{"id":354,"title":"Student Explore Health Unlimited - Claim Form","purpose":"claim","insurer":{"slug":"care-health-insurance","name":"Care Health Insurance Ltd"},"source_pdf":"https://cms.careinsurance.com/cms/public/uploads/download_center/student-explore-health-unlimited---claim-form.pdf","sha256":"2ca0f7b51cdad00b1d6b584eee19809680f2aa88f4b4610d07d923c5dc98618c","pages":7,"collected":"2026-10-20","instructions":{"about":"This form is used by the policyholder or claimant to submit a health insurance claim under the Student Explore Health Unlimited policy.","notes":["Claim form must be completely filled, signed and submitted in original.","Provide at least two contactable mobile numbers and email for communication.","Submit all claim documents in original for smooth processing.","Claim payments are made only through online bank transfers.","Use additional sheets if required.","The issue of this form is not an admission of liability by the company.","The policyholder’s bank details provided in the mandate form are final and not cross-verified by the insurer."],"title":"Student Explore Health Unlimited - Claim Form","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Section A - Details of the Policy","fields":[{"help":"Enter your policy number as printed on your policy document","type":"text","label":"Policy No.","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Policy Schedule No.:","options":[],"required":false,"pdf_field":""},{"help":"City of the insured","type":"text","label":"City :","options":[],"required":false,"pdf_field":""},{"help":"State of the insured","type":"text","label":"State :","options":[],"required":false,"pdf_field":""},{"help":"Provide at least two contactable mobile numbers","type":"phone","label":"Contact number :","options":[],"required":true,"pdf_field":""},{"help":"Provide a valid email address","type":"email","label":"E-mail :","options":[],"required":true,"pdf_field":""},{"help":"Country of residence","type":"text","label":"Country :","options":[],"required":false,"pdf_field":""},{"help":"Postal code","type":"text","label":"Pincode :","options":[],"required":false,"pdf_field":""}],"filled_by":"claimant or policyholder"},{"title":"Section B - Details of Primary Insured","fields":[{"help":"Full name of the primary insured","type":"text","label":"Name : (Surname) (First Name) (Middle Name)","options":[],"required":true,"pdf_field":""},{"help":"Date of birth of the primary insured","type":"date","label":"D.O.B.","options":[],"required":true,"pdf_field":""},{"help":"Select the gender of the primary insured","type":"choice","label":"Gender : Male Female Other","options":["Male","Female","Other"],"required":true,"pdf_field":""},{"help":"Select marital status","type":"choice","label":"Marital Status : Married Single","options":["Married","Single"],"required":false,"pdf_field":""},{"help":"Enter occupation of the primary insured","type":"text","label":"Occupation:","options":[],"required":false,"pdf_field":""},{"help":"Full address of the primary insured","type":"text","label":"Address :","options":[],"required":false,"pdf_field":""},{"help":"Select appropriate title","type":"choice","label":"Title : Mr. Ms.","options":["Mr.","Ms."],"required":false,"pdf_field":""},{"help":"Contact number of the primary insured","type":"phone","label":"Contact number :","options":[],"required":false,"pdf_field":""},{"help":"Email address of the primary insured","type":"email","label":"E-mail :","options":[],"required":false,"pdf_field":""},{"help":"Country of residence","type":"text","label":"Country :","options":[],"required":false,"pdf_field":""},{"help":"Postal code","type":"text","label":"Pincode :","options":[],"required":false,"pdf_field":""},{"help":"Select relationship to the student","type":"choice","label":"Relationship with the Student (Primary Insured) : Self Spouse Child","options":["Self","Spouse","Child"],"required":true,"pdf_field":""}],"filled_by":"claimant or policyholder"},{"title":"Section C - Details Of Insured Person/ Claimant (for Whom The Claim Is For)","fields":[{"help":"Full name of the insured person or claimant","type":"text","label":"Name : (Surname) (First Name) (Middle Name)","options":[],"required":true,"pdf_field":""},{"help":"Date of birth of the insured person","type":"date","label":"D.O.B.","options":[],"required":true,"pdf_field":""},{"help":"Select gender","type":"choice","label":"Gender : Male Female Other","options":["Male","Female","Other"],"required":true,"pdf_field":""},{"help":"Select marital status","type":"choice","label":"Marital Status : Married Single","options":["Married","Single"],"required":false,"pdf_field":""},{"help":"Occupation of the insured