CLAIM ACKNOWLEDGMENT SHEET CLAIM case of No / Delay Intimation Delay in submission of claim, ... from a doctor not less qualified than MD/MS confirming ... by the Medical Council of India

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    10-Apr-2018

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Name of Insurer : Policy No :Insured Name : Patient Name :PHS ID : Employee No :Mobile No : Phone (STD) :E-Mail ID : Type of Claim :Main Hospitalisation / Pre-Post Hospitalisation / OPD Claim / Deficiency Retrieval / Critical Illness / Cash BenefitSr. No DescriptionDocument Status Remarks1 IRDA Claim Form duly signed by the Insured2 Policy Copy3 64VB Compliance Certificate4Original Cancelled Cheque copy of Employee/Proposer with the name of the Account Holder Printed on the Cheque Leaf.5 Photo Identity & Address Proof of Insured (In case claim amount is 1 lac & above)6Original detailed Discharge Summary / Day care summary from the hospital in case of Day Care Treatment / Death Summary in Case of Death Claima) Copy of the Legal heir certificate, if the claim is for the death of the principle insured.b) Copy of Post Mortem Report & Death Certificate (In Accidental Death cases)PARAMOUNT HEALTH SERVICES & INSURANCE TPA PRIVATE LIMITED (IRDA License No. 006)[formerly known as PARAMOUNT HEALTH SERVICES (TPA) PVT.LTD]Plot no.A-442, Road No-28,M.I.D.C Industrial Area, Wagale Estate, Ram Nagar, Vitthal Rukmani Mandir, Thane (W), Mumbai, Pin Code 400 604CLAIM ACKNOWLEDGMENT SHEETCLAIM DOCUMENT CHECK LISTName of Corporate:b) Copy of Post Mortem Report & Death Certificate (In Accidental Death cases)7 Original Final Hospital bill with breakup of each Item8 Original Payment Receipt of Main Hospital bill ( both Deposit / Refund)a) Receipt Of Payments made at the Hospital by Credit Card : Please attach the Xerox Copy of the Credit Card Payment Slip as received from the Vendor9Original copy of Implant Invoice along with Payment Receipts & Implant Labels / Stickers for Stents/Mesh/IOL10 Original bills, original Payment Receipts and investigation / Laboratory Reports11Original medicine bills specifying Patient Name and date of purchase along with supporting Prescriptions.12 Original copy of First Consultation letter and subsequent Prescriptions.13In case of No / Delay Intimation & Delay in submission of claim, a letter from insured is required stating reason for the same14 OTHER DOCUMENTSaOriginal copy of Obstetric history (Gravida, Para, Living children, Abortions) from treating doctor. (Maternity Claim)b Original Sonography Report in case of Maternity ClaimcOriginal A-Scan Report along with IOL Sticker and Tax paid invoice in case of Cataract ClaimdCopy of the First Information Report (FIR) from Police Department / Copy of the Medico-Legal Certificate (MLC) in case of Road Traffic Accident (RTA)eA medical certificate from a doctor not less qualified than MD/MS confirming the diagnosis of critical illness along with the Investigation reports/Other related documents reflecting the critical illness diagnosis. (Critical Illness Cases)fIn case of claims where the insured has submitted documents to another insurance co. /TPA, he needs to submit attested Photocopies of all the documents along with detailed claim settlement letter from the TPA and any unpaid bills and receipt for the same in originals.Claims Submitted by : Insured / Corporate / Agent / Broker / Insurer / HopsitalClaim Submitted by: Mobile No.Claim Submitted by: Mobile No.Date of Claim Submission: DD/MM/YYYY HH:MMPHS Executive Name:Claim Submitted at: PHS - (Location) / Help Desk Signature:Important Points to Remember:-6. Member is advised to keep photocopies of all the papers since Insurer requires all the above documents in original. Documents once submitted will not returned unless approved & agreed by Insurer7. Corrections in any documents are not allowed5. Please visit us at www.paramounttpa.com to check Online Claim Status or download Paramount Mobile App 3. Claim Need to be Submitted within 7 Working Days from Date of Discharge from Hospital4. The above list of documents is indicative. In case of any other document requirement as specified by the Insurance Company, our document recovery team will contact you on receipt of your claim documents by us2. Date of File Received will be considered as next working day for Claim Files picked up at Help Desk 1. Please mark either or against respective