{"id":343,"title":"Health Claim Form - Part B","purpose":"claim","insurer":{"slug":"indiafirst-life-insurance","name":"IndiaFirst Life Insurance Company Limited"},"source_pdf":"https://www.indiafirstlife.com/content/dam/ifliwebsite/in/en/download-center/claims/health-claim-form-part-b-group.pdf","sha256":"a2d0f806809d1e134ed2e02a512c07f6ac5f59467f9b3a6d4e22321e535a1da1","pages":2,"collected":"2026-10-17","instructions":{"about":"This form is used by hospitals to provide detailed information for a health insurance claim related to a patient's hospitalization. It is filled out by the hospital authority.","notes":["Use block letters to fill the form.","Include original pre-authorization request form in lieu of Part A.","Attach all original and required documents as per the checklist.","Use dd-mm-yy format for dates and hh:mm format for times.","Do not enter paise values in the claimed amount.","This form is to be filled by the hospital only.","The issue of this form is not to be taken as an admission of liability."],"title":"Health Claim Form - Part B","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Declaration by the Hospital","fields":[{"help":"Enter the date in dd-mm-yy format","type":"date","label":"Date:","options":[],"required":null,"pdf_field":""},{"help":"Enter the place name","type":"text","label":"Place:","options":[],"required":null,"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"},{"title":"Additional Details in Case of Non Network Hospital (Only Fill in case of Non-network Hospital)","fields":[{"help":"Enter full postal address including street, city, state, and pin code","type":"text","label":"Address of the Hospital:","options":[],"required":null,"pdf_field":""},{"help":"Enter city name","type":"text","label":"City:","options":[],"required":null,"pdf_field":""},{"help":"Enter state name","type":"text","label":"State:","options":[],"required":null,"pdf_field":""},{"help":"Enter pin code","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 registration number as allocated by Medical Council","type":"text","label":"Registration No. with State Code:","options":[],"required":null,"pdf_field":""},{"help":"Enter permanent account number allotted by Income Tax department","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 Yes or No","type":"yes-no","label":"Facilities Available in the Hospital: i. OT:","options":["Yes","No"],"required":null,"pdf_field":""}],"filled_by":"hospital"},{"title":"Claim Documents Submitted - Check List","fields":[{"help":"Check if submitted","type":"checkbox","label":"Claim Form duly signed","options":[],"required":null,"pdf_field":""},{"help":"Check if submitted","type":"checkbox","label":"Investigation reports","options":[],"required":null,"pdf_field":""},{"help":"Check if submitted","type":"checkbox","label":"Original Pre-authorization request","options":[],"required":null,"pdf_field":""},{"help":"Check if submitted","type":"checkbox","label":"Original CT/MR/USG/HPE investigation reports","options":[],"required":null,"pdf_field":""},{"help":"Check if submitted","type":"checkbox","label":"Copy of the Pre-authorization approval letter","options":[],"required":null,"pdf_field":""},{"help":"Check if submitted","type":"checkbox","label":"Original ECG","options":[],"required":null,"pdf_field":""},{"help":"Check if submitted","type":"checkbox","label":"Original Hospital Discharge summary","options":[],"required":null,"pdf_field":""},{"help":"Check if submitted","type":"checkbox","label":"Original Pharmacy Bills","options":[],"required":null,"pdf_field":""},{"help":"Check if submitted","type":"checkbox","label":"Operation Theatre notes","options":[],"required":null,"pdf_field":""},{"help":"Check if submitted if applicable","type":"checkbox","label":"MLC Report & Police FIR","options":[],"required":null,"pdf_field":""},{"help":"Check if submitted","type":"checkbox","label":"Original Hospital Main Bill","options":[],"required":null,"pdf_field":""},{"help":"Check if submitted if applicable","type":"checkbox","label":"Original Death Summary from Hospital where Applicable","options":[],"required":null,"pdf_field":""},{"help":"Check if submitted","type":"checkbox","label":"Hospital Break-up Bill","options":[],"required":null,"pdf_field":""},{"help":"Specify any other documents submitted","type":"text","label":"Any other, Please Specify","options":[],"required":false,"pdf_field":""}],"filled_by":"hospital"},{"title":"Details of the Patient Admitted","fields":[{"help":"Enter full name in block letters","type":"text","label":"a) Name of the Patient:","options":[],"required":true,"pdf_field":""},{"help":"Enter insurance provider registration number","type":"text","label":"b) IP Registration Number:","options":[],"required":null,"pdf_field":""},{"help":"Tick the correct gender","type":"choice","label":"c) Gender:","options":["Male","Female"],"required":true,"pdf_field":""},{"help":"Enter age in years and months","type":"number","label":"d) Age:","options":[],"required":true,"pdf_field":""},{"help":"Use dd-mm-yy format","type":"date","label":"e) Date of Birth:","options":[],"required":null,"pdf_field":""},{"help":"Use dd-mm-yy format","type":"date","label":"f) Date of Admission:","options":[],"required":true,"pdf_field":""},{"help":"Use hh:mm format","type":"text","label":"g) Time:","options":[],"required":null,"pdf_field":""},{"help":"Use dd-mm-yy format","type":"date","label":"h) Date of Discharge:","options":[],"required":true,"pdf_field":""},{"help":"Use hh:mm format","type":"text","label":"i) Time:","options":[],"required":null,"pdf_field":""},{"help":"Tick the correct