{"id":47,"title":"CLAIM FORM FOR HEALTH INSURANCE POLICIES OTHER THAN TRAVEL AND PERSONAL ACCIDENT - PART A","purpose":"claim","insurer":{"slug":"bajaj-general-insurance","name":"Bajaj General Insurance Limited"},"source_pdf":"https://www.bajajgeneralinsurance.com/download-documents/health-insurance/Digital-Reimbursement-claim-Form.pdf","sha256":"0dc3c1854ea72c9c81d325da354421cb4bffdd2f1a82a5745dc198d7c16f9583","pages":6,"collected":"2026-10-17","instructions":{"about":"This form is for submitting a health insurance claim by the insured person for policies other than travel and personal accident. The insured person fills Part A, and the hospital fills Part B.","notes":["To be filled in block letters","Issue of form is not admission of liability","Use dd-mm-yy format for dates","Use hh:mm format for times","Include STD code with phone numbers","Attach original preauthorization request form with Part A","Hospital to fill Part B","Use original bills only","Tick appropriate options carefully"],"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":"Policy no"},{"help":"Enter the social insurance number or certificate number","type":"text","label":"SI. No/Certificate No","options":[],"required":null,"pdf_field":"Certificat no"},{"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":"TEXT 1"},{"help":"","type":"text","label":"Customer ID","options":[],"required":null,"pdf_field":"TEXT 2"},{"help":"Enter the full name of the company","type":"text","label":"Company Name","options":[],"required":null,"pdf_field":"TEXT 3"},{"help":"","type":"text","label":"Employee No","options":[],"required":null,"pdf_field":"TEXT 4"},{"help":"Enter full name of the policyholder (Surname, First name, Middle name)","type":"text","label":"Name","options":[],"required":null,"pdf_field":"TEXT 5"},{"help":"Enter full postal address including street, city and pin code","type":"text","label":"Address","options":[],"required":null,"pdf_field":"TEXT 6"},{"help":"","type":"text","label":"City","options":[],"required":null,"pdf_field":"TEXT 7"},{"help":"","type":"text","label":"State","options":[],"required":null,"pdf_field":"TEXT 8"},{"help":"","type":"number","label":"Pin Code","options":[],"required":null,"pdf_field":"TEXT 9"},{"help":"Include STD code with telephone number","type":"phone","label":"Phone No","options":[],"required":null,"pdf_field":"TEXT 10"},{"help":"Enter complete email address","type":"email","label":"Email ID","options":[],"required":null,"pdf_field":"TEXT 11"}],"filled_by":"insured"},{"title":"Details of Insurance History","fields":[{"help":"Tick Yes or No","type":"choice","label":"Currently covered by any other Mediclaim / Health Insurance","options":["Yes","No"],"required":null,"pdf_field":"Group1"},{"help":"Use dd-mm-yy format","type":"date","label":"Date of commencement of first insurance without break","options":[],"required":null,"pdf_field":"TEXT 12"},{"help":"Enter full name of the insurance company","type":"text","label":"If yes, company name","options":[],"required":null,"pdf_field":"TEXT 13"},{"help":"Enter policy number","type":"text","label":"Policy No","options":[],"required":null,"pdf_field":"TEXT 14"},{"help":"Enter total sum insured as per the policy in rupees","type":"amount","label":"Sum Insured (Rs.)","options":[],"required":null,"pdf_field":"TEXT 15"},{"help":"Tick Yes or No","type":"choice","label":"Have you been hospitalized in the last four years since inception of the contract?","options":["Yes","No"],"required":null,"pdf_field":"Group 2"},{"help":"Use dd-mm-yy format","type":"date","label":"Date","options":[],"required":null,"pdf_field":"TEXT 16"},{"help":"Enter diagnosis details","type":"text","label":"Diagnosis","options":[],"required":null,"pdf_field":"TEXT 17"},{"help":"Tick Yes or No","type":"choice","label":"Previously covered by any other Mediclaim / Health Insurance","options":["Yes","No"],"required":null,"pdf_field":"Group 3"},{"help":"Enter full name of the insurance company","type":"text","label":"If yes, Company Name","options":[],"required":null,"pdf_field":"TEXT 18"}],"filled_by":"insured"},{"title":"Details of Insured Person Hospitalized","fields":[{"help":"Enter full name of the patient","type":"text","label":"Name of the Patient","options":[],"required":null,"pdf_field":"TEXT 19"},{"help":"","type":"text","label":"Health ID card no of the Patient","options":[],"required":null,"pdf_field":"TEXT 20"},{"help":"Tick the appropriate option","type":"choice","label":"Gender","options":["Male","Female","Transgender","Others"],"required":null,"pdf_field":"Group 4"},{"help":"Enter age in years and