Hospital Cash Claim Form

8/2/2019 Hospital Cash Claim Form

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HEALTH INSURANCE

CLAIM FORM

ROYAL SUNDARAM ALLIANCE INSURANCE COMPANY LIMITEDSundaram Towers, 45-46, Whites Road, Chennai-600 014. Ph : +91-44-28517387 - 90 Fax: 2851 5500+91-44-

E-mail : custom er.services@royalsund aram.in

Issuin g office :_____________________

Date of Issue :_____________________

FOR O FFICE USE ONLY

THE ISSUE OF THIS FORM IS NOT TO BE TAKEN AS AN ADMISSION OF LIABILITYPlease ensure that all qu estions are an swered in capital letters.

1. INSURANCE DETAILS

Name o f the Proposer/Policy Holder

Work address / Business address

Date of Birth o f patient

Occupation and Designation of the Patient

Work address / Business address

Please confirm if we need tochange the po licy address to the above

2.DETAILS OF THE INJURY / ILLNESS

Membership Num ber(As appearing in the h ealth card. This is applicable forpolicies serviced by TPA only)

Name of the Patient

Details of Propo ser

Occupation and Designation

Details of the Patient

Commun ication Details

Address for Correspond ence with Pincode

Mobile Number (Mandatory)

Contact Details

Telephon e Numb er - landline

Date of Injury / illness

Nature of Injury / illness

Yes No

Policy Certificate Number

1

D D M M Y Y Y Y


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5.OTHER INSURANCE DETAILS ( With any other Insurance Company)

Is the claiman t covered und er anyother health in surance scheme

If Yes , please give full details belo w

6. CLAIMS HISTORY

Yes No

4.

po licy details und er which the claim is bein g lodged with us. (No claim for any other p olicy shall be

entertained , if it is not d eclared below)

All other Po licy details includin g policies un der which claim is bein g lodged. It is Mand atory to in form all

3. HO SPITAL DETAILS

Details of the Hospital/Nursing Home

Name of the Hospital/Nursing Home

Date o f Adm ission

In th e event of inju ry, please give full details as to th e

circum stances of the acciden t (If the space provided is

inadequ ate attach a separate sheet)

Address & Telephon e nu mb er

Date o f discharge

Time of discharge

Dai ly Benefit Any other BenefitPolicy No Certificate NoAmo un t Claimed

Pre Hospitalization Post Hospitalization

Company Name Policy Numb er Period of InsuranceCumu lative Bon us

Company Name Policy Num ber Period of Insurance Claim Num ber Nature of illness/injury

2

Sum Insured Total Sum Insured

D D M M Y Y Y Y

D D M M Y Y Y Y

Time of Admission

Hospitalization

Amount Settled

am / pm

am / pm


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7. DECLARATION

I hereby warrant the truth of the above particulars in every respect. I agree that if I have made, or will makesuppression or concealment, my right to claim un der the p olicy shall be forfeited.

any false statemen t,

I consent and autho rise Royal Sund aram to seek med ical information along with indo or case paper from any Hospital / Medical

practitioner who h as at any time attended on th e insured person .

TO BE FILLED IN BY ATTENDING PHYSICIAN

10 a)

b) Is the patient suffering from any of the following

diseases

Please give previous medical history of the patient

1. Name and address of the patient

2. Age of the patien t

3. Name and address of the Surgeon / Physician

4. When did the patient start sufferingwith the complaint ?

5. Date of first consultation(prior to hospitalisation)

7. a. Date of adm ission

b. Time o f adm ission

6. Why was the patient adm itted ?(specify comp laint)

9. Diagnosis

I. Bon chial asthma

II. Chron ic Obstructive Pulmo nary disease

III. Hypertension

IV. Diabetes

V. H eart ailmen t

VI. Osteoarthritis

VII. Cerebro vascular attack

VIII. Seizure disord er

IX. Renal / Kidney Disorder

X. Any other

Say Yes / NoIf "yes" Please mention the du ration b elow

Du ratio n in Year Du ratio n in m on th

Place : ____________________________

Date : D D M M Y Y Y Y

Signature or thumb

impression of the Insured (Policy Holder)

D D M M Y Y Y Y

D D M M Y Y Y Y

am / pm

D D M M Y Y Y Y

am / pm

8. a. Date of

b. Time of discharge

discharge


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11. Is the ailment a complication of a

pre-existing disease or condition ?

If Yes , p lease give details

12. Is the present ailmen t directly attributable

to the in fluence of alcoh ol or dru gs ?

If Yes , p lease give details.

13. Is the present ailment congenital in natu re ?

If Yes , p lease give details.

14. Nature of surgery or treatment given for

present ailment

15. For matern ity claims,

LMP

EDD

Gravida

Num ber of living children

(Including the n ew born Baby)

16. Is the Hospital / Nursing Home registered ?

If Yes , p lease give registration nu mber.

17. How many inpatient beds does the Hospital

have (including ICU) ?

18. Does the hospital have a fully equipped

operation theatre and qualified nurses and

doctors roun d th e clock ?

19. Any other remarks you wish to m ake.

4

Doctors Name

Qualification

DoctorsRegistration No.

Seal

Signature of Doctor

Date

I hereby declare that the contents of inform ation furnished an d declared by me o n th e patient's treatment is true and correct to best ofmy knowledge and belief. I shall be h eld personally liable in case any of above information is foun d in correct.

D D M M Y Y Y Y


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Authorization Letter (Mandatory)

From:

Date:

Signature of the Patient

Name of the Patient & IP No : .......................................

To:

The Manager,

Medical Records,

Dear Sir

Reg : Auth orizat ion Letter.

Thanking you,

Yours sin cerely,

Signature of the Proposer

I consent and authorize M/s Royal Sundaram Alliance Insurance Company and their Authorized Service Providers to

seek medical information from your hospital and share copies of indoor case sheets and such ther relevant medical

records and / or meet the Medical Practitioner who has at any time attended on the patient for the

ho spitalization dated .............................. to .......................................

Documents

Hospital Cash Claim Form