{"id":1253,"title":"Hospital Cash/Medical Expenses Claim Form","purpose":"claim","insurer":{"slug":"tata-aig-general-insurance","name":"Tata AIG General Insurance Company Limited"},"source_pdf":"https://www.tataaig.com/s3/ghc_health_sickness_claim_form_ce3443020b.pdf","sha256":"21f5a40adfc0fb3b01fa9d5b4ccf7f3100ebaba22ea911458ecf356946e14ffa","pages":2,"collected":"2026-10-17","instructions":{"about":"This form is used by the insured person to claim hospital cash or medical expenses under their insurance policy.","notes":["Issuance of this form is not an admission of liability or waiver of policy terms.","If space is insufficient, attach additional sheets."],"title":"Hospital Cash/Medical Expenses Claim Form","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Details of Insured","fields":[{"help":"","type":"text","label":"Policy No.","options":[],"required":null,"pdf_field":""},{"help":"First Name, Middle Name, Surname","type":"text","label":"Name","options":[],"required":null,"pdf_field":""},{"help":"City, State, PIN","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Claim No.","options":[],"required":null,"pdf_field":""},{"help":"Office phone number","type":"phone","label":"Phone (O)","options":[],"required":null,"pdf_field":""},{"help":"Mobile phone number","type":"phone","label":"Mobile","options":[],"required":null,"pdf_field":""},{"help":"Email address","type":"email","label":"E-mail","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Name of the contact person","options":[],"required":null,"pdf_field":""},{"help":"Designation of contact person","type":"text","label":"Designation","options":[],"required":null,"pdf_field":""},{"help":"Telephone number of contact person","type":"phone","label":"Tel","options":[],"required":null,"pdf_field":""},{"help":"Fax number of contact person","type":"text","label":"Fax","options":[],"required":null,"pdf_field":""},{"help":"Email of contact person","type":"email","label":"E-mail","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Details of Sickness","fields":[{"help":"Date of sickness or accident (DDMMYYYY)","type":"date","label":"Time and Date","options":[],"required":null,"pdf_field":""},{"help":"Medical diagnosis of sickness or injury","type":"text","label":"Diagnosis","options":[],"required":null,"pdf_field":""},{"help":"Address, City, State, PIN of place of sickness or accident","type":"text","label":"Place and Location","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Treatment Details","fields":[{"help":"","type":"text","label":"Name of the Attending Doctor","options":[],"required":null,"pdf_field":""},{"help":"Telephone number of attending doctor","type":"phone","label":"Tel","options":[],"required":null,"pdf_field":""},{"help":"Fax number of attending doctor","type":"text","label":"Fax","options":[],"required":null,"pdf_field":""},{"help":"Email of attending doctor","type":"email","label":"E-mail","options":[],"required":null,"pdf_field":""},{"help":"Date(s) of consultation (DDMMYYYY)","type":"date","label":"Date(s) of Consultation","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Name of the Hospital(s) (If hospitalized)","options":[],"required":null,"pdf_field":""},{"help":"City, State, PIN","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"Telephone number of hospital","type":"phone","label":"Tel","options":[],"required":null,"pdf_field":""},{"help":"Fax number of hospital","type":"text","label":"Fax","options":[],"required":null,"pdf_field":""},{"help":"Email of hospital","type":"email","label":"E-mail ID","options":[],"required":null,"pdf_field":""},{"help":"Start date of hospitalization (DDMMYYYY)","type":"date","label":"Period of hospitalization: From","options":[],"required":null,"pdf_field":""},{"help":"End date of hospitalization (DDMMYYYY)","type":"date","label":"to","options":[],"required":null,"pdf_field":""},{"help":"Diagnosis or surgery details","type":"text","label":"Diagnosis/Surgery","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Amount of Expenses","fields":[{"help":"Start date of hospital cash coverage period","type":"date","label":"In hospital cash (If covered). From","options":[],"required":null,"pdf_field":""},{"help":"End date of hospital cash coverage period","type":"date","label":"To","options":[],"required":null,"pdf_field":""},{"help":"Amount claimed for hospital cash","type":"amount","label":"Amount","options":[],"required":null,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Have the Police Authorities been informed of this accident?","options":["Yes","No"],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Declaration and Signature","fields":[{"help":"Date of signing","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Place of signing","type":"text","label":"Place","options":[],"required":null,"pdf_field":""},{"help":"Sign here","type":"signature","label":"Signature of the Insured","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"},{"title":"Attending Physician's Statement","fields":[{"help":"","type":"text","label":"Name & Age of Injured Person","options":[],"required":null,"pdf_field":""},{"help":"City, State, PIN","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"Office phone number","type":"phone","label":"Phone (O)","options":[],"required":null,"pdf_field":""},{"help":"Fax number","type":"text","label":"Fax","options":[],"required":null,"pdf_field":""},{"help":"Mobile number","type":"phone","label":"Mobile","options":[],"required":null,"pdf_field":""},{"help":"Describe sickness details","type":"text","label":"Details of the Sickness","options":[],"required":null,"pdf_field":""},{"help":"If yes, give details","type":"text","label":"Was the injured person suffering from any disease","options":[],"required":null,"pdf_field":""},{"help":"Hospitalization details","type":"text","label":"Was the Claimant hospitalized? If so for what period?","options":[],"required":null,"pdf_field":""},{"help":"Treatment and operation details","type":"text","label":"What treatment was given and Operations performed?","options":[],"required":null,"pdf_field":""},{"help":"Start date of home treatment","type":"date","label":"Give all dates of treatment : Home: From","options":[],"required":null,"pdf_field":""},{"help":"End date of home treatment","type":"date","label":"To","options":[],"required":null,"pdf_field":""},{"help":"End date of clinic/hospital treatment","type":"date","label":"To","options":[],"required":null,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Are you his usual medical Attendant ?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Details of previous illness if any","type":"text","label":"If you have treated him for any previous illness, Please give details.","options":[],"required":null,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Have other Doctors been in Attendance or Consultation?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Details of other doctors consulted","type":"text","label":"If yes, Please give details.","options":[],"required":null,"pdf_field":""},{"help":"Doctor's prognosis","type":"text","label":"What is the Prognosis?","options":[],"required":null,"pdf_field":""},{"help":"Doctor to sign here","type":"signature","label":"Doctor's Signature","options":[],"required":true,"pdf_field":""},{"help":"Date of doctor's signature","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Doctor's registration number","type":"text","label":"Regn No.","options":[],"required":null,"pdf_field":""},{"help":"Doctor's name and official seal","type":"text","label":"Doctors Name & Seal","options":[],"required":null,"pdf_field":""},{"help":"City, State, PIN","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"Office phone number","type":"phone","label":"Phone (O)","options":[],"required":null,"pdf_field":""},{"help":"Fax number","type":"text","label":"Fax","options":[],"required":null,"pdf_field":""},{"help":"Mobile number","type":"phone","label":"Mobile","options":[],"required":null,"pdf_field":""}],"filled_by":"attending doctor"}],"deadlines":[],"applies_to":"hospital cash and medical expenses claims","attachments":["Please attach a separate sheet if the space is insufficient"],"declarations":["I declare that I have suffered injuries as described and all details are true and correct.","I agree to forfeit rights to compensation if any details are false or incorrect.","I authorize hospital, doctor, diagnostic laboratory or any other body to provide information or documents to the Insurance Company."],"dropped_labels":4},"pdf_fields":null,"fillable_pdf":false,"send_to":[{"purpose":"claim","channel":"address","value":"TATA AIG General Insurance Company Limited, 5th and 6th Floor, Imperial Towers, H.No 7-1-6-617/A, GHMC No - 615,616, Ameerpet, Hyderabad – 500016, Telangana","label":"Claims Submission Address","level":null,"hours":null,"applies_to":"health","source_url":"https://www.tataaig.com/s3/medicare_select_cis_e7df7ce2ec.pdf","quote":"tion or procedure. Submit claim documents within 15 days of occurrence of incident. Kindly send the claim documents to: TATA AIG General Insurance Company Limited, 5th and 6th Floor, Imperial Towers, H.No 7-1- 6-617/A, GHMC No - 615,616, Ameerpet, Hyderabad – 500016, Telangana, Phone-040-66864900 Assistance: 1. Website www.tataaig.com or Call 24*7 Customer Support No.: 022 6489 8282/1800 267 1","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"email","value":"healthclaimsupport@tataaig.com","label":"Health Claims Support Email","level":null,"hours":null,"applies_to":"health","source_url":"https://www.tataaig.com/s3/medicare_select_prospectus_efd23b0ad6.pdf","quote":"al Towers, H.No 7-1-6-617/A, GHMC No - 615,616, Ameerpet, Hyderabad – 500016, Telangana, Phone: 040-66864900\nEmail ID | healthclaimsupport@tataaig.com\nCustomer Support Number: | 022 6489 8282 / 1800 267 1955 (nly for senior citizen policy holders)\nWebsite | www.tataaig.","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"040-66864900","label":"Claims Administrator Phone","level":null,"hours":null,"applies_to":"health","source_url":"https://www.tataaig.com/s3/medicare_select_prospectus_efd23b0ad6.pdf","quote":"th and 6th Floor, Imperial Towers, H.No 7-1-6-617/A, GHMC No - 615,616, Ameerpet, Hyderabad – 500016, Telangana, Phone: 040-66864900\nEmail ID | healthclaimsupport@tataaig.com\nCustomer Support Number: | 022 6489 8282 / 1800 267 1955 (nly for senior citi","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/tata-aig-general-insurance/1253-hospital-cash-medical-expenses-claim-form"}