{"id":1103,"title":"SBIG Health Super Top-Up Claim Form","purpose":"claim","insurer":{"slug":"sbi-general-insurance","name":"SBI General Insurance Company Limited"},"source_pdf":"https://content.sbigeneral.in/uploads/6961c710792d4a2284f3f3b1a348fa5a.pdf","sha256":"9e02c2fe118643912037c7b52938b704d0cf61872bb1563cdb6308087023de66","pages":7,"collected":"2026-10-17","instructions":{"about":"This form is used by the insured or claimant to submit a health insurance claim for hospitalization and related expenses under the SBIG Health Super Top-Up policy.","notes":["Use dd-mm-yy format for dates and hh:mm format for times.","Enter amounts in rupees without paise values.","Tick the appropriate options where indicated.","Provide all required supporting documents as per the checklist.","Declarations must be signed and dated by the insured and hospital where applicable.","Fill hospital and patient details carefully if hospital is non-network.","Use block letters where possible for clarity."],"title":"SBIG Health Super Top-Up Claim Form","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Details of Hospitalization","fields":[{"help":"Enter the full name of the hospital","type":"text","label":"Name of Hospital where Admitted:","options":[],"required":null,"pdf_field":""},{"help":"Tick the appropriate room category","type":"choice","label":"Room Category occupied:","options":["Day care","Single occupancy","Twin sharing","3 or more beds per room"],"required":null,"pdf_field":""},{"help":"Tick the reason for hospitalization","type":"choice","label":"Hospitalization due to:","options":["Injury","Illness","Maternity"],"required":null,"pdf_field":""},{"help":"Enter the relevant date in dd-mm-yy format","type":"date","label":"Date of Injury / Date Disease first detected /Date of Delivery:","options":[],"required":null,"pdf_field":""},{"help":"Enter date of admission in dd-mm-yy format","type":"date","label":"Date of Admission:","options":[],"required":null,"pdf_field":""},{"help":"Enter time of admission in hh:mm format","type":"text","label":"Time:","options":[],"required":null,"pdf_field":""},{"help":"Enter date of discharge in dd-mm-yy format","type":"date","label":"Date of Discharge:","options":[],"required":null,"pdf_field":""},{"help":"Enter time of discharge in hh:mm format","type":"text","label":"Time:","options":[],"required":null,"pdf_field":""},{"help":"Tick the cause of injury","type":"choice","label":"If Injury give cause:","options":["Road Traffic Accident","Self inflicted","Substance Abuse / Alcohol Consumption"],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"If Medico legal:","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"Reported to police:","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"MLC Report & Police FIR attached:","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter the system of medicine used for treatment","type":"text","label":"System of Medicine:","options":[],"required":null,"pdf_field":""}],"filled_by":"claimant or insured"},{"title":"Details of Claim","fields":[{"help":"Enter amounts in rupees without paise","type":"amount","label":"Details of the treatment expenses claimed","options":[],"required":null,"pdf_field":""},{"help":"Enter amount in rupees","type":"amount","label":"Pre-hospitalization Expenses:","options":[],"required":null,"pdf_field":""},{"help":"Enter amount in rupees","type":"amount","label":"Hospitalization Expenses:","options":[],"required":null,"pdf_field":""},{"help":"Enter amount in rupees","type":"amount","label":"Post-hospitalization Expenses:","options":[],"required":null,"pdf_field":""},{"help":"Enter amount in rupees","type":"amount","label":"Health-Check up Cost:","options":[],"required":null,"pdf_field":""},{"help":"Enter amount in rupees","type":"amount","label":"Ambulance Charges:","options":[],"required":null,"pdf_field":""},{"help":"Enter amount in rupees and specify code","type":"amount","label":"Others (code):","options":[],"required":null,"pdf_field":""},{"help":"Total amount