{"id":361,"title":"CLAIM FORM FOR HEALTH INSURANCE POLICIES OTHER THAN TRAVEL AND PERSONAL ACCIDENT - PART A","purpose":"claim","insurer":{"slug":"generali-central-insurance","name":"Generali Central Insurance Company Limited"},"source_pdf":"https://www.generalicentralinsurance.com/downloads/health-insurance/health-xtra/claim-forms/claim-form.pdf","sha256":"553117c436343f23729ddd8a70c06b4936f822e28bda99069ec2ca4c743819ec","pages":5,"collected":"2026-10-17","instructions":{"about":"This form is used by the insured person to claim health insurance benefits for hospitalization and related expenses under their health insurance policy.","notes":["Fill the form in block letters.","Use original bills only.","KYC documents are mandatory if claim amount is Rs 1 Lakh or more.","Use specified date and time formats as guided.","Attach all relevant supporting documents as per checklist."],"title":"CLAIM FORM FOR HEALTH INSURANCE POLICIES OTHER THAN TRAVEL AND PERSONAL ACCIDENT - PART A","submit":{"to":"","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 social insurance number or certificate number of social health insurance scheme","type":"text","label":"Sl. No/ Certificate no.","options":[],"required":null,"pdf_field":""},{"help":"Enter the TPA ID number as allotted by IRDA and printed in TPA documents","type":"text","label":"Company/ TPA ID No","options":[],"required":null,"pdf_field":""},{"help":"Enter full name of the policyholder: Surname, First name, Middle name","type":"text","label":"Name","options":[],"required":null,"pdf_field":""},{"help":"Enter full postal address including street, city and pin code","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"Enter postal pin code","type":"number","label":"Pin Code","options":[],"required":null,"pdf_field":""},{"help":"Enter phone number including STD code","type":"phone","label":"Phone No","options":[],"required":null,"pdf_field":""},{"help":"Enter complete email address","type":"email","label":"Email ID","options":[],"required":null,"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","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Use dd-mm-yy format","type":"date","label":"Date of commencement of first Insurance without break","options":[],"required":null,"pdf_field":""},{"help":"Enter full name of the insurance company","type":"text","label":"If yes, company name","options":[],"required":null,"pdf_field":""},{"help":"Enter policy number as allotted by the insurance company","type":"text","label":"Policy No.","options":[],"required":null,"pdf_field":""},{"help":"Enter total sum insured in rupees","type":"amount","label":"Sum insured (Rs.)","options":[],"required":null,"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","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Use mm-yy format","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Enter diagnosis details","type":"text","label":"Diagnosis","options":[],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"Previously covered by any other Mediclaim /Health insurance","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter full name of the insurance company","type":"text","label":"If yes, company name","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 Male or Female","type":"choice","label":"Gender","options":["Male","Female"],"required":null,"pdf_field":""},{"help":"Enter age in years","type":"number","label":"Age years","options":[],"required":null,"pdf_field":""},{"help":"Enter age in months","type":"number","label":"Months","options":[],"required":null,"pdf_field":""},{"help":"Use dd-mm-yyyy 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","options":["Self","Spouse","Child","Father","Mother","Other (Please Specify)"],"required":null,"pdf_field":""},{"help":"Tick the appropriate option; specify if Other","type":"choice","label":"Occupation","options":["Service","Self Employed","Home Maker","Student","Retired","Other (Please Specify)"],"required":null,"pdf_field":""},{"help":"Enter phone number including STD code","type":"phone","label":"Phone No","options":[],"required":null,"pdf_field":""},{"help":"Enter complete email address","type":"email","label":"Email ID","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"DETAILS OF HOSPITALIZATION","fields":[{"help":"Enter full name of hospital","type":"text","label":"Name of Hospital where Admited","options":[],"required":null,"pdf_field":""},{"help":"Tick the appropriate room category","type":"choice","label":"Room Category occupied","options":["Day care","Single occupancy","Twin sharing","3 or more beds per room"],"required":null,"pdf_field":""},{"help":"Tick the reason for hospitalization","type":"choice","label":"Hospitalization due to","options":["Injury","Illness","Maternity"],"required":null,"pdf_field":""},{"help":"Use dd-mm-yy format","type":"date","label":"Date of injury / Date Disease first detected /Date of Delivery","options":[],"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 the cause of injury","type":"choice","label":"If injury give cause","options":["Self inflicted","Road Traffic Accident","Substance Abuse / Alcohol Consumption"],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"If Medico legal","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"Reported to Police","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"MLC Report & Police FIR attached","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter the system of medicine followed in treatment","type":"text","label":"System of Medicine","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"DETAILS OF CLAIM","fields":[{"help":"Enter amount claimed in rupees (no paise)","type":"amount","label":"Pre -hospitalization expenses","options":[],"required":null,"pdf_field":""},{"help":"Enter amount