Documente Academic
Documente Profesional
Documente Cultură
Claim Form
PART A
TO BE FILLED IN BY THE INSURED
Non-submission of original bills and receipts is the main reason for delay in claim settlements. Please provide the originals
Provide your bank details for direct/ Electronic Fund Transfer (EFT) for faster claim settlement. Refer Part A - Section G
Do You Know
To receive updates on your claim status, please provide your mobile no. & E-mail ID
You can check your claim status at: www.maxbupa.com Claims Claims status Login to check status
Policy No. :
c)
Company/ TPA ID No :
d)
Name :
e)
Address :
City :
State :
Pin Code :
Phone No. :
Email ID :
a)
Yes
b)
c)
d)
D D M M Y
Sum Insured :
Have you been hospitalized in the last four years since inception of the contract?
e)
Diagnosis :
f)
(DD/MM/YYYY) :
/ No
Yes
(DD/MM/YYYY) :
D D M M Y
/ No
Name :
b)
Relationship : Self
c)
Date of Birth :
f)
Address :
D D M M Y
d)
Age (YY/MM) : Y
City :
M M
e)
State :
Pin Code :
g)
(Please Specify) :
Y
Phone No. :
Email ID :
(Please Specify) :
b)
c)
d)
e)
D D M M Y
f)
Time : (HH/MM) : H H M M
g)
D D M M Y
h)
Time : (HH/MM) : H H M M
i)
j)
/ No
(DD/MM/YYYY) : D D M M Y
ii)
/ No
iii)
/ No
i)
Pre-hospitalisation Expenses
Rs.
ii)
Hospitalisation Expenses
Rs.
iii)
Post-hospitalisation Expenses
Rs.
iv)
Health-Check up Cost
Rs.
1
Please dispatch your claim document to: Max Bupa Corporate Office: Bloc B1/I-2, Mohan Cooperative Industrial Estate, Mathura Road, New Delhi -110044.
Claim Form
v)
Ambulance Charges
Rs.
Total
Rs.
vi)
Days
Others (code)
Rs.
vii)
Pre-hospitalisation Period
b)
c)
i)
Rs.
ii)
Surgical Cash
Rs.
iii)
Rs.
iv)
Convalescence
Rs.
v)
vi)
Others
Rs.
/ No
Days
Pharmacy Bill
ECG
Doctors Prescription
Others
Bill No.
Date
Issued by
Towards
D D M M Y
D D M M Y
Pre-hospitalisation Bills:___Nos
D D M M Y
Post-hospitalisation Bills:___Nos
D D M M Y
Pharmacy Bills
D D M M Y
D D M M Y
D D M M Y
D D M M Y
D D M M Y
D D M M Y
D D M M Y
Amount (Rs.)
s.)
PAN No :
b)
c)
Bank Name :
d)
f)
MICR No :
Account No :
Branch :
/ DD
e)
IFSC Code :
Date :
Place :
D D M M Y
Signature of Insured :
2
Please dispatch your claim document to: Max Bupa Corporate Office: Bloc B1/I-2, Mohan Cooperative Industrial Estate, Mathura Road, New Delhi -110044.
Claim Form
CHECK LIST OF ENCLOSURES FOR SUBMISSION OF CLAIM
Organ Donation/Transplantation
In addition to the documents of general hospitalisation
q Organ Function test / blood test proving organ failure.
q Treatment Certificate issued by the Transplant Surgeon of the hospital
concerned.
Ambulance Benefit
q Duly filled and signed Claim Form.
q Photocopy of ID card / Photocopy of current year policy.
q Original Bill with Original Payment Receipt.
Maternity Expenses
q Copy of the Legal heir certificate, if the claim is for the death of the
principle insured.
Health Check up
q Duly filled and signed Claim Form.
q Photocopy of ID card / Photocopy of current year policy.
q Original Investigation bills, original payment receipts with Reports.
q Original Consultation bills and original payment receipts with
prescription.
Outpatient Benefit/Dental
q Duly filled and signed Claim Form.
q Photocopy of ID card / Photocopy of current year policy.
q Original Medicine bills, original payment receipt.
3
Please dispatch your claim document to: Max Bupa Corporate Office: Bloc B1/I-2, Mohan Cooperative Industrial Estate, Mathura Road, New Delhi -110044.
DESCRIPTION
FORMAT
d) Name
e) Address
Tick Yes or No
c) Company Name
Policy No.
Sum Insured
In rupees
Tick Yes or No
Date
Diagnosis
Open Text
Tick Yes or No
f) Company Name
c) Date of Birth
d) Age
e) Address
f) Gender
g) Occupation
h) Phone No
i) E-mail ID
c) Hospitalization due to
e) Date of admission
f) Time
g) Date of discharge
h) Time
If Medico legal
Tick Yes or No
Reported to Police
Tick Yes or No
Tick Yes or No
Open Text
4
Please dispatch your claim document to: Max Bupa Corporate Office: Bloc B1/I-2, Mohan Cooperative Industrial Estate, Mathura Road, New Delhi -110044.