months","type":"number","label":"Age","options":[],"required":null,"pdf_field":"TEXT 21"},{"help":"Use dd-mm-yy format","type":"date","label":"Date of Birth","options":[],"required":null,"pdf_field":"TEXT 22"},{"help":"Tick the appropriate option or specify if Other","type":"choice","label":"Relationship of Primary insured","options":["Self","Spouse","Child","Father","Mother","Other (Please Specify)"],"required":null,"pdf_field":"Group 5"},{"help":"Tick the appropriate option or specify if Other","type":"choice","label":"Occupation","options":["Service","Self Employed","Homemaker","Student","Retired","Other (Please Specify)"],"required":null,"pdf_field":"Group 6"},{"help":"Enter full postal address including street, city and pin code","type":"text","label":"Address (if different from above)","options":[],"required":null,"pdf_field":"TEXT 23"},{"help":"","type":"text","label":"City","options":[],"required":null,"pdf_field":"TEXT 24"},{"help":"","type":"text","label":"State","options":[],"required":null,"pdf_field":"TEXT 25"},{"help":"","type":"number","label":"Pin Code","options":[],"required":null,"pdf_field":"TEXT 26"},{"help":"Include STD code with telephone number","type":"phone","label":"Phone No","options":[],"required":null,"pdf_field":"TEXT 27"},{"help":"Enter complete email address","type":"email","label":"Email ID","options":[],"required":null,"pdf_field":"TEXT 28"}],"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":"TEXT 29"},{"help":"Tick the appropriate option","type":"choice","label":"Room Category occupied","options":["Day Care","Single occupancy","Twin sharing","3 or more beds per room"],"required":null,"pdf_field":"Group 7"},{"help":"Tick the appropriate option","type":"choice","label":"Hospitalisation due to","options":["Injury","Illness","Maternity"],"required":null,"pdf_field":"Group 8"},{"help":"Use dd-mm-yy format","type":"date","label":"Date of Injury/Date Disease first detected/Date of Delivery","options":[],"required":null,"pdf_field":"TEXT 30"},{"help":"Use dd-mm-yy format","type":"date","label":"Date of admission","options":[],"required":null,"pdf_field":"TEXT 31"},{"help":"Use hh:mm format","type":"text","label":"Time of admission","options":[],"required":null,"pdf_field":"TEXT 32"},{"help":"Use dd-mm-yy format","type":"date","label":"Date of Discharge","options":[],"required":null,"pdf_field":"TEXT 33"},{"help":"Use hh:mm format","type":"text","label":"Time of Discharge","options":[],"required":null,"pdf_field":"TEXT 34"},{"help":"Enter full name of treating doctor","type":"text","label":"Name of treating doctor","options":[],"required":null,"pdf_field":"TEXT 35"},{"help":"Enter diagnosis details","type":"text","label":"Diagnosis","options":[],"required":null,"pdf_field":"TEXT 36"},{"help":"Tick the appropriate option","type":"choice","label":"If injury give cause","options":["Self inflicted","Road Traffic Accident","Substance Abuse /Alcohol Consumption"],"required":null,"pdf_field":"Group 9"},{"help":"Tick Yes or No","type":"choice","label":"If Medico legal","options":["Yes","No"],"required":null,"pdf_field":"Group 10"},{"help":"Tick Yes or No","type":"choice","label":"Reported to police","options":["Yes","No"],"required":null,"pdf_field":"Group 11"},{"help":"Tick Yes or No","type":"choice","label":"MLC report and Police FIR attached","options":["Yes","No"],"required":null,"pdf_field":"Group 12"},{"help":"Enter the system of medicine followed in treating the patient","type":"text","label":"System of Medicine","options":[],"required":null,"pdf_field":"TEXT 37"}],"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":"TEXT 39"},{"help":"Enter place","type":"text","label":"Place","options":[],"required":true,"pdf_field":"TEXT 40"},{"help":"Sign the form","type":"signature","label":"Signature of the Insured","options":[],"required":true,"pdf_field":"TEXT 41"}],"filled_by":"insured"},{"title":"Details of Hospital (Part B)","fields":[{"help":"Enter full name of hospital","type":"text","label":"Name of the hospital","options":[],"required":null,"pdf_field":"TEXT 42"},{"help":"Enter hospital ID as allocated by TPA","type":"text","label":"Hospital ID","options":[],"required":null,"pdf_field":"TEXT 43"},{"help":"Tick the appropriate option","type":"choice","label":"Type of hospital","options":["Network","Non-Network"],"required":null,"pdf_field":"Group 13"},{"help":"Enter full name of treating doctor","type":"text","label":"Name of treating doctor","options":[],"required":null,"pdf_field":"TEXT 44"},{"help":"Enter abbreviations of educational qualifications","type":"text","label":"Qualification","options":[],"required":null,"pdf_field":"TEXT 