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
Indicate which bills are enclosed with the amounts in rupees
c) Details of Lump sum/ cash benefit claimed
SECTION F - DETAILS OF BILLS ENCLOSED
Enter the amount claimed as lump sum/ cash benefit
In rupees (Do not enter paise values)
Tick the right optionClaim Documents Submitted-Check List Indicate which supporting documents are submitted
a) PAN
b) Account Number
As allotted by the Income Tax department
SECTION G - DETAILS OF PRIMARY INSURED'S BANK ACCOUNT
Enter the permanent account number
Enter the bank account number
Enter the bank name along with the branch
As allotted by the bank
Name of the Bank in full
IFSC code of the bank branch in full
c) Bank Name and Branch
d) IFSC Code Enter the IFSC code of the bank branch
SECTION H - DECLARATION BY THE INSURED
GUIDANCE FOR FILLING CLAIM FORM – PART A (To be filled in by the insured)
SECTION A - DETAILS OF PRIMARY INSURED
DATA ELEMENT DESCRIPTION FORMAT
In rupees
Enter the policy number
Enter the social insurance number or the certificate number of social health insurance scheme
Enter the TPA ID No
Enter the full name of the policyholder
Enter the full postal address
License number as allotted by IRDA and printed in TPA documents.
As allotted by the insurance company
As allotted by the organization
Surname, First name, Middle name
Include Street, City and Pin Code
Tick Yes or No
Indicate whether hospitalized in the last four years
Use mm-yy format
Open Text
SECTION C - DETAILS OF INSURED PERSON HOSPITALIZED
a) Name
a) Name of Hospital where admitted
a) Details of Treatment Expenses
Surname, First name, Middle name
Name of hospital in full
In rupees (Do not enter paise values)
b) Gender
b) Room category occupied
b) Claim for Domiciliary Hospitalization
c) Age
c) Hospitalization due to
d) Date of Birth
d) Date of Injury/Date Disease first detected/ Date of Delivery
e) Relationship to primary Insured
e) Date of admission
f) Occupation
Time
g) Address
f) Date of discharge
Phone No
Time
E-mail ID
h) If Injury give cause
ii) System of Medicine
Include Street, City and Pin Code
Use dd-mm-yy format
Use dd-mm-yy format
Use Standard format
Include STD code with telephone number
Use hh:mm format
Complete e-mail address
Tick the right option
Tick Yes or No
Tick Yes or No
Tick the right option. If others, please specify.
Use hh:mm format
Tick the right option. If others, please specify.
Use dd-mm-yy format
Use dd-mm-yy format
Use dd-mm-yy format
Tick Male or Female
Tick the right option
Tick the right option
Number of years and months
Tick the right option
If Medico legal
Reported to Police
MLC Report & Police FIR attached
SECTION B - DETAILS OF INSURANCE HISTORY
Enter the total sum insured as per the policy
Indicate whether currently covered by another Mediclaim / Health Insurance
Use dd-mm-yy formatEnter the date of commencement of first insurance
Name of the organization in fullEnter the full name of the insurance company
a) Policy No.
b) SI. No/ Certificate No.
c) TPA ID No.
d) Name
e) Address
a) Currently covered by any other Mediclaim / Health Insurance?
d) Sum Insured
e) Have you been Hospitalized in the last four years since inception of the contract?
f) Date
g) Diagnosis
c) Date of Commencement of first Insurance without break
b) i. Company Name
ii. Policy No. As allotted by the insurance companyEnter the policy number
Indicate whether hospitalized in the last four years
Enter the date of hospitalization
Enter the diagnosis details
SECTION D - DETAILS OF HOSPITALIZATION
SECTION E - DETAILS OF CLAIM
Enter the full name of the patient
Enter the name of hospital
Enter the amount claimed as treatment expenses
Indicate relationship of patient with policyholder
Enter date of admission
Indicate occupation of patient
Enter time of admission
Enter the full postal address
Enter date of discharge
Enter the phone number of patient
Enter time of discharge
Enter e-mail address of patient
Indicate cause of injury
Indicate whether injury is medico legal
Indicate whether police report was filed
Indicate Gender of the patient
Indicate the room category occupied
Indicate whether claim is for domiciliary hospitalization
Enter age of the patient
Indicate reason of hospitalization
Enter Date of Birth of patient
Enter the relevant date
Indicate whether MLC report and Police FIR attached
Enter the system of medicine followed in treating the patient
Tick Yes or No
Open Text
Read declaration carefully and mention date (in dd:mm:yy format), place (open text) and sign.