claimed in rupees (no paise)","type":"amount","label":"Hospitalization expenses","options":[],"required":null,"pdf_field":""},{"help":"Enter amount claimed in rupees (no paise)","type":"amount","label":"Post-hospitalization expenses","options":[],"required":null,"pdf_field":""},{"help":"Enter amount claimed in rupees (no paise)","type":"amount","label":"Health-Check up cost","options":[],"required":null,"pdf_field":""},{"help":"Enter amount claimed in rupees (no paise)","type":"amount","label":"Ambulance Charges","options":[],"required":null,"pdf_field":""},{"help":"Specify other expenses with code","type":"text","label":"Others (code)","options":[],"required":null,"pdf_field":""},{"help":"Total amount claimed in rupees","type":"amount","label":"Total","options":[],"required":null,"pdf_field":""},{"help":"Enter number of days for pre-hospitalization period","type":"number","label":"Pre -hospitalization period (days)","options":[],"required":null,"pdf_field":""},{"help":"Enter number of days for post-hospitalization period","type":"number","label":"Post -hospitalization period (days)","options":[],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"Claim for Domiciliary Hospitalization","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter amounts claimed for Hospital Daily cash, Surgical Cash, Critical Illness benefit, Convalescence, Pre/Post hospitalization Lump sum benefit, Others","type":"table","label":"Details of Lump sum / cash benefit claimed","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"DETAILS OF PRIMARY INSURED’S BANK ACCOUNT","fields":[{"help":"Enter Permanent Account Number as allotted by Income Tax Department","type":"text","label":"PAN","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 for cheque or demand draft","type":"text","label":"Cheque / DD Payable details","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"}],"deadlines":[],"applies_to":"Health insurance policies other than travel and personal accident","attachments":["Copy of the claim intimation, if any","Hospital Main Bill","Hospital Break-up Bill","Hospital Bill Payment Receipt","Hospital Discharge Summary","Pharmacy Bill","Operation Theater Notes","ECG","Doctor’s request for investigation","Investigation Reports (Including CT / MRI / USG / HPE)","Doctor’s Prescriptions","Others","KYC documents if claim amount is Rs 1 Lakh or more: Duly filled KYC form, Copy of Address proof, Copy of PAN card"],"declarations":["The information furnished in the claim form is true and correct to the best of my knowledge and belief.","False or untrue statements, suppression or concealment of material facts will forfeit the right to claim reimbursement.","Consent and authorize TPA/Insurance Company to seek necessary medical information from hospitals or medical practitioners.","All bills and receipts for the claim are included and no supplementary claim will be made except pre/post-hospitalization claims if any."],"dropped_labels":3},"pdf_fields":null,"fillable_pdf":false,"send_to":[{"purpose":"claim","channel":"email","value":"GCIcare@generalicentral.com","label":"Claim Intimation Email","level":null,"hours":null,"applies_to":"all","source_url":"https://www.generalicentralinsurance.com/motor-insurance/motor-claim-process","quote":"ses.\nCLAIM FORM\nYou can\nclick here\nand check our claim form\nCALL ON\n1800 220233\n1860 500 3333\n022 6783 7800\nEMAIL US AT\nGCIcare@generalicentral.com\nVISIT OUR BRANCH\nYou can check for your nearest branch\nhere\nClaim Process Simplified\nSimple steps to help you file a cl","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"email","value":"GCIClaims@generalicentral.com","label":"Other Claim Intimation Email","level":null,"hours":null,"applies_to":"all","source_url":"https://www.generalicentralinsurance.com/other-claim-process","quote":"NLINE CLAIM INTIMATION\nYou can\nclick here\nto intimate claim\nCALL ON\n1800 220233\n1860 500 3333\n022 6783 7800\nEMAIL US AT\nGCIClaims@generalicentral.com\nVISIT OUR BRANCH\nYou can check for your nearest branch\nhere\nInitiate Quick Claim\nExtended Warranty\nMarine & Others\nProd","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"1800 220 233","label":"Claim Intimation Phone","level":null,"hours":null,"applies_to":"all","source_url":"https://www.generalicentralinsurance.com/motor-insurance/motor-claim-process","quote":"aim under your insurance policy.\nCashless Claim Process\nReimbursement Claim Process\n1\nIntimate us online or  Call us on 1800 220 233\n2\nSurveyor will inspect the vehicle.\n3\nProvide requested documents to surveyor\n4\nApproved claim amount will be communic","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"1860 500 3333","label":"Claim Intimation Phone","level":null,"hours":null,"applies_to":"all","source_url":"https://www.generalicentralinsurance.com/motor-insurance/motor-claim-process","quote":"Motor Claim Process | Generali Central\nGrievance Redressal\nQuick Pay\nNeed Analysis\n1860 500 3333\n|\n022 6783 7800\n1860 500 3333\n022 6783 7800\nProducts\nRenew\nClaim\nHelp & Support\nAbout Us\nTrending Searches\nHealth Insur","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"022 6783 7800","label":"Claim Intimation Phone","level":null,"hours":null,"applies_to":"all","source_url":"https://www.generalicentralinsurance.com/motor-insurance/motor-claim-process","quote":"Motor Claim Process | Generali Central\nGrievance Redressal\nQuick Pay\nNeed Analysis\n1860 500 3333\n|\n022 6783 7800\n1860 500 3333\n022 6783 7800\nProducts\nRenew\nClaim\nHelp & Support\nAbout Us\nTrending Searches\nHealth Insurance\nDog Insuran","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/generali-central-insurance/361-claim-form-for-health-insurance-policies-other-than-travel-and-personal-accident"}