{"id":358,"title":"Care OPD 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/care-opd---claim-form.pdf","sha256":"790535985db00f5930e16ea1841c03b334ae8be85cfbce47c2d5cac059ff7b7c","pages":11,"collected":"2026-10-20","instructions":{"about":"This form is used by the insured person (policyholder or claimant) to claim reimbursement for outpatient department (OPD) medical expenses under their health insurance policy.","notes":["Fill the form completely and in block letters.","Submit original claim form and original documents for smooth processing.","Provide at least two contactable mobile numbers and email ID for communication.","Claim payments are made only through online bank transfers; provide bank details and cancelled cheque.","Submission of documents or bank details does not imply admission of liability by the company.","Use DD/MM/YYYY format for dates and hh:mm format for times where applicable.","If claim amount exceeds Rs 1 Lakh, additional documents are required.","Track claim status online or via SMS using claim reference number.","Use original bills only; photocopies may delay processing."],"title":"Care OPD Claim Form","submit":{"to":"Care Health Insurance-Claims Department, Vipul Tech Square, Tower C, 3rd Floor, Golf Course Road, Sector-43, Gurugram-122009 (Haryana)","how":"post","address":"Vipul Tech Square, Tower C, 3rd Floor, Golf Course Road, Sector-43, Gurugram-122009 (Haryana)"},"purpose":"claim","sections":[{"title":"Section A - Details of Primary Insured","fields":[{"help":"","type":"choice","label":"Title","options":["Mr.","Ms."],"required":null,"pdf_field":""},{"help":"Enter full name in block letters","type":"text","label":"Name (Surname, First Name, Middle Name)","options":[],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Gender","options":["M","F"],"required":true,"pdf_field":""},{"help":"Enter age in years and months","type":"number","label":"Age","options":[],"required":true,"pdf_field":""},{"help":"Use DD/MM/YYYY format","type":"date","label":"Date of Birth","options":[],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Relationship with Primary Insured","options":["Self","Spouse","Child","Father","Mother","Others (Please Specify)"],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Occupation","options":["Service","Self Employed","Homemaker","Retired","Student","Others (Please Specify)"],"required":true,"pdf_field":""},{"help":"","type":"text","label":"City","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"State","options":[],"required":true,"pdf_field":""},{"help":"","type":"number","label":"Pin Code","options":[],"required":true,"pdf_field":""},{"help":"Provide a valid email address","type":"email","label":"E-mail","options":[],"required":true,"pdf_field":""},{"help":"Provide at least two contactable mobile numbers","type":"phone","label":"Phone Number","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"},{"title":"Section B - Details of Insurance History","fields":[{"help":"Enter policy number as allotted by insurance company","type":"text","label":"Policy No.","options":[],"required":true,"pdf_field":""},{"help":"Enter social insurance number or certificate number","type":"text","label":"SL No./Certificate No.","options":[],"required":false,"pdf_field":""},{"help":"Enter TPA ID number","type":"text","label":"Company/TPA ID No.","options":[],"required":false,"pdf_field":""},{"help":"Name of insured person","type":"text","label":"Name (Surname, First Name, Middle Name)","options":[],"required":false,"pdf_field":""},{"help":"Include street, city, state, pin code","type":"text","label":"Address","options":[],"required":false,"pdf_field":""},{"help":"","type":"phone","label":"Phone Number","options":[],"required":false,"pdf_field":""},{"help":"","type":"email","label":"E-mail","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Currently covered by any other Mediclaim/Health Insurance","options":[],"required":true,"pdf_field":""},{"help":"Use DD/MM/YYYY format","type":"date","label":"Date of commencement of first insurance without break","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Previously covered by any other Mediclaim/Health Insurance","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"If yes, Company Name","options":[],"required":false,"pdf_field":""},{"help":"","type":"amount","label":"Sum Insured (Rs.)","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Have you ever been hospitalized in the last 4 years since inception of the contract?","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"},{"title":"Section C - Details of Insured Person Hospitalised","fields":[{"help":"Name of patient","type":"text","label":"Name (Surname, First Name, Middle Name)","options":[],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Gender","options":["M","F"],"required":true,"pdf_field":""},{"help":"Enter age in years and months","type":"number","label":"Age","options":[],"required":true,"pdf_field":""},{"help":"Use DD/MM/YYYY format","type":"date","label":"Date of