{"id":2213,"title":"Health Claim Form / ਹੈਲਥ ਕਲੇਮ ਫਾਰਮ","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_Punjabi_0.pdf","sha256":"f21d434afbf3567248fc61b589a5f41b813b4fc8b6c89840b012294f48119e80","pages":11,"collected":"2026-10-17","instructions":{"about":"This form is used by the insured person and the hospital to claim health insurance benefits from Bandhan Life. Part A is filled by the insured, and Part B is filled by the hospital.","notes":["Form to be filled in block letters.","The issue of this form is not an admission of liability.","Use original bills and receipts for submission.","Fill dates in DD-MM-YYYY format and times in HH:MM format where specified.","Tick appropriate options clearly.","Attach all required documents as per checklist.","Part A to be filled by insured; Part B to be filled by hospital.","Include original pre-authorization request form in lieu of Part A if applicable."],"title":"Health Claim Form / ਹੈਲਥ ਕਲੇਮ ਫਾਰਮ","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Part A - To Be Filled In By The Insured","fields":[{"help":"Enter the company or TPA ID number","type":"text","label":"Company/TPA ID No. / ਕੰਪਨੀ/ ਟੀਪੀਏ ਆਈ.ਡੀ. ਨੰਬਰ","options":[],"required":null,"pdf_field":""},{"help":"Enter the certificate number","type":"text","label":"Sl. no./ Certificate no. / Ŭਮ ਸੰਿਖਆ/ ਸਰਟੀਿਫਕੇਟ ਨੰਬਰ","options":[],"required":null,"pdf_field":""},{"help":"Enter your policy number","type":"text","label":"Policy No/ ਪਾਿਲਸੀ ਨੰਬਰ","options":[],"required":true,"pdf_field":""},{"help":"Enter full name of the primary insured","type":"text","label":"Name / ਨਾਂ","options":[],"required":true,"pdf_field":""},{"help":"Enter city name","type":"text","label":"City/ ਸ਼ਿਹਰ","options":[],"required":null,"pdf_field":""},{"help":"Enter state name","type":"text","label":"State / ਰਾਜ","options":[],"required":null,"pdf_field":""},{"help":"Enter postal pincode","type":"number","label":"Pincode / ਿਪਨ ਕੋਡ","options":[],"required":null,"pdf_field":""},{"help":"Enter full postal address","type":"text","label":"Address/ ਪਤਾ","options":[],"required":null,"pdf_field":""},{"help":"Enter phone number with STD code if applicable","type":"phone","label":"Phone No./ ਫ਼ੋਨ ਨੰਬਰ","options":[],"required":null,"pdf_field":""},{"help":"Enter valid email address","type":"email","label":"Email ID / ਈਮੇਲ ਆਈ.