{"id":583,"title":"HEALTH INFINITY INSURANCE – PART B - CLAIM FORM","purpose":"claim","insurer":{"slug":"indusind-general-insurance","name":"IndusInd General Insurance Company Limited"},"source_pdf":"https://www.indusindinsurance.com/downloads/health-infinity-insurance-b","sha256":"b1f9cdab1d79d220bdaa9ea3fe0b25b5790eaa75031fc50d6940981f2c9ccc00","pages":6,"collected":"2026-10-17","instructions":{"about":"This form is for hospitals to fill in details related to a patient's hospitalization and treatment for submitting a health insurance claim under the Health Infinity Insurance policy.","notes":["Fill the form in BLOCK LETTERS.","Include original pre-authorization request form in lieu of PART A.","Use dd/mm/yyyy format for dates and hh:mm AM/PM for times.","Attach all relevant supporting documents as per the checklist.","If hospital is non-network, fill Section E.","Use abbreviations for doctor's qualifications.","Enter amounts in rupees without paise.","Politically Exposed Persons (PEPs) are defined as per PMLA Rules and AML/CFT Guidelines.","Hospital to sign and stamp the declaration in Section F.","Use the contact details provided for submission or queries."],"title":"HEALTH INFINITY INSURANCE – PART B - CLAIM FORM","submit":{"to":"Health Care Unit: IndusInd General Insurance, No.1-89/3/B/40 to 42/ks/301, 3rd floor, Krishe Block, Krishe Sapphire, Madhapur, Hyderabad - 500081. Email: healthcare@indusindinsurance.com","how":"","address":"No.1-89/3/B/40 to 42/ks/301, 3rd floor, Krishe Block, Krishe Sapphire, Madhapur, Hyderabad - 500081"},"purpose":"claim","sections":[{"title":"SECTION A - DETAILS OF HOSPITAL","fields":[{"help":"Enter the full name of the hospital","type":"text","label":"Name of Hospital","options":[],"required":null,"pdf_field":""},{"help":"Enter the hospital ID as allocated by the TPA","type":"text","label":"Hospital ID","options":[],"required":null,"pdf_field":""},{"help":"Tick the appropriate option","type":"choice","label":"Type of Hospital","options":["Network","Non Network","(If non network, fill Section E)"],"required":null,"pdf_field":""},{"help":"Enter the full name of the treating doctor","type":"text","label":"Name of treating doctor","options":[],"required":null,"pdf_field":""},{"help":"Enter abbreviations of educational qualification","type":"text","label":"Qualification/ Specialization","options":[],"required":null,"pdf_field":""},{"help":"Enter registration number of the doctor with state code as allocated by Medical Council of India","type":"text","label":"Registration No. with State Code","options":[],"required":null,"pdf_field":""},{"help":"Include STD code with telephone number","type":"phone","label":"Phone No.","options":[],"required":null,"pdf_field":""}],"filled_by":"hospital"},{"title":"SECTION B - DETAILS OF THE PATIENT ADMITTED","fields":[{"help":"Enter full name of the patient","type":"text","label":"Name of the Patient","options":[],"required":null,"pdf_field":""},{"help":"Enter insurance provider registration number allotted by the insurance provider","type":"text","label":"IP Registration Number.","options":[],"required":null,"pdf_field":""},{"help":"Tick the appropriate gender","type":"choice","label":"Gender","options":["Male","Female","Others ______________"],"required":null,"pdf_field":""},{"help":"Enter age in years and months","type":"number","label":"Age","options":[],"required":null,"pdf_field":""},{"help":"Use dd/mm/yyyy format","type":"date","label":"Date of Birth","options":[],"required":null,"pdf_field":""},{"help":"Use dd/mm/yyyy format","type":"date","label":"Date of Admission","options":[],"required":null,"pdf_field":""},{"help":"Enter time in hh/mm AM or PM format","type":"text","label":"Time","options":[],"required":null,"pdf_field":""},{"help":"Use dd/mm/yyyy format","type":"date","label":"Date of Discharge","options":[],"required":null,"pdf_field":""},{"help":"Enter time in hh/mm AM or PM format","type":"text","label":"Time","options":[],"required":null,"pdf_field":""},{"help":"Tick the appropriate option","type":"choice","label":"Type of Admission","options":["Emergency","Planned","Day Care","Maternity","Transfer from other Hosp"],"required":null,"pdf_field":""},{"help":"Enter date of delivery in dd/mm/yyyy format","type":"date","label":"If Maternity, (i) Date of Delivery","options":[],"required":null,"pdf_field":""},{"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":""},{"help":"Enter amount in rupees (do not enter paise)","type":"amount","label":"Total claimed amount","options":[],"required":null,"pdf_field":""}],"filled_by":"hospital"},{"title":"SECTION C - DETAILS OF AILMENT DIAGNOSED (PRIMARY)","fields":[{"help":"Enter details of the procedure","type":"text","label":"(iv) Details of Procedure","options":[],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"Pre-authorisation obtained","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter pre-authorization number allotted by TPA","type":"text","label":"Pre-authorisation Number","options":[],"required":null,"pdf_field":""},{"help":"Enter reason for not availing cashless facility","type":"text","label":"If this is a network hospital and cashless facility not availed, give reason","options":[],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"Hospitalisation due to injury","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Tick the appropriate cause","type":"choice","label":"If yes, give cause","options":["Self Inflicted","Road Traffic Accident","Substance Abuse/Alcohol Consumption"],"required":null,"pdf_field":""},{"help":"Tick