CholaMS GENERAL INSURANCE

CHOLAMANDALAM MS GENERAL INSURANCE COMPANY LIMITED

Registered Office:
2nd Floor "DARE House", 2, N.S.C. Bose
Road, Chennal- 600 001
T:+91 (0) 44 4044 5400, F: +91
(0) 44 4044 5550
IRDA Regn. No.123I PAN
AABCC6633K I CIN: U66030TN2001PLCO47977

CLAIM FORM- PARTA

GENERAL INSURANCE
TO BE FILLED IN BY THE INSURED
All The Issue of this Form is not to be
relmbursement claims elther from network/ taken as an admisslon of
non-network llablity
care through Toll Free number 1800-208-5544 or by an e-mallhospltals
to
has to be intimated
Immedlately
to us at the earliest before discharge) to our customer
days from the date of discharge. The help@choalms.
issuance of this form does not
mu rugappa.com Claim
documents should be submitted to us within 30
requlred. Please attach the documents imply Admission of
documents to process the claim. required as indicated. Please note that the lIst ofLiability. Please answer questions completely. Use additional
documents mentioned is an sheet, if
indicative list, we may asK for any other
SECTION A-DETAILS OF PRIMARY INSURED
a) Pollcy No:
b) SI. No/ Certificate No
c) Membership Number
) Name Chondya Selvoroy
(T8,abyapuduw, Peri yarai ckenpecbyam, Coimbotore
Ciy CotneNTOQE tate TAMIL NADO
Pin Code41D47 one No94o848944 Emall D
SECTION B-ADDITIONAL DETAILS IN CASE OF NON NETWORK
a) Currently covered by any other Mediclaim
HOSPITAL
/Health Insurance
b) Date of commencement of first Insurance
Yes No
without brea
(Coples of Pollcles to be
attached) c)ifyes, company
Policy No: name
Sum Insured
d) Have you been hospltalized In the last 4
Diagnosis years? Yes No Date
e)Previously covered by any other Mediclaim/Health insurance
) If yes, company name Yes No
SECTION C-DETAILS OF INSURED PERSON
HOSPITALIZED
a) Name elvaro

b) Gender Male Female

R c) Age Years Months d) Date of Birth
e) Relationship to Primary insured Selr Spouse child Father Mother L
Occupation: Service Self employed Homemaker
Other
Please Specify)
9) Address
Student Retired Other (Please Specit)
18, Palaya pudur eaiyonai Cken paayom,,
Coimbare
cy CoMBATORE State TANIL NADU
Pin Code A 1DA7 Phone No 9 OE LEAHy Emal 1D

SECTION D-DETAILS OF HOSPITALIZATION

Name of Hospltal where Admited S O2Tto CARE CDIMBATOPE
b) Room
Category occuplied Day care Suite Delux Room
c) Hospitalization due to
Singal Occupency L Twin Sharing 3or more beds U Other
Injury llness Maternity d) Date of Injury / Date Disease first detected
) Date of Admission 2122 Time
Date of Discharge
9)
Ifinjury give cause: Self-inflicted 2l22 Time
Road Traffic Accident Substance Abuse/ Alchohol consumption L if Medico legal
2) Reportedto pollce YesNo 3) MLC Report &Pollce FIR attached Yes No
Yes No
j) System of Medicine
k) Type of Hospltalization Emergency/ Planned

SECTION E-DETAILS OF CLAIM

a) Detalls of the treatment expenses claimed
Claim Documents Submltted-
1) Pre-Hospltalization expenses Check LIst
2) Hospitalization expenses
3) Post Hopsltalization expenses 4) health Check up cost
Filled clalm form duly signed
5) Ambulance charges 6) External Alds
Copy of the claim Intimation
) OPD Dental 8) OPD
Final Hospital Bll with detailed break-up
9) Eye Check up cost 10) Minor accompaniment dally cash
Hospltal bill payment recelpt
1) Others (code):
Detalled hospital discharge summary
Total Pharmacy Imedical bills which supporting doctor
Pre hospltalizatlon period prescrlptlon
Days Post hospltalizatlon perlod Days
Operation theatre notes for surgical cases
 Invoice/sticker for the Implants used in
Jomiclliary Hospltallzatlon Yes No (f yes, provide detalls in annexure) the treatment

External Aids vendors supported by the

ls of Lump sum/cash benefit claimed proper prescrlption from Doctor

Obstetric History for maternity claims

2) Surgical cash
Hospltal Cash (OPAL Status)
Copy of MLCI FIR / In case of road traffic
3) Critical illness benefit 4) Convalescence accidents (RTA)
AML documents (Proof of ldentity with
5) Pre/Post hospitalization lumpsum 6) Others: photo, Address proof) for above 1 lac claims
benefit

Total
6000
SECTION F-DETAILS OF BILLS ENCLOSED

S. No. Bill No. Date Issue by Towards Amount

Hospital main bill

Pre-hospitalization Bl: No.s

Post-hospitalization Bill No.s
Pharmacy Bills

SECTIONG-DETAILSOFPRIMARYINSURED'S BANKACCOUNT c) Aadhar Enrollment no.

a) PAN b) Aadhar No.

d) Account No.
121-b8 2031
e) Bank name & branch STA1G ANE of DNo1 PNpPLAyAM
n Cheque/ DD payment Details 9)IFSCCode SBIN o071OSS
Note : PAN & Aadhaar No. Mandatory for as per IRDAI. In case of Non availability of PAN CARD - FORM 60 as per the annexure need to be provided.
If applied for Aadhaar, kindly provide Enrolment ID. Please enclose a copy of Pan Card, Aadhaar Card and Cancelled cheque of Insured.