claimed in rupees","type":"amount","label":"Total","options":[],"required":null,"pdf_field":""},{"help":"Enter number of days","type":"number","label":"Pre-hospitalization period:","options":[],"required":null,"pdf_field":""},{"help":"Enter number of days","type":"number","label":"Post-hospitalization period:","options":[],"required":null,"pdf_field":""},{"help":"Tick Yes or No; if Yes, provide details in annexure","type":"yes-no","label":"Claim for Domiciliary Hospitalization:","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter amounts in rupees without paise","type":"amount","label":"Details of Lump sum / cash benefit claimed","options":[],"required":null,"pdf_field":""},{"help":"Enter amount in rupees","type":"amount","label":"Hospital Daily Cash:","options":[],"required":null,"pdf_field":""},{"help":"Enter amount in rupees","type":"amount","label":"Surgical Cash:","options":[],"required":null,"pdf_field":""},{"help":"Enter amount in rupees","type":"amount","label":"Critical Illness Benefit:","options":[],"required":null,"pdf_field":""},{"help":"Enter amount in rupees","type":"amount","label":"Convalescence:","options":[],"required":null,"pdf_field":""},{"help":"Enter amount in rupees","type":"amount","label":"Pre/Post hospitalization","options":[],"required":null,"pdf_field":""},{"help":"Enter amount in rupees","type":"amount","label":"Others:","options":[],"required":null,"pdf_field":""},{"help":"Tick the documents submitted","type":"checkbox","label":"Claim Documents Submitted- Check List","options":["Claim Form Duly signed","Copy of the claim intimation, if any","Hospital Break-up Bill","Hospital Bill Payment Receipt","Hospital Discharge Summary","Pharmacy Bill","Operation Theatre Notes","ECG","Doctor's request for investigation","Investigation Reports (Including CT/ MRI / USG / HPE)","Doctor's Prescriptions","Others"],"required":null,"pdf_field":""}],"filled_by":"claimant or insured"},{"title":"Details of Bills Enclosed","fields":[{"help":"Fill columns: SI. No, Bill No, Date (DDMMYY), Issued by, Towards, Amount (Rs)","type":"table","label":"Details of Bills Enclosed","options":[],"required":null,"pdf_field":""}],"filled_by":"claimant or insured"},{"title":"Details of Primary Insured's Bank Account","fields":[{"help":"Enter Permanent Account Number as allotted by Income Tax department","type":"text","label":"PAN","options":[],"required":null,"pdf_field":""},{"help":"Enter bank account number as allotted by the bank","type":"text","label":"Account Number","options":[],"required":null,"pdf_field":""},{"help":"Enter full name of bank and branch","type":"text","label":"Bank Name and Branch","options":[],"required":null,"pdf_field":""},{"help":"Enter name of beneficiary for cheque/DD","type":"text","label":"Cheque/DD payable details","options":[],"required":null,"pdf_field":""},{"help":"Enter IFSC code of bank branch","type":"text","label":"IFSC Code","options":[],"required":null,"pdf_field":""}],"filled_by":"claimant or insured"},{"title":"Declaration by the Insured","fields":[{"help":"Read declaration carefully, enter date (dd:mm:yy), place, and sign","type":"signature","label":"Declaration","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"},{"title":"Additional Details in Case of Non Network Hospital","fields":[{"help":"Enter full postal address including city, state, and pin code","type":"text","label":"Address of the Hospital","options":[],"required":null,"pdf_field":""},{"help":"Enter city","type":"text","label":"City","options":[],"required":null,"pdf_field":""},{"help":"Enter state","type":"text","label":"State","options":[],"required":null,"pdf_field":""},{"help":"Enter pin code","type":"text","label":"Pin Code","options":[],"required":null,"pdf_field":""},{"help":"Enter hospital phone number with STD code","type":"phone","label":"Phone No.","options":[],"required":null,"pdf_field":""},{"help":"Enter hospital registration number with state code","type":"text","label":"Registration No. with State Code","options":[],"required":null,"pdf_field":""},{"help":"Enter