{"id":2262,"title":"LIBERTY HEALTH CONNECT INSURANCE CLAIM FORM - PART A","purpose":"claim","insurer":{"slug":"liberty-general-insurance","name":"Liberty General Insurance Limited"},"source_pdf":"https://www.libertyinsurance.in/Docx/LHC%20Claims%20Form_ORD%204254.pdf","sha256":"a5664c844506a9317360b7315e9789a40f04e82321d37def5957056c57408145","pages":7,"collected":"2026-10-17","instructions":{"about":"This form is used by the insured person to claim reimbursement for medical treatment expenses under the Liberty Health Connect insurance policy issued on or before 20th Aug 2018.","notes":["Use block letters to fill the form.","Do not enter paise values in amount fields; enter only rupees.","Use dd-mm-yy format for dates and hh:mm format for times.","Attach original preauthorization request form in lieu of PART A.","The issue of this form is not to be taken as an admission of liability.","Call Toll Free No: 1800 266 5844 for assistance."],"title":"LIBERTY HEALTH CONNECT INSURANCE CLAIM FORM - PART A","submit":{"to":"Liberty General Insurance Limited","how":"post / e-mail / upload / in person","address":"10th Floor, Tower A, Peninsula Business Park, Ganpatrao Kadam Marg, Lower Parel, Mumbai - 400 013\nPhone: +91 22 6700 1313\nEmail: care@libertyinsurance.in"},"purpose":"claim","sections":[{"title":"DETAIL OF CLAIM","fields":[{"help":"Enter amount in rupees","type":"amount","label":"Pre-hospitalization Expenses :","options":[],"required":null,"pdf_field":""},{"help":"Enter amount in rupees","type":"amount","label":"Hospitalization Expenses :","options":[],"required":null,"pdf_field":""},{"help":"Enter amount in rupees","type":"amount","label":"Post-hospitalization Expenses :","options":[],"required":null,"pdf_field":""},{"help":"Enter amount in rupees","type":"amount","label":"Health-Check up Cost :","options":[],"required":null,"pdf_field":""},{"help":"Enter amount in rupees","type":"amount","label":"Ambulance charges :","options":[],"required":null,"pdf_field":""},{"help":"Enter amount in rupees and specify code","type":"amount","label":"Other (code) :","options":[],"required":null,"pdf_field":""},{"help":"Enter number of days","type":"number","label":"Pre-hospitalisation period :","options":[],"required":null,"pdf_field":""},{"help":"Enter number of days","type":"number","label":"Post-hospitalization Period :","options":[],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"Claim for Domiciliary Hospitalization :","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter amounts in rupees","type":"amount","label":"Details Of Lump sum / Cash Benefit Claimed:","options":[],"required":null,"pdf_field":""},{"help":"Enter amount in rupees","type":"amount","label":"Hospital Daily Cash :","options":[],"required":null,"pdf_field":""},{"help":"Enter amount in rupees","type":"amount","label":"Critical Illness Benefit :","options":[],"required":null,"pdf_field":""},{"help":"Enter amount in rupees","type":"amount","label":"Pre/Post Hospitalization Lump Sum Benefit :","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"TO BE FILLED IN BY THE INSURED","fields":[{"help":"Enter your policy number","type":"text","label":"Policy No. :","options":[],"required":true,"pdf_field":""},{"help":"Enter your certificate or serial number","type":"text","label":"SI. No./certificate No. :","options":[],"required":null,"pdf_field":""},{"help":"Enter company or TPA ID number","type":"text","label":"Company / TPA ID No. :","options":[],"required":null,"pdf_field":""},{"help":"Enter full name of insured","type":"text","label":"Name :","options":[],"required":true,"pdf_field":""},{"help":"Enter full postal address","type":"text","label":"Address :","options":[],"required":null,"pdf_field":""},{"help":"Enter city","type":"text","label":"City :","options":[],"required":null,"pdf_field":""},{"help":"Enter state","type":"text","label":"State :","options":[],"required":null,"pdf_field":""},{"help":"Enter postal pin code","type":"number","label":"Pin Code :","options":[],"required":null,"pdf_field":""},{"help":"Enter phone number with STD code","type":"phone","label":"Phone No. :","options":[],"required":null,"pdf_field":""},{"help":"Enter email address","type":"email","label":"Email ID :","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"DETAILS OF INSURANCE HISTORY","fields":[{"help":"Tick Yes or No","type":"yes-no","label":"Currently covered by any other Mediclaim / Health Insurance :","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":"Company Name :","options":[],"required":null,"pdf_field":""},{"help":"Enter policy number of other insurance","type":"text","label":"Policy No :","options":[],"required":null,"pdf_field":""},{"help":"Enter sum insured in rupees","type":"amount","label":"Sum Insured (Rs.) :","options":[],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"Have you been hospitalized in the last 4 year? :","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Date of hospitalization if yes, use dd-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 :","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter previous insurance company name","type":"text","label":"If Yes, Company Name :","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"DETAILS OF INSURED PERSON HOSPITALIZED","fields":[{"help":"Enter name and tick relationship","type":"text","label":"Name :","options":["Self","Spouse","Child","Father","Mother","Other"],"required":true,"pdf_field":""},{"help":"Tick Male or Female","type":"choice","label":"Gender :","options":["Male","Female"],"required":true,"pdf_field":""},{"help":"Enter