{"id":1110,"title":"CLAIM FORM FOR HEALTH INSURANCE POLICIES OTHER THAN TRAVEL AND PERSONAL ACCIDENT – PART A","purpose":"claim","insurer":{"slug":"sbi-general-insurance","name":"SBI General Insurance Company Limited"},"source_pdf":"https://content.sbigeneral.in/uploads/c73b6625bbaa48308601e6b32c9fec8c.pdf","sha256":"3898e161a6b04c374a70b88c02b8cd4af6fd9b7d6f587e496a7397d906bb5283","pages":7,"collected":"2026-10-17","instructions":{"about":"This form is used by the insured person or policyholder to claim health insurance benefits under the Arogya Premier Policy. Part A is filled by the insured, and Part B is filled by the hospital.","notes":["Fill the form in block letters.","Use the specified date formats (dd-mm-yy or mm-yy) and time format (hh:mm) as indicated.","Attach all original bills and documents as per the checklist.","All fields in the Payee Details section are mandatory; enclose a cancelled cheque copy.","Part A is to be filled by the insured; Part B is to be filled by the hospital.","The issue of Part B form is not an admission of liability.","Use the guidance provided for each section to fill the form correctly."],"title":"CLAIM FORM FOR HEALTH INSURANCE POLICIES OTHER THAN TRAVEL AND PERSONAL ACCIDENT – PART A","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"A. DETAILS OF PRIMARY INSURED","fields":[{"help":"Enter the policy number as allotted by the insurance company","type":"text","label":"Policy No:","options":[],"required":null,"pdf_field":""},{"help":"Enter the social insurance number or certificate number as allotted by the organization","type":"text","label":"Sl. No/ Certificate No:","options":[],"required":null,"pdf_field":""},{"help":"Enter the TPA ID number as allotted by IRDA and printed in TPA documents","type":"text","label":"Company/ TPA ID No:","options":[],"required":null,"pdf_field":""},{"help":"Enter the full name of the policyholder (Surname, First name, Middle name)","type":"text","label":"Name:","options":[],"required":null,"pdf_field":""},{"help":"Enter full postal address including street, city, state, and pin code","type":"text","label":"Address :","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"City:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"State:","options":[],"required":null,"pdf_field":""},{"help":"","type":"number","label":"Pin Code:","options":[],"required":null,"pdf_field":""},{"help":"Include STD code with telephone number","type":"phone","label":"Phone No:","options":[],"required":null,"pdf_field":""},{"help":"Enter complete email address","type":"email","label":"Email ID:","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"B. DETAILS OF INSURANCE HISTORY","fields":[{"help":"Tick Yes or No","type":"choice","label":"Currently covered by any other Mediclaim / Health Insurance:","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Use dd-mm-yy format","type":"date","label":"Date of commencement of first Insurance without break:","options":[],"required":null,"pdf_field":""},{"help":"Enter full name of the insurance company","type":"text","label":"If yes, Company Name:","options":[],"required":null,"pdf_field":""},{"help":"Enter policy number as allotted by the insurance company","type":"text","label":"Policy No.:","options":[],"required":null,"pdf_field":""},{"help":"Enter total sum insured as per the policy in rupees","type":"amount","label":"Sum Insured (Rs.):","options":[],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"choice","label":"Have you been hospitalized in the last four years since inception of the contract?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Use mm-yy format","type":"date","label":"Date:","options":[],"required":null,"pdf_field":""},{"help":"Enter diagnosis details","type":"text","label":"Diagnosis:","options":[],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"choice","label":"Previously covered by any other Mediclaim/Health insurance:","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter full name of the insurance company","type":"text","label":"If yes, Company Name:","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"C. DETAILS OF INSURED PERSON HOSPITALIZED","fields":[{"help":"Enter full name of the patient (Surname, First name, Middle name)","type":"text","label":"Name:","options":[],"required":null,"pdf_field":""},{"help":"Tick Male or Female","type":"choice","label":"Gender:","options":["Male","Female"],"required":null,"pdf_field":""},{"help":"Enter age in years and months","type":"number","label":"Age:","options":[],"required":null,"pdf_field":""},{"help":"Use dd-mm-yy format","type":"date","label":"Date of Birth:","options":[],"required":null,"pdf_field":""},{"help":"Tick the right option or specify if Other","type":"choice","label":"Relationship to Primary insured:","options":["Self","Spouse","Child","Father","Mother","Other (Please Specify)"],"required":null,"pdf_field":""},{"help":"Tick the right option or specify if Other","type":"choice","label":"Occupation:","options":["Service","Self Employed","Homemaker","Student","Retired","Other (Please Specify)"],"required":null,"pdf_field":""},{"help":"Enter full postal address including street, city, state, and pin code","type":"text","label":"Address (if different from above):","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"City:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"State:","options":[],"required":null,"pdf_field":""},{"help":"","type":"number","label":"Pin Code:","options":[],"required":null,"pdf_field":""},{"help":"Include STD code with telephone number","type":"phone","label":"Phone