person","type":"text","label":"Occupation:","options":[],"required":false,"pdf_field":""},{"help":"Address of the insured person","type":"text","label":"Address :","options":[],"required":false,"pdf_field":""},{"help":"Select title","type":"choice","label":"Title : Mr. Ms.","options":["Mr.","Ms."],"required":false,"pdf_field":""},{"help":"Contact number","type":"phone","label":"Contact number :","options":[],"required":false,"pdf_field":""},{"help":"Email address","type":"email","label":"E-mail :","options":[],"required":false,"pdf_field":""},{"help":"Country of residence","type":"text","label":"Country :","options":[],"required":false,"pdf_field":""},{"help":"Postal code","type":"text","label":"Pincode :","options":[],"required":false,"pdf_field":""}],"filled_by":"claimant or policyholder"},{"title":"Section D - Details Of Insurance History","fields":[{"help":"Select if currently covered by any other insurance","type":"choice","label":"Currently covered by any other Mediclaim / Health Insurance, Medicare or Government plan : Yes No","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Name of other insurance company if applicable","type":"text","label":"If yes, Company Name :","options":[],"required":false,"pdf_field":""},{"help":"Policy number of other insurance if applicable","type":"text","label":"Policy No. :","options":[],"required":false,"pdf_field":""},{"help":"Sum insured under other policy","type":"amount","label":"Sum Insured (Rs.) :","options":[],"required":false,"pdf_field":""},{"help":"Start date of first insurance without break","type":"date","label":"Date of commencement of first insurance without break (DDMMYY) :","options":[],"required":false,"pdf_field":""},{"help":"Select if previously covered by any other insurance","type":"choice","label":"Previously covered by any other Mediclaim /Health Insurance : Yes No","options":["Yes","No"],"required":true,"pdf_field":""}],"filled_by":"claimant or policyholder"},{"title":"Section E - Details of Claim","fields":[{"help":"Name of the doctor who treated the insured","type":"text","label":"Name of treating doctor :","options":[],"required":false,"pdf_field":""},{"help":"Select cause of injury if applicable","type":"choice","label":"If Injury: Self Inflicted Road Traffic Accident Substance Abuse / Alcohol Consumption Others","options":["Self Inflicted","Road Traffic Accident","Substance Abuse / Alcohol Consumption","Others"],"required":false,"pdf_field":""},{"help":"Details of pre-certification if taken","type":"text","label":"Pre-certification taken for","options":[],"required":false,"pdf_field":""},{"help":"Provide full hospital details","type":"text","label":"Name, address and telephone number of Hospital where treatment was given:","options":[],"required":true,"pdf_field":""},{"help":"Select reason for hospitalization","type":"choice","label":"Hospitalization due to : Injury Illness Maternity","options":["Injury","Illness","Maternity"],"required":true,"pdf_field":""},{"help":"Describe illness or injury","type":"text","label":"Details of Illness/Injury:","options":[],"required":true,"pdf_field":""},{"help":"Indicate if pre-certification was taken","type":"choice","label":"Pre-certification / approval taken: Yes No","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Date of pre-certification approval","type":"date","label":"If Yes Date :","options":[],"required":false,"pdf_field":""},{"help":"Details of medical evacuation if applicable","type":"text","label":"Medical Evacuation From: To: Date:","options":[],"required":false,"pdf_field":""},{"help":"Date of return to home country","type":"date","label":"Date of return to Home Country :","options":[],"required":false,"pdf_field":""},{"help":"Cause of illness or injury","type":"text","label":"Cause of the Illness/Injury:","options":[],"required":false,"pdf_field":""},{"help":"Details if pre-existing condition caused or aggravated illness","type":"text","label":"Was the Illness/incident caused/ aggravated due to a pre-existing condition? Please give details:","options":[],"required":false,"pdf_field":""},{"help":"Date when injury or illness was first detected","type":"date","label":"Date of Injury / Illness first detected (DDMMYYYY):","options":[],"required":false,"pdf_field":""},{"help":"Treatment period start and end dates","type":"date","label":"Date of treatment (DDMMYYYY): From To","options":[],"required":true,"pdf_field":""},{"help":"Reason for medical evacuation if applicable","type":"text","label":"Reason for Medical Evacuation (If Yes)","options":[],"required":false,"pdf_field":""},{"help":"Describe the nature of treatment received","type":"text","label":"Nature of treatment:","options":[],"required":false,"pdf_field":""},{"help":"Indicate