age in years","type":"number","label":"Age : Year","options":[],"required":null,"pdf_field":""},{"help":"Use dd-mm-yy format","type":"date","label":"Date of Birth :","options":[],"required":null,"pdf_field":""},{"help":"Tick appropriate relationship or specify","type":"choice","label":"Relationship to Primary Insured :","options":["Self","Spouse","Child","Father","Mother","Other"],"required":null,"pdf_field":""},{"help":"Tick occupation or specify if Other","type":"text","label":"Occupation :","options":["Service","Self Employed","Homemaker","Student","Retired","Other"],"required":null,"pdf_field":""},{"help":"Enter full postal address if different","type":"text","label":"Address (if different from Above) :","options":[],"required":false,"pdf_field":""},{"help":"Enter city","type":"text","label":"City :","options":[],"required":false,"pdf_field":""},{"help":"Enter state","type":"text","label":"State :","options":[],"required":false,"pdf_field":""},{"help":"Enter postal pin code","type":"number","label":"Pin Code :","options":[],"required":false,"pdf_field":""},{"help":"Enter phone number with STD code","type":"phone","label":"Phone No :","options":[],"required":false,"pdf_field":""},{"help":"Enter email address","type":"email","label":"Email ID :","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"DETAIL OF HOSPITALIZATION","fields":[{"help":"Enter full hospital name","type":"text","label":"Name of Hospital where Admitted :","options":[],"required":true,"pdf_field":""},{"help":"Tick appropriate room category","type":"choice","label":"Room Category Occupied :","options":["Day Care","Single Occupancy","Twin Sharing","3 Or more beds per room"],"required":null,"pdf_field":""},{"help":"Tick appropriate reason","type":"choice","label":"Hospitalization due to :","options":["Injury","Illness","Maternity","Self Inflicted","Road Traffic Accident"],"required":null,"pdf_field":""},{"help":"Use dd-mm-yy format","type":"date","label":"Date of Injury / Date 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":true,"pdf_field":""},{"help":"Enter time of admission in hh:mm format","type":"text","label":"Time :","options":[],"required":null,"pdf_field":""},{"help":"Use dd-mm-yy format","type":"date","label":"Date Of Discharge :","options":[],"required":true,"pdf_field":""},{"help":"Enter time of discharge in hh:mm format","type":"text","label":"Time :","options":[],"required":null,"pdf_field":""},{"help":"Specify cause of injury","type":"text","label":"If Injury Give Cause :","options":[],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"If Medico legal :","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"Reported To Police :","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"MLC Report & Police FIR Attached :","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Specify system of medicine followed","type":"text","label":"System of Medicine :","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"DETAILS OF PRIMARY INSURED","fields":[{"help":"Enter Permanent Account Number","type":"text","label":"PAN :","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 and Branch :","options":[],"required":null,"pdf_field":""},{"help":"Enter name of beneficiary for cheque/DD","type":"text","label":"Cheque/ DD Payable details :","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"},{"title":"DETAILS OF BILL ENCLOSED","fields":[{"help":"Enter bill number","type":"text","label":"Bill No","options":[],"required":null,"pdf_field":""},{"help":"Use dd-mm-yy format","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Enter issuer of bill","type":"text","label":"Issued by","options":[],"required":null,"pdf_field":""},{"help":"Purpose of bill","type":"text","label":"Towards","options":[],"required":null,"pdf_field":""},{"help":"Enter amount in rupees","type":"amount","label":"Amount (Rs.)","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"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 here","type":"signature","label":"Signature of the insured","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"},{"title":"TO BE FILLED IN BY THE HOSPITAL","fields":[{"help":"Enter full hospital name","type":"text","label":"Name of Hospital :","options":[],"required":true,"pdf_field":""},{"help":"Enter hospital ID","type":"text","label":"Hospital ID :","options":[],"required":null,"pdf_field":""},{"help":"Tick appropriate type","type":"choice","label":"Type of Hospital :","options":["Non Network","Network"],"required":null,"pdf_field":""},{"help":"Enter full name of doctor","type":"text","label":"Name of the treating doctor :","options":[],"required":true,"pdf_field":""},{"help":"Enter doctor's qualifications","type":"text","label":"Qualification :","options":[],"required":null,"pdf_field":""},{"help":"Enter registration number with state code","type":"text","label":"Registration No. with State Code :","options":[],"required":null,"pdf_field":""},{"help":"Enter phone number with STD code","type":"phone","label":"Phone No. :","options":[],"required":null,"pdf_field":""},{"help":"Enter full name of patient","type":"text","label":"Name of the Patient :","options":[],"required":true,"pdf_field":""},{"help":"Use dd-mm-yy format","type":"date","label":"Date of Birth :","options":[],"required":null,"pdf_field":""},{"help":"Use dd-mm-yy format","type":"date","label":"Date of Admission :","options":[],"required":true,"pdf_field":""},{"help":"Enter time in hh:mm format","type":"text","label":"Time :","options":[],"required":null,"pdf_field":""},{"help":"Use dd-mm-yy format","type":"date","label":"Date