check boxIndicate which bills are enclosed with the amounts in rupeesc) Details of Lump sum/ cash benefit claimedSECTION F - DETAILS OF BILLS ENCLOSEDEnter the amount claimed as lump sum/ cash benefitIn rupees (Do not enter paise values)Tick the right optionClaim Documents Submitted-Check List Indicate which supporting documents are submitteda) PANb) Account NumberAs allotted by the Income Tax departmentSECTION G - DETAILS OF PRIMARY INSURED'S BANK ACCOUNTEnter the permanent account numberEnter the bank account numberEnter the bank name along with the branchAs allotted by the bankName of the Bank in fullIFSC code of the bank branch in fullc) Bank Name and Branchd) IFSC Code Enter the IFSC code of the bank branchSECTION H - DECLARATION BY THE INSUREDGUIDANCE FOR FILLING CLAIM FORM PART A (To be filled in by the insured)SECTION A - DETAILS OF PRIMARY INSUREDDATA ELEMENT DESCRIPTION FORMATIn rupeesEnter the policy numberEnter the social insurance number or the certificate number of social health insurance schemeEnter the TPA ID NoEnter the full name of the policyholderEnter the full postal addressLicense number as allotted by IRDA and printed in TPA documents.As allotted by the insurance companyAs allotted by the organizationSurname, First name, Middle nameInclude Street, City and Pin CodeTick Yes or NoIndicate whether hospitalized in the last four yearsUse mm-yy formatOpen TextSECTION C - DETAILS OF INSURED PERSON HOSPITALIZEDa) Namea) Name of Hospital where admitteda) Details of Treatment ExpensesSurname, First name, Middle nameName of hospital in fullIn rupees (Do not enter paise values)b) Genderb) Room category occupiedb) Claim for Domiciliary Hospitalizationc) Agec) Hospitalization due tod) Date of Birthd) Date of Injury/Date Disease first detected/ Date of Deliverye) Relationship to primary Insurede) Date of admissionf) OccupationTimeg) Addressf) Date of dischargePhone NoTimeE-mail IDh) If Injury give causeii) System of MedicineInclude Street, City and Pin CodeUse dd-mm-yy formatUse dd-mm-yy formatUse Standard formatInclude STD code with telephone numberUse hh:mm formatComplete e-mail addressTick the right optionTick Yes or NoTick Yes or NoTick the right option. If others, please specify.Use hh:mm formatTick the right option. If others, please specify.Use dd-mm-yy formatUse dd-mm-yy formatUse dd-mm-yy formatTick Male or FemaleTick the right optionTick the right optionNumber of years and monthsTick the right optionIf Medico legalReported to PoliceMLC Report & Police FIR attachedSECTION B - DETAILS OF INSURANCE HISTORYEnter the total sum insured as per the policyIndicate whether currently covered by another Mediclaim / Health InsuranceUse dd-mm-yy formatEnter the date of commencement of first insuranceName of the organization in fullEnter the full name of the insurance companya) Policy No.b) SI. No/ Certificate No.c) TPA ID No.d) Namee) Addressa) Currently covered by any other Mediclaim / Health Insurance?d) Sum Insurede) Have you been Hospitalized in the last four years since inception of the contract?f) Dateg) Diagnosisc) Date of Commencement of first Insurance without breakb) i. Company Nameii. Policy No. As allotted by the insurance companyEnter the policy numberIndicate whether hospitalized in the last four yearsEnter the date of hospitalizationEnter the diagnosis detailsSECTION D - DETAILS OF HOSPITALIZATIONSECTION E - DETAILS OF CLAIMEnter the full name of the patientEnter the name of hospitalEnter the amount claimed as treatment expensesIndicate relationship of patient with policyholderEnter date of admissionIndicate occupation of patientEnter time of admissionEnter the full postal addressEnter date of discharge Enter the phone number of patientEnter time of dischargeEnter e-mail address of patientIndicate cause of injuryIndicate whether injury is medico legalIndicate whether police report was filedIndicate Gender of the patientIndicate the room category occupiedIndicate whether claim is for domiciliary hospitalizationEnter age of the patientIndicate reason of hospitalizationEnter Date of Birth of patientEnter the relevant dateIndicate whether MLC report and Police FIR attachedEnter the system of medicine followed in treating the patientTick Yes or NoOpen TextRead declaration carefully and mention date (in dd:mm:yy format), place (open text) and sign.g) In case of maternity ii. Date of Deliveryii. Gravida Status Enter date of deliveryEnter