION OF CLAIM
Note:
1. When original bills, receipts, prescriptions, reports and other documents are submitted to the other insurer or to the reimbursement provider, verified photocopies attested by such other organisation/ provider have to be submitted.
2. If original bills, receipts, prescriptions, reports and other documents are submitted to Us and Insured Person requires same for claiming from other organisation / provider, then on request from the Insured Person We will provide attested copies of the bills and other documents submitted by the Insured Person.
3. Original cancelled cheque with payee name printed on the cheque is required. If name of payee is not printed on the cheque please attach copy of the first page of bank passbook
4. *Photocopy of Aadhar Card / Aadhar Card number is mandatory for all claims
In-patient Treatment /Day Care Procedures
  Duly filled and signed Claim Form.
  Photocopy of ID card / Photocopy of current year policy.
  Original Detailed Discharge Summary with date of admission & discharge, clinical history, past history / procedure details/ Day care summary
       from the hospital.
  Original consolidated hospital bill with break up of each Item, duly signed by the insured.
  Original payment Receipt of the hospital bill.
  First Consultation letter and subsequent Prescriptions.
  Original bills, original payment receipts and Reports for investigation.
  Original medicine bills and receipts with corresponding Prescriptions.
  Original invoice/Sticker of implants/bills for Implants (viz. Stent /PHS Mesh/ IOL etc.) with original payment receipts
Road Traffic Accident
In addition to the In-patient Treatment documents:
  Copy of the First Information Report from Police Department / Copy of the Medico-Legal Certificate.
In Non Medico legal cases
  Treating Doctor's Certificate giving details of injuries (How, when and where injury sustained)
In Accidental Death cases
  Copy of Post Mortem Report & Death Certificate (If conducted)
For Death Cases
In addition to the In-patient Treatment documents:
  Original Death Summary from the hospital.
  Copy of the Death certificate from treating doctor or the hospital authority.
  Copy of the Legal heir certificate, if the claim is for the death of the principle insured.
Pre and Post-Hospitalization expenses
  Duly filled and signed Claim Form.
  Photocopy of ID card / Photocopy of current year policy.
  Original Medicine bills, original payment receipt with prescriptions.
  Original Investigations bills, original payment receipt with prescriptions and report.
  Original Consultation bills, original payment receipt with prescription.
  Copy of the Discharge Summary of the main claim.
Organ Donation / Transplantation
In addition to the documents of general hospitalization
  Organ Function test / blood test proving organ failure.
  Treatment Certificate issued by the Transplant Surgeon of the hospital concerned.
Ambulance Benefit
  Duly filled and signed Claim Form.
  Photocopy of ID card / Photocopy of current year policy.
  Original Bill with Original Payment Receipt.
  Treating Doctor's consultation prescription indicating Emergency Hospitalization.
CUSTOMER IDENTIFICATION PROCEDURE (AS PER KYC NORMS OF IRDAI)
Please submit the following documents in case of claim amount exceeds Rs. 100,000
Legal name and any other names used (Any one of the mentioned documents) Passport / PAN Card/ Voter's Identity Card/ Driving License/ Letter from a recognized public authority or public servant verifying the identity and residence of the customer
Proof of Residence (Any one of the mentioned documents) Telephone bill/ Bank account statement/ Letter from any recognized public authority/ Electricity bill/ Ration card

HDFC ERGO General Insurance Company Limited. (Formerly HDFC General Insurance Limited from Sept 14, 2016 and L&TGeneral Insurance Company Limited upto Sept 13, 2016). CIN: U66030MH2007PLC177117. Registered & Corporate Office: st1Floor, HDFC House, 165 - 166 Backbay Reclamation, H. T. Parekh Marg, Churchgate, Mumbai – 400 020. Customer Service Address: D-301, 3rd Floor, Eastern Business District (Magnet Mall), LBS Marg, Bhandup (West), Mumbai - 400 078. For more details on the risk factors, terms and conditions, please read the sales brochure before concluding the sale. Trade Logo displayed above belongs to HDFC Bank Ltd and ERGO International AG and used by the Company under license. Customer Service No : 022 6234 6234 / 0120 6234 6234 | Fax: 91 22 66383699 | care@hdfcergo.com | www.hdfcergo.com.UIN:HDFHLIP10002V010910. IRDAI Reg No. 146.