{"id":3,"title":"CLAIM FORM FOR HEALTH INSURANCE POLICIES OTHER THAN TRAVEL AND PERSONAL ACCIDENT - PART A","purpose":"claim","insurer":{"slug":"go-digit-general-insurance","name":"Go Digit General Insurance Limited"},"source_pdf":"https://www.godigit.com/content/dam/godigit/directportal/en/downloads/health/claim-form-for-health-insurance-policies.pdf","sha256":"16a4ba25f51a09b2ceb7c9f411fd37aa7faa2ad4d3c310681ca7751f0e1c8873","pages":4,"collected":"2026-10-17","instructions":{"about":"This form is used by the insured person to claim health insurance benefits for hospitalization and related expenses. Part A is filled by the insured, and Part B is filled by the hospital.","notes":["Fill the form in block letters where specified.","Use original bills and receipts only.","Enter dates in dd-mm-yyyy format unless otherwise specified.","Enter times in hh:mm format.","Do not enter paise values in amount fields.","Attach all relevant documents as per the checklist.","Part A to be filled by the insured; Part B to be filled by the hospital.","For non-network hospitals, additional details must be provided.","Pre-authorization request form must be included with Part B.","Use the guidance section for correct data formats and instructions."],"title":"CLAIM FORM FOR HEALTH INSURANCE POLICIES OTHER THAN TRAVEL AND PERSONAL ACCIDENT - PART A","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"SECTION A - DETAILS OF PRIMARY INSURED","fields":[{"help":"Enter the policy number as allotted by the Insurance Company, in block letters","type":"text","label":"Policy No.:","options":[],"required":null,"pdf_field":""},{"help":"Enter the social insurance or certificate number as allotted by the social health insurance scheme","type":"text","label":"Sl. No/ Certificate no.","options":[],"required":null,"pdf_field":""},{"help":"Enter the TPA ID number as allotted by IRDA and printed in TPA documents","type":"text","label":"Company/ TPA ID No:","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":""}],"filled_by":"insured"},{"title":"SECTION B - 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":"Enter date in dd-mm-yyyy 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":null,"pdf_field":""},{"help":"Enter policy number as allotted by the Insurance Company","type":"text","label":"Policy No.","options":[],"required":null,"pdf_field":""},{"help":"Enter total sum insured as per the policy 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 four years since inception of the contract?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter date of hospitalization in mm-yyyy 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 full name of the Insurance Company","type":"text","label":"If yes, company name:","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"SECTION C - DETAILS OF INSURED PERSON HOSPITALIZED","fields":[{"help":"Enter full name of the patient: Surname, First name, Middle name","type":"text","label":"Name:","options":[],"required":null,"pdf_field":""},{"help":"Tick Male or Female","type":"choice","label":"Gender","options":["Male","Female"],"required":null,"pdf_field":""},{"help":"Enter age in years and months","type":"number","label":"Age years","options":[],"required":null,"pdf_field":""},{"help":"Enter date of birth in dd-mm-yyyy format","type":"date","label":"Date of Birth","options":[],"required":null,"pdf_field":""},{"help":"Tick the appropriate option; if Other, please specify","type":"choice","label":"Relationship to Primary insured:","options":["Self","Spouse","Child","Father","Mother","Other"],"required":null,"pdf_field":""},{"help":"Tick the appropriate option; if Other, please specify","type":"choice","label":"Occupation","options":["Retired","Student","Home Maker","Self Employed","Service","Other"],"required":null,"pdf_field":""},{"help":"Enter phone number including STD code","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"},{"title":"SECTION D - DETAILS OF HOSPITALIZATION","fields":[{"help":"Tick the appropriate option","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 the appropriate option","type":"choice","label":"Hospitalization due to:","options":["Injury","Illness","Maternity"],"required":null,"pdf_field":""},{"help":"Enter date in dd-mm-yyyy format","type":"date","label":"Date of injury / Date Disease first detected / Date of Delivery:","options":[],"required":null,"pdf_field":""},{"help":"Enter date in dd-mm-yyyy format","type":"date","label":"Date of Admission:","options":[],"required":null,"pdf_field":""},{"help":"Enter date in dd-mm-yyyy format","type":"date","label":"Date of Discharge:","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 the appropriate cause","type":"choice","label":"If injury give cause:","options":["Self inflicted","Road Traffic Accident","Substance Abuse / Alcohol Consumption"],"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":"Enter the system of medicine followed in treatment","type":"text","label":"System of Medicine:","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"SECTION E - DETAILS OF CLAIM","fields":[{"help":"Enter amounts in rupees for: Pre-hospitalization expenses, Hospitalization expenses, Post-hospitalization expenses, Health-Check up cost, Ambulance Charges, Others (code), and total; also enter pre and post hospitalization periods in days","type":"table","label":"Details of the Treatment expenses claimed","options":[],"required":null,"pdf_field":""},{"help":"Tick Yes or No; if Yes, provide details in annexure","type":"yes-no","label":"Claim for Domiciliary Hospitalization:","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter amounts in rupees for Hospital Daily cash, Surgical