Paramount Health Services & Insurance TPA Pvt. Ltd.
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Paramount Health Services & Insurance TPA Pvt. Ltd.
IRDA License No: 006

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

(To be filled in block letters)
DETAILS OF PRIMARY INSURED:
DETAILS OF INSURANCE HISTORY:
  
      (Copies of Policies to be attached)
  
               
      
  
DETAILS OF INSURED PERSON HOSPITALIZED:
   years    months      
Self Spouse Child Father Mother Other (Please Specify)
Service   Self Employed   Homemaker   Student   Retired Other (Please Specify)
DETAILS OF HOSPITALIZATION:
Day care     Single occupancy  Twin sharing     3 or more beds per room
Injury Illness Maternity d) Date of Injury | Date Disease first detected | Date of Delivery:      
           :                      :
Yes No
Yes No Yes No   
Paramount Health Services & Insurance TPA Pvt. Ltd.
DETAILS OF CLAIM:
a] Details of the treatment expenses claimed
Sr no. Expense Rs.
i Pre-hospitalization Expenses
ii Hospitalization Expenses
iii Post-hospitalization Expenses
iv Health-Check up Cost
v Ambulance Charges
vi Others (code)
Total
vii Pre-hospitalization period: Days  
viii Post-hospitalization period: Days  
b] Details of Lump sum I cash benefit claimed
Sr no. Expense Rs.
i Hospital Daily Cash
ii Surgical Cash
iii Critical Illness Benefit
iv Convalescence
v PreIPost hospitalization Lump sum benefit
vi Others (code)
Total
Claim Documents Submitted Check List
  Claim Form Duly signed
  Copy of the claim intimation
  Hospital Main Bill
  Hospital Break-up Bill
  Hospital Bill Payment Receipt
  Hospital Discharge Summary
  Pharmacy Bill
  Operation Theatre Notes
  ECG
  Doctor's request for investigation
  Investigation Reports (Including CT I MRI I USG I HPE)
  Doctor's Prescriptions
  Others

c] Claim for Domiciliary Hospitalization Yes No (If Yes, provide details in annexure)
DETAILS OF BILLS ENCLOSED:

Sl. No Bill No Date Issued by Towards Amount (Rs)
1
2
3
4
5
6
7
8
9
10
Total

DETAILS OF PRIMARY INSURED'S BANK ACCOUNT
   
DECLARATION BY THE INSURED:
I hereby declare that the information furnished in this claim form is true & correct to the best of my knowledge and belief. If I have made any false or untrue statement, suppression or concealment of any material fact, my right to claim reimbursement shall be forfeited. I also consent & authorize TPA / insurance company, to seek necessary medical information / documents from any hospital / Medical Practitioner 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 & that I will not be making any supplementary claim except the pre/post-hospitalization claim, if any.
     