hospital PAN as allotted by Income Tax department","type":"text","label":"Hospital PAN","options":[],"required":null,"pdf_field":""},{"help":"Enter number of inpatient beds","type":"number","label":"Number of Inpatient beds","options":[],"required":null,"pdf_field":""},{"help":"Tick available facilities; specify others if any","type":"checkbox","label":"Facilities available in the hospital","options":["OT","ICU","Others"],"required":null,"pdf_field":""}],"filled_by":"hospital"},{"title":"Declaration by the Hospital","fields":[{"help":"Read declaration carefully, enter date (DDMMYYYY), place, and sign","type":"signature","label":"Declaration","options":[],"required":true,"pdf_field":""}],"filled_by":"hospital"},{"title":"Details of Hospital (To be filled by hospital)","fields":[{"help":"Enter full name of hospital","type":"text","label":"Name of Hospital","options":[],"required":null,"pdf_field":""},{"help":"Enter hospital ID as allocated by TPA","type":"text","label":"Hospital ID","options":[],"required":null,"pdf_field":""},{"help":"Tick appropriate option","type":"choice","label":"Type of Hospital","options":["In network","Non network"],"required":null,"pdf_field":""},{"help":"Enter full name of treating doctor","type":"text","label":"Name of treating doctor","options":[],"required":null,"pdf_field":""},{"help":"Enter educational qualifications of doctor","type":"text","label":"Qualification","options":[],"required":null,"pdf_field":""},{"help":"Enter registration number with state code as per Medical Council of India","type":"text","label":"Registration No. with State Code","options":[],"required":null,"pdf_field":""},{"help":"Enter phone number with STD code","type":"phone","label":"Phone No.","options":[],"required":null,"pdf_field":""}],"filled_by":"hospital"},{"title":"Details of Patient Admitted (To be filled by hospital)","fields":[{"help":"Enter full name of patient","type":"text","label":"Name of Patient","options":[],"required":null,"pdf_field":""},{"help":"Enter insurance provider registration number","type":"text","label":"IP Registration Number","options":[],"required":null,"pdf_field":""},{"help":"Tick appropriate gender","type":"choice","label":"Gender","options":["Male","Female"],"required":null,"pdf_field":""},{"help":"Enter age in years and months","type":"text","label":"Age","options":[],"required":null,"pdf_field":""},{"help":"Enter date of birth in dd-mm-yy format","type":"date","label":"Date of Birth","options":[],"required":null,"pdf_field":""},{"help":"Enter date of admission in dd-mm-yy format","type":"date","label":"Date of Admission","options":[],"required":null,"pdf_field":""},{"help":"Enter time of admission in hh:mm format","type":"text","label":"Time","options":[],"required":null,"pdf_field":""},{"help":"Enter date of discharge in dd-mm-yy format","type":"date","label":"Date of Discharge","options":[],"required":null,"pdf_field":""},{"help":"Enter time of discharge in hh:mm format","type":"text","label":"Time","options":[],"required":null,"pdf_field":""},{"help":"Tick the type of admission","type":"choice","label":"Type of Admission","options":[],"required":null,"pdf_field":""},{"help":"Enter date of delivery in dd-mm-yy format if maternity","type":"date","label":"If Maternity - Date of Delivery","options":[],"required":null,"pdf_field":""},{"help":"Enter gravida status if maternity","type":"text","label":"Gravida Status","options":[],"required":null,"pdf_field":""},{"help":"Tick the status of patient at discharge","type":"choice","label":"Status at time of discharge","options":[],"required":null,"pdf_field":""},{"help":"Enter total claimed amount in rupees","type":"amount","label":"Total claimed amount","options":[],"required":null,"pdf_field":""}],"filled_by":"hospital"},{"title":"Details of Ailment Diagnosed (Primary) (To be filled by hospital)","fields":[{"help":"Enter ICD 10 code and description of primary diagnosis","type":"text","label":"ICD 10 Code - Primary