ਡੀ.","options":[],"required":false,"pdf_field":""},{"help":"Tick yes or no","type":"yes-no","label":"Currently covered by any other Mediclaim/ Health Insurance / ਕੀ ਹੁਣ ਿਕਸੇ ਹੋਰ ਮੈਡੀਕਲੇਮ/ ਹੈਲਥ ਇਨਸ਼ੋਰƷ ਸ ਨਾਲ ਕਵਰ ਹੋ?","options":["Yes / ਹਾਂ","No / ਨਹİ"],"required":true,"pdf_field":""},{"help":"Enter date in DD-MM-YYYY format","type":"date","label":"Date of commencement of first insurance without break / ਿਬਨਾਂ ਿਕਸੇ ਰੁਕਾਵਟ ਦੇ ਪਿਹਲੀ ਬੀਮਾ ਦੀ ਸ਼ੁਰੂਆਤ ਦੀ ਤਾਰੀਖ","options":[],"required":false,"pdf_field":""},{"help":"Tick yes or no","type":"yes-no","label":"Previously covered by any other Mediclaim / Health Insurance / ਕੀ ਤੁਸİ ਪਿਹਲਾਂ ਿਕਸੇ ਹੋਰ ਮੈਡੀਕਲੇਮ/ ਹੈਲਥ ਇਨਸ਼ੋਰƷ ਸ ਨਾਲ ਕਵਰ ਸੀ?","options":["Yes / ਹਾਂ","No / ਨਹİ"],"required":true,"pdf_field":""},{"help":"Enter previous insurance company name","type":"text","label":"If yes, Company Name / ਜੇ ਹਾਂ, ਤਾਂ ਕੰਪਨੀ ਦਾ ਨਾਂ","options":[],"required":false,"pdf_field":""},{"help":"Enter previous policy number","type":"text","label":"Policy no./ ਪਾਿਲਸੀ ਨੰਬਰ","options":[],"required":false,"pdf_field":""},{"help":"Enter sum assured amount in rupees","type":"amount","label":"Sum Assured / ਸੰਸ਼ੋਿਧਤ ਰਕਮ (₹)","options":[],"required":false,"pdf_field":""},{"help":"Enter date in DD-MM-YYYY format","type":"date","label":"Date/ ਤਾਰੀਖ","options":[],"required":false,"pdf_field":""},{"help":"Enter diagnosis details","type":"text","label":"Diagnosis/ ਨਿਧਾਨ","options":[],"required":false,"pdf_field":""},{"help":"Tick yes or no","type":"yes-no","label":"Have you been hospitalized in last four years since inception of the contract?/ ਕੀ ਤੁਸİ ਿਪਛਲੇ ਚਾਰ ਸਾਲਾਂ ਿਵੱਚ ਇਸ ਅਨੁਬੰਧ ਦੀ ਸ਼ੁਰੂਆਤ ਤnj ਲੈ ਕੇ ਹਸਪਤਾਲ ਿਵੱਚ ਭਰਤੀ ਹੋਏ ਹੋ?","options":["Yes / ਹਾਂ","No / ਨਹİ"],"required":true,"pdf_field":""},{"help":"Provide company name, policy no., sum assured, date, diagnosis","type":"table","label":"If yes, Please provide details / ਜੇਕਰ ਹਾਂ, ਤਾਂ ਿਕਰਪਾ ਕਰਕੇ ਵੇਰਵੇ ਿਦਓ।","options":[],"required":false,"pdf_field":""},{"help":"Tick applicable occupation","type":"checkbox","label":"Student / ਿਵਿਦਆਰਥੀ","options":["Student","Occupation","Service","Self Employed","Homemaker","Retired","Other (Please Specify)"],"required":false,"pdf_field":""},{"help":"","type":"section","label":"Details Of Hospitalisation / ਹਸਪਤਾਲ ਿਵੱਚ ਭਰਤੀ ਹੋਣ ਦੇ ਵੇਰਵੇ","options":[],"required":null,"pdf_field":""},{"help":"Tick the room category occupied","type":"choice","label":"Room Category Occupied/ ਲਈ ਗਈ ਕਮਰੇ ਦੀ ਸ਼ǖੇਣੀ","options":["Day Care","Single Occupancy","Twin Sharing","3 or more beds per room"],"required":true,"pdf_field":""},{"help":"Enter relevant date in DD-MM-YYYY format","type":"date","label":"Date of Injury/ Date Disease first detected/ Date of Delivery/ ਚੋਟ ਦੀ ਤਾਰੀਖ / ਬੀਮਾਰੀ ਪਿਹਲੀ ਵਾਰ ਪਤਾ ਲੱਗਣ ਦੀ ਤਾਰੀਖ / ਿਡਲੀਵਰੀ ਦੀ ਤਾਰੀਖ","options":[],"required":true,"pdf_field":""},{"help":"Tick the cause of hospitalization","type":"choice","label":"Hospitalization due to/ ਹਸਪਤਾਲ ਿਵੱਚ ਦਾਖਲਾ ਹੋਣ ਦਾ ਕਾਰਨ","options":["Injury","Illness","Maternity"],"required":true,"pdf_field":""},{"help":"Tick cause if injury","type":"choice","label":"If Injury, give cause/ ਜੇਕਰ ਚੋਟ ਹੋਈ ਹੋਵੇ ਤਾਂ ਕਾਰਨ ਿਦਓ","options":["Self Inflicted","Road Traffic Accident","Substance Abuse/ Alcohol Consumption"],"required":false,"pdf_field":""},{"help":"Tick yes or no","type":"yes-no","label":"If Medico-Legal/ ਜੇਕਰ ਮੈਡੀਕੋ-ਲੀਗਲ ਹੈ","options":["Yes / ਹਾਂ","No / ਨਹİ"],"required":false,"pdf_field":""},{"help":"Tick yes or no","type":"yes-no","label":"Reported to Police/ ਪੁਿਲਸ ਨੂੰ ਿਰਪੋਰਟ ਕੀਤੀ","options":["Yes / ਹਾਂ","No / ਨਹİ"],"required":false,"pdf_field":""},{"help":"Tick if attached","type":"checkbox","label":"MLC Report & Police FIR Attached/ ਐਮ.ਐਲ.ਸੀ. ਿਰਪੋਰਟ ਅਤੇ ਪੁਿਲਸ ਐੱਫ.ਆਈ.ਆਰ. ਨੱਥੀ ਕੀਤੀ","options":["Yes / ਹਾਂ","No / ਨਹİ"],"required":false,"pdf_field":""},{"help":"Enter address if different","type":"text","label":"Address (if different from above)/ ਪਤਾ (ਜੇ ਉਪਰੋਕਤ ਤnj ਵੱਖਰਾ ਹੋਵੇ)","options":[],"required":false,"pdf_field":""},{"help":"Enter system of medicine","type":"text","label":"System of Medicine/ ਿਚਕਿਤਸਾ ਪǗ ਣਾਲੀ","options":[],"required":false,"pdf_field":""},{"help":"Tick gender","type":"choice","label":"Gender/ ਿਲੰਗ","options":["Male/ ਮਰਦ","Female/ ਔਰਤ","Third Gender/ ਤੀਜਾ ਿਲੰਗ"],"required":true,"pdf_field":""},{"help":"Enter date of birth in DD-MM-YYYY format","type":"date","label":"Date of birth/ ਜਨਮ ਤਾਰੀਖ","options":[],"required":true,"pdf_field":""},{"help":"Enter age in years","type":"number","label":"Age/ ਉਮਰ","options":[],"required":true,"pdf_field":""},{"help":"Tick relationship or specify","type":"choice","label":"Relationship to Primary Insured / ਮੁੱਖ ਬੀਮਾ ਧਾਰਕ ਨਾਲ ਸਬੰਧ","options":["Self/ ਆਪਣੇ ਆਪ","Spouse/ ਜੀਵਨ ਸਾਥੀ","Child/ ਬੱਚਾ","Father/ ਿਪਤਾ","Mother/ ਮਾਤਾ","Other (Please Specify)/ ਹੋਰ (ਿਕਰਪਾ ਕਰਕੇ ਦਰਸਾਓ)"],"required":true,"pdf_field":""},{"help":"Enter phone number","type":"phone","label":"Phone No./ ਫ਼ੋਨ ਨੰਬਰ","options":[],"required":false,"pdf_field":""},{"help":"Enter email ID","type":"email","label":"Email ID / ਈਮੇਲ ਆਈ.ਡੀ.","options":[],"required":false,"pdf_field":""},{"help":"Enter hospital name","type":"text","label":"Name of Hospital where admitted / ਿਜਸ ਹਸਪਤਾਲ ਿਵੱਚ ਦਾਖਲ ਹੋਏ ਉਸਦਾ ਨਾਂ","options":[],"required":true,"pdf_field":""},{"help":"Enter admission date in DD-MM-YYYY format","type":"date","label":"Date of admission/ ਦਾਖਲਾ ਹੋਣ ਦੀ ਤਾਰੀਖ","options":[],"required":true,"pdf_field":""},{"help":"Enter discharge date in DD-MM-YYYY format","type":"date","label":"Date of discharge/ ਛੁੱਟੀ ਦੀ ਤਾਰੀਖ","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"},{"title":"Part A - Details Of Claim","fields":[{"help":"Enter amount in rupees","type":"amount","label":"Pre-hospitalization Expenses/ ਹਸਪਤਾਲ ਿਵੱਚ ਦਾਖਲੇ ਤnj ਪਿਹਲਾਂ ਦੇ ਖਰਚੇ","options":[],"required":false,"pdf_field":""},{"help":"Enter amount in rupees","type":"amount","label":"Hospitalization