Health Insurance Claim Form

Claim Form

The problems faced by the policyholders/insured while filling a claim form for their health insurance policy are glaringly apparent – because of its complicated but incumbent fields. It’s hard to find any tutorial related to filling a claim form online or seek help from the insurance company in real-time. So stop spending so much time in your head because here we are to help you fill the claim form by discussing every field and what all the details you need to fill in those fields.

As this article is on the verge of listing all the fields in a health insurance claim form, it is important to discuss a little more about the different types of claim forms – Insurance Company Claim Form, TPAs Claim Form and IRDA Claim Form, so that you choose the correct claim form to submit to your insurance company.

Insurance Claim Form

Insurance companies that are not associated with third party administrators have their own insurance claim form. The sections and the details needed in the claim form are similar but sometimes written in a complex manner that you may find it difficult to fill it. To cater to this problem IRDA shared guidelines to uniform fields in the health insurance claim form, which all the insurance companies have customized according to their brand.

Third-Party Administrator

Many insurers are associated with third party administrator and they only accept TPAs claim form to start the claim process. All the fields in TPAs claim form are according to the IRDA guidelines.

IRDA Claim Form

As discussed above that the IRDA Claim form is a guideline to uniform all fields in the claim form. This is obvious that you cannot use it to file your health insurance claim form. Read about the IRDA Claim form fields and what all details you need to fill in those fields below:

Understanding fields in a health insurance claim form


Section A - DETAILS OF PRIMARY INSURED



Who is the Primary Insured?

The primary insured is the person whose name an insurance policy is registered. An insurance policy covers two types of people one is the primary and the other is secondary insured, who is covered under certain conditions. It is very common that people designate their family members in the policy for health insurance coverage and benefits.

  1. Policy number
    The policy number is a unique identity that an insurance company provides its policyholders. You can find this policy number on your insurance certificate or your insurance card right after your name. In policy no. field carefully read your insurance certificate or insurance card and fill the policy number mentioned below your name in the card or certificate.

  2. Serial No./Certificate Number
    Generally it has been seen that people who are covered under some master policy by banks and credit card companies do not have any TPA no., Policy number. This SL number and Certificate number is not a mandatory field until you have a policy with such organisations, you can leave this blank.

  3. Company/TPA ID no.
    In case you are insured under a health insurance plan and your insurer is associated with third party administrator you need to fill your company’s name or TPA ID no. in the required fields. You can find these details on your insurance card.

  4. Name- Primary policyholder name
    Here you need to fill the name of the policyholder whose name is registered on the policy by the insurance company. Always make sure that your name is consistent in the KYC and Bank documents.

  5. Contact Email and Mobile
    The insurance company needs your contact details to communicate the status of your claim. You can submit your contact number and email id that is active. It’s not important to share the registered details at the time of filing the claim form.

Section B - DETAILS OF INSURANCE HISTORY



The insurance company needs to know the details of your alternative health insurance policy but it’s mandatory only when you are filing a claim under your alternative policy. So if you are not using your alternative policy to file the claim there is no need to worry, you can skip this field on the insurance claim form.

If you are using your alternate insurance plan to claim your health coverage and benefits then read below the details you need to fill in the fields that are incumbent:

  • Currently covered by any other Mediclaim/Health Insurance
    As you do have an alternative health insurance policy, mark a tick on “Yes”.

  • Date of commencement of first insurance without a break
    Mention the date of commencement of your alternative policy that is the date from which your policy starts. To find these details refer to the policy certificate or insurance card provided by the insurer.

  • If yes insurance company name
    Fill in the details like insurer name, policy number and the sum insured,

  • Have you been hospitalised in the last four years since the inception of the contract
    Mark a tick on “Yes”, if you have been hospitalised in the last four year since the inception of your alternative policy else leave it. If yes mention date and diagnosis details.

  • Previously covered by any other Mediclaim/Health Insurance
    The insurer wants to know about your lapsed policy if any. If you do have a lapsed health insurance plan under which you were covered previously mark a tick on “Yes”.

  • If yes, company name
    Mention your insurer name if you were covered under a health insurance policy that is no more active.

Section C - DETAILS OF INSURED PERSON HOSPITALIZED



Who is the insured person?
According to the policy, the primary and all the secondary people covered under the health insurance policy can be referred to as insured. Here you need to consider the details of an insured person who was hospitalised.

  1. Name

    Fill in the name of the insured person who was hospitalised as mentioned in his KYC documents and bank documents.

  2. Gender

    Select the gender of the insured.

