VISHAL MEDICO

# 9 Kt-lM BLOCK, 80FEET ROAD.OPP SHANTI

SAGA~.HOTEL. RT. NAGAR.BENGALURU-560032
MOB 9886323336 , 9663505 708 Credit BIii
GST 29AGFPK3626B1ZO
DL No KA/852/20/131615 KAIB~_,. ~,131616
Patient VIBHA RANI CA
Doctor . DEEPSHIKAJHA
Date 15-07-24 Bill No S-19298
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CLAIM FORM - PART A' to 'CLAIM FORM FOR HEALTH INSURANCE POLICIES OTHER THAN TRAVEL AND
PERSONAL ACCIDENT - PART A TO BE FILLED BY THE INSURED

DETAILS OF PRIMARY INSURED:

Sl. No/
Policy No.: 12100034230400000048 Certificate
no.
Company/
CAPGEMINI
TPA ID No:
Name: SANDEEP KUMAR A S EmpID: 46355591 MAID: 5126816471
Address:
City: State:
Pin Code: [PINCODE] Phone No: 9620468495
Email ID: SANDEEP-KUMAR.A-
S@CAPGEMINI.COM

DETAILS OF INSURANCE HISTORY:

Currently covered by any other Date of commencement of first Insurance

Yes No
Mediclaim / Health Insurance: without break:

If yes, company CAPGEMINI 12100034230400000048

Policy No.:
name:

Have you been hospitalized in the last

Sum insured (Rs.): four years since inception of the Yes No Date:
contract?

Previously covered by any other Mediclaim

Diagnosis: Yes No
/Health insurance:
DETAILS OF INSURED PERSON HOSPITALIZED:

Name: VIBHARANI C A Gender: Male Female

Age years: 30 Date of Birth:
Relationship
to Primary SELF SPOUSE CHILD FATHER MOTHER OTHER(PLEASE SPECIFY)
insured:
Occupation: SERVICE SELF EMPLOYED HOME MAKER STUDENT RETIRED OTHER(PLEASE SPECIFY)
Address(if
diffrent from
above):
City: State:
Pin Code: [PINCODE] Phone No: 9620468495
Email ID: SANDEEP-KUMAR.A-S@CAPGEMINI.COM

DETAILS OF HOSPITALIZATION:

Name of Hospital where

amited:

Room Category
DAY CARE SINGLE OCCUPANCY TWIN SHARING 3 OR MORE BEDS PER ROOM
occupied:

Hospitalization due Date of injury / Date Disease first 14-

INJURY ILLNESS MATERNITY
to: detected /Date of Delivery: JUL-2024

Date of Admission: 14-JUL-2024 Time: Date of Discharge: 16-JUL-2024 Time:

SELF INFLICTED ROAD TRAFFIC ACCIDENT SUBSTANCE ABUSE / If Medico YES

If injury give cause: ALCOHOL CONSUMPTION NO
legal:

YES MLC Report & Police FIR System of

Reported to Police: NO YES NO
attached: Medicine:
DETAILS OF CLAIM:

Pre -hospitalization expenses INR Hospitalization expenses INR 4020

Post-hospitalization expenses INR Health-Check up cost: INR
Ambulance Charges: INR Others (code): INR
Pre -hospitalization period: Post -hospitalization period:

Total: INR 4020

b) Claim for Domiciliary
YES NO (IF YES, PROVIDE DETAILS IN ANNEXURE)
Hospitalization:

c) Details of Lump sum / cash benefit

claimed:
Hospital Daily cash: INR Surgical Cash: INR
Critical Illness benefit: INR Convalescence: INR

Total: INR 4020

Claim Documents Submitted - Check List:
Claim form duly signed Copy of the claim intimation, if any Hospital Main Bill Hospital Break-up Bill Hospital Bill Payment
Receipt
Hospital Discharge Summary Pharmacy Bill Operation Theater Notes ECG
Doctor?s request for investigation Investigation Reports (Including CT/ MRI / USG / HPE) Doctor?s Prescriptions Others
DETAILS OF BILLS ENCLOSED:
SI No. Bill No. Date Amount (Rs) Remarks
1 S19298 15-Jul-2024 4020 AntiDInjection
DETAILS OF PRIMARY INSURED?S BANK ACCOUNT:

PAN: Account Number: 193701517434

ICICI BANK LTD., NO. 102, K H
Bank Name: ICICI BANK LIMITED Branch: ROAD, BANGALORE,
KARNATAKA.560027
Cheque / DD Payable
IFSC Code: ICIC0001937
details:

DECLARATION BY THE INSURED: I hereby declare that the information furnished in the claim form is true & correct to the best of my
knowledge and belief. If I have made any false or untrue statement, suppression or concealent of any material fact with respect to
questions asked in relation to this claim, my right to claim reimbrusement 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.