Expenses/ ਹਸਪਤਾਲ ਿਵੱਚ ਦਾਖਲੇ ਦੇ ਖਰਚੇ","options":[],"required":true,"pdf_field":""},{"help":"Tick yes or no","type":"yes-no","label":"Claim for Domiciliary Hospitalization/ ਘਰੇਲੂ ਹਸਪਤਾਲੀਕਰਨ ਲਈ ਦਾਅਵਾ","options":["Yes / ਹਾਂ","No / ਨਹİ"],"required":false,"pdf_field":""},{"help":"Provide details in annexure if applicable","type":"text","label":"If yes, provide details in annexure/ ਜੇ ਹਾਂ, ਤਾਂ ਐਨੇਕਸਰ ਿਵੱਚ ਵੇਰਵੇ ਿਦਓ","options":[],"required":false,"pdf_field":""},{"help":"Enter amount in rupees","type":"amount","label":"Post-hospitalization Expenses/ ਹਸਪਤਾਲ ਤnj ਛੁੱਟੀ ਦੇ ਬਾਅਦ ਦੇ ਖਰਚੇ","options":[],"required":false,"pdf_field":""},{"help":"Enter amount in rupees","type":"amount","label":"Health-Checkup Cost/ ਹੈਲਥ ਚƳ ਕਅੱਪ ਦਾ ਖਰਚਾ","options":[],"required":false,"pdf_field":""},{"help":"Enter amount in rupees","type":"amount","label":"Ambulance Charges/ ਐਂਬੂਲƷ ਸ ਚਾਰਜ","options":[],"required":false,"pdf_field":""},{"help":"Enter other expenses with code","type":"amount","label":"Others (code)/ ਹੋਰ (ਕੋਡ)","options":[],"required":false,"pdf_field":""},{"help":"Enter number of days","type":"number","label":"Pre-hospitalization Period/ ਹਸਪਤਾਲ ਿਵੱਚ ਦਾਖਲੇ ਤnj ਪਿਹਲਾਂ ਦੀ ਿਮਆਦ","options":[],"required":false,"pdf_field":""},{"help":"Enter number of days","type":"number","label":"Post-hospitalization Period/ ਹਸਪਤਾਲ ਤnj ਬਾਅਦ ਦੀ ਿਮਆਦ","options":[],"required":false,"pdf_field":""},{"help":"Enter total amount claimed","type":"amount","label":"Total/ ਕੁੱਲ ਰਕਮ  ₹","options":[],"required":false,"pdf_field":""},{"help":"","type":"section","label":"Details of Lump sum/Cash benefit claimed / ਲੰਪ ਸਮ/ਨਕਦ ਲਾਭ ਦੇ ਵੇਰਵੇ","options":[],"required":null,"pdf_field":""},{"help":"Enter amount in rupees","type":"amount","label":"Hospital Daily Cash/ ਹਸਪਤਾਲ ਰੋਜ਼ਾਨਾ ਨਕਦ ਰਕਮ","options":[],"required":false,"pdf_field":""},{"help":"Enter amount in rupees","type":"amount","label":"Surgical Cash/ ਸਰਜੀਕਲ ਨਕਦ ਰਕਮ","options":[],"required":false,"pdf_field":""},{"help":"Enter amount in rupees","type":"amount","label":"Critical Illness benefit/ ਗੰਭੀਰ ਬੀਮਾਰੀ ਲਾਭ","options":[],"required":false,"pdf_field":""},{"help":"Enter amount in rupees","type":"amount","label":"Convalescence/ ਿਸਹਤ ਯਾਬੀ","options":[],"required":false,"pdf_field":""},{"help":"Enter amount in rupees","type":"amount","label":"Pre/Post Hospitalization Lump sum benefit/ ਪਿਹਲਾਂ/ਬਾਅਦ ਦੇ ਹਸਪਤਾਲੀਕਰਨ ਲਈ ਲੰਪ ਸਮ ਲਾਭ","options":[],"required":false,"pdf_field":""},{"help":"Enter other lump sum benefits","type":"amount","label":"Others/ ਹੋਰ","options":[],"required":false,"pdf_field":""},{"help":"Enter total lump sum amount","type":"amount","label":"Total/ ਕੁੱਲ ਰਕਮ   ₹","options":[],"required":false,"pdf_field":""},{"help":"Sign the claim