{"id":2260,"title":"Liberty’s Hospi-Cash Connect Policy- CLAIM FORM (Effective from 30.09.2024)","purpose":"claim","insurer":{"slug":"liberty-general-insurance","name":"Liberty General Insurance Limited"},"source_pdf":"https://www.libertyinsurance.in/Docx/LIBHLIP21501V022021%20-%20Hospi%20Cash%20Connect%20Policy%20-%20Claim%20Form%20-%20Effective%20from%2030092024.pdf","sha256":"d9a258c5d3207546c33e96ed486d0cff8ba45c747a48ad7fe00c8b01f201745f","pages":6,"collected":"2026-10-17","instructions":{"about":"This form is used by the insured person to claim benefits under the Liberty Hospi-Cash Connect Policy for hospitalization expenses. The insured person fills Part A, and the hospital fills Part B.","notes":["Use dd-mm-yy format for dates unless otherwise specified.","Use hh:mm format for times.","Tick appropriate options where indicated.","Attach separate sheet for additional bills/receipt details if needed.","Original bills and attested copies of documents are required.","The issue of this form is not an admission of liability.","Part B of the claim form is to be filled by the hospital."],"title":"Liberty’s Hospi-Cash Connect Policy- CLAIM FORM (Effective from 30.09.2024)","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Section A - Details of Primary Insured","fields":[{"help":"Enter the policy number as allotted by the insurance company","type":"text","label":"Policy Number","options":[],"required":null,"pdf_field":""},{"help":"Enter the social insurance number or certificate number as allotted","type":"text","label":"SL No / Certificate No/ Claim Number (If any)","options":[],"required":null,"pdf_field":""},{"help":"Enter the TPA ID number as per TPA documents","type":"text","label":"Company/ TPA ID no","options":[],"required":null,"pdf_field":""},{"help":"Enter 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 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":""},{"help":"Enter ABHA ID if available","type":"text","label":"ABHA ID","options":[],"required":null,"pdf_field":""}],"filled_by":"insured person"},{"title":"Section B - Details of Insurance History","fields":[{"help":"Tick Yes or No","type":"yes-no","label":"Currently Covered by any other Mediclaim / Health Insurance? YES / NO","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 insurance company","type":"text","label":"If YES, - Company Name","options":[],"required":null,"pdf_field":""},{"help":"Enter policy number as allotted","type":"text","label":"Policy Number","options":[],"required":null,"pdf_field":""},{"help":"Enter total sum insured in rupees","type":"amount","label":"Sum Insured","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Health Card Number","options":[],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"Have you been hospitalized in the last four years since the inception of the contract? YES / NO","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":"yes-no","label":"Previously covered by any other Mediclaim / Health Insurance: YES/ NO","options":["YES","NO"],"required":null,"pdf_field":""},{"help":"Enter full name of insurance company","type":"text","label":"If Yes company name","options":[],"required":null,"pdf_field":""}],"filled_by":"insured person"},{"title":"Section C - Details of Insured Person Hospitalized","fields":[{"help":"Enter full name of patient","type":"text","label":"Name","options":[],"required":null,"pdf_field":""},{"help":"Tick Male or Female","type":"choice","label":"Gender: Male / Female","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 correct option or specify if Other","type":"choice","label":"Relationship of Primary Insured: Self/ Spouse/ Child/ Father/ Mother/ Other (Please Specify)","options":["Self","Spouse","Child","Father","Mother","Other"],"required":null,"pdf_field":""},{"help":"Tick the correct option or specify if Other","type":"choice","label":"Occupation: Service/ Self Employed/ Homemaker/ Student/ Retired/ Other (Please specify)","options":["Service","Self Employed","Homemaker","Student","Retired","Other"],"required":null,"pdf_field":""},{"help":"Enter full postal address including city, state and pin code","type":"text","label":"Address (If different from above)","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 person"},{"title":"Section D - Details of Hospitalization","fields":[{"help":"Enter full name of hospital","type":"text","label":"Name of the Hospital where admitted","options":[],"required":null,"pdf_field":""},{"help":"Tick the correct option","type":"choice","label":"Room Category Occupied: Day care / Single occupancy / Twin sharing / 3 or more","options":["Day care","Single occupancy","Twin sharing","3 or more"],"required":null,"pdf_field":""},{"help":"Tick the correct option","type":"choice","label":"Hospitalization due to: Illness / Injury / Maternity","options":["Illness","Injury","Maternity"],"required":null,"pdf_field":""},{"help":"Use dd-mm-yy format","type":"date","label":"Date of Injury / 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":"Use