{"id":1065,"title":"CLAIM FORM - PROFESSIONAL INDEMNITY FOR MEDICAL MALPRACTICE","purpose":"claim","insurer":{"slug":"raheja-qbe-general-insurance","name":"Raheja QBE General Insurance Co. Ltd."},"source_pdf":"https://rahejaqbe.com/uploads/images/medical-corporate/pdf/download/claim-form.pdf","sha256":"9589f1fab386d400bd6b5ca220ef5d196a1b74f0097fbe165b7e418946ca46ed","pages":3,"collected":"2026-10-17","instructions":{"about":"This form is for notifying and claiming under the Medical Malpractice Corporate Insurance policy by the insured party when a claim or circumstance that may give rise to a claim occurs.","notes":["The issue of this form is not an admission of liability or waiver of policy terms.","Complete and return the form as soon as a claim or circumstance that may give rise to a claim is known.","If any details are unavailable at submission, they may be sent later."],"title":"CLAIM FORM - PROFESSIONAL INDEMNITY FOR MEDICAL MALPRACTICE","submit":{"to":"Raheja QBE General Insurance Company Limited","how":"","address":"Commerz, 10 Floor, International Business Park, Oberoi Garden City, Western Express Highway, Goregaon(E) Mumbai – 400 063"},"purpose":"claim","sections":[{"title":"A - Insured","fields":[{"help":"","type":"text","label":"Name","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"City & Pin Code","options":[],"required":null,"pdf_field":""},{"help":"Include phone number","type":"text","label":"Contact Person’s Name & Number","options":[],"required":null,"pdf_field":""},{"help":"","type":"email","label":"Email id","options":[],"required":null,"pdf_field":""},{"help":"Enter start and end dates of policy cover","type":"date","label":"Period of Cover From                             To","options":[],"required":null,"pdf_field":""},{"help":"","type":"amount","label":"Limit of Indemnity.","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"B – Details of Claim or circumstances","fields":[{"help":"Include time if possible","type":"date","label":"Date & Time of Occurrence","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Place of incident","options":[],"required":null,"pdf_field":""},{"help":"Describe the incident or circumstance in detail","type":"text","label":"Description of how the Claim has arisen or why a circumstance is being notified. (Pl attach a separate sheet if space is insufficient)","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Have the Police been informed","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"If police informed, provide station name","type":"text","label":"Name of Police Station","options":[],"required":null,"pdf_field":""},{"help":"","type":"date","label":"When did you first learn of the Claim/circumstances?","options":[],"required":null,"pdf_field":""},{"help":"Explain source of information","type":"text","label":"How did you learn about the Claim/circumstances?","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"C – Details of Claim","fields":[{"help":"Claimant's name","type":"text","label":"Name","options":[],"required":null,"pdf_field":""},{"help":"Claimant's address","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"Claimant's city and postal code","type":"text","label":"City & Pin Code","options":[],"required":null,"pdf_field":""},{"help":"Claimant's contact details","type":"text","label":"Contact Person’s Name & Number","options":[],"required":null,"pdf_field":""},{"help":"Claimant's email","type":"email","label":"Email id","options":[],"required":null,"pdf_field":""},{"help":"Specify medical condition treated","type":"text","label":"For what ailment was treatment given","options":[],"required":null,"pdf_field":""},{"help":"Outpatient or inpatient number","type":"text","label":"OPD/In Patient No:","options":[],"required":null,"pdf_field":""},{"help":"Describe treatment given","type":"text","label":"Details of treatment provided","options":[],"required":null,"pdf_field":""},{"help":"Additional relevant information","type":"text","label":"Please give all other information relevant to this claim. Use a separate sheet if required.","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"D – Details of Other Insurances covering this incident","fields":[{"help":"Other insurer's name if any","type":"text","label":"Name of Insurer","options":[],"required":null,"pdf_field":""},{"help":"Office that issued the other policy","type":"text","label":"Policy Issuing Office","options":[],"required":null,"pdf_field":""},{"help":"Other policy number","type":"text","label":"Policy Number","options":[],"required":null,"pdf_field":""},{"help":"Period covered by other policy","type":"text","label":"Policy Period","options":[],"required":null,"pdf_field":""},{"help":"Limit under other policy","type":"amount","label":"Limit of Indemnity","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"}],"deadlines":[],"applies_to":"Professional Indemnity for Medical Malpractice","attachments":["Separate sheet if space is insufficient for description of claim or circumstances","Separate sheet if required for claimant’s medical history","Separate sheet if required for other relevant information"],"declarations":["The information given in this claim form and any further information provided is correct and complete.","If any claim is dishonest or fraudulent by the insured or anyone acting on their behalf, the policy shall be void and all benefits forfeited."],"dropped_labels":1},"pdf_fields":null,"fillable_pdf":false,"send_to":[{"purpose":"claim","channel":"email","value":"customercare@rahejaqbe.com","label":"Claims service mail ID","level":null,"hours":"Monday to Saturday, 9 am to 8 pm","applies_to":"all","source_url":"https://rahejaqbe.com/claims","quote":"Commercial Lines Claims\nClick here\nto track you claim status\nClick here\nto Register a Claim\nIntermediaries\n18001027723\ncustomercare@rahejaqbe.com\nContact Us\nHospital\nLocator\nGarage\nLocator\nRegister\na Claim\nRegister\nComplaint With Us\nPolicy\nServicing\nLet us call you","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"email","value":"info@mediassistindia.com","label":"Medi Assist TPA Email","level":null,"hours":null,"applies_to":"health","source_url":"https://rahejaqbe.com/claims/health-claims","quote":"TPA.\nContact number-\n1800-4259-449\n,\n9122-66620808\n,\n1800202022\n,\n1800220102\n,\n080-28004114/18004257878\nEmail address-\ninfo@mediassistindia.com\n,\ncontact.phs@paramounttpa.com\n,\nsupport@volohealthtpa.com\n,\ncustomersupport@healthindiatpa.com\n,\nhelp@vidalhealthtpa.c","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"email","value":"cashless@mediassist.in","label":"Medi Assist TPA Cashless Email","level":null,"hours":null,"applies_to":"health","source_url":"https://rahejaqbe.com/claims/health-claims","quote":", kindly visit\nhttps://www.medibuddy.in/claim\nToll Free Number :\n1800-4259-449\nEmail Address :\ninfo@mediassistindia.com\ncashless@mediassist.in\nCashless everywhere\nReimbursement claim registration :\nRetail\nCorp employee\nMedi Assist Insurance TPA Pvt. Ltd.\n4th Flo","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"email","value":"contact.phs@paramounttpa.com","label":"Paramount TPA Email","level":null,"hours":null,"applies_to":"health","source_url":"https://rahejaqbe.com/claims/health-claims","quote":"4259-449\n,\n9122-66620808\n,\n1800202022\n,\n1800220102\n,\n080-28004114/18004257878\nEmail address-\ninfo@mediassistindia.com\n,\ncontact.phs@paramounttpa.com\n,\nsupport@volohealthtpa.com\n,\ncustomersupport@healthindiatpa.com\n,\nhelp@vidalhealthtpa.com\n,\nFor claim registration of","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"email","value":"nonetwork.phs@paramounttpa.com","label":"Paramount TPA Non-network Email","level":null,"hours":null,"applies_to":"health","source_url":"https://rahejaqbe.com/claims/health-claims","quote":"ttpa.com/PolicyClaim/PolyClaimStatus.aspx\nToll Free Number :\n9122-66620808\nEmail Address :\ncontact.phs@paramounttpa.com\nnonetwork.phs@paramounttpa.com\nCashless everywhere\nReimbursement claim registration\nClaim tracker/status for all type of claims.