{"id":2211,"title":"Health Claim Form / ȗାȓɧ ଦାବି ଫମର୍","purpose":"claim","insurer":{"slug":"bandhan-life-insurance","name":"Bandhan Life Insurance Limited"},"source_pdf":"https://www.bandhanlife.com/sites/default/files/asset/2026-04/Claim%20Form%20-%20Health_Oriya_0.pdf","sha256":"00c92189d1a43b7bbadb88f3d2d6a3d46705247e736aa9c2f549bacdbb36b881","pages":11,"collected":"2026-10-17","instructions":{"about":"This form is used by the insured person to claim health insurance benefits from Bandhan Life. It collects details about the insured, insurance history, hospitalization, treatment, and claim expenses.","notes":["Form to be filled in block letters.","Use DD-MM-YYYY format for dates unless otherwise specified.","Include STD code with phone numbers.","Attach original pre-authorization request form in lieu of Part A for Part B submission.","Original bills and documents should be attached as per checklist.","Hospital section to be filled by hospital authorities.","Non-network hospital details to be filled only if applicable."],"title":"Health Claim Form / ȗାȓɧ ଦାବି ଫମର୍","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Details Of Primary Insured","fields":[{"help":"","type":"text","label":"Company/TPA ID No. / କǬାନୀ / TPA ID ସଂଖɨା","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Sl. no./ Certificate no. / Ȣମିକ ସଂଖɨା / ȶମାଣପȱ ସଂଖɨା","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Policy no./ ବୀମା ȶଥାମିକ ସଂଖɨା","options":[],"required":null,"pdf_field":""},{"help":"Enter full name of the insured","type":"text","label":"Name / ନାମ","options":[],"required":true,"pdf_field":""},{"help":"Include city, state and pincode","type":"text","label":"Address/ ଠିକଣା","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"City/ ସହର","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"State / ରାଜɨ","options":[],"required":true,"pdf_field":""},{"help":"6 digit postal code","type":"number","label":"Pincode / ପିନ୍ େକାଡ୍","options":[],"required":true,"pdf_field":""},{"help":"Include STD code if applicable","type":"phone","label":"Phone No./ େଫାନ୍ ନǯର","options":[],"required":false,"pdf_field":""},{"help":"","type":"email","label":"Email ID / ଇେମଲ୍ ପରିଚୟ","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Currently covered by any other Mediclaim/ Health Insurance / ବƹର୍ମାନ ଅନɨ େକୗଣସି େମଡିେକɠମ୍/େହଲɕ୍ ଇନ୍ ସୁେରǓ NJାରା କଭର୍ ଭୁଲିଛǏି","options":["Yes / ହଁ","No / ନାହିଁ"],"required":true,"pdf_field":""},{"help":"DD-MM-YYYY format","type":"date","label":"Date of commencement of first insurance without break / ȶଥମ ବୀମାର ଆରǰ ତାରିଖ ବିନା ବିେƤଦ","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Previously covered by any other Mediclaim / Health Insurance / ପୂବର୍ରୁ ଅନɨ େକୗଣସି େମଡିେକɠମ୍/ବୀମା NJାରା କଭର୍ ଥିେଲ?","options":["Yes / ହଁ","No / ନାହିଁ"],"required":true,"pdf_field":""},{"help":"Provide company name, policy no., sum assured, date, diagnosis","type":"text","label":"If yes, Please provide details / ଯଦି ହଁ, ଦୟାକରି ବିବରଣୀ ȶଦାନ କରǏୁ ।","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"Details Of Insurance History","fields":[{"help":"","type":"text","label":"Company Name / କǬାନୀ ନାମ","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Policy no./ ପଲିସି ନǯର୍","options":[],"required":false,"pdf_field":""},{"help":"","type":"amount","label":"Sum Assured / ଆȀାସିତ ରାଶି","options":[],"required":false,"pdf_field":""},{"help":"DD-MM-YYYY