Diagnosis","options":[],"required":null,"pdf_field":""},{"help":"Enter ICD 10 code and description of additional diagnosis","type":"text","label":"Additional Diagnosis","options":[],"required":null,"pdf_field":""},{"help":"Enter ICD 10 code and description of co-morbidities","type":"text","label":"Co-morbidities","options":[],"required":null,"pdf_field":""},{"help":"Enter ICD 10 PCS code and description of first procedure","type":"text","label":"ICD 10 PCS - Procedure 1","options":[],"required":null,"pdf_field":""},{"help":"Enter ICD 10 PCS code and description of second procedure","type":"text","label":"Procedure 2","options":[],"required":null,"pdf_field":""},{"help":"Enter ICD 10 PCS code and description of third procedure","type":"text","label":"Procedure 3","options":[],"required":null,"pdf_field":""},{"help":"Enter details of the procedure","type":"text","label":"Details of Procedure","options":[],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"Pre-authorization obtained","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter pre-authorization number allotted by TPA","type":"text","label":"Pre-authorization Number","options":[],"required":null,"pdf_field":""},{"help":"Enter reason for not obtaining pre-authorization","type":"text","label":"If authorization by network hospital not obtained, give reason","options":[],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"Hospitalization due to injury","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Tick cause of injury","type":"choice","label":"Cause","options":["Road Traffic Accident","Self inflicted","Substance Abuse / Alcohol Consumption"],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"If injury due to substance abuse/alcohol consumption, test conducted to establish this","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"Medico Legal","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"Reported To Police","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter First Information Report number issued by police","type":"text","label":"FIR No.","options":[],"required":null,"pdf_field":""},{"help":"Enter reason for not reporting to police","type":"text","label":"If not reported to police, give reason","options":[],"required":null,"pdf_field":""}],"filled_by":"hospital"},{"title":"Claim Documents Submitted - Check List (To be filled by hospital)","fields":[{"help":"Tick the supporting documents submitted","type":"checkbox","label":"Claim Documents Submitted - Check List","options":[],"required":null,"pdf_field":""}],"filled_by":"hospital"},{"title":"Declaration by the Hospital","fields":[{"help":"Read declaration carefully, enter date (dd:mm:yy), place, and sign and stamp","type":"signature","label":"Declaration","options":[],"required":true,"pdf_field":""}],"filled_by":"hospital"}],"deadlines":[],"applies_to":"health insurance claims for hospitalization, pre-hospitalization, post-hospitalization, domiciliary hospitalization, and lump sum/cash benefits under the SBIG Health Super Top-Up policy","attachments":["Claim Form Duly signed","Copy of the claim intimation, if any","Hospital Break-up Bill","Hospital Bill Payment Receipt","Hospital Discharge Summary","Pharmacy Bill","Operation Theatre Notes","ECG","Doctor's request for investigation","Investigation Reports (Including CT/ MRI / USG / HPE)","Doctor's Prescriptions","Others"],"declarations":["The information furnished in this claim form is true and correct to the best of my knowledge and belief.","False or untrue statements, suppression or concealment of material facts will forfeit the right to claim reimbursement.","Consent and authorize TPA/insurance company to seek necessary medical information/documents from any hospital/Medical Practitioner.","All bills/receipts for this claim are included and no supplementary claim will be made except pre/post-hospitalization claims if any.","Acceptance of the amount is in full discharge of obligations under the policy to the insured person and/or legal heirs.","The insured will hold the insurer indemnified