{"id":2272,"title":"Group 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/Group%20Hospi%20Cash%20Connect%20-%20Claims%20Form.pdf","sha256":"e9f28af8a6d12efceb28db4af43d2133006dc6affb69deb0d45113c986e4e646","pages":6,"collected":"2026-10-17","instructions":{"about":"This form is used by the insured person to claim benefits under the Group Hospi-Cash Connect insurance policy for hospitalization and related expenses.","notes":["Use block letters to fill the form.","Attach original bills and documents as per checklist.","Cancelled cheque copy must be attached for correct payment.","The issue of this form is not an admission of liability.","For hospital section, fill in block letters.","Refer to guidance for filling claim form for format and details."],"title":"Group Hospi-Cash Connect Policy Claim Form","submit":{"to":"Liberty General Insurance Limited","how":"","address":"Unit 1501&1502, 15th Floor, Tower 2, One International Center, Senapati Bapat Marg, Prabhadevi, Mumbai - 400013"},"purpose":"claim","sections":[{"title":"Section A - Details of Primary Insured","fields":[{"help":"Enter the policy number 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 allotted by IRDA","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":""}],"filled_by":"insured person"},{"title":"Section B - Details of Insurance History","fields":[{"help":"Tick Yes or No","type":"choice","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: dd mm yy","options":[],"required":null,"pdf_field":""},{"help":"Enter full name of the insurance company","type":"text","label":"If YES, - Company Name:","options":[],"required":null,"pdf_field":""},{"help":"Enter policy number allotted by the insurance company","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":"Tick Yes or No","type":"choice","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: MM YY","options":[],"required":null,"pdf_field":""},{"help":"Enter diagnosis details","type":"text","label":"Diagnosis:","options":[],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"choice","label":"Previously covered by any other Mediclaim / Health Insurance: YES/ NO","options":["YES","NO"],"required":null,"pdf_field":""},{"help":"Enter full name of the 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 the 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: .... Years .... Months","options":[],"required":null,"pdf_field":""},{"help":"Use dd-mm-yy format","type":"date","label":"Date of Birth : DD MM YY","options":[],"required":null,"pdf_field":""},{"help":"Tick the appropriate 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 appropriate 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 if different from above","type":"text","label":"Address (If different from above) :","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":""}],"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 appropriate 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 appropriate option","type":"choice","label":"Hospitalization due to : Illness / Injury / Maternity","options":["Illness","Injury","Maternity"],"required":null,"pdf_field":""},{"help":"Use dd-mm-yyyy format","type":"date","label":"Date of Injury / Disease first detected / Date of Delivery: DD MM YYYY","options":[],"required":null,"pdf_field":""},{"help":"Use dd-mm-yy format","type":"date","label":"Date of Admission: DD MM YY","options":[],"required":null,"pdf_field":""},{"help":"Enter time of admission in hh:mm format","type":"text","label":"Time : HH MM","options":[],"required":null,"pdf_field":""},{"help":"Use dd-mm-yy format","type":"date","label":"Date of Discharge: DD MM YY","options":[],"required":null,"pdf_field":""},{"help":"Enter time of discharge in hh:mm format","type":"text","label":"Time : HH MM","options":[],"required":null,"pdf_field":""},{"help":"Tick the appropriate 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":"choice","label":"If Medico legal : YES/ NO","options":["YES","NO"],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"choice","label":"Reported to Police: YES/ NO","options":["YES","NO"],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"choice","label":"MLC report or Police FIR attached: YES / NO","options":["YES","NO"],"required":null,"pdf_field":""},{"help":"Enter the system of medicine followed in treatment","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 (do not enter paise)","type":"amount","label":"Details of Treatment Expenses Claimed","options":[],"required":null,"pdf_field":""},{"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: Rs","options":[],"required":null,"pdf_field":""},{"help":"Tick all 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":"Provide Sl. No, Bill No, Date, Issued by, Towards, Amount; 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 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":"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 here","type":"signature","label":"Signature of the Insured","options":[],"required":true,"pdf_field":""}],"filled_by":"insured person"},{"title":"Claim Form - Part B (To be filled in 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 appropriate option","type":"choice","label":"Type of Hospital","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: DD MM YYYY","options":[],"required":null,"pdf_field":""},{"help":"Use dd-mm-yyyy 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-yyyy 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 option","type":"choice","label":"Type of Admission","options":["Emergency","Planned","Day-care","Maternity"],"required":null,"pdf_field":""},{"help":"Use dd-mm-yyyy format","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 appropriate 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":"","type":"text","label":"Primary Diagnosis Codes","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Additional Codes","options":[],"required":null,"pdf_field":""},{"help":"Include ICD 10 PCS codes and descriptions","type":"text","label":"Details of Procedure/s done","options":[],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"choice","label":"Pre authorization Obtained YES/ NO","options":["YES","NO"],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"choice","label":"Hospitalization due to Injury Yes/ No","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Tick appropriate 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":"choice","label":"Reported to police YES / NO","options":["YES","NO"],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"choice","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","type":"choice","label":"If injury due to Substance Abuse/ Alcohol consumption test conducted to establish this? If YES please attach Report 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":""},{"help":"Enter full hospital address","type":"text","label":"Details of Hospital Address of the Hospital","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":"","type":"phone","label":"Phone No","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Registration no with state code","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Hospital PAN","options":[],"required":null,"pdf_field":""},{"help":"","type":"number","label":"No of Inpatient Beds","options":[],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"choice","label":"Facilities in the Hospital OT Yes/ No","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"choice","label":"ICU Yes/ No","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Specify other facilities if any","type":"text","label":"Others","options":[],"required":null,"pdf_field":""},{"help":"Hospital authority to sign and seal","type":"signature","label":"SEAL & SIGNATURE OF THE HOSPITAL AUTHORITY","options":[],"required":true,"pdf_field":""},{"help":"Enter date","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Enter place","type":"text","label":"Place","options":[],"required":true,"pdf_field":""}],"filled_by":"hospital"}],"deadlines":[],"applies_to":"Group Hospi-Cash Connect Policy claims","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","Cancelled cheque copy for bank account"],"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 authorize TPA/insurance company to seek necessary medical information from hospitals or medical practitioners.","All bills and receipts for this claim are included and no supplementary claim will be made except pre/post-hospitalization claims.","Consent 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 and any false statement will forfeit claim rights."],"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/2272-group-hospi-cash-connect-policy-claim-form"}