{"id":2373,"title":"CLAIM FORM - Part A","purpose":"claim","insurer":{"slug":"tata-aig-general-insurance","name":"Tata AIG General Insurance Company Limited"},"source_pdf":"https://www.tataaig.com/s3/all_medicare_c73ac3dea5.pdf","sha256":"1f1179cc6e2d6f84fbd0644459a19ac829b7ed42da4878e228eece78db7976e3","pages":7,"collected":"2026-10-17","instructions":{"about":"This form is for insured persons to claim health insurance benefits under Tata AIG's MediCare variants. The insured person or claimant fills it.","notes":["Fill the form in CAPITAL LETTERS","All financial documents (bills & receipts) should be submitted in original","Please submit a different form for each type of claim","In case of multiple bills, you can attach a separate sheet","Use the checklist provided to ensure all documents are submitted","KYC details are required for Individual/Retail policy holders if the total claimed amount exceeds ₹100,000","Fill dates in DD-MM-YYYY format","For KYC update, tick the relevant sections and strike off others","Refer to instructions at the end of the KYC form for detailed guidelines"],"title":"CLAIM FORM - Part A","submit":{"to":"Health Claims Hub, TATA AIG General Insurance Co. Ltd., Door No. 615, 616, 5th and 6th Floor, Imperial Towers, Ameerpet, Next to Ameerpet Metro Station, Hyderabad - 500016, Telangana","how":"post / email / upload","address":"Email: healthclaimsupport@tataaig.com, Toll-Free: 22 6489 8282 or 1800 229 966 (For Senior Citizens)"},"purpose":"claim","sections":[{"title":"Details of Primary Insured (Section A)","fields":[{"help":"Enter your policy number","type":"text","label":"Policy No.*","options":[],"required":true,"pdf_field":""},{"help":"Unique Health ID if available","type":"text","label":"UHID","options":[],"required":false,"pdf_field":""},{"help":"Claim intimation number if any","type":"text","label":"Intimation Number","options":[],"required":false,"pdf_field":""},{"help":"Enter full name in CAPITAL LETTERS","type":"text","label":"Name*","options":[],"required":true,"pdf_field":""},{"help":"Enter full address","type":"text","label":"Address*","options":[],"required":true,"pdf_field":""},{"help":"Enter your registered email","type":"email","label":"Registered E-mail ID*","options":[],"required":true,"pdf_field":""},{"help":"Enter your registered phone number","type":"phone","label":"Registered Phone Number*","options":[],"required":true,"pdf_field":""},{"help":"Pre-filled as TATA AIG General Insurance Company Ltd.","type":"text","label":"Company Name*","options":[],"required":true,"pdf_field":""},{"help":"Select if you have other health insurance","type":"yes-no","label":"Currently covered by any other Mediclaim/Health Insurance","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Name of other insurance company if applicable","type":"text","label":"If yes, Company Name","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Have you been hospitalized in the last four years since inception of the contract?","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Diagnosis details if hospitalized previously","type":"text","label":"Diagnosis","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"Details of Insurance History (Section B)","fields":[{"help":"Other policy number if any","type":"text","label":"Policy No.","options":[],"required":false,"pdf_field":""},{"help":"Sum insured amount of other policy","type":"amount","label":"Sum Insured (`)","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Previously covered by any other Mediclaim/Health Insurance","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Name of other insurance company","type":"text","label":"If yes, Company Name","options":[],"required":false,"pdf_field":""},{"help":"Other policy number","type":"text","label":"Policy No.","options":[],"required":false,"pdf_field":""},{"help":"Sum insured amount","type":"amount","label":"Sum Insured (`)","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"Details of Insured Person Hospitalized (Section C)","fields":[{"help":"Name of hospitalized person","type":"text","label":"Name","options":[],"required":false,"pdf_field":""},{"help":"Select gender","type":"choice","label":"Gender","options":["Male","Female","Other"],"required":false,"pdf_field":""},{"help":"Select relationship","type":"choice","label":"Relationship to Primary Insured","options":["Self","Spouse","Child","Father","Mother","Father-in-law","Mother-in-law","Other (Please Specify)"],"required":false,"pdf_field":""},{"help":"Enter date of birth","type":"date","label":"Date of birth","options":[],"required":false,"pdf_field":""},{"help":"Enter age in years and months","type":"number","label":"Age","options":[],"required":false,"pdf_field":""},{"help":"Select occupation","type":"choice","label":"Occupation","options":["Service","Self Employed","Homemaker","Student","Retired","Other (Please Specify)"],"required":false,"pdf_field":""},{"help":"Alternate contact number","type":"phone","label":"Alternative Phone