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IPD Checklist

The document outlines the checklist of required documents for submitting hospitalization expense claims, including various forms, identification proofs, and hospital bills. It specifies the need for original and photocopied documents, as well as conditions for late submissions and specific cases like death or accidents. The checklist is intended for employees to ensure all necessary documentation is provided for a successful claim submission.

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abhimanyu thakur
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74 views1 page

IPD Checklist

The document outlines the checklist of required documents for submitting hospitalization expense claims, including various forms, identification proofs, and hospital bills. It specifies the need for original and photocopied documents, as well as conditions for late submissions and specific cases like death or accidents. The checklist is intended for employees to ensure all necessary documentation is provided for a successful claim submission.

Uploaded by

abhimanyu thakur
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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IPD-CHECKLIST FOR CLAIM SUBMISSION

Employee Name: Employee No.:

Company Name:

Mobile No.: Alternate Contact No.:

Email ID:

DOCUMENTS REQUIRED FOR CLAIMING HOSPITALIZATION EXPENSES


1) Claim Form – Part A: Duly completed by the insured on the prescribed format / MS claim form
2) Claim Form – Part B: Duly completed and signed by the hospital authorities
3) PPN Declaration Form ( GIPSA PPN hospital only )- Original
4) Medi Assist TPA ID Card – Photocopy
5) Photo ID proof (Employee ID card, Aadhar card etc.) – Photocopy
6) Cancelled Cheque of Employee’s Bank Account – Original
(Cancelled Cheque, with Employee name printed under place of signature)
7) Delay Letter in case of late submission of claim
8) Discharge Card/Summary – Original
(Gives the summary of diagnosis and treatment in hospital)
9) Death Summary (Instead of Discharge Summary) – Original
(Only in case of death of patient during Hospital stay)
10) Indoor Case Papers (ICP)
11) Police FIR/Medico Legal Certificate (MLC)
(Mandatory for All Road traffic accidents − Duly attested by Police)
12) Hospital Main Bill with bill no. & break up – Original
(With detailed break up of various heads like Room Rent/OT charges/Nursing etc.)
13) Hospital Payment receipt with receipt number – Original
(With seal & signature of hospital)
14) All Payment Receipts with receipt number – Original
(For consultation/surgeon charges, if charged outside the main hospital bill)
15) Investigation bills cum receipt – Original
16) Prescriptions – Original
(On Doctor’s letterhead, mentioning duration and dosage for medicines and advice for
diagnostic tests)
17) Pharmacy bills cum receipt/Cash Memo – Original
18) Investigation Reports – Original
(Reports for all tests done along with images like USG, X−Ray, ECG, etc. and Blood reports)
19) Sticker for the Implants used, along with supporting invoice – Original
(For Implants used in Cataract, Heart Valve, CABG, Abdominal, Knee replacement surgeries)

Document Available ✓

Document Not Available X


Not Applicable NA

Signature of Employee:

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