{"id":137,"title":"REIMBURSEMENT CLAIM FORM","purpose":"claim","insurer":{"slug":"galaxy-health-insurance","name":"Galaxy Health Insurance Company Limited"},"source_pdf":"https://www.galaxyhealth.com/assets/preloaded/GHI%2520Reimbursement%2520Claim%2520Form.pdf","sha256":"d90d4932a655c2b2b7c5805fa4e470f5dffa172ae78478e9ba8c1dcaa46bc285","pages":6,"collected":"2026-10-17","instructions":{"about":"This form is used by the insured person to claim reimbursement for various health insurance benefits including hospitalization, critical illness, outpatient claims, and others. Part A is filled by the insured, and Part B is filled by the hospital.","notes":["Fill the form in BLOCK LETTERS.","Attach a cancelled cheque pertaining to the same bank account; the name of the account holder must be printed on the cheque.","Mention 'Health Claim Documents' on the top of the envelope and include complete sender address along with mobile number.","The issue of this form is not to be taken as an admission of liability.","Use original bills only.","Include the original pre-authorization request form in lieu of Part A if applicable."],"title":"REIMBURSEMENT CLAIM FORM","submit":{"to":"Please send all original documents along with a duly filled and signed claim form to the address mentioned on the top of the claim form","how":"post","address":"“Prestige Polygon”, 12th Top Floor (P), #471, Anna Salai, Nandanam, Chennai - 600 035"},"purpose":"claim","sections":[{"title":"SECTION A – DETAILS OF PRIMARY INSURED","fields":[{"help":"","type":"text","label":"a. Policy No.","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"c. Company/TPA ID No.","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"d. ABHA ID No.","options":[],"required":null,"pdf_field":""},{"help":"Full name of the primary insured","type":"text","label":"e. Name","options":[],"required":null,"pdf_field":""},{"help":"Full postal address","type":"text","label":"f. Address","options":[],"required":null,"pdf_field":""},{"help":"6-digit postal code","type":"number","label":"g. Pin code","options":[],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"h. Phone No.","options":[],"required":null,"pdf_field":""},{"help":"","type":"email","label":"i. Email ID","options":[],"required":null,"pdf_field":""},{"help":"Provide WhatsApp number if consenting to communication","type":"phone","label":"j. WhatsApp No. (with consent to communicate)","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"SECTION B – DETAILS OF INSURANCE HISTORY","fields":[{"help":"","type":"yes-no","label":"a) Currently covered by any other mediclaim/health insurance","options":["YES","NO"],"required":null,"pdf_field":""},{"help":"Name of other insurance company if currently covered","type":"text","label":"c) If yes, Company name","options":[],"required":null,"pdf_field":""},{"help":"Policy number of other insurance","type":"text","label":"1. Policy No.","options":[],"required":null,"pdf_field":""},{"help":"Sum insured under other policy","type":"amount","label":"2. Sum Insured","options":[],"required":null,"pdf_field":""},{"help":"If yes, provide date (DD/MM/YYYY)","type":"yes-no","label":"d. Have you been hospitalized in the last three years since inception of the contract (if yes, kindly mention date)","options":["YES","NO"],"required":null,"pdf_field":""},{"help":"Diagnosis details of previous hospitalization","type":"text","label":"e. Diagnosis","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"f. Previously covered by any other Mediclaim/Health insurance","options":["YES","NO"],"required":null,"pdf_field":""},{"help":"Name of previous insurance company","type":"text","label":"g. If yes, Company Name","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"SECTION C – DETAILS OF INSURED PERSON","fields":[{"help":"Name of the insured person","type":"text","label":"a. Name","options":[],"required":null,"pdf_field":""},{"help":"","type":"choice","label":"b. Gender","options":["Male","Female","Third Gender"],"required":null,"pdf_field":""},{"help":"Age in years","type":"number","label":"c. Age","options":[],"required":null,"pdf_field":""},{"help":"DD/MM/YYYY","type":"date","label":"d. Date of Birth","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"SECTION D – DETAILS OF HOSPITALISATION","fields":[{"help":"DD/MM/YYYY","type":"date","label":"e. Date of admission","options":[],"required":null,"pdf_field":""},{"help":"HHMM (24-hour format)","type":"text","label":"f. Time of admission","options":[],"required":null,"pdf_field":""},{"help":"DD/MM/YYYY","type":"date","label":"g. Date of discharge","options":[],"required":null,"pdf_field":""},{"help":"HHMM (24-hour format)","type":"text","label":"h. Time of discharge","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"ii. Reported to