{"id":2266,"title":"LIBERTY HEALTH CONNECT INSURANCE CLAIM FORM","purpose":"claim","insurer":{"slug":"liberty-general-insurance","name":"Liberty General Insurance Limited"},"source_pdf":"https://www.libertyinsurance.in/Docx/Liberty%20Health%20Connect%20Policy-%20Claim%20form%20(%20For%20policy%20issued%20on%20or%20after%2021th%20Aug%202018%20).pdf","sha256":"0408ca2c50fee50e3ae25c33f7e3c363e6c32d316d7be6ad189bbef79eb97ffc","pages":7,"collected":"2026-10-17","instructions":{"about":"This form is used by the insured person to claim health insurance benefits under the Liberty Health Connect policy. It collects details about the insured, hospitalization, treatment expenses, and insurance history.","notes":["Use block letters to fill the form.","Do not enter paise values, 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.","Original bills and receipts must be attached.","For medico legal cases, attach MLC report and Police FIR.","For non-network hospitals, fill additional details as required.","Call Toll Free No: 1800 266 5844 for assistance."],"title":"LIBERTY HEALTH CONNECT INSURANCE CLAIM FORM","submit":{"to":"Liberty General Insurance Limited","how":"post / e-mail / upload","address":"10th Floor, Tower A, Peninsula Business Park, Ganpatrao Kadam Marg, Lower Parel, Mumbai - 400 013; Email: 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 (days)","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 amount 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":"INSURED DETAILS","fields":[{"help":"Enter the policy number","type":"text","label":"Policy No.","options":[],"required":true,"pdf_field":""},{"help":"Enter social insurance or certificate number","type":"text","label":"SI. No./certificate No.","options":[],"required":true,"pdf_field":""},{"help":"Enter company ID if applicable","type":"text","label":"Company ID No.","options":[],"required":false,"pdf_field":""},{"help":"Enter full name of the insured","type":"text","label":"Name","options":[],"required":true,"pdf_field":""},{"help":"Enter full postal address including street, city, state, pin code","type":"text","label":"Address","options":[],"required":true,"pdf_field":""},{"help":"Enter city","type":"text","label":"City","options":[],"required":true,"pdf_field":""},{"help":"Enter state","type":"text","label":"State","options":[],"required":true,"pdf_field":""},{"help":"Enter postal pin code","type":"number","label":"Pin Code","options":[],"required":true,"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":"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":true,"pdf_field":""},{"help":"Use dd-mm-yy format","type":"date","label":"Date of commencement of first insurance without break","options":[],"required":false,"pdf_field":""},{"help":"Enter full name of insurance company","type":"text","label":"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?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Date of hospitalization in last 4 years, if any","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":true,"pdf_field":""},{"help":"Enter previous insurance company name","type":"text","label":"If Yes, Company Name","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"DETAILS OF INSURED PERSON HOSPITALIZED","fields":[{"help":"Enter full 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 and months","type":"number","label":"Age","options":[],"required":true,"pdf_field":""},{"help":"Use dd-mm-yy format","type":"date","label":"Date of Birth","options":[],"required":true,"pdf_field":""},{"help":"Tick the correct relationship or specify if Other","type":"choice","label":"Relationship to Primary Insured","options":["Self","Spouse","Child","Father","Mother","Other"],"required":true,"pdf_field":""},{"help":"Enter occupation or specify if Other","type":"text","label":"Occupation","options":[],"required":false,"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 the correct room category","type":"choice","label":"Room Category Occupied","options":["Day Care","Single Occupancy","Twin Sharing","3 Or more beds per room"],"required":true,"pdf_field":""},{"help":"Tick the correct reason","type":"choice","label":"Hospitalization due to","options":["Injury","Illness","Maternity","Self Inflicted","Road Traffic Accident"],"required":true,"pdf_field":""},{"help":"Use dd-mm-yy format","type":"date","label":"Date of Injury / Date Disease First Detected / Date of Delivery","options":[],"required":true,"pdf_field":""},{"help":"Use dd-mm-yy format","type":"date","label":"Date of