No:","options":[],"required":null,"pdf_field":""},{"help":"Enter complete email address","type":"email","label":"E-mail ID:","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"D. DETAILS OF HOSPITALIZATION","fields":[{"help":"Enter full name of hospital","type":"text","label":"Name of Hospital where Admitted:","options":[],"required":null,"pdf_field":""},{"help":"Tick the right option","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 right option","type":"choice","label":"Hospitalization due to:","options":["Injury","Illness","Maternity"],"required":null,"pdf_field":""},{"help":"Use dd-mm-yy format","type":"date","label":"Date of Injury / Date Disease first detected /Date of Delivery:","options":[],"required":null,"pdf_field":""},{"help":"Use 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":"Use 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 right option","type":"choice","label":"If Injury give cause:","options":["Self inflicted","Road Traffic Accident","Substance Abuse / Alcohol Consumption"],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"choice","label":"If Medico legal:","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"choice","label":"Reported to police:","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"choice","label":"MLC Report & Police FIR attached:","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter the system of medicine followed in treatment","type":"text","label":"System of Medicine:","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"E. DETAILS OF CLAIM","fields":[{"help":"Enter amounts in rupees for: Pre-hospitalization Expenses, Hospitalization Expenses, Post-hospitalization Expenses, Health-Check up Cost, Ambulance Charges, Others (code), and Total","type":"table","label":"Details of the treatment expenses claimed","options":[],"required":null,"pdf_field":""},{"help":"Enter number of days","type":"number","label":"Pre-hospitalization period (days):","options":[],"required":null,"pdf_field":""},{"help":"Enter number of days","type":"number","label":"Post-hospitalization period (days):","options":[],"required":null,"pdf_field":""},{"help":"Tick Yes or No; if yes, provide details in annexure","type":"choice","label":"Claim for Domiciliary Hospitalization:","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter amounts in rupees for: Hospital Daily Cash, Surgical Cash, Critical Illness Benefit, Convalescence, Pre/Post hospitalization, Others, and Lump sum benefit","type":"table","label":"Details of Lump sum / cash benefit claimed","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","Doctor’s Prescriptions","Others (Including CT/ MRI / USG / HPE)"],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"F. DETAILS OF BILLS ENCLOSED","fields":[{"help":"Fill Sl. No, Bill No, Date, Issued by, Towards, Amount (Rs) for Hospital Main Bill, Pre-hospitalization Bills, Post-hospitalization Bills, Pharmacy Bills, and others","type":"table","label":"Bills Enclosed","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"G. PAYEE DETAILS","fields":[{"help":"Enter full bank name","type":"text","label":"Bank Name:","options":[],"required":true,"pdf_field":""},{"help":"Enter bank branch","type":"text","label":"Bank Branch:","options":[],"required":true,"pdf_field":""},{"help":"Enter bank account number","type":"text","label":"Bank Account No.:","options":[],"required":true,"pdf_field":""},{"help":"Enter IFSC code of bank branch","type":"text","label":"IFSC Code:","options":[],"required":true,"pdf_field":""},{"help":"Enter MICR number","type":"text","label":"MICR No.:","options":[],"required":true,"pdf_field":""},{"help":"Enter Permanent Account Number as allotted by Income Tax department","type":"text","label":"PAN No.:","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"},{"title":"H. DECLARATION BY THE INSURED","fields":[{"help":"Enter date in dd-mm-yy format","type":"date","label":"Date:","options":[],"required":true,"pdf_field":""},{"help":"Sign the form","type":"signature","label":"Signature of the Insured","options":[],"required":true,"pdf_field":""},{"help":"Enter place","type":"text","label":"Place:","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"},{"title":"CLAIM FORM PART B : TO BE FILLED IN BY THE HOSPITAL","fields":[{"help":"Enter full name of hospital","type":"text","label":"Name of the 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 the right option","type":"choice","label":"Type of Hospital:","options":["Network","Non Network"],"required":null,"pdf_field":""},{"help":"Enter full name of treating doctor","type":"text","label":"Name of the treating doctor:","options":[],"required":null,"pdf_field":""},{"help":"Enter educational qualifications","type":"text","label":"Qualification:","options":[],"required":null,"pdf_field":""},{"help":"Enter registration number with state code","type":"text","label":"Registration no with State Code:","options":[],"required":null,"pdf_field":""},{"help":"Include STD code with telephone number","type":"phone","label":"Phone No.:","options":[],"required":null,"pdf_field":""},{"help":"Enter full name of patient","type":"text","label":"Name of the patient:","options":[],"required":null,"pdf_field":""},{"help":"Enter insurance provider registration number","type":"text","label":"IP Registration No:","options":[],"required":null,"pdf_field":""},{"help":"Tick Male or Female","type":"choice","label":"Gender:","options":["Male","Female"],"required":null,"pdf_field":""},{"help":"Enter age in years and months","type":"number","label":"Age:","options":[],"required":null,"pdf_field":""},{"help":"Use