{"id":2263,"title":"LIBERTY HOSPI-CASH CONNECT POLICY CLAIM FORM","purpose":"claim","insurer":{"slug":"liberty-general-insurance","name":"Liberty General Insurance Limited"},"source_pdf":"https://www.libertyinsurance.in/Docx/Liberty%20Hospi-cash%20Connect%20Policy%20-%20Claim%20form.pdf","sha256":"48239aef7c2b28db250f00691dd411c9790fa735d16678453b6866b9abea0050","pages":4,"collected":"2026-10-17","instructions":{"about":"This form is used by the insured person and the hospital to claim benefits under the Liberty Hospi-Cash Connect Policy for hospitalization expenses and related benefits.","notes":["Use dd mm yy format for dates unless otherwise specified.","Use hh mm format for times.","If ABHA ID is not available, create one at https://abdm.gov.in/ and inform the insurer.","Attach separate sheet for additional bills/receipt details if needed.","For documents submission, send to the Pune office or nearest branch.","Original bills and attested copies are required as per checklist.","The issue of this form is not an admission of liability.","Hospital must include original preauthorization request form in lieu of Part A."],"title":"LIBERTY HOSPI-CASH CONNECT POLICY CLAIM FORM","submit":{"to":"Liberty Health 360 - Liberty General Insurance Limited: \"The Capitol\", 4th Floor, New D.P.Road, Near Ashoka Hotel, Vishal Nagar, Pimple Nilakh, Pune- 411027. Alternatively, claim documents can also be sent to your nearest branch.","how":"post","address":"Liberty Health 360 - Liberty General Insurance Limited: \"The Capitol\", 4th Floor, New D.P.Road, Near Ashoka Hotel, Vishal Nagar, Pimple Nilakh, Pune- 411027"},"purpose":"claim","sections":[{"title":"Details of Primary Insured","fields":[{"help":"Enter the policy number as allotted by the insurance company","type":"text","label":"Policy No :","options":[],"required":null,"pdf_field":""},{"help":"Enter the social insurance number or certificate number if applicable","type":"text","label":"SL No / Certificate No/ Claim Number (If any):","options":[],"required":null,"pdf_field":""},{"help":"Enter the Liberty Health 360 ID No.","type":"text","label":"Company ID No :","options":[],"required":null,"pdf_field":""},{"help":"Enter full name of the policyholder","type":"text","label":"Name : SURNAME FIRST NAME MIDDLE NAME","options":[],"required":null,"pdf_field":""},{"help":"Enter full postal address including city, state and pin code","type":"text","label":"Address : City : State : Pin Code :","options":[],"required":null,"pdf_field":""},{"help":"If ABHA ID is not available, create one at https://abdm.gov.in/ and inform the insurer","type":"text","label":"ABHA Id :","options":[],"required":false,"pdf_field":""},{"help":"","type":"phone","label":"Phone No :","options":[],"required":null,"pdf_field":""},{"help":"","type":"email","label":"Email ID :","options":[],"required":null,"pdf_field":""}],"filled_by":"insured person"},{"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 the insurance company","type":"text","label":"If Yes Company Name :","options":[],"required":false,"pdf_field":""},{"help":"Enter policy number of other insurance","type":"text","label":"Policy No :","options":[],"required":false,"pdf_field":""},{"help":"Enter sum insured in rupees","type":"amount","label":"Sum Insured (Rs.) :","options":[],"required":false,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"Have you been hospitalized in the last 4 years since the inception of the contract?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Use dd mm yy format","type":"date","label":"Date :","options":[],"required":false,"pdf_field":""},{"help":"Enter diagnosis details","type":"text","label":"Diagnosis :","options":[],"required":false,"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 name of previous insurance company","type":"text","label":"If Yes, Company Name :","options":[],"required":false,"pdf_field":""}],"filled_by":"insured person"},{"title":"Details of Insured Person Hospitalized","fields":[{"help":"Enter full name of the hospitalized person","type":"text","label":"Name : SURNAME FIRST NAME MIDDLE NAME","options":[],"required":null,"pdf_field":""},{"help":"Tick the appropriate gender","type":"choice","label":"Gender :","options":["Male","Female"],"required":null,"pdf_field":""},{"help":"Enter age in years and months","type":"number","label":"Age : Year YY Months mm","options":[],"required":null,"pdf_field":""},{"help":"Tick