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STS Document Checklist

The document outlines the checklist and required enclosures for submitting claims related to medical expenses, including necessary forms, identification, and supporting documents. It specifies mandatory documents such as hospital bills, discharge summaries, and various certificates depending on the type of claim (death, maternity, accidental). Additionally, it includes a self-declaration confirming that the documents have not been submitted to any other insurance company.

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tusharsharma4ever2
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16 views2 pages

STS Document Checklist

The document outlines the checklist and required enclosures for submitting claims related to medical expenses, including necessary forms, identification, and supporting documents. It specifies mandatory documents such as hospital bills, discharge summaries, and various certificates depending on the type of claim (death, maternity, accidental). Additionally, it includes a self-declaration confirming that the documents have not been submitted to any other insurance company.

Uploaded by

tusharsharma4ever2
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Corporate Name :

Employee Name :
Date :
Employee Id / TPA Id :
Email Id :
KYC details of Insured: Pan Card , Aadhaar Card & NEFT details. (Cancelled Cheque with
printed name)
CHECK LIST OF ENCLOSURES FOR SUBMISSION OF CLAIMS YES√ NO×
Duly filled in Claim Form , ECS form , Cancel copy of CHEQUE & photo Id of Patient
attested from hospital
Photocopy of TPA card
Whether intimation given to TPA or HR within If not, declaration for delay in intimation
Approval from HR Leader
Declaration for delay submission in case claim documents not submitted within time limit
Basic Mandatory documents (Part A)
Original copy of consolidated bill on hospitals pre-printed stationery having serial
number , detail break-ups cost wise and quantity wise as break-up of laboratory
charges: Disposals Medicines, Medicines used in OT, Injections, Professional /
Consultancy charges, Nursing charges, Details of
Medical care (if any),Details for equipment charges (if any), Room rent – break-up with
number of days
Original copy of the receipt of payment (Bill Payment Receipt with Revenue Stamp) also to
attach receipts for advances if any paid to the hospital, consultants/surgeons within &
outside the main hospital bill.
Original Discharge summary in pre-printed stationery of hospital duly signed by the
consultant with hospital stamp and registration number of the hospital with Name, Age,
Gender of the patient &
summary of diagnosis and treatments done.
All original prescriptions for the medicine bills attached
All the Original Investigation Reports with Advice / prescriptions letter for Pathological and
Medical investigation with X-ray /MRI films .
Xerox copy of hospital registration certificate . If Registration is not there then declaration
from hospital stating no’s of beds in the hospital, 24hrs Nursing staff, Fully Equipped
Operation Theater & Qualified Doctors in the hospital. & Doctor/Surgeon's Registration
Number (On Doctor's Letter Head with
signature)
Require photo-copy of Indoor case papers.
If hospitalization is for 2 days then declaration from hospital authorities stating time of
Admission & Discharge
First consultation letter for the presenting complaints.
For Death Cases along with part A: Death summary in pre-printed stationery of hospital
signed by the consultant with hospital stamp and registration number of the hospital &
death certificate from
municipal corporation
For Maternity Cases along with part A: Original copy of treating doctor certificate, & obstetric
history (Gravida, Para, Living children, Abortions) & Last original sonography report
For Accidental Cases along with part A: 1. Attested copy of Medico - Legal Certificate (MLC)
report
2. Attested copy of FIR 3. Original copy of treating doctor's certificate with circumstances
and injuries sustained how / when / where (Alcoholic/drugs/intoxicant history before accident)
TAX INVOICE PHOTO COPY required for example 1> For IOL in case of Cataract 2> For
Stent / Valve / Pacemaker in case of CABG surgery / Open Heart 3>For Artificial Joints in
case of TKR / THR 4> Wire and rods in case accidents Etc..

STS Test Solution India Private Limited


CIN: U26510HR2024PTC121964
Registered Office: Unit No. 812, 8th Floor, Emaar Capital Tower 1, MG Road, Sikanderpur,
Sector – 26 Gurugram - 122002 Haryana India | Tel: +91 124 4726 430 | Fax: +91 124 4726 431
Self Declaration: This is to confirm that the above mentioned documents have not been
submitted by me to any other insurance company.
Number of pages submitted by the Claimant
(To write page number : Sr.No.01 onwards : for all the pages of your Claim Document)

Remarks : Employee Receiver


Sign Sign

Checklist Issued By : Ms. Anshi Singh


HR Manager
Issue Date : 22/04/2025

STS Test Solution India Private Limited


CIN: U26510HR2024PTC121964
Registered Office: Unit No. 812, 8th Floor, Emaar Capital Tower 1, MG Road, Sikanderpur,
Sector – 26 Gurugram - 122002 Haryana India | Tel: +91 124 4726 430 | Fax: +91 124 4726 431

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