GUIDANCE FOR FILLING CLAIM FORM – PART A (To be filled in by the insured)
DATA ELEMENT DESCRIPTION FORMAT
SECTION A - DETAILS OF PRIMARY INSURED
a) Policy No. Enter the policy number As allotted by the insurance company
b) SI. No/ Certificate No. Enter the social insurance number or the certificate number of social health insurance scheme As allotted by the organization
c) Company TPA ID No. Enter the TPA ID No License number as allotted by IRDA and printed in TPA documents.
d) Name Enter the full name of the policyholder Surname, First name, Middle name
e) Address Enter the full postal address Include Street, City and Pin Code
SECTION B - DETAILS OF INSURANCE HISTORY
a) Currently covered by any other Mediclaim / Health Insurance? Indicate whether currently covered by another Mediclaim / Health Insurance Tick Yes or No
eb) Date of Commencement of first Insurance without break Enter the date of commencement of first insurance Use dd-mm-yy format
c) Company Name Enter the full name of the insurance company Name of the organization in full
Policy No. Enter the policy number As allotted by the insurance company
Sum Insured Enter the total sum insured as per the policy In rupees
d) Have you been Hospitalized in the last 4 years Indicate whether hospitalized in the last 4 years Tick Yes or No
Date Enter the date of hospitalization Use mm-yy format
Diagnosis Enter the diagnosis details Open Text
Previously Covered by any other Mediclaim/ Health Insurance? Indicate whether previously covered by another Mediclaim / Health Insurance Tick Yes or No
f) Company Name Enter the full name of the insurance company Name of the organization in full
SSECTION C - DETAILS OF INSURED PERSON HOSPITALIZED
a) Name Enter the full name of the patient Surname, First name, Middle name
b) Gender Indicate Gender of the patient Tick Male or Female
c) Age Enter age of the patient Number of years and months
d) Date of Birth Enter Date of Birth of patient Use dd-mm-yy format
e) Relationship to primary Insured Indicate relationship of patient with policyholder Tick the right option. If others, please specify.
f) Occupation Indicate occupation of patient Tick the right option. If others, please specify
g) Address Enter the full postal address Include Street, City and Pin Code
h) Phone No Enter the phone number of patient Include STD code with telephone number
i) E-mail ID Enter e-mail address of patient Complete e-mail address
SECTION D - DETAILS OF HOSPITALIZATION
a) Name of Hospital where admitted Enter the name of hospital Name of hospital in full
b) Room category occupied Indicate the room category occupied Tick the right option
c) Hospitalization due to Indicate reason of hospitalization Tick the right option
d) Date of Injury/Date Disease first detected/ Date of Delivery Enter the relevant date Use dd-mm-yy format
e) Date of admission Enter date of admission Use dd-mm-yy format
f) Time Enter time of admission Use hh:mm format
g) Date of discharge Enter date of discharge Use dd-mm-yy format
h) Time Enter time of discharge Use hh:mm format
i) If Injury give cause Indicate cause of injury Tick the right option
If Medico legal Indicate whether injury is medico legal Tick Yes or No
Reported to Police Indicate whether police report was filed Tick Yes or No
MLC Report & Police FIR attached Indicate whether MLC report and Police FIR attached Tick Yes or No
j) System of Medicine Enter the system of medicine followed in treating the patient Open Text
SECTION E - DETAILS OF CLAIM
a) Details of Treatment Expenses Enter the amount claimed as treatment expenses In rupees (Do not enter paise values)
b) Claim for Domiciliary Hospitalization Indicate whether claim is for domiciliary hospitalization Tick Yes or No
c) Details of Lump sum/ cash benefit claimed Enter the amount claimed as lump sum/ cash benefit In rupees (Do not enter paise values)
d) Claim Documents Submitted-Check List Indicate which supporting documents are submitted Tick the right option
SECTION F - DETAILS OF BILLS ENCLOSED
Indicate which bills are enclosed with the amounts in rupees
SECTION G - DETAILS OF PRIMARY INSURED’S BANK ACCOUNT
a) PAN Enter the permanent account number As allotted by the Income Tax department
b) Account Number Enter the bank account number As allotted by the bank
c) Bank Name and Branch Enter the bank name along with the branch Name of the Bank in full
d) Cheque/ DD payable details Enter the name of the beneficiary the cheque/ DD should be made out to Name of the individual/ organization in full
e) IFSC Code Enter the IFSC code of the bank branch IFSC code of the bank branch in full
SECTION H - DECLARATION BY THE INSURED
Read declaration carefully and mention date (in dd:mm:yy format), place (open text) and sign

CLAIM FORM - PART B
TO BE FILLED IN BY THE HOSPITAL
The issue of this Form is not to be taken as an admission of liability Please include the original preauthorization request form in lieu of PART A

(To be filled in block letters)
DETAILS OF HOSPITAL
Paramount Health Services & Insurance TPA Pvt. Ltd.
                          
      
DETAILS OF THE PATIENT ADMITTED
         :            :
       
             
DETAILS OF AILMENT DIAGNOSED (PRIMARY)
a) ICD 10 Codes Description
i Primary Diagnosis:
ii. Additional Diagnosis:
iii. Co-morbidities:
v. Co-morbidities:
b) ICD 10 PCS Description
i. Procedure 1:
ii. Procedure 2:
iii. Procedure 3:
iv. Details of Procedure:
              
                                  
    
        
 
     
 
      
CLAIM DOCUMENTS SUBMITTED - CHECK LIST
DETAILS IN CASE OF NON NETWORK HOSPITAL (ONLY FILL IN CASE OF NON-NETWORK HOSPITAL)
  
           

DECLARATION BY THE INSURED (PLEASE READ VERY CAREFULLY)
Paramount Health Services & Insurance TPA Pvt. Ltd.
I hereby declare that the information furnished in this claim form is true & correct to the best of my knowledge and belief. If I have made any false or untrue statement, suppression or concealment of any material fact, my right to claim reimbursement shall be forfeited.I also consent & authorize TPA I insurance company, to seek necessary medical information I documents from any hospital I Medical Practitioner who has attended on the person against whom this claim is made.I hereby declare that I have included all the bills I receipts for the purpose of this claim & that I will not be making any supplementary claim except the preIpost hospitalization claim, if any.
     