Admission","options":[],"required":true,"pdf_field":""},{"help":"Use hh:mm format","type":"text","label":"Time of Admission","options":[],"required":false,"pdf_field":""},{"help":"Use dd-mm-yy format","type":"date","label":"Date of Discharge","options":[],"required":true,"pdf_field":""},{"help":"Use hh:mm format","type":"text","label":"Time of Discharge","options":[],"required":false,"pdf_field":""},{"help":"Describe cause of injury","type":"text","label":"If Injury Give Cause","options":[],"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 system of medicine used","type":"text","label":"System of Medicine","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"CLAIM DOCUMENTS SUBMITTED - CHECK LIST","fields":[{"help":"Tick if submitted","type":"checkbox","label":"Claim Form Duly Signed","options":[],"required":true,"pdf_field":""},{"help":"Tick if submitted","type":"checkbox","label":"Copy of the claim Intimation","options":[],"required":true,"pdf_field":""},{"help":"Tick if submitted","type":"checkbox","label":"Hospital Main Bill","options":[],"required":true,"pdf_field":""},{"help":"Tick if submitted","type":"checkbox","label":"Hospital Break-up Bill","options":[],"required":true,"pdf_field":""},{"help":"Tick if submitted","type":"checkbox","label":"Hospital Bill Payment Receipt","options":[],"required":false,"pdf_field":""},{"help":"Tick if submitted","type":"checkbox","label":"Hospital Discharge Summary","options":[],"required":true,"pdf_field":""},{"help":"Tick if submitted","type":"checkbox","label":"Pharmacy Bill","options":[],"required":false,"pdf_field":""},{"help":"Tick if submitted","type":"checkbox","label":"Operation Theater Notes","options":[],"required":false,"pdf_field":""},{"help":"Tick if submitted","type":"checkbox","label":"ECG","options":[],"required":false,"pdf_field":""},{"help":"Tick if submitted","type":"checkbox","label":"Doctor’s Request For Investigation","options":[],"required":false,"pdf_field":""},{"help":"Tick if submitted","type":"checkbox","label":"Investigation Report (Including CT / MRI / USG / HPE)","options":[],"required":false,"pdf_field":""},{"help":"Specify other documents submitted","type":"text","label":"Other","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"DETAILS OF BILL ENCLOSED","fields":[{"help":"Enter bill number","type":"text","label":"Bill No","options":[],"required":false,"pdf_field":""},{"help":"Use dd-mm-yy format","type":"date","label":"Date","options":[],"required":false,"pdf_field":""},{"help":"Enter issuer of bill","type":"text","label":"Issued by","options":[],"required":false,"pdf_field":""},{"help":"Purpose of bill","type":"text","label":"Towards","options":[],"required":false,"pdf_field":""},{"help":"Enter amount in rupees","type":"amount","label":"Amount (Rs.)","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"DETAILS OF PRIMARY INSURED’S BANK ACCOUNT","fields":[{"help":"Enter Permanent Account Number","type":"text","label":"Pan","options":[],"required":false,"pdf_field":""},{"help":"Enter bank account number","type":"text","label":"Account Number","options":[],"required":true,"pdf_field":""},{"help":"Enter full bank name and branch","type":"text","label":"Bank Name and Branch","options":[],"required":true,"pdf_field":""},{"help":"Enter name of beneficiary for cheque/DD","type":"text","label":"Cheque/ DD Payable details","options":[],"required":false,"pdf_field":""},{"help":"Enter IFSC code of bank branch","type":"text","label":"IFSC Code","options":[],"required":true,"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 the form","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":false,"pdf_field":""},{"help":"Tick the correct type","type":"choice","label":"Type of Hospital","options":["Non Network","Network"],"required":true,"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":false,"pdf_field":""},{"help":"Enter registration number with state code","type":"text","label":"Registration No. with State 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 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":true,"pdf_field":""},{"help":"Use dd-mm-yy format","type":"date","label":"Date of Admission","options":[],"required":true,"pdf_field":""},{"help":"Use hh:mm format","type":"text","label":"Time of Admission","options":[],"required":false,"pdf_field":""},{"help":"Use dd-mm-yy format","type":"date","label":"Date of Discharge","options":[],"required":true,"pdf_field":""},{"help":"Use hh:mm format","type":"text","label":"Time of Discharge","options":[],"required":false,"pdf_field":""},{"help":"Tick the correct