45"},{"help":"Enter registration number with state code as allocated by medical council","type":"text","label":"Registration No with State Code","options":[],"required":null,"pdf_field":"TEXT 46"},{"help":"Include STD code with telephone number","type":"phone","label":"Phone No","options":[],"required":null,"pdf_field":"TEXT 47"},{"help":"","type":"text","label":"Rohini Code","options":[],"required":null,"pdf_field":"TEXT 48"},{"help":"","type":"text","label":"NABH CODE","options":[],"required":null,"pdf_field":"TEXT 49"},{"help":"","type":"text","label":"State Level Certificate","options":[],"required":null,"pdf_field":"TEXT 50"},{"help":"","type":"text","label":"Higher Level Certificate","options":[],"required":null,"pdf_field":"TEXT 51"},{"help":"","type":"text","label":"National Quality Assurance Standards","options":[],"required":null,"pdf_field":"TEXT 52"},{"help":"","type":"text","label":"National Health System Resource Center","options":[],"required":null,"pdf_field":"TEXT 53"}],"filled_by":"hospital"},{"title":"Details of the Patient Admitted (Part B)","fields":[{"help":"Enter full name of patient","type":"text","label":"Name of the patient","options":[],"required":null,"pdf_field":"TEXT 54"},{"help":"Enter insurance provider registration number","type":"text","label":"IP registration Number","options":[],"required":null,"pdf_field":"TEXT 55"},{"help":"Tick the appropriate option","type":"choice","label":"Gender","options":["Male","Female"],"required":null,"pdf_field":"Group 14"},{"help":"Enter age in years and months","type":"number","label":"Age","options":[],"required":null,"pdf_field":"TEXT 56"},{"help":"Use dd-mm-yy format","type":"date","label":"Date of birth","options":[],"required":null,"pdf_field":"TEXT 57"},{"help":"Use dd-mm-yy format","type":"date","label":"Date of admission","options":[],"required":null,"pdf_field":"TEXT 58"},{"help":"Use hh:mm format","type":"text","label":"Time of admission","options":[],"required":null,"pdf_field":"TEXT 59"},{"help":"Use dd-mm-yy format","type":"date","label":"Date of discharge","options":[],"required":null,"pdf_field":"TEXT 60"},{"help":"Use hh:mm format","type":"text","label":"Time of discharge","options":[],"required":null,"pdf_field":"TEXT 61"},{"help":"Tick the appropriate option","type":"choice","label":"Type of Admission","options":["Emergency","Planned","Day Care","Maternity"],"required":null,"pdf_field":"Group 15"},{"help":"Enter gravida status if maternity","type":"text","label":"Gravida Status","options":[],"required":null,"pdf_field":"TEXT 63"},{"help":"Tick the appropriate option","type":"choice","label":"Status at time of discharge","options":["Discharge to home","Discharge to another hospital","Deceased"],"required":null,"pdf_field":"Group 16"},{"help":"Enter total claimed amount in rupees (no paise)","type":"amount","label":"Total claimed Amount","options":[],"required":null,"pdf_field":"TEXT 64"}],"filled_by":"hospital"},{"title":"Details of Ailment Diagnosed (Primary) (Part B)","fields":[{"help":"Enter ICD 10 PCS and description of first procedure","type":"text","label":"ICD 10 PCS - Procedure 1","options":[],"required":null,"pdf_field":"TEXT 68"},{"help":"Enter details of the procedure","type":"text","label":"Details of Procedure","options":[],"required":null,"pdf_field":"TEXT 71"},{"help":"Tick Yes or No","type":"choice","label":"Pre-Authorization Obtained","options":["Yes","No"],"required":null,"pdf_field":"Group 17"},{"help":"Enter pre-authorization number as allotted by TPA","type":"text","label":"Pre-Authorization Number","options":[],"required":null,"pdf_field":"TEXT 72.0"},{"help":"Tick Yes or No","type":"choice","label":"Hospitalization due to injury","options":["Yes","No"],"required":null,"pdf_field":"Group 18"},{"help":"Tick Yes or No and attach reports if Yes","type":"choice","label":"If injury due to Substance abuse/alcohol consumption, Test conducted to establish this","options":["Yes","No"],"required":null,"pdf_field":"Group 20"},{"help":"Tick Yes or No","type":"choice","label":"Medico Legal","options":["Yes","No"],"required":null,"pdf_field":"Group 21"},{"help":"Tick Yes or No","type":"choice","label":"Reported to Police","options":["Yes","No"],"required":null,"pdf_field":"Group 22"},{"help":"Enter FIR number if applicable","type":"text","label":"FIR no","options":[],"required":null,"pdf_field":"TEXT 74.0.0"},{"help":"Enter reason","type":"text","label":"If not reported to police give reason","options":[],"required":null,"pdf_field":"TEXT 75.0"}],"filled_by":"hospital"},{"title":"Claim Documents - Check List (Part