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 Benefit

Sr. No Description

Document

Status Remarks

1 IRDA Claim Form duly signed by the Insured

2 Policy Copy

3 64VB Compliance Certificate

4

Original 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)

6

Original detailed Discharge Summary / Day care summary from the hospital in case of

Day Care Treatment / Death Summary in Case of Death Claim

a) 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 – 400 604

CLAIM ACKNOWLEDGMENT SHEET

CLAIM DOCUMENT CHECK LIST

Name of Corporate:

b) Copy of Post Mortem Report & Death Certificate (In Accidental Death cases)

7 Original Final Hospital bill with breakup of each Item

8 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 Vendor

9

Original copy of Implant Invoice along with Payment Receipts & Implant Labels /

Stickers for Stents/Mesh/IOL

10 Original bills, original Payment Receipts and investigation / Laboratory Reports

11

Original medicine bills specifying Patient Name and date of purchase along with

supporting Prescriptions.

12 Original copy of First Consultation letter and subsequent Prescriptions.

13

In case of No / Delay Intimation & Delay in submission of claim, a letter from insured is

required stating reason for the same

14 OTHER DOCUMENTS

a

Original copy of Obstetric history (Gravida, Para, Living children, Abortions) from

treating doctor. (Maternity Claim)

b Original Sonography Report in case of Maternity Claim

c

Original A-Scan Report along with IOL Sticker and Tax paid invoice in case of Cataract

Claim

d

Copy of the First Information Report (FIR) from Police Department / Copy of the

Medico-Legal Certificate (MLC) in case of Road Traffic Accident (RTA)

e

A 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)

f

In 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 / Hopsital

Claim Submitted by: Mobile No.Claim Submitted by: Mobile No.

Date of Claim

Submission: DD/MM/YYYY HH:MM

PHS 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 Insurer

7. Corrections in any documents are not allowed

5. 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 Hospital

4. 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 us

2. 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 box

Group MediPrime Claim Form PART A

TO BE FILLED IN BY THE INSURED The issue of this Form is not to be taken as an admission of liability

Policy No. Sl. No. /Certificate No.

Name of the TPA: Insured / Claimant Details (In block letters) 1. Name & Address of the Policyholder Name

Address City State Pin Code

Contact Information Mobile Phone

Email

2. Details of the Hospitalised Person

Name

Relationship Date of Birth D D M M Y Y Y Y

Address

City State Pin Code

Gender Male Female Occupation

Contact Information Mobile Phone

Email 3. Hospitalisation due to Illness Injury Others

Details

Date of Injury sustained

If injury, how did it occur ?

D D M M Y Y Y Y

Disease first detected / Last Menstrual Period

D D M M Y Y Y Y

If injury, whether is it a Medico Legal Case (MLC) YES NO

If MLC, whether reported to police? YES NO

System of medicine : Allopathic Other systems of medicine

4. Insurance History Name of the Company & Policy Name :

Date of commencement of first Insurance for the person (without break) D D M M Y Y Y Y

Are you presently covered with any other Mediclaim / Health Insurance Policy? YES NO If Yes, give details - Company / Policy No. / Sum Insured (copies of policies to be attached)

5. Name of the Hospital where admitted

Room Category occupied Day care

6. Past Hospitalisation History

a) Have you been hospitalised in the last 4 years? b) If Yes, Diagnosis

c) Month and Year of Diagnosis M M Y Y Y Y

7. Is this claim for Domiciliary Hospitalisation? (If yes, please provide details of annexures attached) :

Single occupancy Twin sharing 3 or more

YES NO

YES NO

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8. Policyholder's Bank Account particulars

a) Policyholders PAN No. e) IFSC Code

b) Account No. f) MICR No.

c) Payable details: Cheque DD NEFT (* Please attach a cancelled cheque pertaining to the same)

d) Bank Name / Branch* Note: It is agreed that the Policyholder / Claimant will intimate in writing to TATA AIG General Insurance Co. Ltd. about any change in bank account details. 9. Details of the treatment expenses claimed

a) Pre-hospitalisation Expenses Rs. b) Hospitalisation Expenses Rs. c) Post-hospitalisation Expenses Rs. d) Health-Check up Cost Rs. e) Ambulance Charges Rs. f) Organ donor Rs. g) Domiciliary hospitalisation Rs. h) Others Rs.

10. Details of bills enclosed Sl. No Bill No Date Issued by Towards Amount (Rs.)

11. For details of Claim Documents to be submitted to the TPA, please refer to the CHECK LIST Declaration by the Insured I hereby declare that the information furnished in this Claim Form is true and correct to the best of my knowledge and belief. If I have made any false or untrue statement or suppressed or concealed any material fact with respect to the queries raised in the proposal form and claim form, my right to claim reimbursement shall be forfeited. I also consent and authorize TPA / Insurance Company, to seek necessary medical information / documents from any hospital / Medical Practitioner / Insurer 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/Hospitalization / event and that I will not be making any further claims under this inpatient hospitalization for the illness / injury except the Pre / Post - hospitalization claim, if any. I hereby also agree that in the event of the death of Policyholder or an Insured Person, the claim payment will be made to the Nominee (as named in the Schedule) or the legal heir in case not mentioned on the Schedule. Place :

Signature of the Insured / Policyholder / Claimant Date D D M M Y Y Y Y

Communication details of TPA (kindly submit the dully filled & signed claim form along with original documents at following address) Family Health Plan (TPA) Ltd - Claims Department Tata AIG General Insurance Company (TAGIC) Ground Floor, Srinilaya - Cyber Spazio, Road No: 2, Banjara Hills, Hyderabad 500 034 • FHPL Toll Free No: 1800 425 4090

CHECK LIST OF ENCLOSURES FOR SUBMISSION OF CLAIM

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 / 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 or. Original bills, payment receipts and reports investigations. Original medicine bills and receipts with corresponding prescriptions. Original invoice / 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 (if conducted). Copy of Death Certificate.