form","type":"signature","label":"Claim Form Duly Signed/ ਸਹੀਤ ਭਿਰਆ ਹੋਇਆ ਕਲੇਮ ਫਾਰਮ","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"},{"title":"Part A - Details Of Bills Enclosed","fields":[{"help":"Provide bill number, date, issued by, towards, amount","type":"table","label":"Details Of Bills Enclosed / ਨੱਥੀ ਕੀਤੀਆਂ ਰਸੀਦਾਂ ਦੇ ਵੇਰਵੇ","options":[],"required":false,"pdf_field":""},{"help":"Enter number of pre-hospitalization bills enclosed","type":"number","label":"Pre-hospitalization Bills: _______________ Nos./ ਪਿਹਲਾਂ ਦੇ ਹਸਪਤਾਲੀਕਰਨ ਿਬਲ _______________ ਸੰਿਖਆ","options":[],"required":false,"pdf_field":""},{"help":"Tick if main hospital bill is enclosed","type":"checkbox","label":"Hospital Main Bill/ ਹਸਪਤਾਲ ਮੁੱਖ ਿਬੱਲ","options":["Yes / ਹਾਂ","No / ਨਹİ"],"required":false,"pdf_field":""},{"help":"Tick if pharmacy bills are enclosed","type":"checkbox","label":"Pharmacy Bills/ ਫਾਰਮੇਸੀ ਰਸੀਦਾਂ","options":["Yes / ਹਾਂ","No / ਨਹİ"],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"Part A - Details Of Primary Insured’s Bank Accounts","fields":[{"help":"Enter PAN number","type":"text","label":"PAN/ ਪੈਨ","options":[],"required":false,"pdf_field":""},{"help":"Enter bank account number","type":"text","label":"Account Number/ ਖਾਤਾ ਨੰਬਰ","options":[],"required":true,"pdf_field":""},{"help":"Enter bank name","type":"text","label":"Bank Name/ ਬƷ ਕ ਦਾ ਨਾਂ","options":[],"required":true,"pdf_field":""},{"help":"Enter bank branch","type":"text","label":"Bank Branch/ ਬƷ ਕ ਸ਼ਾਖਾ","options":[],"required":false,"pdf_field":""},{"help":"Enter cheque or DD payable details","type":"text","label":"Cheque/ DD Payable Details/ ਚੈਕ / ਡੀ.ਡੀ. ਭੁਗਤਾਨ ਵੇਰਵੇ","options":[],"required":false,"pdf_field":""},{"help":"Enter IFSC code","type":"text","label":"IFSC Code/ ਆਈਐਫਐਸਸੀ ਕੋਡ","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"},{"title":"Part A - Declaration By The Insured","fields":[{"help":"Sign here","type":"signature","label":"Signature of Insured / ਬੀਮਾ ਧਾਰਕ ਦੇ ਹਸਤਾਖਰ","options":[],"required":true,"pdf_field":""},{"help":"Enter date of signing","type":"date","label":"Date/ ਤਾਰੀਖ","options":[],"required":true,"pdf_field":""},{"help":"Enter place of signing","type":"text","label":"Place/ ਸਥਾਨ","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"Part B - To Be Filled In By The Hospital","fields":[{"help":"Tick hospital type","type":"choice","label":"Type of Hospital / ਹਸਪਤਾਲ ਦੀ ਿਕਸਮ","options":["Network / ਨੈਟਵਰਕ","Non-Network (If non-network, fill section E) / ਗੈਰ-ਨੈਟਵਰਕ"],"required":true,"pdf_field":""},{"help":"Enter hospital name","type":"text","label":"Name of the Hospital / ਹਸਪਤਾਲ ਦਾ ਨਾਂ","options":[],"required":true,"pdf_field":""},{"help":"Enter hospital