SECTION H-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, medical
who has attended on the person agalnst whom this claim Is made. I hereby declare that I have included all the
information / documents from any hospital / Medical Practitioner
bills/ recelpts for the purpose of this claim & that I will not be making any supplementary claim except the pre/post hospitalizatlon claim, if any.

Signature of the insured

D 19/422
Date Place E
FILLING CLAIM FORM-PARTA
GUIDANCE FOR
(To be filled in by the insured)

DATA ELEMENT
DESCRIPTION FORMAT

SECTION A-DETAILS OF PRIMARY INSURED

Enter the policy number As allotted by the Insurance company

a) Policy No. Enter the social insurance number or the certlficate number of social health insurance scheme As allotted by the organization
b) SI. Not Certificate No.
License number as allotted by IRDA and printed in
Enter the TPA ID No TPA documents.
c) Company TPA ID No.

Enter the full name of the policyholder Surname, First name, Middle name
| ) Name
Enter the full postal address Include Street, City and Pin Code
e Address

SECTION B-DETAILS DF INSURANCE HISTORY

Health Mediclaim/ Health Insurance Tick Yes or No

a) Currently covered by any other Mediclaim/ Indicate whether currentily covered by another
insurance7
Use dd-mm-yy format
b) Date of Commencement of first insurance wunouEnter the date of commencement of tirst insurance
break Enter the full name of the Insurance company
Name of the organization In ful

Company Name As allotted by the Insurance company

Enter the pollcy number
y No.
rOy Enter the total sum Insured as per the pollcy
In rupees
Sum Insured
Tick Yes or No
Indicate whether hospltalized In the last 4 years
) Have you been Hospltallzed In the last 4 years
Use mm-yy format
Date
Enter the date of hospitallzation
OpenText
Enter the dlegnosis detalls
Diagnosis
Tick Yes or No
e Previously Covered by any other Mediclalm/ Indicate whether prevlously covered by another Mediclalm / Health Insurance

Health Insurance? In full

Name of the organizeton
Company Name Enter the full name
of the insurance company
 SECTION C DETAILS OF INSURED PERSON HOSPITALIZED

Entor the full name of the patlent Surname, First name, Middle name

ndicate Gender of the patient Tick Male or Female

Enter age Number of years and months

Age of the patient
d) Date of Birth Enter Date of Birth of patlent Use dd-mm-y format
e) Relationship to primary Insured Indlcate relationship of patlent with pollcyholder Tick the right option. If others. please specify

Occupation Indicate occupatlon of patlent Tick the right option. If others, please specify

9) 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

) E-mell ID Enter e-mall address of patient Complete e-mall address

SECTION D-DETAILS OF HOSPITALIZATION

Enter the name of hospital Name of hospital in full
a) Name
of Hospltal where admited
b) Room category occupied Indicate the room category occupled Tick the right option

c) Hospitalization due to Indicate reason of hospitalization Tick the rlght option

d) Date of Injury/Date Disease first detected/ Date Use dd-mm-yy format

Enter the relevant date
of Deliveryy
e) Date of admission Enter date of admlsslon Use dd-mm-yy
format

Time Enter time of admlssion Use hh:mm format

9) Date of discharge Enter date of discharge Use dd-mm-yy format

h) Time Enter time of discharge Use hh:mm format

1) If Injury give cause Indicate cause of injury Tick the right option

Indicate whether Tick Yes or No

IfMedico legal injury ls medico legal
Reported to Police Indicate whether police report was filed Tick Yes or No
No
MLC Report & Police FlR attached Indicate whether MLC report and Police FIR attached Tick Yes or

Enter the system of medicine followed in treating the patient Open Text
i) System ofMedicine
SECTION E-DETAILS OF CLAIM U

a) Detail's of Treatment Expenses Enter the amount claimed as reatment expenses In rupees (Do not enter paise values)

|b) Claim for Domiciliary Hospitalization Indicate whether claim is for domicliary hospitalization Tick Yes or No

Enter the amount claimed as lump sum/ cash beneft In rupees (Do not enter paise values)
c)Details of Lump sum/ cash benefit claimed
Indicate which supporting documents are submitted Tick the right option
| d) Claim Documents Submitted-Check List

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

Enter the permanent account number As allotted by the Income Tax department
a ) PAN

b) Aadhar Card (Mandatory)

Enter the 16 digit Aadhar Number
As provided by Govt Of India.
Enter the Aadhaar Enrollment No as per your sheet As provided by Govt OfIndia.
|c)Aadhaar Card Enrollment No
Enter the bank account number As allotted by the bank
) Account Number
with the branch Name of the Bank in full
e) Bank Name and Branch. Enterthe bank name along
Enter the name of the beneficlary the chequel DD should be made out to Name of the individual organization in full
| ) Cheque/ DD payable details.

IFSC Code
Enter the IFSC code of the bank branch IFSC code of the bank branch in full
| 9)
SECTION H-DECLARATION BY THE INSURED
mention date (fin dd:mm:yy format), place (open text) and sign.
Read declaration carefully and

123
CIN: U66030TN2001PLCO47977 IRDA Regn. No.