{"id":344,"title":"CLAIM FORM FOR HEALTH INSURANCE POLICY OTHER THAN TRAVEL AND PERSONAL ACCIDENT - PART A","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-a-individual.pdf","sha256":"101fbc86cd5c1934c821d397c50ed87d843adb7acf5ff0970fb61ad381b753ff","pages":2,"collected":"2026-10-17","instructions":{"about":"This form is used by the insured person or policyholder to claim health insurance benefits for hospitalization and related expenses.","notes":["Fill the form in block letters.","Do not enter paise values in amount fields.","Use specified date formats (dd-mm-yy or mm-yy) and time format (hh:mm) as indicated.","Attach original bills and documents as listed in the checklist.","For domiciliary hospitalization claims, provide details in an annexure.","Refer policy documents for TPA contact details for claim submission."],"title":"CLAIM FORM FOR HEALTH INSURANCE POLICY OTHER THAN TRAVEL AND PERSONAL ACCIDENT - PART A","submit":{"to":"Please refer your policy documents for the Name and complete Address of your TPA for submitting your claim documents.","how":"","address":""},"purpose":"claim","sections":[{"title":"Details of Primary Insured","fields":[{"help":"Enter the policy number as allotted by the insurance company","type":"text","label":"Policy No:","options":[],"required":null,"pdf_field":""},{"help":"Enter the TPA ID No as allotted by IRDA and printed in TPA documents","type":"text","label":"Company/ TPA ID No:","options":[],"required":null,"pdf_field":""},{"help":"Enter the full name of the policyholder (Surname, First name, Middle name)","type":"text","label":"Name:","options":[],"required":null,"pdf_field":""},{"help":"Enter the 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 e-mail address","type":"email","label":"Email:","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"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 the appropriate gender","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:","options":[],"required":null,"pdf_field":""},{"help":"Tick the appropriate option; specify if Other","type":"choice","label":"Relationship to 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; 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 primary insured","type":"text","label":"Address (if different from above):","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"City:","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"State:","options":[],"required":false,"pdf_field":""},{"help":"","type":"number","label":"Pin Code:","options":[],"required":false,"pdf_field":""},{"help":"Include STD code with telephone number","type":"phone","label":"Phone No:","options":[],"required":false,"pdf_field":""},{"help":"Enter complete e-mail address","type":"email","label":"Email:","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: 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":false,"pdf_field":""},{"help":"Enter policy number as allotted by the insurance company","type":"text","label":"Policy No:","options":[],"required":false,"pdf_field":""},{"help":"Enter total sum insured in Rupees","type":"amount","label":"Sum Insured (`.):","options":[],"required":false,"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? Yes No","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Use mm-yy format","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: Yes No","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter full name of the insurance company","type":"text","label":"If yes, Companys Name:","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"Details of Hospitalization","fields":[{"help":"Enter full name of hospital","type":"text","label":"Name of 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 beds per room","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: Injury Illness Maternity","options":["Injury","Illness","Maternity"],"required":null,"pdf_field":""},{"help":"Use dd-mm-yy format","type":"date","label":"Date of admission:","options":[],"required":null,"pdf_field":""},{"help":"Use hh:mm format","type":"text","label":"Time:","options":[],"required":null,"pdf_field":""},{"help":"Use dd-mm-yy format","type":"date","label":"Date of discharge:","options":[],"required":null,"pdf_field":""},{"help":"Use hh:mm format","type":"text","label":"Time:","options":[],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"If Medico legal: Yes No","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"Reported to police: Yes No","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"MLC Report & Police FIR attached: Yes No","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter the system of medicine followed in treating the patient","type":"text","label":"System of Medicine:","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Details of Claim","fields":[{"help":"Enter amounts in Rupees (do not enter paise values)","type":"amount","label":"a) Details of the treatment expenses claimed","options":[],"required":null,"pdf_field":""},{"help":"Enter amount in Rupees","type":"amount","label":"i. Pre-hospitalization expenses:","options":[],"required":null,"pdf_field":""},{"help":"Enter amount in Rupees","type":"amount","label":"ii. Hospitalization