  3. Age year

    Fill in the age of the inured, for example, age years - 54, months – 8.

  4. Date of birth

    Enter the date of birth of insured as mentioned in the KYC documents and bank documents.

  5. Relationship to primary insured

    Mention the relationship of the primary insured and the insured person for whom you are filing the claim form.

  6. Occupation

    Mark a tick on any one of the options according to the nature of the occupation of the insured person.

  7. Address

    Mention the address and contact details of the insured where an insurance company can contact.


Section D - DETAILS OF HOSPITALIZATION



  • Name of the hospital where admitted
    Fill in the name of the hospital where the insured was admitted.

  • Room category
    Under this field, you may get confused due to some medical terms that are not commonly used. Read what you should fill in those fields below:

    • Daycare:
      Due to medical advancement there are many medical procedures or surgeries that are completed in less than 24 hours. Any medical treatment for which the insured is hospitalised for a short period of time or less than 24 hours you will need to mark a tick on Day Care.

    • Single Occupancy:
      Every insurance policy has a limit for room rent and therefore your insurer asks you the type of room chosen by you at the time of hospitalisation. Here you need to fill in the details of your room category. Select a single occupancy room if the insured was hospitalised in a single occupancy room.

    • Twin Sharing:
      If the insured was hospitalised in twin sharing, mark a tick in twin sharing field.

    • 3 or more beds per room:
      If the insured was hospitalised in 3 or more beds per room category you should choose this field.

    • ICU/NICU:
      There might be the chances that you have incurred ICU/ INCU charges during the course of hospitalisation of the insured. For that, you can mention those expenses by writing it separately in this column.

  • Hospitalization due to
    Now some incidents are very easy to differentiate between injury, illness and maternity whereas in some cases you will find yourself confused to choose between these 3 fields. Read below how to categorise the incident and what all details you need to mention:

    Injury:

    Any injury that led the insured to get hospitalised is covered under the insurance policy but under certain terms and conditions. There are 3 types of injuries as mentioned below:

    1. Self-inflicted injury case:
      Injury might be the result of one’s self-action and such injuries are very difficult to recognise while you are filling the claim form. In case any injury occurs due to your own action, behaviour, or decision is known as self-inflicted injury. For example, you have fallen down the stairs as the floor was wet due to drizzling, you will have to mark a tick on Self-inflicted injury field in the claim form.

    2. Road Traffic Accident:
      As the name suggests the injury caused due to an accident on road is known as Road Traffic Accident. In this case, you need to submit the FIR copy and Medico-legal. In road traffic accident mark a tick on Road Traffic Accident field and if you have FIR Copy and Medico-Legal then mark a tick on Yes in both the fields.

    3. Substance Abuse/Alcohol Consumption:
      In both the aforementioned cases the doctor will test and report in the prescription that whether the person was under the influence of substance abuse/alcohol or not. If the insured is found under the influence of substance abuse/alcohol, the policy will not cover the medical expenses.

    Illness:
    Any medical treatment resulted due to sickness falls under illness category, for example, Dengue, Malaria, Typhoid and more.

    Maternity:
    In case of maternity you can mark a tick on maternity.

  • Date of injury/ disease first detected/ date delivery:
    If you remember the date, mention the date in the field else just mention the month of injury/disease/date of delivery.

  • Date of admission
    Mention the date of admission. You can check it in the discharge summary.

  • Time of admission
    You will find this detail in the discharge summary. In case if it is not mentioned by hospital leave it blank.

  • Date of discharge
    Mention the date of discharge. You can check it in the discharge summary given by the hospital.

  • Time
    You will find this detail in the discharge summary. In case it is not mentioned by the hospital leave it blank.

  • If Injury give causes

    • Self-inflicted injury case:
      In case any injury occurs due to your own action, behavior, or decision, mark a tick on Self-inflicted injury field in the claim form.

    • Road Traffic Accident:
      As the name suggests the injury caused due to an accident on road is known as Road Traffic Accident. If the injury is caused due to road accident mark a tick on Road Traffic Accident.

    • Substance Abuse/ Alcohol Consumption:
      In both the aforementioned cases the doctor will test and report in the prescription that whether the person was under the influence of substance abuse/alcohol or not. If the insured is found under the influence of substance abuse/alcohol the policy will not cover the medical expenses.