dd-mm-yy format","type":"date","label":"Date of Birth:","options":[],"required":null,"pdf_field":""},{"help":"Use 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":"Use 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 right option","type":"choice","label":"Type of Admission:","options":["Emergency","Planned","Day Care","Maternity"],"required":null,"pdf_field":""},{"help":"Use dd-mm-yy format","type":"date","label":"If Maternity - Date of Delivery:","options":[],"required":null,"pdf_field":""},{"help":"Enter gravida status","type":"text","label":"Gravida Status:","options":[],"required":null,"pdf_field":""},{"help":"Tick the right option","type":"choice","label":"Status at the time of discharge:","options":["Discharge to home","Discharge to another hospital","Deceased"],"required":null,"pdf_field":""},{"help":"Enter total claimed amount in rupees","type":"amount","label":"Total claimed amount:","options":[],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"choice","label":"Pre-authorization obtained:","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter pre-authorization number as allotted by TPA","type":"text","label":"Pre-authorization Number:","options":[],"required":null,"pdf_field":""},{"help":"Enter reason","type":"text","label":"If authorization by network hospital not obtained, give reason:","options":[],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"choice","label":"Hospitalization due to Injury:","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Tick the right option","type":"choice","label":"If Injury, give cause:","options":["Self-Inflicted","Road Traffic Accident","Substance abuse/ alcohol consumption"],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"choice","label":"If Medico Legal:","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"choice","label":"Reported to Police:","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter FIR number","type":"text","label":"FIR No.:","options":[],"required":null,"pdf_field":""},{"help":"Enter reason","type":"text","label":"If not reported to police give reason:","options":[],"required":null,"pdf_field":""},{"help":"Tick the documents submitted","type":"checkbox","label":"Claim Documents Submitted Check List","options":["Claim Form duly signed","Investigation reports","Original Pre-authorization request","CT/MR/USG/HPE investigation reports","Copy of the Pre-authorization approval letter","Doctors reference slip for investigation ECG","Copy of photo ID card of patient verified by hospital","Pharmacy bills","Hospital Discharge summary","Operation Theatre notes","MLC report & Police FIR","Hospital main bill","Original death summary from hospital where applicable","Hospital break-up bill","Any other (please specify)"],"required":null,"pdf_field":""}],"filled_by":"hospital"},{"title":"E. 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":"","type":"text","label":"City:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"State:","options":[],"required":null,"pdf_field":""},{"help":"","type":"number","label":"Pin Code:","options":[],"required":null,"pdf_field":""},{"help":"Include STD code with telephone number","type":"phone","label":"Phone No.:","options":[],"required":null,"pdf_field":""},{"help":"Enter registration number with state code","type":"text","label":"Registration No. with State Code:","options":[],"required":null,"pdf_field":""},{"help":"Enter permanent account number","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 the facilities available; specify others if any","type":"checkbox","label":"Facilities available in the hospital:","options":["OT","ICU","Others"],"required":null,"pdf_field":""}],"filled_by":"hospital"},{"title":"F. DECLARATION BY THE HOSPITAL","fields":[{"help":"Enter date in dd-mm-yy format","type":"date","label":"Date:","options":[],"required":null,"pdf_field":""},{"help":"Enter place","type":"text","label":"Place:","options":[],"required":null,"pdf_field":""},{"help":"Sign and stamp the form","type":"signature","label":"Signature of hospital:","options":[],"required":null,"pdf_field":""}],"filled_by":"hospital"}],"deadlines":[],"applies_to":"Health insurance claims other than travel and personal accident claims","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","Doctor’s Prescriptions","Others (Including CT/ MRI / USG / HPE)","Original Pre-authorization request form","Copy of the Pre-authorization approval letter","Doctors reference slip for investigation ECG","Copy of photo ID card of patient verified by hospital","MLC report & Police FIR","Original death summary from hospital where applicable"],"declarations":["The information furnished in this claim form is true and correct to the best of the insured's knowledge and belief.","False or untrue statements, suppression or concealment of material facts will forfeit the right to claim reimbursement.","Consent and authorization is given to TPA/insurance company to seek necessary medical information from hospitals or medical practitioners.","All bills and receipts for the claim are included and no supplementary claim will be made except for pre/post-hospitalization claims.","The hospital declares that the information furnished is true and correct to the best of their knowledge and belief.","False or untrue statements, suppression or concealment of material facts by the hospital will forfeit the right to claim under this claim."],"dropped_labels":2},"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/1110-claim-form-for-health-insurance-policies-other-than-travel-and-personal-accident"}