{"id":36,"title":"CLAIM FORM FOR HOSPITALIZATION REIMBURSEMENT BENEFIT FOR SECURE EARNINGS AND WELLNESS ADVANTAGE PLAN","purpose":"claim","insurer":{"slug":"axis-max-life-insurance","name":"Axis Max Life Insurance Limited"},"source_pdf":"https://www.axismaxlife.com/static-page/assets/homepage/SEWA%20Claim%20Form.pdf","sha256":"65d4d857c1526ce71e616060085a8167f59b04b50a26cef204430fdff635f901","pages":5,"collected":"2026-10-17","instructions":{"about":"This form is for claiming hospitalization reimbursement benefits under the Secure Earnings and Wellness Advantage Plan. Part A is filled by the insured person and Part B by the hospital.","notes":["Fill the form in block letters.","Attach original bills, receipts, and reports as per checklist.","Submit documents to TPA office or email as provided.","For claims exceeding Rs. 100,000, submit KYC documents as per IRDA norms.","Beware of spurious/fraud phone calls; IRDAI does not sell policies or announce bonuses.","For NEFT payments, transfer only to the specified Axis Bank account number and IFSC code."],"title":"CLAIM FORM FOR HOSPITALIZATION REIMBURSEMENT BENEFIT FOR SECURE EARNINGS AND WELLNESS ADVANTAGE PLAN","submit":{"to":"TPA office","how":"post / e-mail","address":"TPA Name: MD India Health Insurance TPA Pvt. Ltd., S. No. 46/1, E-space, A-2 Building, 2nd Floor, Pune Nagar Road, Vadgaonsheri, Pune 411014. Email ID: customercare@mdindia.com"},"purpose":"claim","sections":[{"title":"Part A - To be filled in by the Insured","fields":[{"help":"Enter the policy number","type":"text","label":"Policy No .","options":[],"required":null,"pdf_field":""},{"help":"Enter the TPA ID number","type":"text","label":"Company/TPA ID No .","options":[],"required":null,"pdf_field":""},{"help":"Enter the full name of the policyholder","type":"text","label":"Name","options":[],"required":null,"pdf_field":""},{"help":"Enter the full postal address","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":"Enter phone number","type":"phone","label":"Phone No .","options":[],"required":null,"pdf_field":""},{"help":"Enter email address","type":"email","label":"E-mail ID","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Other Insurance History","fields":[{"help":"Enter policy number of other insurance","type":"text","label":"Policy No.","options":[],"required":null,"pdf_field":""},{"help":"Enter name of other insurance company","type":"text","label":"Company Name","options":[],"required":null,"pdf_field":""},{"help":"Enter sum assured under other insurance","type":"amount","label":"Sum Assured","options":[],"required":null,"pdf_field":""},{"help":"Select status of other insurance policy","type":"choice","label":"Status (Active/Lapsed/Applied/Matured)","options":["Active","Lapsed","Applied","Matured"],"required":null,"pdf_field":""},{"help":"Enter claim status under other insurance","type":"text","label":"Claim Status","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Details of Insured Person Hospitalised","fields":[{"help":"Enter full name of the patient","type":"text","label":"Name","options":[],"required":null,"pdf_field":""},{"help":"Select gender of the patient","type":"choice","label":"Gender","options":["Male","Female"],"required":null,"pdf_field":""},{"help":"Enter completed age of the patient","type":"number","label":"Current Age","options":[],"required":null,"pdf_field":""},{"help":"Enter date of birth of patient in DDMMYYYY format","type":"date","label":"Date of Birth","options":[],"required":null,"pdf_field":""},{"help":"Select occupation of patient; specify if Other","type":"choice","label":"Occupation","options":["Service","Self-employed","Homemaker","Retired","Student","Other"],"required":null,"pdf_field":""},{"help":"Specify occupation if 'Other' selected","type":"text","label":"Please specify","options":[],"required":false,"pdf_field":""},{"help":"Enter 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":"Enter phone number of patient","type":"phone","label":"Phone No .","options":[],"required":false,"pdf_field":""},{"help":"Enter email address of patient","type":"email","label":"E-mail ID","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"Details of Hospitalization","fields":[{"help":"Enter hospital name","type":"text","label":"Name of the Hospital where admitted","options":[],"required":null,"pdf_field":""},{"help":"Select room category","type":"choice","label":"Room category occupied","options":["ICU","Non-ICU"],"required":null,"pdf_field":""},{"help":"Select reason for hospitalization","type":"choice","label":"Hospitalization due