\nParamount TPA Office","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"email","value":"assistance@volohealthtpa.com","label":"Volo Health TPA Email","level":null,"hours":null,"applies_to":"health","source_url":"https://rahejaqbe.com/claims/health-claims","quote":"ed (Annual Disclosure) – Disclosures Data (22-23)\nTPA Details\nVolo Health\nToll Free Number :\n1800202022\nEmail Address :\nassistance@volohealthtpa.com\ncashlesseverywhere@volohealthtpa.com\nsupport@volohealthtpa.com\ncashless@volohealthtpa.com\nCashless everywhere\nReimburse","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"email","value":"cashlesseverywhere@volohealthtpa.com","label":"Volo Health TPA Cashless Email","level":null,"hours":null,"applies_to":"health","source_url":"https://rahejaqbe.com/claims/health-claims","quote":"losures Data (22-23)\nTPA Details\nVolo Health\nToll Free Number :\n1800202022\nEmail Address :\nassistance@volohealthtpa.com\ncashlesseverywhere@volohealthtpa.com\nsupport@volohealthtpa.com\ncashless@volohealthtpa.com\nCashless everywhere\nReimbursement claim registration\nClaim tracker","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"email","value":"support@volohealthtpa.com","label":"Volo Health TPA Support Email","level":null,"hours":null,"applies_to":"health","source_url":"https://rahejaqbe.com/claims/health-claims","quote":"202022\n,\n1800220102\n,\n080-28004114/18004257878\nEmail address-\ninfo@mediassistindia.com\n,\ncontact.phs@paramounttpa.com\n,\nsupport@volohealthtpa.com\n,\ncustomersupport@healthindiatpa.com\n,\nhelp@vidalhealthtpa.com\n,\nFor claim registration of other policies (\nSaral Surak","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"email","value":"cashless@volohealthtpa.com","label":"Volo Health TPA Cashless Email","level":null,"hours":null,"applies_to":"health","source_url":"https://rahejaqbe.com/claims/health-claims","quote":"1800202022\nEmail Address :\nassistance@volohealthtpa.com\ncashlesseverywhere@volohealthtpa.com\nsupport@volohealthtpa.com\ncashless@volohealthtpa.com\nCashless everywhere\nReimbursement claim registration\nClaim tracker/status for all type of claims.\nVolo Health Insurance","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"email","value":"customersupport@healthindiatpa.com","label":"HealthIndia Insurance TPA Email","level":null,"hours":null,"applies_to":"health","source_url":"https://rahejaqbe.com/claims/health-claims","quote":"004114/18004257878\nEmail address-\ninfo@mediassistindia.com\n,\ncontact.phs@paramounttpa.com\n,\nsupport@volohealthtpa.com\n,\ncustomersupport@healthindiatpa.com\n,\nhelp@vidalhealthtpa.com\n,\nFor claim registration of other policies (\nSaral Suraksha Bima\n,\nPravasi Bhartiya Bima Yoja","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"email","value":"preauth@healthindiaindiatpa.com","label":"HealthIndia Insurance TPA Preauth Email","level":null,"hours":null,"applies_to":"health","source_url":"https://rahejaqbe.com/claims/health-claims","quote":"pa.com/CustomerCorner/ClaimStatus.aspx\nToll Free Number :\n1800220102\nEmail Address :\ncustomersupport@healthindiatpa.com\npreauth@healthindiaindiatpa.com\nCashless everywhere\nReimbursement claim registration\nClaim tracker/status for all type of claims.\nHealthIndia Insurance","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"email","value":"help@vidalhealthtpa.com","label":"Vidal Health Insurance TPA Email","level":null,"hours":null,"applies_to":"health","source_url":"https://rahejaqbe.com/claims/health-claims","quote":"o@mediassistindia.com\n,\ncontact.phs@paramounttpa.com\n,\nsupport@volohealthtpa.com\n,\ncustomersupport@healthindiatpa.com\n,\nhelp@vidalhealthtpa.com\n,\nFor claim registration of other policies (\nSaral Suraksha Bima\n,\nPravasi Bhartiya Bima Yojana\n,\nGroup Hospital Cash\n,","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"email","value":"claims@rahejaqbe.com","label":"Claims email for two wheeler bundled policy","level":null,"hours":null,"applies_to":"motor","source_url":"https://rahejaqbe.com/uploads/images/tw-bundle/pdf/download/tw-bundle-_Prospectus-V01.pdf","quote":"800-102-7723 or in writing at the nearest Offices or through an intermediary.