the appropriate relationship","type":"choice","label":"Relationship to Primary Insured :","options":["Self","Spouse","Child","Father","Mother","Other (Please specify)"],"required":null,"pdf_field":""},{"help":"Tick the appropriate occupation","type":"choice","label":"Occupation :","options":["Service","Self Employed","Homemaker","Student","Retired","Other (Please specify)"],"required":null,"pdf_field":""},{"help":"Enter full postal address if different from primary insured","type":"text","label":"Address (if different from Above) : City : State : Pin Code :","options":[],"required":false,"pdf_field":""},{"help":"","type":"phone","label":"Phone No :","options":[],"required":false,"pdf_field":""},{"help":"","type":"email","label":"Email ID :","options":[],"required":false,"pdf_field":""},{"help":"If ABHA ID is not available, create one at https://abdm.gov.in/ and inform the insurer","type":"text","label":"ABHA Id :","options":[],"required":false,"pdf_field":""}],"filled_by":"insured person"},{"title":"Detail of Hospitalization","fields":[{"help":"Enter full name of hospital","type":"text","label":"Name of Hospital where Admitted :","options":[],"required":null,"pdf_field":""},{"help":"Tick the appropriate room category","type":"choice","label":"Room Category Occupied :","options":["Day Care","Single Occupancy","Twin Sharing","3 Or more"],"required":null,"pdf_field":""},{"help":"Tick the reason for hospitalization","type":"choice","label":"Hospitalization due to :","options":["Injury","Illness","Maternity"],"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":null,"pdf_field":""},{"help":"Use 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":null,"pdf_field":""},{"help":"Use hh mm format","type":"text","label":"Time :","options":[],"required":null,"pdf_field":""},{"help":"Tick the cause of injury if applicable","type":"choice","label":"If Injury Give Cause :","options":["Self Inflicted","Road Traffic Accident","Substance / Alcohol Consumption"],"required":false,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"If Medico legal :","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"Reported To Police :","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"MLC Report & Police FIR Attached :","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Enter the system of medicine used for treatment","type":"text","label":"System of Medicine :","options":[],"required":null,"pdf_field":""}],"filled_by":"insured person"},{"title":"Detail of Claim","fields":[{"help":"Enter amount claimed in rupees","type":"amount","label":"Daily Hospital Cash (DHC) Benefit :","options":[],"required":false,"pdf_field":""},{"help":"Enter amount claimed in rupees","type":"amount","label":"Daily Hospital Cash (DHC) - Only Accidents Benefit :","options":[],"required":false,"pdf_field":""},{"help":"Enter amount claimed in rupees","type":"amount","label":"Double Accident Benefit (DAB) :","options":[],"required":false,"pdf_field":""},{"help":"Enter amount claimed in rupees","type":"amount","label":"Double ICU Benefit (DIB) - Sickness :","options":[],"required":false,"pdf_field":""},{"help":"Enter amount claimed in rupees","type":"amount","label":"Double ICU Benefit (DIB) - Accident :","options":[],"required":false,"pdf_field":""},{"help":"Enter amount claimed in rupees","type":"amount","label":"Double Critical Illness Benefit (DCI) - Listed Critical Illnesses :","options":[],"required":false,"pdf_field":""},{"help":"Enter amount claimed in rupees","type":"amount","label":"Day care Procedure Cash - Listed Procedures :","options":[],"required":false,"pdf_field":""},{"help":"Enter amount claimed in rupees","type":"amount","label":"Recovery Benefit :","options":[],"required":false,"pdf_field":""},{"help":"Enter amount claimed in rupees","type":"amount","label":"Convalescence Benefit :","options":[],"required":false,"pdf_field":""},{"help":"Enter amount claimed in rupees","type":"amount","label":"Special care on Minor Surgeries :","options":[],"required":false,"pdf_field":""},{"help":"Enter amount claimed in rupees","type":"amount","label":"Special care on Major Surgeries :","options":[],"required":false,"pdf_field":""},{"help":"Enter total claim amount in rupees","type":"amount","label":"Total : Rs.","options":[],"required":false,"pdf_field":""}],"filled_by":"insured person"},{"title":"Claim Documents Submitted - Check