DECLARATION BY THE HOSPITAL: (PLEASE READ VERY CAREFULLY)
We hereby declare that the information furnished in this Claim Form is true & correct to the best of our knowledge and belief. If we have made any false or untrue statement, suppression or concealment of any material fact,our right to claim under this claim shall be forfeited. The signature of the insured is taken on this form after Claim Form B is fully filled up by us
     
GUIDANCE FOR FILLING CLAIM FORM – PART B (To be filled in by the hospital)
DATA ELEMENT DESCRIPTION FORMAT
SECTION A - DETAILS OF HOSPITAL
a) Name of Hospital Enter the name of hospital Name of hospital in full
b) Hospital ID Enter ID number of hospital As allocated by the TPA
c) Type of Hospital Indicate whether In network or non network nospital Tick the right option
d) Name of treating doctor Enter the name of the treating doctor Name of doctor in full
e) Qualification Enter the qualifications of the treating doctor Abbreviations of educational qualifications
f) Registration No. with State Code Enter the registration number of the doctor along with the state code As allocated by the Medical Council of India
g) Phone No. Enter the phone number of doctor Include STD code with telephone number
SECTION B - DETAILS OF THE PATIENT ADMITTED
a) Name of Patient Enter the name of hospital Name of hospital in full
b) IP Registration Number Enter insurance provider registration number As allotted by the insurance provider
c) Gender Indicate Gender of the patient Tick Male or Female
d) Age Enter age of the patient Number of years and months
e) Date of Admission Enter date of admission Use dd-mm-yy format
f) Time Enter time of admission Use hh:mm format
g) Date of Discharge Enter date of discharge Use dd-mm-yy format
h) Time Enter time of discharge Use hh:mm format
i) Type of Admission Indicate type of admission of patient Tick the right option
j) If Maternity
Date of Delivery Enter Date of Delivery if maternity Use dd-mm-yy format
Gravida Status Enter Gravida status if maternity Use standard format
k) Status at time of discharge Indicate status of patient at time of discharge Tick the right option
SSECTION C - DETAILS OF AILMENT DIAGNOSED (PRIMARY)
a) ICD 10 Code
Primary Diagnosis Enter the ICD 10 Code and description of the primary diagnosis Standard Format and Open text
Additional Diagnosis Enter the ICD 10 Code and description of the additional diagnosis Standard Format and Open text
Co-morbidities Enter the ICD 10 Code and description of the co-morbidities Standard Format and Open text
b) ICD 10 PCS
Procedure 1 Enter the ICD 10 PCS and description of the first procedure Standard Format and Open text
Procedure 2 Enter the ICD 10 PCS and description of the second procedure Standard Format and Open text
Procedure 3 Enter the ICD 10 PCS and description of the third procedure Standard Format and Open text
Details of Procedure Enter the details of the procedure Open text
c) Present Ailment is a Complication of PED Indicate whether present ailment is a complication of some pre-existing disease Tick Yes or No
d) Pre-authorization obtained Indicate whether pre-authorization obtained Tick Yes or No
e) Pre-authorization Number Enter pre-authorization number As allotted by TPA
f) If authorization by network hospital not obtained, give reason Enter reason for not obtaining pre-authorization number Open text
g) Hospitalization due to injury Indicate if hospitalization is due to injury Tick Yes or No
Cause Indicate cause of injury Tick the right option
If injury due to substance abuse/alcohol consumption, test conducted to establish this Indicate whether test conducted Tick Yes or No
Medico Legal Indicate whether injury is medico legal Tick Yes or No
Reported To Police Indicate whether police report was filed Tick Yes or No
FIR No. Enter first information report number As issued by police authorities
If not reported to police, give reason Enter reason for not reporting to police Open Text
SECTION D - CLAIM DOCUMENTS SUBMITTED-CHECK LIST
Indicate which supporting documents are submitted
SECTION E - DETAILS IN CASE OF NON NETWORK HOSPITAL
a) Address Enter the full postal address Include Street, City and Pin Code
b) Phone No. Enter the phone number of hospital Include STD code with telephone number
c) Registration No. Enter the registration number of patient As allocated by the Hospital
d) PAN Enter the permanent account number As allotted by the Income Tax department
e) Number of Inpatient Beds Enter the number of inpatient beds Digits
f) Facilities available in the hospital Indicate facilities available in the hospital Tick the right option. If others, please specify
SECTION F - DECLARATION BY THE INSURED
Read declaration carefully and mention date (in dd:mm:yy format), place (open text) and sign.
SECTION G - DECLARATION BY THE HOSPITAL
Read declaration carefully and mention date (in dd:mm:yy format), place (open text) and sign and stamp