ID","type":"text","label":"Hospital ID / ਹਸਪਤਾਲ ਆਈਡੀ","options":[],"required":false,"pdf_field":""},{"help":"Enter treating doctor's name","type":"text","label":"Name of the Treating Doctor / ਿਚਕਤਸਾ ਕਰ ਰਹੇ ਡਾਕਟਰ ਦਾ ਨਾਂ","options":[],"required":true,"pdf_field":""},{"help":"Enter doctor's qualification","type":"text","label":"Qualification / ਯੋਗਤਾ","options":[],"required":false,"pdf_field":""},{"help":"Enter registration number with state code","type":"text","label":"Registration No. with State Code / ਰਾਜ ਕੋਡ ਸਮੇਤ ਰਿਜਸਟǗੇਸ਼ਨ ਨੰਬਰ","options":[],"required":false,"pdf_field":""},{"help":"Enter phone number with STD code","type":"phone","label":"Phone No./  ਫ਼ੋਨ ਨੰਬਰ","options":[],"required":false,"pdf_field":""},{"help":"Enter patient name","type":"text","label":"Name of the Patient/ ਰੋਗੀ ਦਾ ਨਾਂ","options":[],"required":true,"pdf_field":""},{"help":"Enter IP registration number","type":"text","label":"IP Registration Number / ਆਈਪੀ ਰਿਜਸਟǗੇਸ਼ਨ ਨੰਬਰ","options":[],"required":false,"pdf_field":""},{"help":"Enter admission date in DD-MM-YYYY format","type":"date","label":"Date of Admission/ ਦਾਖਲੇ ਦੀ ਤਾਰੀਖ","options":[],"required":true,"pdf_field":""},{"help":"Enter admission time in HH:MM format","type":"text","label":"Time/ ਸਮਾਂ","options":[],"required":false,"pdf_field":""},{"help":"Enter total claimed amount in rupees","type":"amount","label":"Total claimed amount/ ਕੁੱਲ ਦਾਅਵਾ ਰਾਸ਼ੀ ₹","options":[],"required":true,"pdf_field":""},{"help":"Enter discharge date in DD-MM-YYYY format","type":"date","label":"Date of Discharge/ ਛੁੱਟੀ ਦੀ ਤਾਰੀਖ","options":[],"required":true,"pdf_field":""},{"help":"Enter age in years","type":"number","label":"Age/ ਉਮਰ","options":[],"required":true,"pdf_field":""},{"help":"Enter date of birth in DD-MM-YYYY format","type":"date","label":"Date of Birth/ ਜਨਮ ਤਾਰੀਖ","options":[],"required":true,"pdf_field":""},{"help":"Tick type of admission","type":"choice","label":"Type of Admission / ਦਾਖਲੇ ਦੀ ਿਕਸਮ","options":["Emergency/ ਐਮਰਜƷ ਸੀ","Planned/ ਯੋਜਨਾ ਬੱਧ","Daycare/ ਡੇਅਕੇਅਰ","Maternity/ ਮਾਤਾ ਬਣਨਾ"],"required":true,"pdf_field":""},{"help":"Tick discharge status","type":"choice","label":"Status at time of discharge / ਛੁੱਟੀ ਸਮDŽ ਦੀ ਸਿਥਤੀ","options":["Discharge to home/ ਘਰ ਛੁੱਟੀ","Deceased/ ਿਮǗ ਤਕ","Discharge to another hospital/ ਿਕਸੇ ਹੋਰ ਹਸਪਤਾਲ ਭੇਿਜਆ"],"required":true,"pdf_field":""},{"help":"Fill gravida status and date of delivery","type":"section","label":"If Maternity/ ਜੇਕਰ ਮਾਤਾ ਬਣਨ ਦੀ ਹਾਲਤ ਹੋਵੇ","options":[],"required":false,"pdf_field":""},{"help":"Enter gravida status","type":"text","label":"Gravida Status/ ਗਰਭ ਹਾਲਤ ਦੀ ਸਿਥਤੀ","options":[],"required":false,"pdf_field":""},{"help":"Enter delivery date in DD-MM-YYYY format","type":"date","label":"Date