List","fields":[{"help":"Tick if submitted","type":"checkbox","label":"Original Claim Form Duly Filled","options":[],"required":null,"pdf_field":""},{"help":"Tick if submitted","type":"checkbox","label":"Copy of the Claim Intimation, if any","options":[],"required":null,"pdf_field":""},{"help":"Tick if submitted","type":"checkbox","label":"Attested copy of Hospital Main Bill with Break Up Bill","options":[],"required":null,"pdf_field":""},{"help":"Tick if submitted","type":"checkbox","label":"Attested copy of Hospital Bill Payment Receipt","options":[],"required":null,"pdf_field":""},{"help":"Tick if submitted","type":"checkbox","label":"Attested copy of Hospital Discharge Summary","options":[],"required":null,"pdf_field":""},{"help":"Tick if submitted","type":"checkbox","label":"Attested copy of Operation Theater Notes","options":[],"required":null,"pdf_field":""},{"help":"Specify any other documents submitted","type":"text","label":"Others","options":[],"required":false,"pdf_field":""}],"filled_by":"insured person"},{"title":"Details of Bill Enclosed","fields":[{"help":"List each bill with number, date (dd mm yy), issuer, purpose, and amount in rupees","type":"table","label":"SI. No, Bill No, Date, Issued by, Towards, Amount (Rs.)","options":[],"required":null,"pdf_field":""}],"filled_by":"insured person"},{"title":"Details Primary Insured's Account","fields":[{"help":"Enter Permanent Account Number allotted by Income Tax department","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 and Branch :","options":[],"required":null,"pdf_field":""},{"help":"Enter name of beneficiary for payment","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":"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 of signing","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":"Hospital Details (Part B)","fields":[{"help":"Enter full hospital name","type":"text","label":"Name of Hospital :","options":[],"required":null,"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":["Network","Non Network"],"required":null,"pdf_field":""},{"help":"Enter full name of treating doctor","type":"text","label":"Name of the treating doctor : SURNAME FIRST NAME MIDDLE NAME","options":[],"required":null,"pdf_field":""},{"help":"Enter doctor's qualification","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 hospital phone number","type":"phone","label":"Phone No :","options":[],"required":null,"pdf_field":""}],"filled_by":"hospital"},{"title":"Details of the Patient Admitted (Hospital)","fields":[{"help":"Enter full name of patient","type":"text","label":"Name of the Patient : SURNAME FIRST NAME MIDDLE NAME","options":[],"required":null,"pdf_field":""},{"help":"Enter inpatient registration number","type":"text","label":"IP Registration Number :","options":[],"required":null,"pdf_field":""},{"help":"Tick appropriate gender","type":"choice","label":"Gender :","options":["Male","Female"],"required":null,"pdf_field":""},{"help":"Enter age in years and months","type":"number","label":"Age : Year YY Months mm","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 appropriate admission type","type":"choice","label":"Type of Admission :","options":["Emergency","Planned","Day Care","Maternity"],"required":null,"pdf_field":""},{"help":"Use dd mm yy format","type":"date","label":"If Maternity : i. Date of Delivery :","options":[],"required":false,"pdf_field":""},{"help":"Enter grade of status","type":"text","label":"ii. Grade of status :","options":[],"required":false,"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":"Enter total claimed amount in rupees","type":"amount","label":"Total Claimed Amount : Rs.","options":[],"required":null,"pdf_field":""}],"filled_by":"hospital"},{"title":"Details of Ailment Diagnosed","fields":[{"help":"Enter primary diagnosis and ICD 10 code","type":"text","label":"Ailment Diagnosed (Primary) ICD 10 Codes - Codes Description","options":[],"required":null,"pdf_field":""},{"help":"Enter additional diagnosis and codes","type":"text","label":"ICD 10 Codes - Code & Description","options":[],"required":null,"pdf_field":""},{"help":"Enter primary diagnosis","type":"text","label":"Primary Diagnosis :","options":[],"required":null,"pdf_field":""},{"help":"Enter first procedure done","type":"text","label":"Procedure 1 :","options":[],"required":false,"pdf_field":""},{"help":"Enter additional diagnosis","type":"text","label":"Additional