police?","options":["YES","NO"],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"SECTION E - DETAILS OF CLAIM","fields":[{"help":"","type":"yes-no","label":"vi) Ambulance Charges","options":["YES","NO"],"required":null,"pdf_field":""},{"help":"","type":"text","label":"vii) Others, If Any","options":[],"required":null,"pdf_field":""},{"help":"Amount claimed for each applicable benefit","type":"amount","label":"Amount (INR)","options":[],"required":null,"pdf_field":""},{"help":"Total claim amount","type":"amount","label":"Total Amount (INR)","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"SECTION F – DETAILS OF BILLS ENCLOSED","fields":[{"help":"","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Bill No","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Issued By","options":[],"required":null,"pdf_field":""},{"help":"Purpose of the bill","type":"text","label":"Towards","options":[],"required":null,"pdf_field":""},{"help":"","type":"amount","label":"Amount (Rs)","options":[],"required":null,"pdf_field":""},{"help":"Total amount of bills enclosed","type":"amount","label":"Total Amount","options":[],"required":null,"pdf_field":""},{"help":"Write the total amount in words","type":"text","label":"Total Amount (In Words):","options":[],"required":null,"pdf_field":""},{"help":"Number of pharmacy bills enclosed","type":"number","label":"Pharmacy Bills: ____________nos","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"SECTION G – DETAILS OF PRIMARY INSURED’S BANK ACCOUNT","fields":[{"help":"Permanent Account Number","type":"text","label":"a) PAN number of the primary insured","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"b) Name of the primary insured","options":[],"required":null,"pdf_field":""},{"help":"Bank account number for claim payment","type":"text","label":"c) Account number","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"d) Bank name and branch","options":[],"required":null,"pdf_field":""},{"help":"Name of the payee as per bank records","type":"text","label":"e) Payee Name","options":[],"required":null,"pdf_field":""},{"help":"Bank IFSC code","type":"text","label":"f) IFSC Code","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"g) Cheque/DD Payable details","options":[],"required":null,"pdf_field":""},{"help":"Central KYC number if available","type":"text","label":"h) CKYC of the primary insured","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"SECTION H – DECLARATION BY THE INSURED","fields":[{"help":"","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Place","options":[],"required":null,"pdf_field":""},{"help":"Signature of the insured person","type":"signature","label":"Signature of Insured","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"},{"title":"SECTION A – DETAILS OF HOSPITAL (Part B)","fields":[{"help":"","type":"text","label":"a) Name of the hospital where treated","options":[],"required":null,"pdf_field":""},{"help":"","type":"choice","label":"c) Type of Hospital","options":["Network","Non Network (If non network fill section D)"],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"g) Phone No.","options":[],"required":null,"pdf_field":""}],"filled_by":"hospital"},{"title":"SECTION B – DETAILS OF PATIENT ADMITTED (Part B)","fields":[{"help":"","type":"choice","label":"c) Gender","options":["Male","Female","Third Gender"],"required":null,"pdf_field":""},{"help":"","type":"number","label":"d) Age","options":[],"required":null,"pdf_field":""},{"help":"DD/MM/YYYY","type":"date","label":"e) Date of birth","options":[],"required":null,"pdf_field":""},{"help":"","type":"choice","label":"f) Type of management","options":["Medical","Surgical"],"required":null,"pdf_field":""},{"help":"DD/MM/YYYY","type":"date","label":"g) Date of admission","options":[],"required":null,"pdf_field":""},{"help":"HH/MM","type":"text","label":"h) Time of admission","options":[],"required":null,"pdf_field":""},{"help":"DD/MM/YYYY","type":"date","label":"i) Date of discharge","options":[],"required":null,"pdf_field":""},{"help":"HH/MM","type":"text","label":"j) Time of discharge","options":[],"required":null,"pdf_field":""},{"help":"","type":"choice","label":"k) Type of admission","options":["Emergency","Daycare","Planned","Maternity"],"required":null,"pdf_field":""},{"help":"","type":"amount","label":"o) Total claimed amount (INR)","options":[],"required":null,"pdf_field":""}],"filled_by":"hospital"},{"title":"SECTION C – DETAILS OF AILMENTS DIAGNOSED (PRIMARY) (Part B)","fields":[{"help":"ICD 10 diagnosis codes","type":"text","label":"a) ICD 10 Codes","options":[],"required":null,"pdf_field":""},{"help":"Procedure codes","type":"text","label":"b) ICD 10 PCS","options":[],"required":null,"pdf_field":""}],"filled_by":"hospital"},{"title":"SECTION D – ADDITIONAL DETAILS IN CASE OF NON NETWORK HOSPITAL (Part