B)","fields":[{"help":"","type":"checkbox","label":"Claim form duly signed","options":[],"required":null,"pdf_field":""},{"help":"","type":"checkbox","label":"Original Pre-Authorization request","options":[],"required":null,"pdf_field":""},{"help":"","type":"checkbox","label":"Copy of Pre-Authorization letter","options":[],"required":null,"pdf_field":""},{"help":"","type":"checkbox","label":"Copy of photo ID card of patient verified by hospital","options":[],"required":null,"pdf_field":""},{"help":"","type":"checkbox","label":"Hospital discharge summary","options":[],"required":null,"pdf_field":""},{"help":"","type":"checkbox","label":"Operation theatre notes","options":[],"required":null,"pdf_field":""},{"help":"","type":"checkbox","label":"Hospital main bill","options":[],"required":null,"pdf_field":""},{"help":"","type":"checkbox","label":"Hospital break up bill","options":[],"required":null,"pdf_field":""},{"help":"","type":"checkbox","label":"Doctor's reference slip for investigation","options":[],"required":null,"pdf_field":""},{"help":"","type":"checkbox","label":"ECG","options":[],"required":null,"pdf_field":""},{"help":"","type":"checkbox","label":"Pharmacy bills","options":[],"required":null,"pdf_field":""},{"help":"","type":"checkbox","label":"MLC report & Police FIR","options":[],"required":null,"pdf_field":""},{"help":"","type":"checkbox","label":"Original death summary from hospital where applicable","options":[],"required":null,"pdf_field":""},{"help":"Specify any other documents submitted","type":"text","label":"Any other, please specify","options":[],"required":false,"pdf_field":"TEXT 75.1"}],"filled_by":"hospital"},{"title":"Additional Details in Case of Non Network Hospital (Part B)","fields":[{"help":"Enter full postal address including street, city and pin code","type":"text","label":"Address of hospital","options":[],"required":null,"pdf_field":"TEXT 75.2"},{"help":"","type":"text","label":"City","options":[],"required":null,"pdf_field":"TEXT 75.3"},{"help":"","type":"text","label":"State","options":[],"required":null,"pdf_field":"TEXT 75.4"},{"help":"","type":"number","label":"Pin Code","options":[],"required":null,"pdf_field":"TEXT 75.5"},{"help":"Include STD code with telephone number","type":"phone","label":"Phone No","options":[],"required":null,"pdf_field":"TEXT 75.6"},{"help":"Enter registration number with state code as allocated by Medical Council of India","type":"text","label":"Registration no with State Code","options":[],"required":null,"pdf_field":"TEXT 75.7"},{"help":"Enter permanent account number allotted by Income Tax department","type":"text","label":"Hospital PAN","options":[],"required":null,"pdf_field":"TEXT 75.8"},{"help":"Enter number of inpatient beds","type":"number","label":"Number of Inpatient beds","options":[],"required":null,"pdf_field":"TEXT 75.9"},{"help":"Tick the appropriate options and specify if Others","type":"choice","label":"Facilities available in hospital","options":["OT","ICU","Others (please specify)"],"required":null,"pdf_field":"Group 23"}],"filled_by":"hospital"},{"title":"Declaration by the Hospital","fields":[{"help":"Enter date in dd:mm:yy format","type":"date","label":"Date","options":[],"required":true,"pdf_field":"TEXT 76"},{"help":"Enter place","type":"text","label":"Place","options":[],"required":true,"pdf_field":"TEXT 77"},{"help":"Sign and stamp the form","type":"signature","label":"Signature and Seal of the Hospital Authority","options":[],"required":true,"pdf_field":"TEXT 78"}],"filled_by":"hospital"}],"deadlines":[],"applies_to":"Health insurance policies other than travel and personal accident","attachments":["Original preauthorization request form","Pre-Authorization letter copy","Photo ID card of patient verified by hospital","Hospital discharge summary","Operation theatre notes","Hospital main bill","Hospital break up bill","Investigation reports (CT/MR/USG/HPE)","Doctor's reference slip for investigation","ECG","Pharmacy bills","MLC report & Police FIR","Original death summary from hospital where applicable","Any other documents as specified"],"declarations":["Consent to verify and obtain identity/address proof through Central KYC Registry or other portals for KYC verification","Declaration that information furnished is true and correct to the best of knowledge and belief","If false statement or concealment of material fact, right to claim shall be forfeited"],"dropped_labels":10},"pdf_fields":[{"name":"Policy no","page":1,"type":"text","label":"e) Company Name"},{"name":"Certificat no","page":1,"type":"text","label":"e) Company 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