to","options":["Illness","Injury","Maternity"],"required":null,"pdf_field":""},{"help":"Enter relevant date in DDMMYYYY format","type":"date","label":"Date of Injury/Date of disease first detected/Date of delivery","options":[],"required":null,"pdf_field":""},{"help":"Enter date of admission in DDMMYYYY format","type":"date","label":"Date of admission","options":[],"required":null,"pdf_field":""},{"help":"Enter time of admission in HH:MM format","type":"text","label":"Time of admission","options":[],"required":null,"pdf_field":""},{"help":"Enter date of discharge in DDMMYYYY format","type":"date","label":"Date of discharge","options":[],"required":null,"pdf_field":""},{"help":"Enter time of discharge in HH:MM format","type":"text","label":"Time of discharge","options":[],"required":null,"pdf_field":""},{"help":"Select cause if injury","type":"choice","label":"If injury, give cause","options":["Self inflicted","Road traffic accident","Substance abuse","Alcohol consumption"],"required":false,"pdf_field":""},{"help":"Indicate if injury is medico legal","type":"yes-no","label":"If Medico legal","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Indicate if police was informed","type":"yes-no","label":"Reported to police","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Select system of medicine used","type":"choice","label":"System of medicine","options":["Allopathy","Homeopathy","Ayurveda","Unani","Naturopathy"],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Details of Claim","fields":[{"help":"Enter number of ICU days","type":"number","label":"ICU","options":[],"required":null,"pdf_field":""},{"help":"Enter number of non-ICU days","type":"number","label":"Non ICU","options":[],"required":null,"pdf_field":""},{"help":"Enter amount claimed for surgical cash","type":"amount","label":"Surgical cash","options":[],"required":null,"pdf_field":""},{"help":"Enter amount claimed for critical illness benefit","type":"amount","label":"Critical illness beneefit","options":[],"required":null,"pdf_field":""},{"help":"Tick all documents submitted","type":"checkbox","label":"Claim documents submitted check list","options":["Duly filled and signed claim form","Copy of intimation letter, if any","Hospital main bill","Hospital break up bill","Hospital bill payment receipt","Hospital discharge summary","Pharmacy bill","Operation theater notes","Doctor's request for investigation","Doctor's prescription","All investigation reports including ECG, CT, MRI/USG/HPE","KYC of LA and/or Nominee (Personalized cancelled cheque, Passbook/PAN)"],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Details of Primary Insured's Bank Account","fields":[{"help":"Enter Permanent Account Number","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 bank name and branch","type":"text","label":"Bank name/Branch","options":[],"required":null,"pdf_field":""},{"help":"Enter name for cheque/DD payment","type":"text","label":"Payable details: Cheque/DD","options":[],"required":null,"pdf_field":""},{"help":"Enter IFSC code of bank branch","type":"text","label":"IFSC Code","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Declaration by the Insured","fields":[{"help":"Enter date of signing in DDMMYYYY 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 Insured","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"},{"title":"Part B - To be filled in by the Hospital","fields":[{"help":"Enter hospital name","type":"text","label":"Name of hospital","options":[],"required":null,"pdf_field":""},{"help":"Enter hospital ID","type":"text","label":"Hospital ID","options":[],"required":null,"pdf_field":""},{"help":"Select hospital type","type":"choice","label":"Type of hospital","options":["Network","Non-network"],"required":null,"pdf_field":""},{"help":"Enter treating doctor's name","type":"text","label":"Name of the treating doctor","options":[],"required":null,"pdf_field":""},{"help":"Enter doctor's qualification","type":"text","label":"Qualification","options":[],"required":null,"pdf_field":""},{"help":"Enter doctor's registration number with state code","type":"text","label":"Registration no. with state code","options":[],"required":null,"pdf_field":""},{"help":"Enter hospital phone number","type":"phone","label":"Phone no .","options":[],"required":null,"pdf_field":""},{"help":"Enter patient name","type":"text","label":"Name of the Patient","options":[],"required":null,"pdf_field":""},{"help":"Enter patient registration number","type":"text","label":"Registration no .","options":[],"required":null,"pdf_field":""},{"help":"Select patient