    • i) Medico-Legal

      In case of a road traffic accident, self-inflicted injuries the hospital is liable to prepare medico-legal. If you have the Medico-Legal prepared by the hospital, mark a tick on Yes.

      ii) Reported to Police

      The hospital is also liable to inform the policy about any road traffic accident or self-inflicted injuries. If you have the FIR copy, mark a tick on Yes.

      iii) MLC Report & Police FIR Attached

      If you have the copy of MLC Report & FIR and you are attaching it with the claim form mark a tick on Yes.

  • System of Medicine
    Here you need to mention the nature of treatment taken by the insured, for example, Allopath, Homeopath or Ayurveda.

Section E - DETAILS OF CLAIM



  • Details of the treatment expenses claimed

    i) Pre-hospitalisation expenses -

    There are expenses that incur before the hospitalisation, for example, doctor consultation fees, medical bills and more. You can claim for the expenses incurred before 30 days of hospitalization under your health insurance policy.

    ii) Hospitalization expenses

    The expenses incurred due to insured hospitalisation are known as hospitalization expenses. It is basically the expenses that incurred due to the treatment of insured.

    iii) Post-hospitalization expenses

    There are expenses that incur after the hospitalisation, for example, doctor consultation fees, medicine bills and more. You can claim for the expenses incurred after 90 days of hospitalisation discharge date under your health insurance policy.

    iv) Health check-up costs

    All the diagnosis tests costs are covered under the health insurance plan. Calculate those expenses accurately and mention the amount in this field.

    v) Ambulance charges

    Mention the ambulance charges if incurred in this field.

    vi) Other

    Apart from the aforementioned categories if you have incurred any other expenses related to medical emergency like pharmacy bills, physiotherapy mention it here.

    Total

    Add the entire treatment expenses claimed as mentioned in different field above and fill it here.

    vii) Pre-hospitalisation Period

    The insurance company covers the pre hospitalisation amount only for 30 days before the hospitalisation date. Here you need to mention the pre hospitalisation period (no. of days) mentioned in your policy certificate.

    viii) Post-hospitalization period

    The insurance company covers the pre hospitalisation amount only for 90 days after the hospitalisation date. Here you need to mention the post hospitalisation period (no. of days) mentioned in your policy certificate.

  • Claim Domiciliary Hospitalisation
    Any medical treatment that is done at home is known as domiciliary hospitalisation, for example, if the patient is on dialysis at home with all the machines, it is known as domiciliary hospitalisation. Mention the expenses of domiciliary hospitalisation here.

  • Details of Lump Sum/ Cash Benefit Claimed

    i) Hospital Daily Cash

    A certain amount of cash that is used while the insured is hospitalised is known as Hospital daily cash in insurance industry. The health insurance plan also provides a limited amount on a daily basis as hospital daily cash during the hospitalisation. This coverage is over and above the sum insured under your insurance policy. Check the eligible amount in your policy certificate and enter the expenses incurred. You do not need to submit any bills or proofs for these expenses.

    ii) Surgical Cash

    The expenses of the treatment, surgery, operation is known as surgical cash. It is mentioned in your final bill that you have to submit to the insurance company in original.

    iii) Critical Illness Benefit

    For this filed you will have to check if your policy offers critical illness benefits. If it does offer the coverage you can mention the expenses that incurred due to critical illness in this field.

    iv) Convalescence

    There are policy that pays lump sum amount till the time a insured recovers fully. There are only few policies that offers this benefits, check your policy coverage and if it covers the convalescence fill the amount according to the limit of the policy.

    v) Pre/Post Hospitalization Lump Sum Benefit

    Here you need to calculate the lump sum amount that you have spent over the pre/post hospitalisation.

    vi) Others

    Total:

    Add the entire expenses claimed as mentioned in different field above and fill it here.


Section F - DETAILS OF BILLS ENCLOSED



There are only 10 fields in this section which demands you to enter the bill details of all the expenses incurred due to medical emergency. What if you have more than 10 bills to claim? Don’t worry you can make some more tables according to the space available in this section of the claim form.

Here you need to mention the details and expenses in this section. Here you need to calculate the bill separately for pharmacy, doctor consultation and more before the hospitalisation and post the hospitalisation and fill it respectively.

Section G - DETAILS OF PRIMARY INSURED'S BANK ACCOUNT



After your health insurance policy will get approved the insurance company needs the bank account details of primary insured to transfer the approved amount, for this your need to submit your cancelled cheque in original with your name mentioned on it.

Section H - DECLARATION BY THE INSURED



The primary policyholder whose name an insurance policy is registered is required to put his signature in this field.


Fill all the above fields with correct information to avoid health insurance claim denial.