Yes or No and 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":"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":"Enter FIR number as issued by police","type":"text","label":"FIR No.","options":[],"required":null,"pdf_field":""},{"help":"Enter reason for not reporting to police","type":"text","label":"If not reported to Police, give reason","options":[],"required":null,"pdf_field":""}],"filled_by":"hospital"},{"title":"SECTION D - CLAIM DOCUMENTS SUBMITTED – CHECKLIST","fields":[{"help":"","type":"yes-no","label":"Claim form Duly signed","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Original Pre-authorisation request","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Copy of Pre-authorisation approval letter","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Copy of photo ID card of patient verified by hospital","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Hospital Discharge Summary","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Operation Theatre /Anesthesia notes","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Hospital Main/Final Bill","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Hospital Break-up Bill","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Investigation Report","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"ECG/ CT / MRI / USG / HPE /Other investigation reports","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Doctor’s reference slip for investigation","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Previous Consultation Papers","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Pharmacy Bills","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"MLC Report & Police FIR","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Original death summary from hospital, where applicable","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Specify any other documents submitted","type":"text","label":"Any other, please specify","options":[],"required":null,"pdf_field":""}],"filled_by":"hospital"},{"title":"SECTION E - DETAILS IN CASE OF NON-NETWORK HOSPITAL","fields":[{"help":"Enter full postal address including city, pin code, and state","type":"text","label":"Address of the Hospital","options":[],"required":null,"pdf_field":""},{"help":"Enter name of contact person","type":"text","label":"Contact person Name","options":[],"required":null,"pdf_field":""},{"help":"Include STD code with telephone number","type":"phone","label":"Phone No.","options":[],"required":null,"pdf_field":""},{"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":""},{"help":"Enter hospital's Permanent Account Number","type":"text","label":"Hospital PAN","options":[],"required":null,"pdf_field":""},{"help":"Enter number of inpatient beds","type":"number","label":"Number of inpatient beds","options":[],"required":null,"pdf_field":""},{"help":"Tick the facilities available; specify if Others","type":"checkbox","label":"Facilities available in the hospital","options":["OT","ICU","Others"],"required":null,"pdf_field":""}],"filled_by":"hospital (only if non-network)"},{"title":"PEP DECLARATION","fields":[{"help":"Tick Yes or No","type":"yes-no","label":"Are you a Politically Exposed Person (PEP)?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter position held if PEP","type":"text","label":"If yes, please mention the position held","options":[],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"Is any of your close relation or family member a PEP?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter name, relation and position held","type":"text","label":"If yes, please mention the name and relation and the position held by such close relative/family member.","options":[],"required":null,"pdf_field":""},{"help":"Enter place of signing","type":"text","label":"Place","options":[],"required":null,"pdf_field":""},{"help":"Enter date of signing","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Sign here","type":"signature","label":"Signature of Proposer","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"GENERAL DECLARATION","fields":[{"help":"Enter place of signing","type":"text","label":"Place","options":[],"required":null,"pdf_field":""},{"help":"Enter date of signing","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Sign here","type":"signature","label":"Signature of Proposer","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"SECTION F - DECLARATION BY THE HOSPITAL","fields":[{"help":"Enter date of signing","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Enter place of signing","type":"text","label":"Place","options":[],"required":null,"pdf_field":""},{"help":"Sign and stamp here","type":"signature","label":"Signature & Seal of the Hospital Authority","options":[],"required":null,"pdf_field":""}],"filled_by":"hospital"}],"deadlines":[],"applies_to":"Health Infinity Insurance – Part B claims","attachments":["Original pre-authorization request form (in lieu of PART A)","Original Pre-authorisation request","Copy of Pre-authorisation approval letter","Copy of photo ID card of patient verified by hospital","Hospital Discharge Summary","Operation Theatre /Anesthesia notes","Hospital Main/Final Bill","Hospital Break-up Bill","Investigation Report","ECG/ CT / MRI / USG / HPE /Other investigation reports","Doctor’s reference slip for investigation","Previous Consultation Papers","Pharmacy Bills","MLC Report & Police FIR","Original death summary from hospital, where applicable","Any other documents as specified"],"declarations":["The information furnished in this Claim Form