of Discharge :","options":[],"required":true,"pdf_field":""},{"help":"Enter time in hh:mm format","type":"text","label":"Time :","options":[],"required":null,"pdf_field":""},{"help":"Tick appropriate status","type":"choice","label":"Status at time of discharge :","options":["Discharge to home","Discharge to another hospital","Deceased"],"required":null,"pdf_field":""},{"help":"Use dd-mm-yy format","type":"date","label":"If Maternity : Date of Delivery :","options":[],"required":null,"pdf_field":""},{"help":"Enter grade of status","type":"text","label":"Grade of status :","options":[],"required":null,"pdf_field":""},{"help":"Tick appropriate type","type":"choice","label":"Type of Admission :","options":["Emergency","Planned","Day Care","Maternity"],"required":null,"pdf_field":""},{"help":"Tick Male or Female","type":"choice","label":"Gender :","options":["Male","Female"],"required":true,"pdf_field":""},{"help":"Enter inpatient registration number","type":"text","label":"IP Registration Number :","options":[],"required":null,"pdf_field":""},{"help":"Enter age in years","type":"number","label":"Age : Year","options":[],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"Pre-authorization obtained :","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter pre-authorization number if obtained","type":"text","label":"Pre-authorization Number :","options":[],"required":null,"pdf_field":""},{"help":"Explain reason for no authorization","type":"text","label":"If authorization by network hospital not obtained, give reason :","options":[],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"Hospitalization due to Injury :","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Tick cause or specify if Other","type":"choice","label":"If Yes, give cause :","options":["Self-inflicted","Road Traffic Accident","Substance abuse/ alcohol consumption","Other"],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"If injury due to substance abuse/ alcohol consumption, Test Conducted to establish this :","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Tick Yes or No and attach report if Yes","type":"yes-no","label":"If Medico Legal :","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"Reported To Police :","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter FIR number if reported","type":"text","label":"FIR no :","options":[],"required":null,"pdf_field":""},{"help":"Explain reason for no police report","type":"text","label":"If not reported to police give reason :","options":[],"required":null,"pdf_field":""}],"filled_by":"hospital"},{"title":"DETAILS IN CASE OF NON NETWORK HOSPITAL","fields":[{"help":"Enter full postal address","type":"text","label":"Address of Hospital :","options":[],"required":null,"pdf_field":""},{"help":"Enter city","type":"text","label":"City :","options":[],"required":null,"pdf_field":""},{"help":"Enter state","type":"text","label":"State :","options":[],"required":null,"pdf_field":""},{"help":"Enter postal pin code","type":"number","label":"Pin Code :","options":[],"required":null,"pdf_field":""},{"help":"Enter phone number with STD code","type":"phone","label":"Phone No :","options":[],"required":null,"pdf_field":""},{"help":"Enter hospital registration number","type":"text","label":"Registration No :","options":[],"required":null,"pdf_field":""},{"help":"Enter hospital PAN","type":"text","label":"PAN :","options":[],"required":null,"pdf_field":""},{"help":"Enter number of inpatient beds","type":"number","label":"Number of Inpatient beds :","options":[],"required":null,"pdf_field":""},{"help":"Tick available facilities and specify if Other","type":"checkbox","label":"Facilities available in the hospital :","options":["OT","ICU","Other"],"required":null,"pdf_field":""}],"filled_by":"hospital"},{"title":"DECLARATION BY THE HOSPITAL","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 and stamp here","type":"signature","label":"Signature and Seal of the hospital Authority","options":[],"required":true,"pdf_field":""}],"filled_by":"hospital"}],"deadlines":[],"applies_to":"Liberty Health Connect Policy - Claim form (For policy issued on or before 20th Aug 2018)","attachments":["copy of policies to be attached","Claim Form Duly Signed","Copy of the claim Intimation","Hospital Main Bill","Hospital Break-up Bill","Hospital Bill Payment Receipt","Hospital Discharge Summary","Pharmacy Bill","Operation Theater Notes","ECG","Doctor’s Request For Investigation","Investigation Report (Including CT / MRI / USG / HPE)","Other","Original Preauthorization request form","Copy of Pre-authorization Approval letter","Copy of photo ID card of patient verified by hospital","MLC report & Police FIR","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.","If any false or untrue statement, suppression or concealment of any material fact is made, the right to claim reimbursement shall be forfeited.","Consent and authorization is given to TPA / insurance company to seek necessary medical information / documents from any hospital / Medical Practitioner.","All bills / receipts for the purpose of this claim are included and no supplementary claim will be made except pre/post-hospitalization claim, if any.","The hospital declares that the information furnished in this Claim Form is true and correct to the best of their knowledge and belief.","The insured's signature is taken after Claim Form B is fully filled by the hospital."],"dropped_labels":3},"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/2262-liberty-health-connect-insurance-claim-form-part-a"}