g) In case of maternity
ii. Date of Delivery
ii. Gravida Status
Enter date of delivery
Enter gravida status
GUIDANCE FOR FILLING CLAIM FORM – PART B (To be filled in by the hospital)
DATA ELEMENT DESCRIPTION FORMAT
SECTION A - DETAILS OF HOSPITAL
SECTION B – DETAILS OF THE PATIENT ADMITTED
SECTION C – DETAILS OF AILMENT DIAGNOSED
a) Name of Hospital
a) Name of Patient
a) ICD 10 Code
b) Hospital ID
b) IP Registration Number
1. Primary Diagnosis
2. Additional Diagnosis
c) Type of Hospital
c) Gender
ICD 10 PCS
d) Age
1. Procedure 1
2. Procedure 2
3. Procedure 3
e) Date of Birth
4. Details of Procedure
d) Name of treating doctor
e) Qualification
f) Registration No. with State Code
g) Phone No.
f) Type of Admission
b) Hospitalization due to injury
g) Date & Time of Admission
1. Cause
h) Date & Time of Admission
I) If Maternity
1. Date of Delivery
2.Gravida Status
j) Status at time of discharge
3 & 4. Co-morbidities
2. If injury due to substance abuse/alcohol consumption, test conducted to establish this
Name of hospital in full
Name of hospital in full
As allocated by the TPA
As allotted by the insurance provider
Standard Format and Open text
Standard Format and Open text
Standard Format and Open text
Tick the right option
Tick Male or Female
Number of years and months
Standard Format and Open text
Standard Format and Open text
Standard Format and Open text
Use dd-mm-yy format
Open text
Name of doctor in full
Abbreviations of educational qualifications
As allocated by the Medical Council of India
Include STD code with telephone number
Tick Yes or No
Use dd-mm-yy format & hh:mm format
Tick the right option
Tick the right option
Use dd-mm-yy format & hh:mm format
Use dd-mm-yy format
Use standard format
Tick the right option
Tick Yes or No
SECTION D - DETAILS IN CASE OF NON NETWORK HOSPITAL
Read declaration carefully and mention date (in dd:mm:yy format), place (open text) and sign and stamp
3. Medico Legal
4. Reported to Police
5. FIR No.
6. If not reported to police, give reason
a) Address
b) Phone No.
d) Hospital PAN
e) Number of Inpatient beds
f) Facilities available in the hospital
c) Registration No. with State Code
c) Complaints/ Symptoms
d) Previous medical history
e) Specific diseases
f) Complication of pre-existing diseases
g) Alcoholism
h) Smoking of tobacco
Indicate whether present ailment is a complication that existed prior to policy inception
Enter the name of hospital
Enter the name of hospital
Enter ID number of hospital
Enter insurance provider registration number
Enter the ICD 10 Code and description of the primary diagnosis
Enter the ICD 10 Code and description of the additional diagnosis
Indicate whether In network or non network hospital
Indicate Gender of the patient
Enter age of the patient
Enter the ICD 10 PCS and description of the first procedure
Enter the ICD 10 PCS and description of the second procedure
Enter the ICD 10 PCS and description of the third procedure
Enter date of birth
Enter the details of the procedure
Enter the name of the treating doctor
Enter the qualifications of the treating doctor
Enter the registration number of the doctor along with the state code
Enter the phone number of doctor
Indicate if hospitalization is due to injury
Enter date & time of admission
Indicate cause of injury
Indicate type of admission of patient
Enter date & time of discharge
Enter Date of Delivery if maternity
Enter Gravida status if maternity
Indicate status of patient at time of discharge
Enter the ICD 10 Code and description of the co-morbidities
Indicate whether test conducted
SECTION E - DECLARATION BY THE HOSPITAL
Indicate whether injury is medico legal
Indicate whether police report was filed
Enter first information report number
Enter reason for not reporting to police
Enter the full postal address
Enter the phone number of hospital
Enter the permanent account number
Enter the number of inpatient beds
Indicate facilities available in the hospital
Enter the registration number of the doctor along with the state code
Indicate the date when the symptom/complaintfirst started
Enter the medical history
State Yes or No
Indicate Yes or No. If yes state quantity consumed
Indicate Yes or No. If yes state units consumed
Tick Yes or No
Tick Yes or No
As issued by police authorities
Open Text
Include Street, City and Pin Code
Include STD code with telephone number
As allocated by the Medical Council of India
As allotted by the Income Tax department
Digits
Tick the right option. If others, please specify
use dd-mm-yy format
Open text
Duration should be in years and months
Open text
Open text
Open text