Cash, Critical Illness benefit, Convalescence, Pre/Post hospitalization Lump sum benefit, Others, and total","type":"table","label":"Details of Lump sum / cash benefit claimed","options":[],"required":null,"pdf_field":""},{"help":"Tick the documents submitted","type":"checkbox","label":"Claim Documents Submitted - Check List","options":["Claim form duly signed","Copy of the claim intimation, if any","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 Reports (Including CT / MRI / USG / HPE)","Doctor’s Prescriptions","Others"],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"SECTION F - DETAILS OF BILLS ENCLOSED","fields":[{"help":"List bills with Sl. No., Bill No., Date, Issued by, Towards, Amount (Rs.)","type":"table","label":"Details of Bills Enclosed","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"SECTION G - DETAILS OF PRIMARY INSURED’S BANK ACCOUNT","fields":[{"help":"Enter Permanent Account Number as allotted by Income Tax Department","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 individual/organization to whom cheque/DD should be payable","type":"text","label":"Cheque / DD Payable details:","options":[],"required":null,"pdf_field":""},{"help":"Enter IFSC code of the bank branch","type":"text","label":"IFSC Code:","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"SECTION H - DECLARATION BY THE INSURED","fields":[{"help":"Enter date in dd-mm-yyyy 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"},{"title":"CLAIM FORM - PART B (TO BE FILLED BY THE HOSPITAL)","fields":[{"help":"Enter full name of hospital","type":"text","label":"Name of the hospital:","options":[],"required":null,"pdf_field":""},{"help":"Enter hospital ID as allocated by TPA","type":"text","label":"Hospital ID:","options":[],"required":null,"pdf_field":""},{"help":"Enter full name of treating doctor","type":"text","label":"Name of the treating doctor:","options":[],"required":null,"pdf_field":""},{"help":"Enter educational qualifications of doctor","type":"text","label":"Qualification:","options":[],"required":null,"pdf_field":""},{"help":"Tick the appropriate option","type":"choice","label":"Type of Hospital:","options":["Network","Non Network"],"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 phone number including 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":null,"pdf_field":""},{"help":"Enter insurance provider registration number","type":"text","label":"IP Registration Number:","options":[],"required":null,"pdf_field":""},{"help":"Tick Male or Female","type":"choice","label":"Gender:","options":["Male","Female"],"required":null,"pdf_field":""},{"help":"Enter date of birth in dd-mm-yyyy format","type":"date","label":"Date of birth:","options":[],"required":null,"pdf_field":""},{"help":"Enter date of admission in dd-mm-yyyy format","type":"date","label":"Date of Admission:","options":[],"required":null,"pdf_field":""},{"help":"Enter date of discharge in dd-mm-yyyy format","type":"date","label":"Date of Discharge:","options":[],"required":null,"pdf_field":""},{"help":"Enter date of delivery in dd-mm-yyyy format","type":"date","label":"Date of Delivery (if Maternity):","options":[],"required":null,"pdf_field":""},{"help":"Enter gravida status","type":"text","label":"Gravida Status (if Maternity):","options":[],"required":null,"pdf_field":""},{"help":"Tick the appropriate option","type":"choice","label":"Type of Admission:","options":["Planned","Emergency","Day Care","Maternity"],"required":null,"pdf_field":""},{"help":"Tick the appropriate option","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:","options":[],"required":null,"pdf_field":""},{"help":"Enter ICD 10 PCS codes and descriptions for Procedure 1, 2, 3 and details of procedure","type":"table","label":"DETAILS OF PROCEDURE - ICD 10 PCS","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":"Enter reason for not obtaining 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 the appropriate cause","type":"choice","label":"If Yes, give cause:","options":["Self-inflicted","Road Traffic Accident","Substance abuse / alcohol consumption"],"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","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 applicable","type":"text","label":"FIR No.:","options":[],"required":null,"pdf_field":""},{"help":"Enter reason for not reporting to police","type":"text","label":"If not reported to police give reason:","options":[],"required":null,"pdf_field":""},{"help":"Tick the documents submitted","type":"checkbox","label":"Claim Documents Submitted - Check List","options":["Claim Form duly signed","Original Pre-authorization request","Copy of the Pre-authorization approval letter","Copy of Photo ID Card of patient Verified by hospital","Hospital Discharge summary","Operation Theatre Notes","Hospital main bill","Hospital break-up bill","Investigation reports","CT/MR/USG/HPE investigation reports","Doctor’s reference slip for investigation","ECG","Pharmacy bills","MLC reports & Police FIR","Original death summary from hospital where applicable","Any other"],"required":null,"pdf_field":""},{"help":"Fill only if hospital is non-network","type":"group","label":"ADDITIONAL DETAILS IN CASE OF NON NETWORK HOSPITAL","fields":[{"help":"Enter full postal address including city, state, pin code","type":"text","label":"Address of the Hospital","options":[],"required":null,"pdf_field":""},{"help":"Enter hospital phone number including STD code","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 facilities available","type":"checkbox","label":"Facilities available in the hospital","options":["OT","ICU"],"required":null,"pdf_field":""}],"options":[],"required":null,"pdf_field":""},{"help":"Hospital