Number","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"Details of Hospitalization (Section D)","fields":[{"help":"Date admitted to hospital","type":"date","label":"Date of Admission","options":[],"required":false,"pdf_field":""},{"help":"Date discharged from hospital","type":"date","label":"Date of Discharge","options":[],"required":false,"pdf_field":""},{"help":"Select cause if injury","type":"choice","label":"If Injury, give cause","options":["Self Inflicted","Road Traffic Accident","Substance Abuse/Alcohol Consumption"],"required":false,"pdf_field":""},{"help":"Select if case is medico legal","type":"yes-no","label":"If Medico legal","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Attach medico legal certificate and FIR if yes","type":"yes-no","label":"MLC Report & Police FIR attached","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Select system of medicine","type":"choice","label":"System of Medicine","options":["Allopathy"],"required":false,"pdf_field":""},{"help":"Select if reported to police","type":"yes-no","label":"Reported to police","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Select room category","type":"choice","label":"Room Category occupied","options":["Single Occupancy","Twin Sharing","3 or more beds per room"],"required":false,"pdf_field":""},{"help":"Select reason for hospitalization","type":"choice","label":"Hospitalization due to","options":["Illness","Maternity","Day Care","Injury"],"required":false,"pdf_field":""},{"help":"Hospital where admitted","type":"text","label":"Name of Hospital","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"Details of Claim (Section E)","fields":[{"help":"Date of claim form signing","type":"date","label":"Date","options":[],"required":false,"pdf_field":""},{"help":"Sign the form","type":"signature","label":"Signature of the Insured","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"},{"title":"Details of Bills Enclosed (Section F)","fields":[{"help":"Select claim type","type":"choice","label":"Type of claims","options":["In-Patient Treatment","Pre & Post-Hospitalization Expenses","Day Care Procedures","Health Checkup","Daily Cash for choosing Shared Accommodation","OPD Treatment","OPD Treatment – Dental","Maternity Cover","High End Diagnostics","Critical Illness","Accidental death benefits"],"required":false,"pdf_field":""},{"help":"Total amount claimed","type":"amount","label":"Total expenses","options":[],"required":false,"pdf_field":""},{"help":"Details of treatment expenses","type":"text","label":"Details of the treatment expenses claimed","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"Details of Primary Insured Bank Account (Section G)","fields":[{"help":"Permanent Account Number","type":"text","label":"PAN","options":[],"required":false,"pdf_field":""},{"help":"Bank account number for claim payment","type":"text","label":"Account No.","options":[],"required":false,"pdf_field":""},{"help":"Bank name and branch","type":"text","label":"Bank Name and Branch","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"Details of Bills (Table) (Section F)","fields":[{"help":"Fill columns: S. No., Bill No., Date, Issued by, Towards, Grand Total Amount","type":"table","label":"Details of Bills Enclosed","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"Declaration by the Insured (Section H)","fields":[{"help":"Read and agree to declaration before signing","type":"text","label":"Declaration","options":[],"required":true,"pdf_field":""},{"help":"Provide cheque details for payment","type":"text","label":"Cheque/DD Payable details","options":[],"required":false,"pdf_field":""},{"help":"Bank IFSC code","type":"text","label":"IFSC Code","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"Details of Hospital (Section A of Part B)","fields":[{"help":"Hospital name","type":"text","label":"Name of the Hospital","options":[],"required":true,"pdf_field":""},{"help":"Hospital ROHINI ID if any","type":"text","label":"ROHINI ID","options":[],"required":false,"pdf_field":""}],"filled_by":"hospital"},{"title":"Details of the Patient Admitted (Section B of Part B)","fields":[{"help":"Patient's full name","type":"text","label":"Name of the Patient","options":[],"required":true,"pdf_field":""},{"help":"Inpatient registration number","type":"text","label":"IP Registration Number","options":[],"required":false,"pdf_field":""},{"help":"Patient's date of birth","type":"date","label":"Date of Birth","options":[],"required":false,"pdf_field":""},{"help":"Admission date","type":"date","label":"Date of Admission","options":[],"required":false,"pdf_field":""},{"help":"Discharge date","type":"date","label":"Date of Discharge","options":[],"required":false,"pdf_field":""},{"help":"Select admission type","type":"choice","label":"Type of Admission","options":["Emergency","Planned","Day Care","Maternity"],"required":false,"pdf_field":""},{"help":"Obstetric history if maternity","type":"text","label":"Gravida Status (G, P, L, A)","options":[],"required":false,"pdf_field":""},{"help":"Select discharge status","type":"choice","label":"Status at time of discharge","options":["Discharge to home","Discharge to another hospital","Deceased"],"required":false,"pdf_field":""},{"help":"Total amount claimed","type":"amount","label":"Total claimed amount `","options":[],"required":false,"pdf_field":""},{"help":"Select hospital type","type":"choice","label":"Type of Hospital","options":["Network","Non-network","Valued Provider-Pan India"],"required":false,"pdf_field":""},{"help":"Doctor's full name","type":"text","label":"Name of the treating Doctor","options":[],"required":false,"pdf_field":""},{"help":"Doctor's contact number","type":"phone","label":"Phone No.","options":[],"required":false,"pdf_field":""},{"help":"Doctor's registration number","type":"text","label":"Registration No. (with State Code)","options":[],"required":false,"pdf_field":""},{"help":"Patient's age","type":"number","label":"Age (Years, Months)","options":[],"required":false,"pdf_field":""}],"filled_by":"hospital"},{"title":"Additional Details in Case of Non-Network Hospital (Section D of Part B)","fields":[{"help":"Hospital name if non-network","type":"text","label":"Name of the Hospital","options":[],"required":false,"pdf_field":""},{"help":"Hospital address","type":"text","label":"Address","options":[],"required":false,"pdf_field":""},{"help":"City or town","type":"text","label":"City/Town","options":[],"required":false,"pdf_field":""},{"help":"District","type":"text","label":"District","options":[],"required":false,"pdf_field":""},{"help":"Postal code","type":"text","label":"Pin Code","options":[],"required":false,"pdf_field":""},{"help":"State","type":"text","label":"State","options":[],"required":false,"pdf_field":""},{"help":"Hospital PAN number","type":"text","label":"Hospital PAN","options":[],"required":false,"pdf_field":""},{"help":"Number of beds","type":"number","label":"Number of In-patient beds","options":[],"required":false,"pdf_field":""}],"filled_by":"hospital"},{"title":"Declaration by the Hospital (Section E of Part B)","fields":[{"help":"Hospital authority to sign and seal","type":"text","label":"Declaration","options":[],"required":true,"pdf_field":""},{"help":"Date of declaration","type":"date","label":"Date","options":[],"required":false,"pdf_field":""},{"help":"Place of declaration","type":"text","label":"Place","options":[],"required":false,"pdf_field":""},{"help":"Signature and seal","type":"signature","label":"Signature and Seal of the Hospital Authority","options":[],"required":true,"pdf_field":""}],"filled_by":"hospital"},{"title":"Pre-authorization Details (Hospital Section)","fields":[{"help":"Indicate if pre-authorization obtained","type":"yes-no","label":"Pre-authorization obtained","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Reason for no pre-authorization","type":"text","label":"If authorization by network hospital not obtained, give reason","options":[],"required":false,"pdf_field":""},{"help":"Attach test 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":"Pre-authorization number if any","type":"text","label":"Pre-authorization Number","options":[],"required":false,"pdf_field":""},{"help":"Indicate medico legal case","type":"yes-no","label":"If Medico legal","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"FIR number if applicable","type":"text","label":"FIR No.","options":[],"required":false,"pdf_field":""},{"help":"Reason for no police report","type":"text","label":"If not reported to police, give reason","options":[],"required":false,"pdf_field":""},{"help":"Indicate if reported to police","type":"yes-no","label":"Reported to Police","options":["Yes","No"],"required":false,"pdf_field":""}],"filled_by":"hospital"},{"title":"KYC Application Form - Individual (Part C)","fields":[{"help":"Select account type","type":"choice","label":"Account Type*","options":["New","Normal","Minor","Aadhaar OTP based E-KYC","Update"],"required":true,"pdf_field":""},{"help":"Enter full name as per ID proof","type":"text","label":"Name* (Same as ID proof)","options":[],"required":true,"pdf_field":""},{"help":"If applicable","type":"text","label":"Maiden Name","options":[],"required":false,"pdf_field":""},{"help":"Enter father's or spouse's name","type":"text","label":"Father / Spouse Name","options":[],"required":false,"pdf_field":""},{"help":"Enter mother's name","type":"text","label":"Mother Name","options":[],"required":false,"pdf_field":""},{"help":"Enter date of birth","type":"date","label":"Date of Birth*","options":[],"required":true,"pdf_field":""},{"help":"Select gender","type":"choice","label":"Gender*","options":["M- Male","F- Female","T-Transgender"],"required":true,"pdf_field":""},{"help":"Permanent Account Number","type":"text","label":"Pan*","options":[],"required":true,"pdf_field":""},{"help":"Tick if Form 60 furnished","type":"checkbox","label":"Form 60 furnished","options":[],"required":false,"pdf_field":""},{"help":"Enter