expenses:","options":[],"required":null,"pdf_field":""},{"help":"Enter amount in Rupees","type":"amount","label":"iii. Post-hospitalization expenses:","options":[],"required":null,"pdf_field":""},{"help":"Enter amount in Rupees","type":"amount","label":"iv. Health-Check up cost:","options":[],"required":null,"pdf_field":""},{"help":"Enter amount in Rupees","type":"amount","label":"v. Ambulance charges:","options":[],"required":null,"pdf_field":""},{"help":"Specify other expenses with code","type":"text","label":"vi. Others (code):","options":[],"required":false,"pdf_field":""},{"help":"Total treatment expenses claimed","type":"amount","label":"Total","options":[],"required":null,"pdf_field":""},{"help":"Enter number of days","type":"number","label":"vii. Pre-hospitalization period: days","options":[],"required":null,"pdf_field":""},{"help":"Enter number of days","type":"number","label":"viii. Post-hospitalization period: days","options":[],"required":null,"pdf_field":""},{"help":"Tick Yes or No; if Yes, attach annexure with details","type":"yes-no","label":"b) Claim for domiciliary hospitalization: Yes No (If yes, provide details in annexure)","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter amount in Rupees","type":"amount","label":"i. Hospital daily cash:","options":[],"required":null,"pdf_field":""},{"help":"Enter amount in Rupees","type":"amount","label":"ii. Surgical cash","options":[],"required":null,"pdf_field":""},{"help":"Enter amount in Rupees","type":"amount","label":"iv. Convalescence:","options":[],"required":null,"pdf_field":""},{"help":"Enter amount in Rupees","type":"amount","label":"vi. Others:","options":[],"required":false,"pdf_field":""},{"help":"Total lump sum/cash benefit claimed","type":"amount","label":"Total","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 claim intimation, if any","Original Main Hospital Bill with Break Up","Original Hospital Bill Payment Receipts","Original and complete discharge card","Original investigation bills/ receipts with original Investigation report","Original Pharmacy bill with corresponding prescription/ request","Copies of identity and age proofs of insured hospitalized","Copy of Bank pass book/ statement of policyholder’s (of nominee in case of death of Policyholder) personal account along with cancelled Cheque"],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Details of Bills Enclosed","fields":[{"help":"Fill details of bills enclosed with amounts in Rupees","type":"table","label":"SI. No Bill No Date Issued by Towards Amount (`)","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Details of Primary Insured's Bank Account","fields":[{"help":"Enter name as per bank records","type":"text","label":"Name as per Bank Records:","options":[],"required":null,"pdf_field":""},{"help":"Enter Permanent Account Number allotted by Income Tax department","type":"text","label":"PAN:","options":[],"required":null,"pdf_field":""},{"help":"Enter account type - Saving or Current","type":"text","label":"Type of Account","options":[],"required":null,"pdf_field":""},{"help":"Enter bank account number as allotted by the bank","type":"text","label":"Account number:","options":[],"required":null,"pdf_field":""},{"help":"Enter full name of bank and branch","type":"text","label":"Bank name and Branch:","options":[],"required":null,"pdf_field":""},{"help":"Enter name of beneficiary to whom cheque/DD should be made out","type":"text","label":"Cheque/ DD Payable details:","options":[],"required":null,"pdf_field":""},{"help":"Enter IFSC code of bank branch in full","type":"text","label":"IFSC Code:","options":[],"required":null,"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 here","type":"signature","label":"Signature of the Policy Holder","options":[],"required":true,"pdf_field":""},{"help":"Sign here","type":"signature","label":"Signature of the Insured","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"}],"deadlines":[],"applies_to":"Health insurance policies other than travel and personal accident","attachments":["Annexure for domiciliary hospitalization details if applicable","Claim intimation copy if any","Original Main Hospital Bill with Break Up","Original Hospital Bill Payment Receipts","Original and complete discharge card","Original investigation bills/ receipts with original Investigation report","Original Pharmacy bill with corresponding prescription/ request","Copies of identity and age proofs of insured hospitalized","Copy of Bank pass book/ statement of policyholder’s (or nominee in case of death) personal account along with cancelled Cheque"],"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.","I consent and authorize TPA/insurance company to seek necessary medical information/documents from any hospital or medical practitioner who attended the person against whom this claim is made.","I declare that I have included all bills/receipts for this claim and will not make any supplementary claim except pre/post-hospitalization claims if any."],"dropped_labels":7},"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/344-claim-form-for-health-insurance-policy-other-than-travel-and-personal-accident-p"}