Diagnosis :","options":[],"required":false,"pdf_field":""},{"help":"Enter second procedure done","type":"text","label":"Procedure 2 :","options":[],"required":false,"pdf_field":""},{"help":"Enter co-morbid conditions","type":"text","label":"Co-morbidities :","options":[],"required":false,"pdf_field":""},{"help":"Enter third procedure done","type":"text","label":"Procedure 3 :","options":[],"required":false,"pdf_field":""},{"help":"Enter details of procedures performed","type":"text","label":"Details of Procedure/s done :","options":[],"required":false,"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":false,"pdf_field":""},{"help":"Explain reason if pre-authorization not obtained","type":"text","label":"If authorization by network hospital not obtained, give reason :","options":[],"required":false,"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 of injury if applicable","type":"choice","label":"If Yes, give cause","options":["Self-inflicted","Road Traffic Accident","Substance abuse/ alcohol consumption"],"required":false,"pdf_field":""},{"help":"Tick if test conducted and attach report if Yes","type":"yes-no","label":"If injury due to substance abuse/ alcohol consumption, Test Conducted to establish this :","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"If Medico Legal :","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Enter FIR number if applicable","type":"text","label":"FIR no :","options":[],"required":false,"pdf_field":""},{"help":"Explain reason if not reported","type":"text","label":"If not reported to police give reason:","options":[],"required":false,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"Reported to police :","options":["Yes","No"],"required":false,"pdf_field":""}],"filled_by":"hospital"},{"title":"Details of Hospital","fields":[{"help":"Enter full hospital address","type":"text","label":"Address of Hospital : City : State : Pin Code :","options":[],"required":null,"pdf_field":""},{"help":"Enter hospital phone number","type":"phone","label":"Phone No :","options":[],"required":null,"pdf_field":""},{"help":"Enter hospital registration number with state code","type":"text","label":"Registration no with state code :","options":[],"required":null,"pdf_field":""},{"help":"Enter hospital PAN number","type":"text","label":"Hospital 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 if operation theater available","type":"yes-no","label":"Facilities in the Hospital : i) OT :","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Tick if ICU available","type":"yes-no","label":"ii) ICU :","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Specify other facilities if any","type":"text","label":"iii) Other :","options":[],"required":false,"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 of signing","type":"text","label":"Place :","options":[],"required":true,"pdf_field":""},{"help":"Hospital authority to sign and seal","type":"signature","label":"Seal & Signature of the Hospital Authority","options":[],"required":true,"pdf_field":""}],"filled_by":"hospital"}],"deadlines":[],"applies_to":"Health insurance 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","MLC Report & Police FIR (if applicable)","Test Report for substance abuse/alcohol consumption (if applicable)","Original preauthorization request form (for hospital part)"],"declarations":["The information furnished in this claim form is true and correct to the best of my knowledge and belief.","False or untrue statements or concealment of material facts will forfeit the right to claim reimbursement.","Consent is given to Liberty Health 360 / insurance company to seek necessary medical information from hospitals or medical practitioners.","All bills and receipts for this claim have been included and no supplementary claim will be made except pre/post-hospitalization claims.","Consent is given to Liberty General Insurance Limited to process/share personal information with group companies or service providers for insurance and related products.","Hospital declares that information furnished is true and correct to the best of their knowledge and belief.","False or untrue statements or concealment of material facts by hospital will forfeit the right to claim under this policy."],"dropped_labels":2},"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/2263-liberty-hospi-cash-connect-policy-claim-form"}