B)","fields":[{"help":"","type":"text","label":"a) Address of the Hospital","options":[],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"b) Phone No.","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"d) Hospital PAN","options":[],"required":null,"pdf_field":""}],"filled_by":"hospital"},{"title":"SECTION E – DECLARATION BY HOSPITAL","fields":[{"help":"","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Place","options":[],"required":null,"pdf_field":""},{"help":"Signature and seal of authorized hospital representative","type":"signature","label":"Signature and seal of the Hospital Authority","options":[],"required":true,"pdf_field":""}],"filled_by":"hospital"}],"deadlines":[],"applies_to":"health insurance reimbursement claims including in-patient hospitalization, pre and post hospitalization, critical illness, outpatient claims, hospital daily cash, health check-up, and others","attachments":["Duly filled and signed Claim Form","Hospital main bill","Hospital bill payment receipt","Pharmacy bill","Copy of intimation letter, if any","Hospital bill break up","Hospital discharge summary","Operation theatre notes","Investigation/diagnostic Reports with bills and payment receipt","ECG","Copy of the non-network provider’s registration certificate","KYC documents","Doctors request for investigations","Doctors Prescriptions","MLC/FIR copy if applicable","Implant stickers for all implants used during surgeries","Copy of discharge summary/discharge certificate along with time of admission and discharge for hospital cash benefit","Cancelled cheque copy with primary insured name printed or bank passbook copy with clear name/account no./bank details","Original pre-authorization request form (in lieu of Part A)"],"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 is given to TPA/insurance company to seek necessary medical information/documents from any hospital/medical practitioner who attended the insured.","All bills/receipts for the claim are included and no supplementary claim will be made except pre/post-hospitalisation 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":38},"pdf_fields":null,"fillable_pdf":false,"send_to":[{"purpose":"claim","channel":"email","value":"support@galaxyhealth.com","label":"General Support Email","level":null,"hours":null,"applies_to":"all","source_url":"https://www.galaxyhealth.com/claims/cashless-claim","quote":"(P), #471, Anna Salai, Nandanam,\nChennai - 600 035.\nCIN: U65120TN2023PLC165765 | IRDAI Registration Number: 167\nEmail: support@galaxyhealth.com |\nToll Free Number: 1800 203 0007\nCompany\nAbout Us\nWork With Us\nAgent Registration\nContact Us\nMedia Center\nServices\nNet","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"email","value":"reimbursement@galaxyhealth.com","label":"Reimbursement Claims Email","level":null,"hours":null,"applies_to":"health","source_url":"https://www.galaxyhealth.com/contact-us","quote":"Claims\nFor Cashless claims.\ncashless@galaxyhealth.com\nReimbursement Claims\nFor Reimbursement related Claim Assistance.\nreimbursement@galaxyhealth.com\nCashless Everywhere Claims\nGet Cashless facility for claim in Non-Network Hospital.\nanywherecashless@galaxyhealth.com\nH","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"1800 203 0007","label":"Toll Free Number for Claims","level":null,"hours":null,"applies_to":"health","source_url":"https://www.galaxyhealth.com/claims/cashless-claim","quote":"Cashless Health Insurance Claim Process | Galaxy Health Insurance\nToll Free Number: 1800 203 0007\nProducts\nHealth Insurance\nGalaxy Marvel\nGalaxy Promise\nGalaxy Twin 360\nArogya Sanjeevani Policy, Galaxy Health Insuranc","fetched_at":"2026-10-20"},{"purpose":"cashless","channel":"email","value":"cashless@galaxyhealth.com","label":"Cashless Claims Email","level":null,"hours":null,"applies_to":"health","source_url":"https://www.galaxyhealth.com/contact-us","quote":"enior Citizens\nFor Claims Assistance.\nsr.citizens@galaxyhealth.com\n1800 203 0007\nCashless Claims\nFor Cashless claims.\ncashless@galaxyhealth.com\nReimbursement Claims\nFor Reimbursement related Claim Assistance.\nreimbursement@galaxyhealth.com\nCashless Everywhere Cla","fetched_at":"2026-10-20"},{"purpose":"cashless","channel":"email","value":"anywherecashless@galaxyhealth.com","label":"Cashless Everywhere Claims Email","level":null,"hours":null,"applies_to":"health","source_url":"https://www.galaxyhealth.com/contact-us","quote":"nce.\nreimbursement@galaxyhealth.com\nCashless Everywhere Claims\nGet Cashless facility for claim in Non-Network Hospital.\nanywherecashless@galaxyhealth.com\nHospital Empanelment\nFor Hospital Network and Empanelment Enquiry.\nserviceprovider@galaxyhealth.com\n044 4001 7232\nMonda","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/galaxy-health-insurance/137-reimbursement-claim-form"}