option","type":"choice","label":"j) Type of Admission:","options":["Emergency","Planned","Day Care","Maternity"],"required":true,"pdf_field":""},{"help":"Use dd-mm-yy format","type":"date","label":"k) If Maternity i. Date of Delivery","options":[],"required":false,"pdf_field":""},{"help":"Tick the correct option","type":"choice","label":"l) Status at Time of Discharge:","options":["Discharge to Home","Discharge to Another Hospital","Deceased"],"required":true,"pdf_field":""},{"help":"Enter amount in rupees, do not enter paise","type":"amount","label":"m) Total Claimed Amount","options":[],"required":true,"pdf_field":""}],"filled_by":"hospital"},{"title":"Details of Hospital","fields":[{"help":"Enter full hospital name","type":"text","label":"a) Name of the Hospital:","options":[],"required":true,"pdf_field":""},{"help":"Enter hospital ID as allocated by TPA","type":"text","label":"b) Hospital ID:","options":[],"required":null,"pdf_field":""},{"help":"Tick the correct option","type":"choice","label":"c) Type of Hospital:","options":["Network","Non Network"],"required":true,"pdf_field":""},{"help":"Enter full name of treating doctor","type":"text","label":"d) Name of the Treating Doctor:","options":[],"required":true,"pdf_field":""},{"help":"Enter registration number with state code as allocated by Medical Council","type":"text","label":"f) Registration No. with State Code:","options":[],"required":null,"pdf_field":""},{"help":"Include STD code with telephone number","type":"phone","label":"g) Phone No.","options":[],"required":null,"pdf_field":""}],"filled_by":"hospital"},{"title":"Details of Ailment Diagnosed (Primary)","fields":[{"help":"Tick Yes or No","type":"yes-no","label":"c) Pre-authorization Obtained:","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Enter pre-authorization number allotted by TPA","type":"text","label":"d) Pre-authorization Number:","options":[],"required":false,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"f) Hospitalization Due to Injury:","options":["Yes","No"],"required":true,"pdf_field":""}],"filled_by":"hospital"}],"deadlines":[],"applies_to":"","attachments":["Claim Form duly signed","Investigation reports","Original Pre-authorization request","Original CT/MR/USG/HPE investigation reports","Copy of the Pre-authorization approval letter","Doctor’s reference slip for investigation","Copy of photo ID card of patient verified by hospital","Original ECG","Original Hospital Discharge summary","Original Pharmacy Bills","Operation Theatre notes","MLC Report & Police FIR","Original Hospital Main Bill","Original Death Summary from Hospital where Applicable","Hospital Break-up Bill","Any other, Please Specify"],"declarations":["The hospital declares that the information furnished is true and correct to the best of their knowledge and belief.","If any false or untrue statement, suppression or concealment of material fact is made, the right to claim shall be forfeited."],"dropped_labels":21},"pdf_fields":null,"fillable_pdf":false,"send_to":[{"purpose":"claim","channel":"address","value":"IndiaFirst Life Insurance Company Ltd., 12th and 13th Floor, North [C] wing, Tower 4, Nesco IT Park, Nesco Center, Western Express Highway, Goregaon (East), Mumbai – 400063","label":"Claims documents submission address","level":null,"hours":null,"applies_to":"life","source_url":"https://www.indiafirstlife.com/claims/claims-overview","quote":"ntative will reach out to you soon to guide you through our life insurance plans that fit your life goals\nHome\nClaims - IndiaFirst Life Insurance\nClaims Overview\nLife Insurance Claim Process\nAt IndiaFirst Life, we stand firmly with our customers in their hour of grief. We provide a streamlined claim registration and settlement process, ensuring a worry-free future for our customers. With a focus on efficiency","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"email","value":"claims.support@indiafirstlife.com","label":"Claims support email","level":null,"hours":null,"applies_to":"life","source_url":"https://www.indiafirstlife.com/claims/claims-overview","quote":"rstlife.com/claims/claims-overview/register-claim-online\n\"\nEmail:\nShare soft copies of all the mandatory documents at '\nclaims.support@indiafirstlife.com\n'\nCall:\nContact us at 1800-209-8700 for assistance. Our representative will guide you through the claim process registr","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"1800-209-8700","label":"Claims assistance phone","level":null,"hours":null,"applies_to":"life","source_url":"https://www.indiafirstlife.com/claims/claims-overview","quote":"\"\nEmail:\nShare soft copies of all the mandatory documents at '\nclaims.support@indiafirstlife.com\n'\nCall:\nContact us at 1800-209-8700 for assistance. Our representative will guide you through the claim process registration.\nVisit Us:\nDrop soft/hard copi","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"url","value":"https://www.indiafirstlife.com/claims/claims-overview/register-claim-online","label":"Register your claim online","level":null,"hours":null,"applies_to":"life","source_url":"https://www.indiafirstlife.com/claims/claims-overview","quote":"Claim Process\nClaim Documents\nFAQs for Claim\nStep 1. Claim Registration\nAnswer\nOnline:\nRegister your claim online at \"\nhttps://www.indiafirstlife.com/claims/claims-overview/register-claim-online\n\"\nEmail:\nShare soft copies of all the mandatory documents at '\nclaims.support@indiafirstlife.com\n'\nCall:\nContact us at","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/indiafirst-life-insurance/343-health-claim-form-part-b"}