format","type":"date","label":"Date/ ତାରିଖ","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Diagnosis/ ନିƷର୍ୟ","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"Details Of Insured Person Hospitalised","fields":[{"help":"","type":"checkbox","label":"Student / ଛାȱ/ଛାȱୀ","options":["Student"],"required":false,"pdf_field":""},{"help":"","type":"choice","label":"Occupation/ ବୃƸି","options":["Service / େସବାକାରୀ","Self Employed / Șୟଂ ଚାଲାଚଳ","Homemaker / ଘେର କାଯର୍ɨରତା","Retired / ଅବସର Ȥହଣ କରିଛǏି","Other (Please Specify) / ଅନɨ (ଦୟାକରି ଉେǺଖ କରǏୁ)"],"required":false,"pdf_field":""},{"help":"","type":"choice","label":"Room Category Occupied/ େଯ କȹା ବɧବହୃତ େହଲା","options":["Day Care/ େଡ େକୟର","Single Occupancy/ ସିơଲ୍ ଓକୁɨପାǓି","Twin Sharing/ ଯୁଗɝ ଅଂଶୀଦାରୀ","3 or more beds per room/ ୩ କିǯା ତାହାଠାରୁ ଅଧିକ େବଡ୍"],"required":false,"pdf_field":""},{"help":"DD-MM-YYYY format","type":"date","label":"Date of Injury/ Date Disease first detected/ Date of Delivery/ ଘାତକତାର ତାରିଖ/ େରାଗ ȶଥମ ଚିȞିତ େହବାର ତାରିଖ/ ସǏାନଜନନ ତାରିଖ","options":[],"required":false,"pdf_field":""},{"help":"","type":"choice","label":"Hospitalization due to/ ଭƸʋର କାରଣ","options":["Injury/ ଘାତକତା","Illness/ େରାଗ","Maternity / ଗଭର୍ଧାରଣ ସǯǗିତ"],"required":false,"pdf_field":""},{"help":"","type":"choice","label":"If Injury, give cause/  ଯଦି ଘାତକତା, କାରଣ ଦିଅǎୁ","options":["Self Inflicted/ Șୟଂେȶରିତ","Road Traffic Accident/ େରାଡ୍ Ȭାଫିକ୍ ଦୁଘର୍ଟନା","Substance Abuse/ Alcohol Consumption / ପଦାଥର୍ ଅପବɨବହାର/ମଦɨପାନ"],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"If Medico-Legal/ ଯଦି େମଡିେକା-ଆଇନଗତ","options":["Yes / ହଁ","No / ନାହିଁ"],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Reported to Police/ େପାଲିସ୍ କୁ ରିେପାଟର୍ କରାଯାଇଛି","options":["Yes / ହଁ","No / ନାହିଁ"],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"MLC Report & Police FIR Attached/ MLC ରିେପାଟ୍ର୍  ଏବଂ FIR ଲଗା ଅଛି","options":["Yes / ହଁ","No / ନାହିଁ"],"required":false,"pdf_field":""},{"help":"HH:MM format","type":"text","label":"Time/ ସମୟ","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Address (if different from above)/ ଠିକଣା (ଯଦି ଉପେରାƌରୁ ଭିǚ)","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"City/ ସହର","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"State / ରାଜɨ","options":[],"required":false,"pdf_field":""},{"help":"","type":"number","label":"Pincode / ପିନ୍ େକାଡ୍","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"System of Medicine/ ଔଷଧ ȶଣାଳୀ","options":[],"required":false,"pdf_field":""},{"help":"","type":"choice","label":"Gender/ ଲିƠ","options":["Male/ ପୁରୁଷ","Female/ ନାରୀ","Third Gender/ ତୃତୀୟ ଲିơ"],"required":true,"pdf_field":""},{"help":"DD-MM-YYYY format","type":"date","label":"Date of birth/ ଜǜ ତାରିଖ","options":[],"required":true,"pdf_field":""},{"help":"In years","type":"number","label":"Age/ ବୟସ୍","options":[],"required":false,"pdf_field":""},{"help":"","type":"choice","label":"Relationship to Primary Insured / ȵାଥମିକ ବୀମାଧାରୀƜ ସହ ଲିƜ","options":["Self/ ନିଜ","Spouse/ ଜୀବାନ ସାଥୀ","Child/ ସǏାନ","Father/ ପିତା","Mother/ ମା","Other (Please Specify)/ ଅନɨ (ଦୟାକରି ଉେǺଖ କରǏୁ)"],"required":true,"pdf_field":""},{"help":"Include STD code if applicable","type":"phone","label":"Phone No./ େଫାନ୍ ନǯର","options":[],"required":false,"pdf_field":""},{"help":"","type":"email","label":"Email ID / ଇେମଲ୍ ଆଇ ଡି","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Name