gravida status GUIDANCE FOR FILLING CLAIM FORM PART B (To be filled in by the hospital)DATA ELEMENT DESCRIPTION FORMATSECTION A - DETAILS OF HOSPITALSECTION B DETAILS OF THE PATIENT ADMITTEDSECTION C DETAILS OF AILMENT DIAGNOSEDa) Name of Hospitala) Name of Patienta) ICD 10 Codeb) Hospital IDb) IP Registration Number1. Primary Diagnosis2. Additional Diagnosisc) Type of Hospitalc) GenderICD 10 PCSd) Age1. Procedure 12. Procedure 23. Procedure 3e) Date of Birth4. Details of Procedured) Name of treating doctore) Qualificationf) Registration No. with State Codeg) Phone No.f) Type of Admissionb) Hospitalization due to injuryg) Date & Time of Admission1. Causeh) Date & Time of AdmissionI) If Maternity1. Date of Delivery2.Gravida Statusj) Status at time of discharge3 & 4. Co-morbidities2. If injury due to substance abuse/alcohol consumption, test conducted to establish thisName of hospital in fullName of hospital in fullAs allocated by the TPAAs allotted by the insurance providerStandard Format and Open textStandard Format and Open textStandard Format and Open textTick the right optionTick Male or FemaleNumber of years and monthsStandard Format and Open textStandard Format and Open textStandard Format and Open textUse dd-mm-yy formatOpen textName of doctor in fullAbbreviations of educational qualificationsAs allocated by the Medical Council of IndiaInclude STD code with telephone numberTick Yes or NoUse dd-mm-yy format & hh:mm formatTick the right optionTick the right optionUse dd-mm-yy format & hh:mm formatUse dd-mm-yy formatUse standard formatTick the right optionTick Yes or NoSECTION D - DETAILS IN CASE OF NON NETWORK HOSPITALRead declaration carefully and mention date (in dd:mm:yy format), place (open text) and sign and stamp3. Medico Legal4. Reported to Police5. FIR No.6. If not reported to police, give reasona) Addressb) Phone No.d) Hospital PANe) Number of Inpatient bedsf) Facilities available in the hospitalc) Registration No. with State Codec) Complaints/ Symptomsd) Previous medical historye) Specific diseasesf) Complication of pre-existing diseasesg) Alcoholismh) Smoking of tobaccoIndicate whether present ailment is a complication that existed prior to policy inceptionEnter the name of hospitalEnter the name of hospitalEnter ID number of hospitalEnter insurance provider registration numberEnter the ICD 10 Code and description of the primary diagnosisEnter the ICD 10 Code and description of the additional diagnosisIndicate whether In network or non network hospitalIndicate Gender of the patientEnter age of the patientEnter the ICD 10 PCS and description of the first procedureEnter the ICD 10 PCS and description of the second procedureEnter the ICD 10 PCS and description of the third procedureEnter date of birthEnter the details of the procedureEnter the name of the treating doctorEnter the qualifications of the treating doctorEnter the registration number of the doctor along with the state codeEnter the phone number of doctorIndicate if hospitalization is due to injuryEnter date & time of admissionIndicate cause of injuryIndicate type of admission of patientEnter date & time of dischargeEnter Date of Delivery if maternityEnter Gravida status if maternityIndicate status of patient at time of dischargeEnter the ICD 10 Code and description of the co-morbiditiesIndicate whether test conductedSECTION E - DECLARATION BY THE HOSPITALIndicate whether injury is medico legalIndicate whether police report was filedEnter first information report numberEnter reason for not reporting to policeEnter the full postal addressEnter the phone number of hospitalEnter the permanent account numberEnter the number of inpatient bedsIndicate facilities available in the hospitalEnter the registration number of the doctor along with the state codeIndicate the date when the symptom/complaintfirst startedEnter the medical historyState Yes or NoIndicate Yes or No. If yes state quantity consumedIndicate Yes or No. If yes state units consumedTick Yes or NoTick Yes or NoAs issued by police authoritiesOpen TextInclude Street, City and Pin CodeInclude STD code with telephone numberAs allocated by the Medical Council of IndiaAs allotted by the Income Tax departmentDigitsTick the right option. If others, please specifyuse dd-mm-yy formatOpen textDuration should be in years and monthsOpen textOpen textOpen textPage 1Page 2

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