Birth","options":[],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Occupation","options":["Service","Self Employed","Homemaker","Retired","Student","Others (Please Specify)"],"required":true,"pdf_field":""},{"help":"Include street, city, state, pin code","type":"text","label":"Address","options":[],"required":false,"pdf_field":""},{"help":"","type":"phone","label":"Phone Number","options":[],"required":false,"pdf_field":""},{"help":"","type":"email","label":"E-mail","options":[],"required":false,"pdf_field":""},{"help":"Enter diagnosis details","type":"text","label":"Diagnosis","options":[],"required":false,"pdf_field":""},{"help":"Use DD/MM/YYYY format","type":"date","label":"Date","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Have you ever been hospitalized in the last 4 years since inception of the contract?","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"},{"title":"Section D - Details Of Expenses","fields":[{"help":"Enter full name of hospital or clinic","type":"text","label":"Name of Hospital/Clinic","options":[],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Expenses due to","options":["Injury","Illness","Maternity"],"required":true,"pdf_field":""},{"help":"Use DD/MM/YYYY format","type":"date","label":"Date of Injury/Date Disease first detected","options":[],"required":false,"pdf_field":""},{"help":"","type":"choice","label":"If injury, give cause","options":["Self Inflicted","Road Traffic Accident","Substance Abuse/Alcohol Consumption"],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"If Medico Legal","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Reported to Police","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"MLC Report & Police FIR attached","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"Section E - Details of Claim","fields":[{"help":"Columns: (I) Physical Consultations with General Physicians, (ii) Physical Consultations with Specialist Doctors, (iii) OPD Pharmacy, (iv) OPD Physiotherapy, (v) Psychologist Counselling, (vi) Preventive Health check-up, (vii) AYUSH Treatment, (viii) Dental Care, (ix) Vision Care, (x) Therapy Expenses, (xi) Medical Devices, (xii) OPD Diagnostic tests, (xiii) Others (code), Total","type":"table","label":"Details of the treatment expenses claimed","options":[],"required":true,"pdf_field":""},{"help":"Tick the documents you are submitting","type":"checkbox","label":"Claim Documents Submitted- Check List","options":["Claim Form Duly signed","Hospital/clinic Main Bill","Hospital/clinic Break-up Bill","Pharmacy Bill","ECG","Doctor's request for investigation","Investigation Reports (Including CT / MRI / USG / HPE)","Doctor's Prescriptions"],"required":true,"pdf_field":""}],"filled_by":"insured"},{"title":"Section G - Details of Primary Insured’s Bank Account","fields":[{"help":"Permanent Account Number as allotted by Income Tax department","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":"Full name of bank and branch","type":"text","label":"Bank Name & Branch","options":[],"required":true,"pdf_field":""},{"help":"Name of beneficiary for cheque/DD","type":"text","label":"Cheque/DD payable details","options":[],"required":true,"pdf_field":""},{"help":"IFSC code of bank branch","type":"text","label":"IFSC Code","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"},{"title":"Section H - Declaration by the Insured","fields":[{"help":"Use DD/MM/YYYY format","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Place","options":[],"required":true,"pdf_field":""},{"help":"","type":"signature","label":"Signature of the Insured","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"},{"title":"Part B - To be filled by the Hospital","fields":[{"help":"Full name of hospital or clinic","type":"text","label":"Name of the Hospital/Clinic","options":[],"required":true,"pdf_field":""},{"help":"As allocated by TPA","type":"text","label":"Hospital ID","options":[],"required":false,"pdf_field":""},{"help":"If non-network, fill Section E","type":"choice","label":"Type of Hospital/Clinic","options":["Network","Non-network"],"required":true,"pdf_field":""},{"help":"Abbreviations of educational qualifications","type":"text","label":"Qualification","options":[],"required":false,"pdf_field":""},{"help":"As allocated by Medical Council of India","type":"text","label":"Registration No. with State Code","options":[],"required":false,"pdf_field":""},{"help":"Include STD code","type":"phone","label":"Contact No.","options":[],"required":false,"pdf_field":""},{"help":"Full name of patient","type":"text","label":"Name of the Patient","options":[],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Gender","options":["M","F"],"required":true,"pdf_field":""},{"help":"Age in years and months","type":"number","label":"Age","options":[],"required":true,"pdf_field":""},{"help":"Use DD/MM/YYYY format","type":"date","label":"Date of Birth","options":[],"required":true,"pdf_field":""},{"help":"In rupees, no paise","type":"amount","label":"Total Claimed Amount","options":[],"required":true,"pdf_field":""},{"help":"Describe procedures