of Hospital where admitted / ଭƹʌ େହାଇଥିବା ହȖିଟାȼ ନାମ","options":[],"required":true,"pdf_field":""},{"help":"DD-MM-YYYY format","type":"date","label":"Date of admission/ ଭƹʌ ତାରିଖ","options":[],"required":true,"pdf_field":""},{"help":"DD-MM-YYYY format","type":"date","label":"Date of discharge/ ଛାଡ଼ିବା ତାରିଖ","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"},{"title":"Details Of Claim","fields":[{"help":"Enter amount in ₹","type":"amount","label":"Pre-hospitalization Expenses/ ଭƹʌ ପ◌ূବର୍ ଖƣର୍","options":[],"required":false,"pdf_field":""},{"help":"Enter amount in ₹","type":"amount","label":"Hospitalization Expenses/ ଭƹʌ ଖƣର୍","options":[],"required":false,"pdf_field":""},{"help":"If yes, provide details in annexure","type":"yes-no","label":"Claim for Domiciliary Hospitalization/ ଗୃହଭିƹିକ ଭƹʌ ପାଇଁ ଦାବି","options":["Yes / ହଁ","No / ନାହିଁ"],"required":false,"pdf_field":""},{"help":"Enter amount in ₹","type":"amount","label":"Post-hospitalization Expenses/ ଭƹʌ ପେର ଖƣର୍","options":[],"required":false,"pdf_field":""},{"help":"Enter amount in ₹","type":"amount","label":"Health-Checkup Cost/ ȘାȔɨତଦାରୁକି ଖƣର୍","options":[],"required":false,"pdf_field":""},{"help":"Enter amount in ₹","type":"amount","label":"Ambulance Charges/ ଅ ɨାǯୁେଲǓ ଶୁǴ","options":[],"required":false,"pdf_field":""},{"help":"Specify code and amount","type":"amount","label":"Others (code)/ ଅନɨ (େକାଡ୍)","options":[],"required":false,"pdf_field":""},{"help":"Number of days","type":"number","label":"Pre-hospitalization Period/ ଭƹʌ ପୂବର୍ ସମୟକାଳ","options":[],"required":false,"pdf_field":""},{"help":"Number of days","type":"number","label":"Post-hospitalization Period: Days/ ଭƹʌ ପେର ସମୟକାଳ","options":[],"required":false,"pdf_field":""},{"help":"Total claim amount in ₹","type":"amount","label":"Total/ େମାଟ  ₹","options":[],"required":false,"pdf_field":""},{"help":"Columns: Hospital Daily Cash, Surgical Cash, Critical Illness benefit, Convalescence, Pre/Post Hospitalization Lump sum benefit, Others, Total (all amounts in ₹)","type":"table","label":"Details of Lump sum/Cash benefit claimed / ଲǫସମ୍ Șପʋତ/ଜମା ȵତିଫଳର ବିବରଣୀ","options":[],"required":false,"pdf_field":""},{"help":"Tick all documents submitted","type":"checkbox","label":"Claim Documents Submitted - Check List / ଦାବି ନାମାଜ ଦାଖଲ – ଯାƩ ସୂଚୀ","options":["Copy of the Claim Intimation (if any)","Hospital Break-up Bill","Hospital Bill Payment Receipt","Hospital Discharge Summary","Pharmacy Bill","Operation Theatre Notes","Doctor’s Request for Investigation","ECG","Investigation Reports (Including CT/ MRI/ USG/ HPE)","Doctor’s Prescriptions","Others"],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"Details Of Primary Insured’s Bank Accounts","fields":[{"help":"Permanent Account Number","type":"text","label":"PAN/ ପɨାନ୍","options":[],"required":false,"pdf_field":""},{"help":"Bank account number for claim payment","type":"text","label":"Account Number/ ଖାତା ସଂଖɨା","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Bank Name/ ବɨାƝର ନାମ","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Bank Branch/ ବɨାƝ ଶାଖା","options":[],"required":false,"pdf_field":""},{"help":"Details of cheque or demand draft if applicable","type":"text","label":"Cheque/ DD Payable Details/ େଚକ୍/ଡି.