hh:mm format","type":"text","label":"Time of Admission","options":[],"required":null,"pdf_field":""},{"help":"Use dd-mm-yy format","type":"date","label":"Date of Discharge","options":[],"required":null,"pdf_field":""},{"help":"Use hh:mm format","type":"text","label":"Time of Discharge","options":[],"required":null,"pdf_field":""},{"help":"Tick the correct option","type":"choice","label":"If injury, give cause: Self Inflicted / Road Traffic Accident / Substance Abuse or Alcohol Consumption","options":["Self Inflicted","Road Traffic Accident","Substance Abuse or Alcohol Consumption"],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"If Medico legal: YES/ NO","options":["YES","NO"],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"Reported to Police: YES/ NO","options":["YES","NO"],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"MLC report or Police FIR attached: YES / NO","options":["YES","NO"],"required":null,"pdf_field":""},{"help":"Enter system of medicine followed","type":"text","label":"System of medicine","options":[],"required":null,"pdf_field":""}],"filled_by":"insured person"},{"title":"Section E - Details of Claim","fields":[{"help":"Enter amount claimed in rupees","type":"amount","label":"Daily Hospital Cash (DHC) Benefit","options":[],"required":null,"pdf_field":""},{"help":"Enter amount claimed in rupees","type":"amount","label":"Daily Hospital Cash (DHC) - Only Accidents Benefit","options":[],"required":null,"pdf_field":""},{"help":"Enter amount claimed in rupees","type":"amount","label":"Double Accident Benefit (DAB)","options":[],"required":null,"pdf_field":""},{"help":"Enter amount claimed in rupees","type":"amount","label":"Double ICU Benefit (DIB) – Sickness","options":[],"required":null,"pdf_field":""},{"help":"Enter amount claimed in rupees","type":"amount","label":"Double ICU Benefit (DIB) – Accident","options":[],"required":null,"pdf_field":""},{"help":"Enter amount claimed in rupees","type":"amount","label":"Double Critical Illness Benefit (DCI) - Listed Critical Illnesses","options":[],"required":null,"pdf_field":""},{"help":"Enter amount claimed in rupees","type":"amount","label":"Day care Procedure Cash - Listed Procedures","options":[],"required":null,"pdf_field":""},{"help":"Enter amount claimed in rupees","type":"amount","label":"Recovery Benefit","options":[],"required":null,"pdf_field":""},{"help":"Enter amount claimed in rupees","type":"amount","label":"Convalescence Benefit","options":[],"required":null,"pdf_field":""},{"help":"Enter amount claimed in rupees","type":"amount","label":"Special care on Minor Surgeries","options":[],"required":null,"pdf_field":""},{"help":"Enter amount claimed in rupees","type":"amount","label":"Special care on Major Surgeries","options":[],"required":null,"pdf_field":""},{"help":"Enter total amount claimed in rupees","type":"amount","label":"Total","options":[],"required":null,"pdf_field":""},{"help":"Tick the documents submitted","type":"checkbox","label":"Claim Documents Submitted Check List","options":["Original Claim Form Duly Filled","Copy of the Claim Intimation, if any","Attested copy of Hospital Main Bill with Break Up Bill","Attested copy of Hospital Bill Payment Receipt","Attested copy of Hospital Discharge Summary","Attested copy of Operation Theater Notes","Others"],"required":null,"pdf_field":""}],"filled_by":"insured person"},{"title":"Section F - Details of Bills Enclosed","fields":[{"help":"Fill Sl. No, Bill No, Date, Issued by, Towards, Amount for each bill; attach separate sheet if needed","type":"table","label":"Details of Bills Enclosed","options":[],"required":null,"pdf_field":""}],"filled_by":"insured person"},{"title":"Section G - Details of Primary Insured's Bank Account","fields":[{"help":"Enter Permanent Account Number as allotted by Income Tax","type":"text","label":"PAN No","options":[],"required":null,"pdf_field":""},{"help":"Enter bank account number","type":"text","label":"Account Number","options":[],"required":null,"pdf_field":""},{"help":"Enter full bank name and branch","type":"text","label":"Bank Name/ Branch","options":[],"required":null,"pdf_field":""},{"help":"Enter name of beneficiary for cheque/DD/NEFT","type":"text","label":"Payable details: Cheque/ DD/NEFT* Payable to","options":[],"required":null,"pdf_field":""},{"help":"Enter IFSC code of bank branch","type":"text","label":"IFSC Code","options":[],"required":null,"pdf_field":""}],"filled_by":"insured person"},{"title":"Section H - Declaration by the Insured","fields":[{"help":"Enter date in dd:mm:yy format","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Enter place","type":"text","label":"Place","options":[],"required":true,"pdf_field":""},{"help":"Sign the form","type":"signature","label":"Signature of the Insured","options":[],"required":true,"pdf_field":""}],"filled_by":"insured person"},{"title":"Claim Form - Part B (To be filled by the Hospital)","fields":[{"help":"Enter full hospital name","type":"text","label":"Name