if any claim is made against the insurer by any other person.","The hospital declares that the information furnished is true and correct to the best of their knowledge and belief.","False or untrue statements by the hospital will forfeit the right to claim under this claim."],"dropped_labels":0},"pdf_fields":null,"fillable_pdf":false,"send_to":[{"purpose":"claim","channel":"email","value":"customer.care@sbigeneral.in","label":"Motor Claims Email","level":null,"hours":null,"applies_to":"motor","source_url":"https://www.sbigeneral.in/claim/motor","quote":"m\nRegister or Track Claim Status with one simple click\nIntimate Claim\nCheck Claim Status\n1800 102 1111\n(Available 24/7)\ncustomer.care@sbigeneral.in\nMail ID\nSmooth rides, smoother claims\nBecause you deserve worry-free journeys, always\nDownload SBIG App\nRegister or Tra","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"email","value":"sbig.health@sbigeneral.in","label":"Health Claims Email","level":null,"hours":null,"applies_to":"health","source_url":"https://www.sbigeneral.in/claim/health","quote":"ailable 24/7\n1800 210 3366\n/\n1800 210 6366\nSMS Us:\n“HEALTHCLAIM”\nto\n561612\nEmail Us:\nseniorcitizen.health@sbigeneral.in\nsbig.health@sbigeneral.in\n18,000+\nNetwork Hospitals\nHealth Vertical Office:\nSBI General Insurance Company Limited,\n9th Floor, Westport, Pan Card","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"email","value":"seniorcitizen.health@sbigeneral.in","label":"Senior Citizen Health Claims Email","level":null,"hours":null,"applies_to":"health","source_url":"https://www.sbigeneral.in/claim/health","quote":"Feel Free to Reach Out\nCall Us:\nAvailable 24/7\n1800 210 3366\n/\n1800 210 6366\nSMS Us:\n“HEALTHCLAIM”\nto\n561612\nEmail Us:\nseniorcitizen.health@sbigeneral.in\nsbig.health@sbigeneral.in\n18,000+\nNetwork Hospitals\nHealth Vertical Office:\nSBI General Insurance Company Limited,\n9th","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"1800 102 1111","label":"Motor Claims Toll-free Number","level":null,"hours":"Available 24/7","applies_to":"motor","source_url":"https://www.sbigeneral.in/claim/motor","quote":"e Claim\nFAQs\nDownload Claim Form\nRegister or Track Claim Status with one simple click\nIntimate Claim\nCheck Claim Status\n1800 102 1111\n(Available 24/7)\ncustomer.care@sbigeneral.in\nMail ID\nSmooth rides, smoother claims\nBecause you deserve worry-free journ","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"1800 210 3366","label":"Health Claims Toll-free Number","level":null,"hours":"Available 24/7","applies_to":"health","source_url":"https://www.sbigeneral.in/claim/health","quote":"e simple click\nCheck Claim Status\nIntimate Claim\nFor any Queries, Please Feel Free to Reach Out\nCall Us:\nAvailable 24/7\n1800 210 3366\n/\n1800 210 6366\nSMS Us:\n“HEALTHCLAIM”\nto\n561612\nEmail Us:\nseniorcitizen.health@sbigeneral.in\nsbig.health@sbigeneral.in","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"1800 210 6366","label":"Health Claims Toll-free Number","level":null,"hours":"Available 24/7","applies_to":"health","source_url":"https://www.sbigeneral.in/claim/health","quote":"heck Claim Status\nIntimate Claim\nFor any Queries, Please Feel Free to Reach Out\nCall Us:\nAvailable 24/7\n1800 210 3366\n/\n1800 210 6366\nSMS Us:\n“HEALTHCLAIM”\nto\n561612\nEmail Us:\nseniorcitizen.health@sbigeneral.in\nsbig.health@sbigeneral.in\n18,000+\nNetwork","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"sms","value":"561612","label":"Health Claims SMS 'HEALTHCLAIM'","level":null,"hours":null,"applies_to":"health","source_url":"https://www.sbigeneral.in/claim/health","quote":"y Queries, Please Feel Free to Reach Out\nCall Us:\nAvailable 24/7\n1800 210 3366\n/\n1800 210 6366\nSMS Us:\n“HEALTHCLAIM”\nto\n561612\nEmail Us:\nseniorcitizen.health@sbigeneral.in\nsbig.health@sbigeneral.in\n18,000+\nNetwork Hospitals\nHealth Vertical Office","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/sbi-general-insurance/1103-sbig-health-super-top-up-claim-form"}