ଡି େପ େଜାଗɨ ବିବରଣୀ","options":[],"required":false,"pdf_field":""},{"help":"Indian Financial System Code of bank branch","type":"text","label":"IFSC Code/ IFSC େକାଡ୍","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"},{"title":"Declaration By The Insured","fields":[{"help":"","type":"signature","label":"Signature of Insured / ବୀମାȶାǞƝ େରାହା","options":[],"required":true,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date/ ତାରିଖ","options":[],"required":true,"pdf_field":""},{"help":"Place of signing","type":"text","label":"Place/ Ȕାନ","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"Details Of Hospital (Part B)","fields":[{"help":"","type":"choice","label":"Type of Hospital / ହȕିଟାଲ ȵକାର","options":["Network","Non-Network (If non-network, fill section E)"],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Name of the Hospital / ହȖିଟାଲ୍ ର ନାମ","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Hospital ID / ହȖିଟାଲ୍ ID","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Name of the Treating Doctor / ଚିକିǂାକ ଡାƌରƝ ନାମ","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Qualification / େଯାଗɨତା","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Registration No. with State Code / ରାଜɨ ଏକାଡ୍ ସହିତ ପƬିକରଣ ନଂ","options":[],"required":false,"pdf_field":""},{"help":"","type":"phone","label":"Phone No./ େଫାନ୍ ନଂ","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Name of the Patient/ ଭƸʋ େହାଇଥିବା େରାଗୀƝ ନାମ","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"IP Registration Number / IP ପƬିକରଣ ନଂ","options":[],"required":false,"pdf_field":""},{"help":"DD-MM-YYYY format","type":"date","label":"Date of Admission/ ଭƹʌ ତାରିଖ","options":[],"required":true,"pdf_field":""},{"help":"HH:MM format","type":"text","label":"Time/ ସମୟ","options":[],"required":false,"pdf_field":""},{"help":"","type":"amount","label":"Total claimed amount/ େମାଟ ଦାବିରାଶି ₹","options":[],"required":true,"pdf_field":""},{"help":"DD-MM-YYYY format","type":"date","label":"Date of Discharge/ ଡିସ୍ ଚାଜର୍ ତାରିଖ","options":[],"required":true,"pdf_field":""},{"help":"In years","type":"number","label":"Age/ ବୟସ୍","options":[],"required":false,"pdf_field":""},{"help":"DD-MM-YYYY format","type":"date","label":"Date of Birth/ ଜǛ ତାରିଖ","options":[],"required":false,"pdf_field":""},{"help":"","type":"choice","label":"Type of Admission / ଭƸʋ ȵକାର","options":["Emergency/ ତƸାଳିକ","Planned/ େଯାଜିତ","Daycare/ େଡେକୟାର","Maternity/  ଗଭର୍ାବȔା"],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Status at time of discharge / ଡିସ୍ ଚାଜର୍ ସମୟେର ȓିତି","options":["Discharge to home/  ଘରକୁ ଛାଡାଯାଇଛି","Deceased/  ଦିହାନ୍ ତ","Discharge to another hospital/ ଅନɨ ହȖିଟାଲ୍ କୁ ଛାଡାଯାଇଛି"],"required":true,"pdf_field":""},{"help":"","type":"text","label":"If Maternity/ ଗଭର୍ାବȓା େହେଲ Gravida Status/ ଗଭର୍ା Ȕିତି","options":[],"required":false,"pdf_field":""},{"help":"DD-MM-YYYY format","type":"date","label":"Date of Delivery/ ଡିଲିେଭରି ତାରିଖ","options":[],"required":false,"pdf_field":""},{"help":"International Classification of Diseases codes","type":"text","label":"ICD 10 Codes/ ଆଇସିଡି 10 ସଂେକତ","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Primary Diagnosis/ ȶାଥମିକ ନିଦାନ","options":[],"required":true,"pdf_field":""}],"filled_by":"hospital"},{"title":"Declaration By The Hospital","fields":[{"help":"","type":"date","label":"Date/ ତାରିଖ","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Place/ ଠାକୁଆଁ","options":[],"required":false,"pdf_field":""},{"help":"","type":"signature","label":"Signature and Seal of the Hospital Authority/ ହȖିଟାଲ୍ କƹର୍ୃǀର ଦȒଖତ ଏବଂ େମାହର","options":[],"required":true,"pdf_field":""}],"filled_by":"hospital"},{"title":"Details In Case Of Non Network Hospital","fields":[{"help":"","type":"text","label":"City/ ସହର","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"State / ରାଜɨ","options":[],"required":false,"pdf_field":""},{"help":"","type":"number","label":"Pincode / ପିନ୍ େକାଡ୍","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Address of the Hospital/ ହȖିଟାଲ୍ ଠିକଣା","options":[],"required":false,"pdf_field":""},{"help":"","type":"phone","label":"Phone No./ େଫାନ୍ ନଂ.","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Hospital PAN/ ହȖିଟାଲର ପɨାନ୍ ନǯର","options":[],"required":false,"pdf_field":""},{"help":"","type":"number","label":"Number of inpatient beds/ ଇନେପେସନɏ େବଡ୍ ସଂଖɨା","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Registration No. with State Code/ ରାଜɨ େକାଡ୍ ସହିତ ପƬିକରଣ ନǯର","options":[],"required":false,"pdf_field":""},{"help":"","type":"checkbox","label":"Facilities available in the hospital/ ଡାƋରଖାନାେର ଉପଲǧ ସୁବିଧା","options":["OT/ ଓଟି","ICU/ ଆଇସିୟୁ","Others/ ଅନɨ"],"required":false,"pdf_field":""}],"filled_by":"hospital"}],"deadlines":[],"applies_to":"health insurance claims","attachments":["Copy of the Claim Intimation (if any)","Hospital Break-up Bill","Hospital Bill Payment Receipt","Hospital Discharge Summary","Pharmacy Bill","Operation Theatre Notes","Doctor’s Request for Investigation","ECG","Investigation Reports (Including CT/ MRI/ USG/ HPE)","Doctor’s Prescriptions","Others","Copy of the Pre-authorization Approval Letter","Original Pre-authorization request","Copy of Photo ID Card of Patient Verified by Hospital","MLC Report & Police FIR","Original Death Summary from Hospital Where Applicable"],"declarations":["The insured declares that the information provided is true and correct to the best of their knowledge and belief.","False or untrue statements, suppression or concealment of material facts will forfeit the right to claim reimbursement.","The insured consents and authorizes TPA/Insurance company to seek necessary medical information from hospitals or medical practitioners.","The insured declares that all bills/receipts for the claim are included and no supplementary claims except pre/post-hospitalization will be made.","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 their right to claim."],"dropped_labels":1},"pdf_fields":null,"fillable_pdf":false,"send_to":[{"purpose":"claim","channel":"address","value":"submit duly completed claim forms and other documents at the nearest Bandhan Life Branch Office or at our Head Office","label":"Claim Intimation and Registration","level":null,"hours":null,"applies_to":"life","source_url":"https://www.bandhanlife.com/customer-service/claims-process","quote":"nes can use the amount when they need it most.\nClaim Intimation and Registration\nFor Claims intimation to Bandhan Life, submit duly completed claim forms and other documents at the nearest Bandhan Life Branch Office or at our Head Office. Please click on the below links to see/ download the requirement list, claim forms and to locate our nearest branch of","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/bandhan-life-insurance/2211-health-claim-form-ur"}