gender","type":"choice","label":"Gender","options":["Male","Female"],"required":null,"pdf_field":""},{"help":"Enter patient age in years and months","type":"number","label":"Age","options":[],"required":null,"pdf_field":""},{"help":"Enter patient date of birth in DDMMYYYY format","type":"date","label":"Date of birth","options":[],"required":null,"pdf_field":""},{"help":"Enter admission date in DDMMYYYY format","type":"date","label":"Date of admission","options":[],"required":null,"pdf_field":""},{"help":"Enter admission time in HH:MM format","type":"text","label":"Time of admission","options":[],"required":null,"pdf_field":""},{"help":"Enter discharge date in DDMMYYYY format","type":"date","label":"Date of discharge","options":[],"required":null,"pdf_field":""},{"help":"Enter discharge time in HH:MM format","type":"text","label":"Time of discharge","options":[],"required":null,"pdf_field":""},{"help":"Select type of admission","type":"choice","label":"Type of admission emergency","options":["Planned","Day care"],"required":null,"pdf_field":""},{"help":"Enter gravida status if maternity","type":"text","label":"Gravida status","options":[],"required":false,"pdf_field":""},{"help":"Select discharge status","type":"choice","label":"Status at time of discharge","options":["Discharge to home","Discharge to another hospital","Deceased"],"required":null,"pdf_field":""},{"help":"Enter additional diagnosis details","type":"text","label":"Additional diagnosis","options":[],"required":false,"pdf_field":""},{"help":"Enter procedure 2 details","type":"text","label":"Procedure 2","options":[],"required":false,"pdf_field":""},{"help":"Enter co-morbidities details","type":"text","label":"Co-morbidities","options":[],"required":false,"pdf_field":""},{"help":"Enter procedure 3 details","type":"text","label":"Procedure 3","options":[],"required":false,"pdf_field":""},{"help":"Enter additional co-morbidities details","type":"text","label":"Co-morbidities","options":[],"required":false,"pdf_field":""},{"help":"Enter procedure 4 details","type":"text","label":"Procedure 4","options":[],"required":false,"pdf_field":""},{"help":"Indicate if present ailment is complication of pre-existing condition","type":"yes-no","label":"Present ailment is a complication of Pre-existing?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Specify details if yes","type":"text","label":"If Yes, specify details","options":[],"required":false,"pdf_field":""},{"help":"Indicate if hospitalization due to injury","type":"yes-no","label":"Hospitalization due to injury","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Select cause if injury","type":"choice","label":"If Yes, give cause","options":["Self-inflicted","Road traffic accident","Substance abuse/alcohol consumption"],"required":false,"pdf_field":""},{"help":"Indicate if test conducted; attach reports if yes","type":"yes-no","label":"If Injury due to substance abuse/alcohol consumption, test conducted to establish this","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Indicate if injury is medico legal","type":"yes-no","label":"If Medico legal","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Indicate if police was informed","type":"yes-no","label":"Reported to police","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Enter FIR number if applicable","type":"text","label":"FIR no.","options":[],"required":false,"pdf_field":""},{"help":"Explain reasons if police not informed","type":"text","label":"If not reported to police give reasons","options":[],"required":false,"pdf_field":""},{"help":"Tick all documents submitted","type":"checkbox","label":"Claim documents submitted check list","options":["Claim form duly signed","Copy of photo ID card of Patient verified by hospital","Hospital discharge summary","Operation theatre notes","Hospital main bill","Hospital break-up bill","All Investigation reports including (CT/MRI/USG/HPE/ECG etc.)","Pharmacy bills","KYC of LA/Nominee (personalized cancelled cheque/passbook, PAN, Aadhar)"],"required":null,"pdf_field":""}],"filled_by":"hospital"},{"title":"Details in case of Non-Network Hospital","fields":[{"help":"Enter hospital address","type":"text","label":"Address of hospital","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":"Enter hospital phone number","type":"phone","label":"Phone no .","options":[],"required":null,"pdf_field":""},{"help":"Enter hospital registration number","type":"text","label":"Registration no .","options":[],"required":null,"pdf_field":""},{"help":"Enter hospital