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-hospitalisation expenses Duly filled and signed Claim Form. Photocopy of ID card.

Original medicine bills, payment receipt with prescriptions. Original investigations bills, payment receipt with prescriptions and investigation report. Original consultation bills & payment receipt.

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

Original bill with payment receipt. Treating Doctor's consultation prescription indicating emergency hospitalization.

Annual Health Check up Duly filled and signed Claim Form. Photocopy of ID card. Original investigation bills & payment receipts with investigation report.

Original consultation bills and payment receipts with prescription. Daily Cash Benefit

Duly filled and signed Claim Form. Photocopy of ID card.

Outpatient Benefit / Accidental & Post Bite Vaccination Duly filled and signed Claim Form.

Photocopy of ID card. Original Medicine bills & payment receipt. Original Investigations bills & payment receipt with investigation report. Original consultation bills & payment receipt with prescription. Details of any outpatient procedures. Dental X-ray film.

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PART B

For Office Use Only (Refer IRDA / TAC Master for codes wherever applicable) 1) TPA Code 2) Insurer Code

3) Product Code 4) Policy Number

5) Policy Start Date D D M M Y Y Y Y 6) Policy End Date D D M M Y Y Y Y

7) Sum Insured 8) Bonus Sum Insured

9) Master Claim ID Accrued, if any

10) Diagnosis Code Primary Diagnosis

Additional Diagnosis Co-morbidities

11) Procedure Code Procedure 1

Procedure 2 Procedure 3

12) Details of Claim Paid Indemnity Benefit a. Room & b. ICU Charges

Nursing Charges c. OT Charges d. Medicine & Consummable

Charges e. Professional f. Investigation Charges

Fees' Charges g. Ambulance h. Miscellaneous Charges

Charges 13) Total Claim Paid 14) Total Rejected Amount

15) Reason for Rejection 16) Reason for Reduction of Claim of Claim

17) Whether claim paid 18) If Yes, PED Code was for PED

19) Whether claim paid under alternate medicine Yes No

20) Amount of co-payment / deductible applicable

21) Corporate Buffer Utilized, if any

22) Date of Payment D D M M Y Y

24) Date of Claim D D M M Y Y

Y Y 23) Payment Reference Number

Y Y 25) Date of receipt of complete

D D M M Y Y Y Y Intimation claim documents

PART C (TO BE FILLED IN BY THE HOSPITAL)

The insurance of this Form is not to be taken as an admission of liability Please include the original pre-authorisation request form in lieu of PART A 1. Name of the Hospital where treated

2. Hospital ID : 3. Type of Hospital : Network Non Network

4. In case of Non Network, please provide below details

Address of the Hospital

City State Pin Code Telephone No. (with STD) Registration No.

No.of Inpatient beds Hospital PAN No.

Other facilities available in the hospital :

i) OT YES NO

ii) ICU YES NO iii) Others :

5. Details of the patient admitted Name of the patient

IP Registration No.

Gender : Male Female

Date of Birth D D M M Y Y Y Y

Date of Admission D D M M Y Y Y Y Time AM / PM Date of Discharge D D M M Y Y Y Y Time AM / PM

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6. Ailment Diagnosed (Primary)

ICD 10 Code Primary Diagnosis

Additional Diagnosis Co-morbidities

Details of Procedure/s done :

ICD 10 PCS : Procedure 1 : Procedure 2 : Procedure 3 : 7. Type of Admission

Emergency Planned Day-care Others :

Date of delivery, if maternity D D M M Y Y Y Y Gravida Status : 8. Is the treatment for an injury? If, yes, give details

a) Was it self inflicted? YES NO

b) Whether Road Traffic Accident YES NO

c) If Medico Legal Certificate (MLC), whether notified to police - YES NO

d) MLC / FIR No.:

e) If MLC not notified, give reasons :

9. Was the Injury/ disease caused due to Substance abuse / Alcohol consumption YES NO If Yes whether any test was conducted to establish this? If Yes please attach Report YES NO

10. Whether the present ailment is a complication of any illness suffered in the past YES NO

If Yes, specify details 11. Whether Pre-authorisation obtained YES NO

a) If Yes, Pre Auth No.:

b) If authorisation by network hospital not obtained, give reason : 12. Details of the Treating Doctor

a) Name of the Treating Doctor

b) Registration No. with state code

c) Mobile No.

d) Qualification : 13. For details of Claim Documents to be submitted to the TPA, please refer to the Capital Declaration by the hospital We hereby declare that the information furnished in this Claim Form is true and correct to the best of our knowledge and belief. If we have made any false or untrue statement, suppressed or concealed any material fact, our right to claim under this claim shall be forfeited.

Seal & Signature Of The Hospital Authority

Date D D M M Y Y Y Y Customer Identification Procedure (as per KYC norms of IRDA) 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 Passport/ PAN Card/ Voter's Identity Card/ Driving License/ mentioned documents) identity and residence of the customer Letter from a recognized public authority or public servant verifying the Proof of Residence Telephone bill/ Bank account statement/ Letter from any recognized (Any one of the mentioned documents) public authority/ Electricity bill/ Ration card

Insurance is the subject matter of the solicitation. For more details on risk factors, terms and conditions, please read sales brochure carefully, before concluding a sale.

Tata AIG General Insurance Company Limited Registered Office : Peninsula Corporate Park, Piramal Tower, 9th Floor, G.K. Marg, Lower Parel, Mumbai - 400013. Toll Free No. 1800 266 7780 Visit us at www.tataaiginsurance.in

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