Date: Place: Signature of the Insured

 GUIDANCE FOR FILLING CLAIM FORM - PART A (To be filled in by the insured)

DATA ELEMENT DESCRIPTION FORMAT

SECTION A - DETAILS OF PRIMARY INSURED
As allotted by the Insurance
a) Policy No. Enter the policy number
Company
Enter the social insurance number or the
b) Sl. No/ Certificate No. certificate number of social health insurance As allotted by the oraganization
scheme
Licence number as allotted by
c) Company TPA ID No. Enter the TPA ID No. IRDA and printed in TPA
documents.
Surname, First name, Middle
d) Name Enter the full name of the policyholder
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 Indicate whether currently covered by
Tick Yes or No
Insurance? another Mediclaim / Health Insurance
b) Date of commencement of first Insurance without Enter the date of commencement of first
Use dd-mm-yy-forrmat
break Insurance
Enter the full name of the Insurance
c) Company Name Name of the organization in full
Company
As allotted by the Insurance
Policy No. Enter the policy number
Company
Sum insured Enter the total sum insured as per the policy In rupees
d) Have you been Hospitalized in the last four years Indicate whether hospitalized in the last four
Tick Yes or No
since Inception of the contract? years
Date Enter the date of Hospitalization Use mm-yy format
Diagnosis Enter the diagnosis details Open Text
e) Previously covered by any other Mediclaim / Indicate whether previously covered by
Tick Yes or No
Health Tick Yes or No Insurance? another mediclaim / Health Insurance
Enter the full name of the Insurance
f) Company Name Name of the organization in full
Company
SECTION C - DETAILS OF INSURED PERSON HOSPITALIZED
Surname, First name, Middle
a) Name Enter the full name of the patient
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
Indicate relationship of patient with Tick the right option, if others,
e) Relationship to primary Insured
policyholder please specify
Tick the right option. If others,
f) Occupation indicate occupation of patient
please specify.
g) Address Enter the full postal address Include Street, City and Pin code
Include STD code with telephone
h) Phone No Enter the phone number of patient
number
1) E-mail ID Enter e-mail address of patient Complete e-mail address
SECTION D - DETAILS OF HOSPITALIZATION
a) Name of Hospital where admited 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
Enter the relevant date Use dd-mm-yy format
Delivery
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) 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
indicate whether MLC report and Police FIR
MLC Report & Police FIR attached Tick Yes or No
attached
Enter the system of medicine followed in
i) System of Medicene Open Text
treating the patient
SECTION E - DETAILS OF CLAIM
Enter the amount claimed as treatment In rupees (Do not enter paise
a) Details of Treatment Expences
expences values)
 indicate whether claim is for domiciliary
b) Claim for Domiciliary Hospitalization Tick Yes or No
hospitalization
Enter the amount claimed as lump sum / In rupees (Do not enter paise
c) Details of Lump sum/ Cash benifit claimed
cash benefit values)
indicate which supporting documents are
d) Claim documents Submitted-Check List Tick the right option
submitted
SECTION F - DETAILS OF BILLS ENCLOSED
Indicate which bills are enclosed with the amount in
rupees
SECTION G - DETAILS OF PRIMARY INSURED?s BANK ACCOUNT
As allotted by the Income Tax
a) PAN Enter the permanent account number
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
Enter the name of the beneficiary the cheque Name of the individual /
d) Cheque/ DD payable details
/ DD should be made out to organization in full
IFSC code of the Bank branch in
e) IFSC Code Enter the IFSC code of the Bank branch
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

DETAILS OF HOSPITAL:

a) Name of the
hospital:

b) Hospital ID: c) Type of Hospital: Network Non Network (if non network fill section E)

d) Name of the treating e) Qualification:

doctor:
f) Registration No. with g) Phone No.:
State Code:
DETAILS OF THE PATIENT ADMITTED:

a) Name of the VIBHARANI C A

Patient:

b) IP Registration c) Gender: d) Date of

Male Female
Number: birth:

e) Date of Admission: 14-JUL-2024 Time: f) Date of Discharge: 16-JUL-2024 Time:

g) Type of Emergency Planned Day Care h) If 1) Date of 2) Gravida

Admission: Maternity Maternity: Delivery: Status:

i) Status at time of Discharge to home Discharge to another hospital j) Total claimed

discharge: Deceased amount:
DETAILS OF AILMENT DIAGNOSED (PRIMARY):

a) ICD 10 Codes Description

I. Primary Diagnosis
ii. Additional Diagnosis:
iii. Co-morbidities:
iv. Co-morbidities:
b) ICD 10 Codes Description
i. Procedure 1:
ii. Procedure 2:
iii. Procedure 3:
iv. Details of Procedure

c) Pre-authorization obtained: Yes No d) Pre-authorization Number:

e) If authorization by network hospital not obtained,

give reason:

f) Hospitalization due to
injury: Yes No

i) If Yes, give cause Self-inflicted Road Traffic Accident Substance abuse / alcohol consumption
ii) If injury due to substance abuse /
alcohol consumption, Test conducted to Yes No (If Yes, attach reports)
establish this:
iii) If Medico legal: Yes No
iv) Reported to Police: Yes No
v) FIR No.:
vi) If not reported to police give reason:
CLAIM DOCUMENTS SUBMITTED - CHECK LIST:

Claim form duly signed Original Pre-authorization request Copy of the Pre-authorization approval letter Copy of Photo ID
Card of patient Verified by hospital Hospital Discharge summary
Operation Theatre Notes Investigation reports Hospital main bill Hospital break-up bill
CT/MR/USG/HPE investigation reports Doctor?s reference slip for investigation ECG Pharmacy bills
MLC reports & Police FIR Original death summary from hospital where applicable Any other, please specify
ADDITIONAL DETAILS IN CASE OF NON NETWORK HOSPITAL (ONLY FILL IN CASE OF NON-NETWORK
HOSPITAL):
a) Address of the Hospital CHAITANYA HOSPITAL,
City: State:
Pin Code: Phone No: Registration No. with
[PINCODE] 9620468495
State Code:
Number of inpatient
Hospital PAN:
beds
Facilities available in the
i. OT YES NO ii. ICU YES NO
hospital
DECLARATION BY THE HOSPITAL:
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.

Signature and Seal of the

Date: Place: Hospital Authority:

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 the hospital: Enter the name of hospital Name of the hospital in full
b) Hospital ID Enter ID number of hospital As allocated by the TPA
c) Type of Hospital Enter the name of the treating doctor Name of doctor in full
Abbreviations of
e) Qualification Enter the qualification of the treating doctor
educational qualifications
Enter the registration number of the doctor along As allocated by the Medical
f) Registration No. with State Code
with the state code Council of India
Include STD code with
g) Phone No. Enter the phone number of doctor
telephone number
SECTION B - DETAILS OF THE PATIENT ADMITTED
a) Name of Patient Enter the name of patient Name of patient in full
As allotted by the insurance
b) IP registration Number Enter insurance provider registration number
provider
c) Gender Indicate Gender of the patient Tick Male or Female
Number of years and
d) Age Enter age of the patient
months
e) Date of Birth Enter date of birth Use dd-mm-yy format
f) Date of Admission Enter date of admission Use dd-mm-yy format
g) Time Enter Time of admission Use hh:mm format
h) Date of Discharge Enter date of Discharge Use dd-mm-yy format
i) Time Enter time of Discharge Use hh:mm format
j) Type of Admission Indicate type of admission of patient Tick the right option
k) If Maternity
i) Date of Delivery Enter Date of Delivery if maternity Use dd-mm-yy format
ii) Gravida Status Enter Gravida status if maternity Use standard format
l) Status at time of discharge Indicate status of patient at time of discharge Tick the right option
In rupees (Do not enter
M) Total claimed amount Indicate the total claimed amount
paise values)
SECTION C - DETAILS OF AILMENT DIAGNOSED (PRIMARY)
a) ICD 10 Code
b) Gender Indicate Gender of the patient Tick Male or Female
Enter the ICD 10 Code and description of the Standard Format and Open
Primary Diagnosis
primary diagnosis text
Enter the ICD 10 Code and description of the Standard Format and Open
Additional Diagnosis
additional diagnosis text
Enter the ICD 10 Code and description of the Co- Standard Format and Open
Co-morbidities
morbidities text
b) ICD 10 PCS
Enter the ICD 10 Code and description of the first Standard Format and Open
Procedure 1
procedure text
Enter the ICD 10 Code and description of the Standard Format and Open
Procedure 2
second procedure text
Enter the ICD 10 Code and description of the third Standard Format and Open
Procedure 3
procedure text
Details of Procedure Enter the details of the procedure Open text
c) Pre-authorization obtained Indicate whether pre-authorization obtained Tick Yes or No
d) Pre-authorization Number Enter pre-authorization number As allotted by TPA
e) If authorization by network hospital not obtained, Enter reason for not obtaining pre-authorization
Open text
give reason number
f) 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
Indicate whether test conducted Tick Yes or No
test conducted to establish this
Medico Legal Indicate whether injury is medico legal Tick Yes or No
Reported to Police Indicate whether police report was filed Tick Yes or Not
As issued by police
FIR No. Enter first information report number
authrities
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
Include Street, City and Pin
a) Address Enter the full postal address
Code
Include STD code with
b) Phone No. Enter the phone number of hospital
telephone number
Enter the registration number of the Hospital
As allocated by the City
c) Registration No. with State Code obtained from local body like City Corporation /
Corporation / Municipality
Municipality
As allocated by the Income
d) Hospital PAN Enter the permanent account number
Tax Department
e) Number of Inpatient beds Enter the number of inpatient beds Digits
Tick the right option. If
f) Facilities available in the hospital Indicate facilities available in the hospital
others, please specify
SECTION F - DECLARATION BY THE HOSPITAL
Read declaration carefully and mention date (in
dd:mm:yy format), place (open text) and sign. and
stamp

DECLARATION:

Date Employee Signature

Date of Submission Generated On :- 20 Aug 2024