authority to sign and stamp with date and place","type":"declaration","label":"Declaration by the Hospital","options":[],"required":true,"pdf_field":""}],"filled_by":"hospital"}],"deadlines":[],"applies_to":"Health insurance policies other than travel and personal accident","attachments":["Claim form duly signed","Copy of the claim intimation, if any","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 Reports (Including CT / MRI / USG / HPE)","Doctor’s Prescriptions","Others","Original Pre-authorization request form (for Part B)","Copy of the Pre-authorization approval letter","Copy of Photo ID Card of patient Verified by hospital","MLC reports & Police FIR","Original death summary from hospital where applicable"],"declarations":["The insured declares that the information furnished is true and correct to the best of their knowledge and belief.","False or untrue statements or concealment of material facts will forfeit the right to claim reimbursement.","The insured consents and authorizes TPA/Insurance Company to seek necessary medical information from hospitals or medical practitioners.","The insured declares that all bills/receipts for the claim are included and no supplementary claim will be made except for pre/post-hospitalization claims.","The hospital declares that the information furnished is true and correct to the best of their knowledge and belief.","False or untrue statements or concealment of material facts by the hospital will forfeit the right to claim under this claim."],"dropped_labels":8},"pdf_fields":null,"fillable_pdf":false,"send_to":[{"purpose":"claim","channel":"email","value":"healthclaims@godigit.com","label":"Health Claims Email","level":null,"hours":null,"applies_to":"health","source_url":"https://www.godigit.com/claims","quote":"outside India)\ntravelclaims@godigit.com\nHealth Reimbursement\r\n                            Claims Helpline\n1800-258-4242\nhealthclaims@godigit.com\nFile health\r\n                                    claim online\n(Click on this link for online health claims)\nCashless He","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"email","value":"travelclaims@godigit.com","label":"Travel Claims Email","level":null,"hours":null,"applies_to":"travel","source_url":"https://www.godigit.com/claims","quote":"799022308\n(This is a missed call only number for\r\n                                customers dialing from outside India)\ntravelclaims@godigit.com\nHealth Reimbursement\r\n                            Claims Helpline\n1800-258-4242\nhealthclaims@godigit.com\nFile health","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"1800-258-5956","label":"Motor Claims Helpline","level":null,"hours":"24/7","applies_to":"motor","source_url":"https://www.godigit.com/claims","quote":"Chat bot and this is a chat only number. One stop solution for all your queries!)\nhello@godigit.com\n1800-258-5956\nFor International\r\n                            Travel Insurance Claims\n+91-7799022308\n(This is a missed call only numbe","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"1800-258-4242","label":"Health Reimbursement Claims Helpline","level":null,"hours":"24/7","applies_to":"health","source_url":"https://www.godigit.com/claims","quote":"dialing from outside India)\ntravelclaims@godigit.com\nHealth Reimbursement\r\n                            Claims Helpline\n1800-258-4242\nhealthclaims@godigit.com\nFile health\r\n                                    claim online\n(Click on this link for online h","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"+91-7799022308","label":"International Travel Insurance Claims missed call number","level":null,"hours":"24/7","applies_to":"travel","source_url":"https://www.godigit.com/claims","quote":"l your queries!)\nhello@godigit.com\n1800-258-5956\nFor International\r\n                            Travel Insurance Claims\n+91-7799022308\n(This is a missed call only number for\r\n                                customers dialing from outside India)\ntravelcla","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"7026061234","label":"WhatsApp Self-Serve Chat bot for Motor Claims","level":null,"hours":"09 am to 10 pm","applies_to":"motor","source_url":"https://www.godigit.com/claim/grievance-redressal-procedure","quote":"om\n(Response in 3 days)\nCall us at\nMotor: 1800-258-5956\nHealth: 1800-258-4242\n(Available 24/7).\nChat with our expert on\n7026061234\n(All days, 09 am to 10 pm)\nTo read the Digit Protection of Policyholder Interest\r\n                      Policy –\nClick","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"7709996079","label":"Cashless Helpline for Health Customers","level":null,"hours":null,"applies_to":"health","source_url":"https://www.godigit.com/claims","quote":"claim online\n(Click on this link for online health claims)\nCashless Helpline for\nHealth Customers\n7709996079\nhealthclaims@godigit.com\nSenior Citizen and Differently Abled Persons Helpline\n1800-258-4242\nseniors@godigit.com\nCashle","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"8066970001","label":"Cashless Helpline for Hospitals","level":null,"hours":null,"applies_to":"health","source_url":"https://www.godigit.com/claims","quote":"Senior Citizen and Differently Abled Persons Helpline\n1800-258-4242\nseniors@godigit.com\nCashless Helpline for\nHospitals\n8066970001\nhealth.network@godigit.com\nFor other Queries &\r\n                            Claims\n1800-258-5956\nhello@godigit.com\nEsca","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/go-digit-general-insurance/3-claim-form-for-health-insurance-policies-other-than-travel-and-personal-accident"}