Tick Yes or No
b) Account Number
Enter the name of the beneficiary the cheque/ DD should be made out to
e) IFSC Code
PART B
(TO BE FILLED IN BY THE HOSPITAL IN CASE OF CASHLESS CLAIMS)
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
SECTION A - DETAILS OF HOSPITAL
a)
b)
Hospital ID :
c)
e)
Qualification :
f)
F I
R S T
g)
N A M E
M I
D D L E
N A M E
Phone No :
b)
IP Registration Number :
d)
Age (YY/MM) : Y Y M M
e)
D D M M Y Y Y Y
g)
D D M M Y Y Y Y
S U R N A M E
i)
j)
If Maternity
i)
k)
N A M E
M I
D D L E
N A M E
H H M M
f)
H H M M
h)
ii)
Gravida Status :
D D M M Y Y Y Y
R S T
c)
Total Claimed
F I
Rs.
5
Please dispatch your claim document to: Max Bupa Corporate Office: Bloc B1/I-2, Mohan Cooperative Industrial Estate, Mathura Road, New Delhi -110044.
Primary Diagnosis :
ii)
Additional Diagnosis :
ICD 10 Codes
Description
ICD 10 PCS
Description
iii) Co-morbidities :
iv) Co-morbidities :
b)
i)
Procedure 1 :
ii)
Procedure 2 :
iii) Procedure 3 :
iv) Details of Procedure :
Yes / No
c)
Pre-authorization obtained :
e)
f)
Yes
d) Pre-authorization No. :
/ No
/ No
ii) IIf Injury due to Substance abuse / alcohol consumption, Test Conducted to establish this:
iii) Medico Legal Yes
/ No
Yes
es
Y
/ No
/ No
Investigation reports
Pharmacy Bills
Address :
City :
State :
Pin Code :
Phone No. :
c)
e)
No of In-patient Beds :
ii)
ICU : Yes / No
Email ID :
d)
f)
Hospital PAN :
OT : Yes / No
iii) Others :
Place :
6
Please dispatch your claim document to: Max Bupa Corporate Office: Bloc B1/I-2, Mohan Cooperative Industrial Estate, Mathura Road, New Delhi -110044.
DESCRIPTION
FORMAT
a) Name of Hospital
b) Hospital ID
c) Type of Hospital
e) Qualification
Enter the registration number of the doctor along with the state code
g) Phone No.
a) Name of Patient
b) IP Registration Number
c) Gender
d) Age
e) Date of Birth
f) Date of Admission
g) Time
h) Date of Discharge
i) Time
j) Type of Admission
Date of Delivery
Gravida Status
k) If Maternity
Additional Diagnosis
Co-morbidities
b) ICD 10 PCS
Procedure 1
Procedure 2
Procedure 3
Details of Procedure
Open text
Tick Yes or No
d) Pre-authorization obtained
Tick Yes or No
e) Pre-authorization Number
As allotted by TPA
Open text
7
Please dispatch your claim document to: Max Bupa Corporate Office: Bloc B1/I-2, Mohan Cooperative Industrial Estate, Mathura Road, New Delhi -110044.
Tick Yes or No
Cause
Tick Yes or No
Medico Legal
Tick Yes or No
Reported To Police
Tick Yes or No
FIR No.
Open Text
b) Phone No.
c) Registration No.
d) Hospital PAN
Digits
Photograph
i.
ii.
Pan Card
If Pan Card is not available please submit any of the documents mentioned below stating reason for
not having Pan Card.
Part A
Proof of legal name and
any other names used
a)
Passport
b)
c)
Driving License
d)
e)
Letter issued by Unique identification Authority of India containing details of name address and
f)
Job Card iss ued by NREGA duly signed by an officer of the State Government
Aadhar Number
8
Please dispatch your claim document to: Max Bupa Corporate Office: Bloc B1/I-2, Mohan Cooperative Industrial Estate, Mathura Road, New Delhi -110044.
i.
Electricity Bill not older than 6 months from the date of Insurance Contract
ii.
Telephone Bill pertaining to any kind of telephone connection like mobile, landline, wireless etc.
Provided it is not older than 6 months from the date of claim submission
Part B
Proof of Residence
iii.
Ration Card
iv.
Valid lease agreement along with rent receipts which is not more than 3 months old as a residence
v.
Saving Bank Passbook with details of permanent/ present residence address ( updated upto 1 month
proof
prior to claim submission document)
vi.
Statement of saving bank account with details of present/ present address ( updated upto 1 month
prior to claim submission document)
I hereby declare that I have submitted above mentioned documents and recent photograph (not more than 6 months old) for the purpose of claim and the said
documents are valid and effective.
Date : D D M M Y Y Y Y
Signature of Policyholder :
(Please attach copy of a cancelled blank cheque of your bank for ensuring accuracy of name of the bank, branch name, Account number
and IFSC code. If name of the payee is not printed on the cheque leaf please attach copy of the first page of the bank passbook also )
Registered office: Max House, 1 Dr. Jha Marg, Okhla, New Delhi - 110020 Corporate Office: Block B1/I-2, Mohan Cooperative Industrial Estate, Mathura Road,
New Delhi -110044. UAN No. MB/BR/2013-2014/208. Insurance is the subject matter of solicitation.
Max Bupa Health Insurance Co. Ltd.(IRDA Registration no. 145). 'Max', 'Max logo', 'Bupa' and HEARTBEAT logo are trademarks of their respective owners
and are being used by Max Bupa Health Insurance Company Limited under license.
To
Date __/____/__
Medical Superintendent
Consent Letter
Name:
Signature/ Thumb Impression