{"id":53,"title":"CLAIM FORM FOR HOSPITALIZATION REIMBURSEMENT BENEFIT FOR AXIS MAX LIFE GROUP SMART HEALTH INSURANCE 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/Group%20Smart%20Health%20Insurance%20Claim%20Form.pdf","sha256":"8d4b2066a11e4e2fa739f11c2be376c9dc8f1ba6ffc158e153c63bacc84fcfc0","pages":5,"collected":"2026-10-17","instructions":{"about":"This form is for claiming hospitalization reimbursement benefits under the Axis Max Life Group Smart Health Insurance Plan. It is filled by the insured person and the hospital.","notes":["Fill the form in block letters.","Attach original bills and documents as listed in the checklist.","In case of medico legal injury, attach MLC report and FIR/DD Entry.","For claims exceeding Rs. 100,000, submit KYC documents as per IRDA norms.","Do not trust calls, SMSes or emails offering discounts; only pay premiums to the specified Axis Bank account.","Use the contact details and website provided for any queries or submission.","The form is divided into Part A (to be filled by insured) and Part B (to be filled by hospital).","Ensure all dates are entered in DDMMYYYY format and times in HH:MM format."],"title":"CLAIM FORM FOR HOSPITALIZATION REIMBURSEMENT BENEFIT FOR AXIS MAX LIFE GROUP SMART HEALTH INSURANCE PLAN","submit":{"to":"TPA office or email as given","how":"post / e-mail / upload","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":"Unique ID/Certificate of Insurance Number/Employee ID/Member Enrolment Number","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 (Surname, First name, Middle name)","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 the phone number","type":"phone","label":"Phone No .","options":[],"required":null,"pdf_field":""},{"help":"Enter the email address","type":"email","label":"E-mail ID","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Section B - Other Insurance History","fields":[{"help":"Enter the policy number of other insurance","type":"text","label":"Policy No.","options":[],"required":null,"pdf_field":""},{"help":"Enter the full name of the insurance company","type":"text","label":"Company Name","options":[],"required":null,"pdf_field":""},{"help":"Enter the total sum insured as per the policy","type":"amount","label":"Sum Assured","options":[],"required":null,"pdf_field":""},{"help":"Select the current status of the policy","type":"choice","label":"Status (Active/Lapsed/Applied/Matured)","options":["Active","Lapsed","Applied","Matured"],"required":null,"pdf_field":""},{"help":"Enter the claim status under other insurance","type":"text","label":"Claim Status","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Section C - Details of Insured Person Hospitalised","fields":[{"help":"Enter the full name of the patient","type":"text","label":"Name","options":[],"required":null,"pdf_field":""},{"help":"Select the gender of the patient","type":"choice","label":"Gender","options":["Male","Transgender","Female"],"required":null,"pdf_field":""},{"help":"Enter date of birth in DDMMYYYY format","type":"date","label":"Date of Birth","options":[],"required":null,"pdf_field":""},{"help":"Select the occupation of the patient","type":"choice","label":"Occupation","options":["Service","Retired","Self-employed","Homemaker","Student","Other"],"required":null,"pdf_field":""},{"help":"If occupation is Other, specify here","type":"text","label":"Please specify","options":[],"required":null,"pdf_field":""},{"help":"Enter full postal address if different from primary insured","type":"text","label":"Address (if different from above)","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 of patient","type":"phone","label":"Phone No .","options":[],"required":null,"pdf_field":""},{"help":"Enter email address of patient","type":"email","label":"E-mail ID","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Section D - Details of Hospitalization","fields":[{"help":"Enter the name of the hospital","type":"text","label":"Name of the Hospital where admitted","options":[],"required":null,"pdf_field":""},{"help":"Select the room category occupied","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","Investigation"],"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 of injury if applicable","type":"choice","label":"If injury, give cause","options":["Self-inflicted","Road traffic/other accident","Substance abuse/alcohol abuse"],"required":null,"pdf_field":""},{"help":"Indicate if injury is medico legal","type":"yes-no","label":"If Medico legal","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Indicate if injury was reported to police","type":"yes-no","label":"Reported to police","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Select system of medicine followed","type":"choice","label":"Type of Treatment","options":["Allopathy","Homeopathy","Others"],"required":null,"pdf_field":""},{"help":"Specify other system of medicine if selected","type":"text","label":"If Others, please specify","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Section E - 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 benefit","type":"amount","label":"Surgical benefit","options":[],"required":null,"pdf_field":""},{"help":"Enter amount claimed for critical illness benefit","type":"amount","label":"Critical illness benefit","options":[],"required":null,"pdf_field":""},{"help":"Tick all documents submitted with the claim","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)","In case of accident, copy of first Information Report"],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Section G - 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 of beneficiary for cheque/DD","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":"Section H - 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/Nominee","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 specialization","type":"text","label":"Specialization","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","Other"],"required":null,"pdf_field":""},{"help":"Enter age in years and months","type":"number","label":"Age","options":[],"required":null,"pdf_field":""},{"help":"Enter date of birth in DDMMYYYY format","type":"date","label":"Date of birth","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 type of admission","type":"choice","label":"Type of admission","options":["Planned","Day care"],"required":null,"pdf_field":""},{"help":"Enter gravida status if maternity","type":"text","label":"Gravida status","options":[],"required":null,"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":"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":null,"pdf_field":""},{"help":"Indicate if hospitalization is due to injury","type":"yes-no","label":"Hospitalization due to injury","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Select cause of injury if applicable","type":"choice","label":"If Yes, give cause","options":["Self-inflicted","Road traffic accident","Substance abuse/alcohol consumption"],"required":null,"pdf_field":""},{"help":"Indicate if test was 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":null,"pdf_field":""},{"help":"Indicate if injury is medico legal","type":"yes-no","label":"If Medico legal","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Indicate if injury was reported to police","type":"yes-no","label":"Reported to police","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter FIR number if applicable","type":"text","label":"FIR no.","options":[],"required":null,"pdf_field":""},{"help":"Explain reasons if not reported","type":"text","label":"If not reported to police give reasons","options":[],"required":null,"pdf_field":""},{"help":"Tick all documents submitted with the claim","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 in-patient beds","type":"number","label":"Number of in-patient beds","options":[],"required":null,"pdf_field":""}],"filled_by":"hospital"},{"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/Nominee","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"},{"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/Nominee","options":[],"required":true,"pdf_field":""}],"filled_by":"hospital"}],"deadlines":[],"applies_to":"Hospitalization reimbursement benefit claims under Axis Max Life Group Smart Health Insurance 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)","In case of accident, copy of first Information Report","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)","Treating doctor's certificate giving details of injuries (how, when and where injury sustained) (in Non Medico legal cases)","Legal identity documents (Passport/PAN card/voter's identity card/driving license/letter from recognized public authority or public servant verifying identity and residence)","Proof of residence (Telephone bill/bank account statement/letter from recognized public authority/electricity bill/ration card) if claim amount exceeds Rs. 100,000"],"declarations":["The information furnished in this claim form is true and correct to the best of my knowledge and belief.","If any false or untrue statement, suppression or concealment of any 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.","Voluntary consent is provided to use Aadhar to conduct identity check towards KYC compliance by Axis Max Life Insurance.","Hospital declares that information furnished is true and correct to the best of their knowledge and belief.","Hospital acknowledges that the insured's signature is taken after the claim form is fully filled by the hospital."],"dropped_labels":7},"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/53-claim-form-for-hospitalization-reimbursement-benefit-for-axis-max-life-group-sma"}