city or town","type":"text","label":"City / Town / Village*","options":[],"required":true,"pdf_field":""},{"help":"Enter district","type":"text","label":"District*","options":[],"required":true,"pdf_field":""},{"help":"Enter state or union territory code","type":"text","label":"State / U.T Code*","options":[],"required":true,"pdf_field":""},{"help":"Enter postal code","type":"text","label":"Pin / Post Code*","options":[],"required":true,"pdf_field":""},{"help":"Enter country code","type":"text","label":"ISO 3166 Country Code*","options":[],"required":true,"pdf_field":""},{"help":"Attach recent passport size photo","type":"photo","label":"Photo*","options":[],"required":true,"pdf_field":""},{"help":"Sign or thumb impression","type":"signature","label":"Signature / Thumb Impression of Applicant","options":[],"required":true,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Place of signing","type":"text","label":"Place","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"}],"deadlines":["Incase of delay in submitting the documents (Post 30 days from Date of Discharge), please provide a separate covering letter with the reason for the delay"],"applies_to":"health insurance claims under MediCare variants","attachments":["Copy of cancelled cheque for the proposer (Main Policy holder) - Account holder’s name, account number and IFSC code should be printed on the submitted copy","CKYC Form along with Photograph + PAN Card Copy of the Proposer + Address Proof (if claimed amount is more than 1 Lakh)","Claim form - Please fill all the mandatory fields with appropriate information","TATA AIG Health Card or Policy Copy","ID, Address & Age Proof of the Patient","Discharge/ Daycare Summary from the hospital indicating the presenting complaints, diagnosis, treatment given and past medical history","Consolidated Final Bill along with breakup of the individual items","Proof of payment paid at hospital - cash receipt","In case of Implants being used - Please share relevant Invoice & Sticker","Pharmacy & Lab Bills","Diagnostic/ Lab Reports for submitted bills","Doctor Prescriptions for submitted pharmacy bills","Medical records and consultation papers prior to hospitalization","Any previously approved settlement letter from other insurance (if any)","In case of accidental injuries, please submit Medico-Legal Certificate (MLC) /First Information Report (FIR)","In case of death of the proposer, details of nominee (as per policy schedule), along with address & ID proof of nominee","Hospital Registration Certificate"],"declarations":["The information furnished in this Claim Form is true & 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 and authorize 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","Hospital declaration that information furnished is true and correct to the best of their knowledge and belief","Prohibition of Rebates as per Section 41 of Insurance Act, 1938 - no inducement or rebate allowed"],"dropped_labels":15},"pdf_fields":null,"fillable_pdf":false,"send_to":[{"purpose":"claim","channel":"address","value":"TATA AIG General Insurance Company Limited, 5th and 6th Floor, Imperial Towers, H.No 7-1-6-617/A, GHMC No - 615,616, Ameerpet, Hyderabad – 500016, Telangana","label":"Claims Submission Address","level":null,"hours":null,"applies_to":"health","source_url":"https://www.tataaig.com/s3/medicare_select_cis_e7df7ce2ec.pdf","quote":"tion or procedure. Submit claim documents within 15 days of occurrence of incident. Kindly send the claim documents to: TATA AIG General Insurance Company Limited, 5th and 6th Floor, Imperial Towers, H.No 7-1- 6-617/A, GHMC No - 615,616, Ameerpet, Hyderabad – 500016, Telangana, Phone-040-66864900 Assistance: 1. Website www.tataaig.com or Call 24*7 Customer Support No.: 022 6489 8282/1800 267 1","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"email","value":"healthclaimsupport@tataaig.com","label":"Health Claims Support Email","level":null,"hours":null,"applies_to":"health","source_url":"https://www.tataaig.com/s3/medicare_select_prospectus_efd23b0ad6.pdf","quote":"al Towers, H.No 7-1-6-617/A, GHMC No - 615,616, Ameerpet, Hyderabad – 500016, Telangana, Phone: 040-66864900\nEmail ID | healthclaimsupport@tataaig.com\nCustomer Support Number: | 022 6489 8282 / 1800 267 1955 (nly for senior citizen policy holders)\nWebsite | www.tataaig.","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"040-66864900","label":"Claims Administrator Phone","level":null,"hours":null,"applies_to":"health","source_url":"https://www.tataaig.com/s3/medicare_select_prospectus_efd23b0ad6.pdf","quote":"th and 6th Floor, Imperial Towers, H.No 7-1-6-617/A, GHMC No - 615,616, Ameerpet, Hyderabad – 500016, Telangana, Phone: 040-66864900\nEmail ID | healthclaimsupport@tataaig.com\nCustomer Support Number: | 022 6489 8282 / 1800 267 1955 (nly for senior citi","fetched_at":"2026-10-20"}],"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/tata-aig-general-insurance/2373-claim-form-part-a"}