\n• Alternatively, you can also reach us at claims@rahejaqbe.com You can report with vehicle/ report claim at network garage whereby claim registration shall be done by network garage","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"18001027723","label":"Claims call centre","level":null,"hours":"Monday to Saturday, 9 am to 8 pm","applies_to":"all","source_url":"https://rahejaqbe.com/claims","quote":"ims!\nExplore\nCommercial Lines Claims\nClick here\nto track you claim status\nClick here\nto Register a Claim\nIntermediaries\n18001027723\ncustomercare@rahejaqbe.com\nContact Us\nHospital\nLocator\nGarage\nLocator\nRegister\na Claim\nRegister\nComplaint With Us\nPolic","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"1800-4259-449","label":"Medi Assist TPA Toll Free Number","level":null,"hours":null,"applies_to":"health","source_url":"https://rahejaqbe.com/claims/health-claims","quote":"p Up\n,\nArogya Sanjeevani\n,\nGroup Health Insurance\n,\nGroup Health Super Top Up\n) kindly contact our TPA.\nContact number-\n1800-4259-449\n,\n9122-66620808\n,\n1800202022\n,\n1800220102\n,\n080-28004114/18004257878\nEmail address-\ninfo@mediassistindia.com\n,\ncontact.","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"9122-66620808","label":"Paramount TPA Toll Free Number","level":null,"hours":null,"applies_to":"health","source_url":"https://rahejaqbe.com/claims/health-claims","quote":"njeevani\n,\nGroup Health Insurance\n,\nGroup Health Super Top Up\n) kindly contact our TPA.\nContact number-\n1800-4259-449\n,\n9122-66620808\n,\n1800202022\n,\n1800220102\n,\n080-28004114/18004257878\nEmail address-\ninfo@mediassistindia.com\n,\ncontact.phs@paramounttpa","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"1800202022","label":"Volo Health TPA Toll Free Number","level":null,"hours":null,"applies_to":"health","source_url":"https://rahejaqbe.com/claims/health-claims","quote":"Health Insurance\n,\nGroup Health Super Top Up\n) kindly contact our TPA.\nContact number-\n1800-4259-449\n,\n9122-66620808\n,\n1800202022\n,\n1800220102\n,\n080-28004114/18004257878\nEmail address-\ninfo@mediassistindia.com\n,\ncontact.phs@paramounttpa.com\n,\nsuppor","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"1800220102","label":"HealthIndia Insurance TPA Toll Free Number","level":null,"hours":null,"applies_to":"health","source_url":"https://rahejaqbe.com/claims/health-claims","quote":"ance\n,\nGroup Health Super Top Up\n) kindly contact our TPA.\nContact number-\n1800-4259-449\n,\n9122-66620808\n,\n1800202022\n,\n1800220102\n,\n080-28004114/18004257878\nEmail address-\ninfo@mediassistindia.com\n,\ncontact.phs@paramounttpa.com\n,\nsupport@volohealtht","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"080-28004114/18004257878","label":"Vidal Health Insurance TPA Toll Free Number","level":null,"hours":null,"applies_to":"health","source_url":"https://rahejaqbe.com/claims/health-claims","quote":"Health Super Top Up\n) kindly contact our TPA.\nContact number-\n1800-4259-449\n,\n9122-66620808\n,\n1800202022\n,\n1800220102\n,\n080-28004114/18004257878\nEmail address-\ninfo@mediassistindia.com\n,\ncontact.phs@paramounttpa.com\n,\nsupport@volohealthtpa.com\n,\ncustomersupport@he","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"1800-102-7723","label":"Call centre for claims intimation","level":null,"hours":"9 am to 8 pm, Monday to Saturday","applies_to":"all","source_url":"https://rahejaqbe.com/uploads/images/two-wheeler-package/pdf/download/tw-package-prospectus-V01.pdf","quote":"ct numbers specified in the Schedule to the Policy.\n• Intimation of claim can also be made to Raheja QBE Call centre at 1800-102-7723 or in writing at the nearest Offices or through the intermediary.\n• Alternatively, you can also reach us at customercar","fetched_at":"2026-10-20"}],"how_to_use":"Ask the user for each field in order, in plain words; never invent an answer. Labels are as printed. If fillable_pdf is true, pdf_fields gives the PDF's own field names so the file can be filled directly. The printed form decides if anything differs.","url":"https://indiainsurances.com/forms/raheja-qbe-general-insurance/1065-claim-form-professional-indemnity-for-medical-malpractice"}