performed","type":"text","label":"Details of Procedure","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"If not reported to Police, give reason","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"If Injury due to Substance abuse / Alcohol consumption, Test conducted to establish this","options":[],"required":false,"pdf_field":""},{"help":"First Information Report number","type":"text","label":"FIR No.","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Present ailment is a complication of PED","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Expenses due to Injury","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"If Medico legal","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Reported to Police","options":[],"required":false,"pdf_field":""}],"filled_by":"hospital"},{"title":"Section D - Claim Documents Submitted - Checklist (Hospital)","fields":[{"help":"","type":"checkbox","label":"Duly signed Claim form","options":[],"required":true,"pdf_field":""},{"help":"","type":"checkbox","label":"Hospital /clinic Main bill","options":[],"required":true,"pdf_field":""},{"help":"","type":"checkbox","label":"Hospital/ clinic Break up bill","options":[],"required":true,"pdf_field":""},{"help":"","type":"checkbox","label":"Pharmacy bills","options":[],"required":false,"pdf_field":""},{"help":"Including CT / MRI / USG / HPE","type":"checkbox","label":"Investigation Reports","options":[],"required":false,"pdf_field":""},{"help":"","type":"checkbox","label":"CT / MRI / USG / HPE investigation reports","options":[],"required":false,"pdf_field":""},{"help":"","type":"checkbox","label":"ECG","options":[],"required":false,"pdf_field":""},{"help":"","type":"checkbox","label":"Doctor's reference slip for investigation","options":[],"required":false,"pdf_field":""},{"help":"","type":"checkbox","label":"Copy of photo ID card of patient verified by hospital","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Any Other, please specify","options":[],"required":false,"pdf_field":""}],"filled_by":"hospital"},{"title":"Section A - Details of Hospital (Hospital)","fields":[{"help":"Include street, city, state, pin code","type":"text","label":"Address of the Hospital/Clinic","options":[],"required":true,"pdf_field":""},{"help":"Include STD code","type":"phone","label":"Contact No.","options":[],"required":true,"pdf_field":""},{"help":"As allocated by Medical Council of India","type":"text","label":"Registration No. with State Code","options":[],"required":true,"pdf_field":""},{"help":"Permanent Account Number","type":"text","label":"Hospital/Clinic PAN","options":[],"required":false,"pdf_field":""},{"help":"","type":"number","label":"No. of inpatient beds","options":[],"required":false,"pdf_field":""},{"help":"Tick available facilities","type":"checkbox","label":"Facilities available in the hospital /Clinic","options":["OT","ICU","Others"],"required":false,"pdf_field":""}],"filled_by":"hospital"},{"title":"Section E - Additional Details in case of Non-Network Hospital/Clinic","fields":[{"help":"Use DD/MM/YYYY format","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Place","options":[],"required":true,"pdf_field":""}],"filled_by":"hospital"},{"title":"Section F - Declaration by the Hospital","fields":[{"help":"Use DD/MM/YYYY format","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Place","options":[],"required":true,"pdf_field":""},{"help":"","type":"signature","label":"Signature & Seal of the Hospital Authority","options":[],"required":true,"pdf_field":""}],"filled_by":"hospital"},{"title":"Consent Letter","fields":[{"help":"","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"","type":"signature","label":"Signature of the Claimant","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Address of the Insured","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"}],"deadlines":["Refund any excess amount credited to your account within 7 days of communication from Care Health Insurance Limited"],"applies_to":"Care OPD claims under Care Health Insurance Limited policies","attachments":["Original cancelled cheque of the policyholder","Original claim documents as per Section E checklist","Indoor Case Papers","Hospital Discharge Summary","Payment Receipts","Consultation Papers","MLC Report & Police FIR (if applicable)","Additional documents if claim amount is more than Rs 1 Lakh"],"declarations":["The information furnished in this claim form is true and 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/Company to seek necessary medical information/documents from hospitals or medical practitioners.","All bills/receipts for the claim are included and no supplementary claim will be made except pre/post-hospitalization claims if any.","Hospital declaration that information furnished is true and correct and false statements will forfeit claim rights.","Consent authorizing Care Health Insurance Limited and its agents to seek medical information/records related to the treatment."],"dropped_labels":11},"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/358-care-opd-claim-form"}