is true and correct to the best of knowledge and belief.","False or untrue statements, suppression or concealment of material facts will forfeit the right to claim.","Authorization is given to IGICL officials to verify hospitalization records for the patient.","If the proposer or close relatives become Politically Exposed Persons (PEP) in future, they will inform the insurer as mandated.","All premiums have been/will be paid from bonafide sources and not from proceeds of crime under PMLA.","The insurer has the right to call for documents to establish sources of funds.","The insurer may cancel the contract if found guilty under money laundering laws.","The insurer will verify KYC and PAN details and the proposer is responsible for any mismatch consequences."],"dropped_labels":8},"pdf_fields":null,"fillable_pdf":false,"send_to":[{"purpose":"claim","channel":"email","value":"services@indusindinsurance.com","label":"Health Insurance Claims Email","level":1,"hours":null,"applies_to":"health","source_url":"https://www.indusindinsurance.com/health-insurance-claims","quote":"nce Claim\nTravel Insurance Claim\nCommercial Insurance Claim\nSupport\nSign In\nSelf Help\nVideo Chat\nContact Us\nEmail us at\nservices@indusindinsurance.com\ngrievances@indusindinsurance.com\ncareers@indusindinsurance.com\nCall us at\n+91 22 48903009 (Paid Number)\n+91 22 65934185","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"email","value":"indusind@europ-assistance.in","label":"Travel Insurance Claims Email","level":null,"hours":null,"applies_to":"travel","source_url":"https://www.indusindinsurance.com/travel-insurance-claim","quote":"91-22-67347844\nInternational Travel (while in India):\n1800 209 5522\nWhatsApp:\n7400422200 for Inland Travel Claim\nEmail:\nindusind@europ-assistance.in\nMobile Application:\nIndusInd Insurance App\nWebsite:\nOnline Claim Intimation\nOffline Visit:\nLocate your nearest branch\nh","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"+91 22 48903009","label":"Car Insurance Claim Intimation","level":null,"hours":null,"applies_to":"motor","source_url":"https://www.indusindinsurance.com/car-insurance-claim","quote":"Us\nEmail us at\nservices@indusindinsurance.com\ngrievances@indusindinsurance.com\ncareers@indusindinsurance.com\nCall us at\n+91 22 48903009 (Paid Number)\n+91 22 65934185 (Senior Citizen)\n+91 7400422200 (WhatsApp)\n+91 22 48903051 (Become our Partner)\nVisit us:","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"022 65934189","label":"Motor Claims Helpline","level":null,"hours":null,"applies_to":"motor","source_url":"https://www.indusindinsurance.com/car-insurance-claim","quote":"ation.\nNeed Guidance on Car Coverage?\nTalk to Our Professional Advisors\nCall Us\nCall Us!!\nHealth -\n022 65934188\nMotor -\n022 65934189\nTravel -\n022 65934184\nSteps to Take After a Car ​Accident\nThe following steps can expedite the road accident insurance","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"022 65934188","label":"Health Claims Helpline","level":null,"hours":null,"applies_to":"health","source_url":"https://www.indusindinsurance.com/health-insurance-claims","quote":"your nearest location.\nExpert health advice you can trust\nGet in touch with our team today!\nCall Us\nCall Us!!\nHealth -\n022 65934188\nMotor -\n022 65934189\nTravel -\n022 65934184\nCommon Reasons for Health Insurance Claim Rejection\nIncomplete Documentation","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"022 65934184","label":"Travel Claims Helpline","level":null,"hours":null,"applies_to":"travel","source_url":"https://www.indusindinsurance.com/health-insurance-claims","quote":"e you can trust\nGet in touch with our team today!\nCall Us\nCall Us!!\nHealth -\n022 65934188\nMotor -\n022 65934189\nTravel -\n022 65934184\nCommon Reasons for Health Insurance Claim Rejection\nIncomplete Documentation\nYour claim gets rejected when you don't gi","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"+912248903009","label":"Inland Travel Helpline","level":null,"hours":null,"applies_to":"travel","source_url":"https://www.indusindinsurance.com/travel-insurance-claim","quote":"rds your registered bank account.\nHow to Contact Us For Travel Insurance Claim?\nContact Details\nInland Travel Helpline:\n+912248903009\nInternational Travel (while abroad):\n91-22-67347843/ 91-22-67347844\nInternational Travel (while in India):\n1800 209 552","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"91-22-67347843","label":"International Travel Helpline (abroad)","level":null,"hours":null,"applies_to":"travel","source_url":"https://www.indusindinsurance.com/travel-insurance-claim","quote":"For Travel Insurance Claim?\nContact Details\nInland Travel Helpline:\n+912248903009\nInternational Travel (while abroad):\n91-22-67347843/ 91-22-67347844\nInternational Travel (while in India):\n1800 209 5522\nWhatsApp:\n7400422200 for Inland Travel Claim\nEmail","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"1800 209 5522","label":"International Travel Helpline (in India)","level":null,"hours":null,"applies_to":"travel","source_url":"https://www.indusindinsurance.com/travel-insurance-claim","quote":"912248903009\nInternational Travel (while abroad):\n91-22-67347843/ 91-22-67347844\nInternational Travel (while in India):\n1800 209 5522\nWhatsApp:\n7400422200 for Inland Travel Claim\nEmail:\nindusind@europ-assistance.in\nMobile Application:\nIndusInd Insurance","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/indusind-general-insurance/583-health-infinity-insurance-part-b-claim-form"}