of the Hospital","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Hospital ID","options":[],"required":null,"pdf_field":""},{"help":"Tick the correct option","type":"choice","label":"Type of Hospital: Network / Non Network","options":["Network","Non Network"],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Name of the treating Doctor","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Qualification","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Registration No with State Code","options":[],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"Phone No","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Name of the patient","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"IP Registration Number","options":[],"required":null,"pdf_field":""},{"help":"","type":"choice","label":"Gender: Male/ Female","options":["Male","Female"],"required":null,"pdf_field":""},{"help":"","type":"number","label":"Age","options":[],"required":null,"pdf_field":""},{"help":"Use dd mm yyyy format","type":"date","label":"Date of Birth","options":[],"required":null,"pdf_field":""},{"help":"","type":"date","label":"Date of Admission","options":[],"required":null,"pdf_field":""},{"help":"Use hh:mm format","type":"text","label":"Time of Admission","options":[],"required":null,"pdf_field":""},{"help":"","type":"date","label":"Date of Discharge","options":[],"required":null,"pdf_field":""},{"help":"Use hh:mm format","type":"text","label":"Time of Discharge","options":[],"required":null,"pdf_field":""},{"help":"Tick the correct option","type":"choice","label":"Type of Admission: Emergency / Planned / Day-care / Maternity","options":["Emergency","Planned","Day-care","Maternity"],"required":null,"pdf_field":""},{"help":"","type":"date","label":"If Maternity Date of delivery","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Gravida Status","options":[],"required":null,"pdf_field":""},{"help":"Tick the correct option","type":"choice","label":"Status at the time of Discharge: Discharge to Home/ Discharge to another Hospital/ Deceased","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":"","type":"text","label":"Ailment Diagnosed (Primary)","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"ICD 10 Code","options":[],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"Pre authorization Obtained YES/ NO","options":["YES","NO"],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"Hospitalization due to Injury Yes/ No","options":["YES","NO"],"required":null,"pdf_field":""},{"help":"Tick the correct option","type":"choice","label":"If Yes Give cause: Self-Inflicted/ Road Traffic Accident / Substance Abuse / Alcohol Consumption","options":["Self-Inflicted","Road Traffic Accident","Substance Abuse","Alcohol Consumption"],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"Reported to police YES / NO","options":["YES","NO"],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"Medico Legal YES / NO","options":["YES","NO"],"required":null,"pdf_field":""},{"help":"","type":"text","label":"FIR No","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"If not reported to police, give reasons","options":[],"required":null,"pdf_field":""},{"help":"Tick Yes or No and attach report if Yes","type":"yes-no","label":"If injury due to Substance Abuse/ Alcohol consumption test conducted to establish this? YES/ NO","options":["YES","NO"],"required":null,"pdf_field":""},{"help":"","type":"text","label":"If authorization by network hospital not obtained, give reason","options":[],"required":null,"pdf_field":""}],"filled_by":"hospital"}],"deadlines":[],"applies_to":"Claims under Liberty Hospi-Cash Connect Policy","attachments":["Original Claim Form Duly Filled","Copy of the Claim Intimation, if any","Attested copy of Hospital Main Bill with Break Up Bill","Attested copy of Hospital Bill Payment Receipt","Attested copy of Hospital Discharge Summary","Attested copy of Operation Theater Notes","Others"],"declarations":["The information furnished in this claim form is true and correct to the best of my knowledge and belief.","If any false or untrue statement, suppression or concealment of material fact is made, the right to claim reimbursement shall be forfeited.","Consent and authorization to TPA/insurance company to seek necessary medical information/documents from hospitals or medical practitioners.","All bills/receipts for the claim are included and no supplementary claim will be made except pre/post-hospitalization claim if any.","Consent to process/share personal information and data with group companies or service providers for insurance and related products.","Hospital declaration that information furnished is true and correct and any false statement will forfeit claim rights."],"dropped_labels":8},"pdf_fields":null,"fillable_pdf":false,"send_to":[],"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/liberty-general-insurance/2260-libertys-hospi-cash-connect-policy-claim-form-effective-from-30-09-2024"}