PAN","type":"text","label":"PAN","options":[],"required":null,"pdf_field":""},{"help":"Enter number of inpatient beds","type":"number","label":"Number of in-patient beds","options":[],"required":null,"pdf_field":""}],"filled_by":"hospital"},{"title":"Declaration by the Hospital","fields":[{"help":"Enter date of signing in DDMMYYYY 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":"Hospital to sign after filling form","type":"signature","label":"Signature of Insured","options":[],"required":true,"pdf_field":""}],"filled_by":"hospital"}],"deadlines":[],"applies_to":"Hospitalization reimbursement benefit claims under Secure Earnings and Wellness Advantage Plan","attachments":["Duly filled and signed claim form","Copy of intimation letter, if any","Hospital main bill","Hospital break up bill","Hospital bill payment receipt","Hospital discharge summary","Pharmacy bill","Operation theater notes","Doctor's request for investigation","Doctor's prescription","All investigation reports including ECG, CT, MRI/USG/HPE","KYC of LA and/or Nominee (Personalized cancelled cheque, Passbook/PAN)","Copy of photo ID card of Patient verified by hospital","Copy of bills, copy of payment receipts and reports for investigation","First consultation letter and subsequent prescriptions","Copy of detailed discharge summary with date of admission & discharge, clinical history, past history/procedure details/day care summary from the hospital","Copy of consolidated hospital bill with break up of each item, duly signed by the insured","Copy of medicine bills and receipts with corresponding prescriptions","Copy of invoice/sticker of implants/bills for Implants (viz. Stent/PHS mesh/IOL, etc) with payment receipts","Copy of the First Information Report from police department/copy of the Medico-Legal certificate (for road traffic accident in non medico legal cases)","Treating doctor's certificate giving details of injuries (how, when and where injury sustained)"],"declarations":["The information furnished in this claim form is true and correct to the best of the insured's 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.","Consent and authorization is given to TPA/insurance company to seek necessary medical information/documents from any hospital/Medical Practitioner who attended the person against whom this claim is made.","Consent is voluntarily provided to use Aadhar to conduct identity check towards KYC compliance by Axis Max Life Insurance.","The hospital declares that the information furnished is true and correct to the best of their knowledge and belief.","If the hospital makes any false or untrue statement, suppression or concealment of material fact, their right to claim under this claim shall be forfeited.","The signature of the insured is taken on this form after Claim Form B is fully filled up by the hospital."],"dropped_labels":8},"pdf_fields":null,"fillable_pdf":false,"send_to":[{"purpose":"claim","channel":"email","value":"claims.support@axismaxlife.com","label":"Claims Support Email","level":1,"hours":null,"applies_to":"all","source_url":"https://www.axismaxlife.com/claims-centre","quote":"the insured event occurs. Claims can be notified through the website, branch, agent advisor, Axis Bank branch, email at claims.support@axismaxlife.com, or by sending written communication to the Claims Department at the Operations Centre in Gurgaon.\nWhat is the claim pr","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"1860-120-5577","label":"Customer Service Helpline","level":1,"hours":"9:00 AM to 6:00 PM Monday to Saturday","applies_to":"all","source_url":"https://www.axismaxlife.com/claims-centre","quote":"ny escalation/feedback/queries.\nCustomer Service\nWhatsapp\n: +91-7428396005\nSend ‘Hi’ from your registered mobile number\n1860-120-5577\n9:00 AM to 6:00 PM\n(Monday to Saturday)\nservice.helpdesk@axismaxlife.com\nPlease write to us incase of any escalation/fe","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"+91-124-648-8900","label":"Online Sales Helpline","level":1,"hours":"09:30 AM to 06:30 PM (Monday to Sunday except National Holidays)","applies_to":"all","source_url":"https://www.axismaxlife.com/claims-centre","quote":"Show More\nOnline Sales Helpline\nWhatsapp\n: +91-7428396005\nSend ‘Quick Help’ from your registered mobile number\nPhone\n: +91-124-648-8900\n09:30 AM to 06:30 PM\n(Monday to Sunday except National Holidays)\nservice.helpdesk@axismaxlife.com\nPlease write to us in","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/axis-max-life-insurance/36-claim-form-for-hospitalization-reimbursement-benefit-for-secure-earnings-and-wel"}