if pre-certification was taken and date","type":"choice","label":"Pre-certification / approval taken Yes No If Yes Date :","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Indicate if medical evacuation was done","type":"choice","label":"Medical Evacuation Yes No","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Indicate if medical repatriation was done","type":"choice","label":"Medical Repatriation Yes No","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Reason for medical repatriation if applicable","type":"text","label":"Reason for Medical Repatriation (If Yes)","options":[],"required":false,"pdf_field":""},{"help":"Date of medical repatriation","type":"date","label":"Medical Repatriation Date:","options":[],"required":false,"pdf_field":""},{"help":"Indicate if coverage exists at home country","type":"choice","label":"Coverage at home country Yes No","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Confirm medical condition details","type":"text","label":"Confirm the medical condition","options":[],"required":false,"pdf_field":""},{"help":"Tick the benefits claimed and provide details as applicable","type":"checkbox","label":"If a claim is made for any of the following Benefits kindly tick the appropriate Benefit and fill in the corresponding below details : Dental Treatment due to accident, Home Health Nurse, Intercollegiate, interscholastic, intramural, club sports, In-patient Care and Day-Care Treatment, Maternity Benefit, Out-Patient Treatment, New born Benefit, Adventure Sports Injury, Pediatric Dental and Vision, Hospice and palliative care, Daily Allowance, Durable Medical Equipment, Extended Care / Inpatient Clinics /in-patient Rehabilitation, Emergency Medical Evacuation and Repatriation","options":["Dental Treatment due to accident","Home Health Nurse","Intercollegiate, interscholastic, intramural, club sports","In-patient Care and Day-Care Treatment","Maternity Benefit","Out-Patient Treatment","New born Benefit","Adventure Sports Injury","Pediatric Dental and Vision","Hospice and palliative care","Daily Allowance","Durable Medical Equipment","Extended Care / Inpatient Clinics /in-patient Rehabilitation","Emergency Medical Evacuation and Repatriation"],"required":false,"pdf_field":""}],"filled_by":"claimant or policyholder"},{"title":"Section F - Details Of Primary Insured's Bank Account","fields":[{"help":"Enter PAN number","type":"text","label":"PAN :","options":[],"required":true,"pdf_field":""},{"help":"Bank account number for claim payment","type":"text","label":"Account Number :","options":[],"required":true,"pdf_field":""},{"help":"Name and branch of the bank","type":"text","label":"Bank Name and Branch :","options":[],"required":true,"pdf_field":""},{"help":"Details as per cancelled cheque","type":"text","label":"Cheque/DD Payable details :","options":[],"required":false,"pdf_field":""},{"help":"Bank IFSC code","type":"text","label":"IFSC Code :","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant or policyholder"},{"title":"Section G - Declaration by the Insured","fields":[{"help":"Date of signing the declaration","type":"date","label":"Date (DD/MM/YYYY):","options":[],"required":true,"pdf_field":""},{"help":"Sign the form here","type":"signature","label":"Signature of the Claimant :","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant or policyholder"}],"deadlines":[],"applies_to":"Claims under the Student Explore Health Unlimited policy","attachments":["Original claim form signed","At least two contactable mobile numbers and email","Original claim documents as per Section E","Bank account details with cancelled cheque","KYC documents if claim amount is more than Rs 1 Lakh","Consultation papers (medical practitioner’s prescription)","Indoor case papers (daily hospital notes)","Hospital discharge summary","Payment receipts for hospital bills and investigations"],"declarations":["The information given in this claim form is true, correct and complete.","No material information relevant to the claim has been withheld or not disclosed.","False or fraudulent statements or concealment of information will void the policy and claims.","Submission of documents or bank details does not imply admission of liability by the company.","The policyholder agrees to refund any excess amount credited in error within 7 days of notification.","The policyholder agrees that RTGS/NEFT transaction charges, if any, are borne by the policyholder.","The policyholder authorizes the company and its representatives to obtain necessary information for claim processing and subrogation."],"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/care-health-insurance/354-student-explore-health-unlimited-claim-form"}