status","type":"choice","label":"Status at time of discharge","options":["Discharge to home","Discharge to another hospital","Deceased"],"required":true,"pdf_field":""},{"help":"Tick the correct type","type":"choice","label":"Type of Admission","options":["Emergency","Planned","Day Care","Maternity"],"required":true,"pdf_field":""},{"help":"Use dd-mm-yy format","type":"date","label":"If Maternity - Date of Delivery","options":[],"required":false,"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":false,"pdf_field":""},{"help":"Enter age in years and months","type":"number","label":"Age (Year, Months)","options":[],"required":true,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"Pre-authorization obtained","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Enter pre-authorization number if obtained","type":"text","label":"Pre-authorization Number","options":[],"required":false,"pdf_field":""},{"help":"Explain reason for no authorization","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":false,"pdf_field":""},{"help":"Tick cause of injury","type":"choice","label":"If Yes, give cause","options":["Self-inflicted","Road Traffic Accident","Substance abuse/ alcohol consumption"],"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","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"If Medico Legal (If Yes, Attach Report)","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 for no police report","type":"text","label":"If not reported to police give reason","options":[],"required":false,"pdf_field":""},{"help":"Tick all documents submitted","type":"checkbox","label":"Claim Documents Submitted - Check List","options":["Claim Form Duly Signed","Original Pre-authorization request","Copy of Pre-authorization Approval letter","Copy of photo ID card of patient verified by hospital","Hospital Discharge summary","Operation Theater notes","Hospital main bill","Hospital break-up bill","Investigation report","CT/MR/USG/HPE investigation report","Doctor’s reference slip for investigation","ECG","Pharmacy bills","MLC report & Police FIR","Original death summary from hospital where applicable","Any other"],"required":false,"pdf_field":""}],"filled_by":"hospital"},{"title":"DETAILS IN CASE OF NON NETWORK HOSPITAL","fields":[{"help":"Enter full postal address including city, state, pin code","type":"text","label":"Address of Hospital","options":[],"required":true,"pdf_field":""},{"help":"Enter postal pin code","type":"number","label":"Pin Code","options":[],"required":true,"pdf_field":""},{"help":"Enter phone number with STD code","type":"phone","label":"Phone No","options":[],"required":false,"pdf_field":""},{"help":"Enter hospital registration number","type":"text","label":"Registration No","options":[],"required":false,"pdf_field":""},{"help":"Enter hospital PAN","type":"text","label":"PAN","options":[],"required":false,"pdf_field":""},{"help":"Enter number of inpatient beds","type":"number","label":"Number of Inpatient beds","options":[],"required":false,"pdf_field":""},{"help":"Tick available facilities","type":"checkbox","label":"Facilities available in the hospital","options":["OT","ICU","Other"],"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","type":"text","label":"Place","options":[],"required":true,"pdf_field":""},{"help":"Sign and stamp the form","type":"signature","label":"Signature and Seal of the hospital Authority","options":[],"required":true,"pdf_field":""}],"filled_by":"hospital"}],"deadlines":[],"applies_to":"Health insurance claims for Liberty Health Connect Policy issued on or after 21th Aug 2018","attachments":["Copy of policies (if currently covered by other Mediclaim / Health Insurance)","Claim Intimation copy","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)","MLC Report & Police FIR (if medico legal case)","Original Preauthorization request form","Copy of Pre-authorization Approval letter","Copy of photo ID card of patient verified by hospital","Original death summary from hospital (where applicable)"],"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 any material fact is made, the right to claim reimbursement shall be forfeited.","Consent and authorize the company to seek necessary medical information/documents from any hospital or medical practitioner who attended the person against whom this claim is made.","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 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":5},"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/2266-liberty-health-connect-insurance-claim-form"}