of Delivery/ ਿਡਿਲਵਰੀ ਦੀ ਤਾਰੀਖ","options":[],"required":false,"pdf_field":""}],"filled_by":"hospital"},{"title":"Part B - Details of Ailment Diagnosed and Procedures","fields":[{"help":"Describe co-morbidities","type":"text","label":"Co-morbidities/ ਸਿਹ-ਬੀਮਾਰੀਆਂ","options":[],"required":false,"pdf_field":""},{"help":"Enter ICD 10 codes","type":"text","label":"ICD 10 Codes/ ਆਈਸੀਡੀ 10 ਕੋਡ","options":[],"required":false,"pdf_field":""},{"help":"Enter primary diagnosis","type":"text","label":"Primary Diagnosis/ ਮੁੱਖ ਿਨਦਾਨ","options":[],"required":true,"pdf_field":""},{"help":"Enter ICD 10 PCS codes for procedures","type":"text","label":"ICD 10 PCS / ਆਈਸੀਡੀ 10 ਪੀਸੀਐਸ","options":[],"required":false,"pdf_field":""},{"help":"Enter first procedure description","type":"text","label":"Procedure 1/ ਕਾਰਵਾਈ 1","options":[],"required":false,"pdf_field":""},{"help":"Enter second procedure description","type":"text","label":"Procedure 2/ ਕਾਰਵਾਈ 2","options":[],"required":false,"pdf_field":""},{"help":"Enter third procedure description","type":"text","label":"Procedure 3/ ਕਾਰਵਾਈ 3","options":[],"required":false,"pdf_field":""},{"help":"Provide detailed procedure information","type":"text","label":"Details of Procedure/ ਕਾਰਵਾਈ ਦੀ ਿਵਸਥਾਰਤ ਜਾਣਕਾਰੀ","options":[],"required":false,"pdf_field":""},{"help":"Tick yes or no","type":"yes-no","label":"Pre-authorization obtained/ ਪੂਰਵ-ਅਿਧਕਾਰੀ ਪǗ ਾਪਤ ਕੀਤੀ ਗਈ","options":["Yes / ਹਾਂ","No / ਨਹİ"],"required":false,"pdf_field":""},{"help":"Enter pre-authorization number","type":"text","label":"Pre-authorization Number/ ਪੂਰਵ-ਅਿਧਕਾਰੀ ਨੰਬਰ","options":[],"required":false,"pdf_field":""},{"help":"Explain reason if no authorization","type":"text","label":"If authorization by network hospital not obtained, give reason/ ਜੇਕਰ ਨੈਟਵਰਕ ਹਸਪਤਾਲ ਤnj ਅਨੁਮਤੀ ਨਹİ ਲੀ ਗਈ, ਤਾਂ ਕਾਰਨ ਦੱਸੋ","options":[],"required":false,"pdf_field":""},{"help":"Tick yes or no","type":"yes-no","label":"Hospitalization due to injury/ ਚੋਟ ਕਾਰਨ ਦਾਖਲ ਹੋਣਾ","options":["Yes / ਹਾਂ","No / ਨਹİ"],"required":false,"pdf_field":""},{"help":"Tick cause of injury","type":"choice","label":"If yes, give cause/ ਜੇਕਰ ਹਾਂ, ਤਾਂ ਕਾਰਨ ਦੱਸੋ","options":["Self Inflicted/ ਆਪਣੇ ਆਪ ਨੂੰ ਚੋਟ","Road traffic accident/ ਸੜਕ ਹਾਦਸਾ","Substance abuse/ alcohol consumption / ਨਸ਼ੇ/ਸ਼ਰਾਬ ਦੀ ਵਰਤnj"],"required":false,"pdf_field":""},{"help":"Tick yes or no","type":"yes-no","label":"If injury due to Substance Abuse / Alcohol Consumption, Test Conducted to establish this/ ਜੇਕਰ ਨਸ਼ੇ ਜਾਂ ਸ਼ਰਾਬ ਕਾਰਨ ਚੋਟ ਹੋਈ, ਕੀ ਇਹ ਸਾਬਤ ਕਰਨ ਲਈ ਟੈਸਟ ਕੀਤਾ ਿਗਆ ਸੀ?","options":["Yes / ਹਾਂ","No / ਨਹİ"],"required":false,"pdf_field":""},{"help":"Tick yes or no","type":"yes-no","label":"If Medico-Legal/ ਕੀ ਇਹ ਮੈਡੀਕੋ-ਲੀਗਲ ਹੈ?","options":["Yes / ਹਾਂ","No / ਨਹİ"],"required":false,"pdf_field":""},{"help":"Tick yes or no","type":"yes-no","label":"Reported to Police/ ਪੁਿਲਸ ਨੂੰ ਿਰਪੋਰਟ ਿਦੱਤੀ ਗਈ?","options":["Yes / ਹਾਂ","No / ਨਹİ"],"required":false,"pdf_field":""},{"help":"Enter FIR number if applicable","type":"text","label":"FIR No/ ਐਫਆਈਆਰ ਨੰਬਰ","options":[],"required":false,"pdf_field":""},{"help":"Explain reason if not reported","type":"text","label":"If not reported to Police, give reason/ ਜੇਕਰ ਪੁਿਲਸ ਨੂੰ ਿਰਪੋਰਟ ਨਹį ਿਦੱਤੀ ਗਈ, ਤਾਂ ਕਾਰਨ ਦੱਸੋ","options":[],"required":false,"pdf_field":""}],"filled_by":"hospital"},{"title":"Part B - Declaration By The Hospital","fields":[{"help":"Enter date of declaration","type":"date","label":"Date/ ਤਾਰੀਖ","options":[],"required":true,"pdf_field":""},{"help":"Enter place of declaration","type":"text","label":"Place/ ਸਥਾਨ","options":[],"required":false,"pdf_field":""},{"help":"Signature and seal of hospital authority","type":"signature","label":"Signature and Seal of the Hospital Authority/ ਹਸਪਤਾਲ ਅਿਧਕਾਰੀ ਦੇ ਦਸਤਖਤ ਅਤੇ ਮੁਹਰ","options":[],"required":true,"pdf_field":""}],"filled_by":"hospital"}],"deadlines":[],"applies_to":"Health insurance claims","attachments":["Hospital Main Bill/ ਹਸਪਤਾਲ ਦੀ ਮੁੱਖ ਰਸੀਦ","Copy of the Claim Intimation (if any)/ ਕਲੇਮ ਇੰਿਤਮਾਟੀ ਦੀ ਕਾਪੀ (ਜੇ ਹੋਏ)","Hospital Break-up Bill/ ਹਸਪਤਾਲ ਦੀ ਿਵਸਥਾਰ ਰਸੀਦ","Hospital Bill Payment Receipt/ ਹਸਪਤਾਲ ਦੀ ਭੁਗਤਾਨ ਰਸੀਦ","Hospital Discharge Summary/ ਹਸਪਤਾਲ ਿਡਸਚਾਰਜ ਸਾਰ","Pharmacy Bill/ ਫਾਰਮੇਸੀ ਦੀ ਰਸੀਦ","Operation Theatre Notes/ ਓਪਰੇਸ਼ਨ ਥੀਏਟਰ ਨੋਟਸ","Doctor’s Request for Investigation/ ਡਾਕਟਰ ਦੀ ਜਾਂਚ ਲਈ ਬੇਨਤੀ","ECG/ ਈ.ਸੀ.ਜੀ.","Investigation Reports (Including CT/ MRI/ USG/ HPE)/ ਜਾਂਚ ਿਰਪੋਰਟਾਂ (CT/ MRI/ USG/ HPE ਸਮੇਤ)","Doctor’s Prescriptions/ ਡਾਕਟਰ ਦੀ ਦਵਾਈ ਿਲਖਤ","MLC Report & Police FIR (if applicable)","Copy of the Pre-authorization Approval Letter","Original Pre-authorization request","Copy of Photo ID Card of Patient Verified by Hospital","Investigation Reports","CT / MRI / USG / HPE Investigation Reports","Doctor’s Reference Slip for Investigation ECG","Hospital Discharge Summery","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 may lead to forfeiture of claim rights.","Consent is given to TPA/Insurance company to obtain necessary medical information from hospitals or doctors.","All bills and receipts for the claim have been included and no supplementary claims will be made except pre/post hospitalization claims.","The hospital declares that the information furnished is true and correct to the best of their knowledge and belief.","False statements or concealment of material facts by the hospital may lead to forfeiture of claim rights."],"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/2213-health-claim-form"}