{"id":584,"title":"PRE-AUTHORIZATION HEALTH - CLAIM FORM","purpose":"claim","insurer":{"slug":"indusind-general-insurance","name":"IndusInd General Insurance Company Limited"},"source_pdf":"https://www.indusindinsurance.com/downloads/preauthorization-health-claim-form","sha256":"42ae050ea14964d94627beded6cb89f4e4dbcf0f672cd1f661f7c8950ec8ec0b","pages":5,"collected":"2026-10-17","instructions":{"about":"This form is used to request preauthorization for a health insurance claim and is filled by the insured, treating doctor, and hospital.","notes":["Fill all columns in block letters","Use unique number received by insured/member/beneficiary","Fax or email the completed form from hospital","Attach required documents as per claim amount","Discrepancies in hospital records may void authorization and claim","Inform insurer of any changes in diagnosis or treatment plan before discharge","Respond to queries promptly to avoid delays or denial","Authorization denial letter will be shared within 24 hours of complete info","Use original bills and documents as per policy terms"],"title":"PRE-AUTHORIZATION HEALTH - 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","how":"fax or e-mail","address":"Fax: 022 4890 3009 (paid), Email: healthcare@indusindinsurance.com"},"purpose":"claim","sections":[{"title":"PART 1 - INSURED DETAILS","fields":[{"help":"","type":"text","label":"Insured Name:","options":[],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"Mobile No.:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Policy No.:","options":[],"required":null,"pdf_field":""},{"help":"","type":"email","label":"E-mail Id:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"If Group Policy, Company Name:","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Employee id","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"PAN No.:","options":[],"required":null,"pdf_field":""},{"help":"","type":"choice","label":"Source of Funds:","options":["Business","Profession","Salary","Agricultural Income","Savings","Others"],"required":null,"pdf_field":""},{"help":"","type":"choice","label":"Monthly Income:","options":["Upto ` 20,000","` 20,001 to ` 50,000","` 50,001 to ` 1,00,000","` 1,00,001 and above"],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Agent/Sub Agent Name:","options":[],"required":false,"pdf_field":""},{"help":"","type":"phone","label":"Agent Mobile No.:","options":[],"required":false,"pdf_field":""},{"help":"","type":"email","label":"Agent Email ID:","options":[],"required":false,"pdf_field":""}],"filled_by":""},{"title":"PART 2 - PATIENT DETAILS","fields":[{"help":"","type":"text","label":"Patient Name:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Patient UHID:","options":[],"required":false,"pdf_field":""},{"help":"Enter age in years","type":"number","label":"Age:","options":[],"required":null,"pdf_field":""},{"help":"Format DD/MM/YYYY","type":"date","label":"DOB:","options":[],"required":null,"pdf_field":""},{"help":"","type":"choice","label":"Gender:","options":["Male","Female"],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"Patient Mobile No:","options":[],"required":false,"pdf_field":""},{"help":"","type":"email","label":"Patient Email id:","options":[],"required":false,"pdf_field":""},{"help":"","type":"choice","label":"Relation with insured:","options":["Self","Spouse","Mother","Father","Son","Daughter","Others___________________"],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Address:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"City:","options":[],"required":null,"pdf_field":""},{"help":"","type":"number","label":"Pin Code:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Attendant Name:","options":[],"required":false,"pdf_field":""},{"help":"","type":"phone","label":"Agent Mobile No.:","options":[],"required":false,"pdf_field":""},{"help":"","type":"email","label":"Agent Email ID:","options":[],"required":false,"pdf_field":""}],"filled_by":""},{"title":"PART 3 - SERVICE PROVIDER DETAILS","fields":[{"help":"","type":"text","label":"Hospital Name:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Hospital Code:","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Hospital Address:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"City:","options":[],"required":null,"pdf_field":""},{"help":"","type":"number","label":"Pin Code:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Contact Details (Hospital Employee)","options":[],"required":false,"pdf_field":""},{"help":"Prefix with Dr.","type":"text","label":"Treating Doctor Detail Name:","options":[],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"Telephone No./ Mobile No.:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Qualification:","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Claim No.:","options":[],"required":false,"pdf_field":""}],"filled_by":""},{"title":"PART 4 - CASE INFORMATION (FILLED BY TREATING DOCTOR)","fields":[{"help":"","type":"text","label":"Presenting Complaint:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Duration:","options":[],"required":false,"pdf_field":""},{"help":"Format DD/MM/YYYY","type":"date","label":"Date of first onset/Consult","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"H/O of past illness related to present complaint:","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Relevant Clinical findings:","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Investigation findings:","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Provisional Diagnosis:","options":[],"required":null,"pdf_field":""},{"help":"","type":"choice","label":"Treatment Plan:","options":["Medical","Surgical"],"required":null,"pdf_field":""},{"help":"Fill gravida, para, live births, abortions","type":"text","label":"In case of Maternity: Obstetric History: G ____ P____ L____ A ____","options":[],"required":false,"pdf_field":""},{"help":"Last Menstrual Period date","type":"date","label":"LMP:","options":[],"required":false,"pdf_field":""},{"help":"Expected Delivery Date","type":"date","label":"EDD.:","options":[],"required":false,"pdf_field":""},{"help":"Attach copy if applicable","type":"checkbox","label":"Attached Copy of:","options":["MLC","FIR","Pl"],"required":false,"pdf_field":""},{"help":"","type":"text","label":"MLC/FIR Number:","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Place:","options":[],"required":false,"pdf_field":""},{"help":"Mark Yes or No for each condition and provide duration/details","type":"table","label":"Past Medical History","options":["Condition","Yes/No","Duration/Details"],"required":false,"pdf_field":""}],"filled_by":"treating doctor"},{"title":"PART 5 - BILLING DETAILS (FILLED BY HOSPITAL)","fields":[{"help":"","type":"choice","label":"Room Type:","options":["Single AC","Single NON AC","Twin Sharing AC","Twin Sharing NON AC","Multi-bed","Others"],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Hospital Room Name.:","options":[],"required":false,"pdf_field":""},{"help":"","type":"choice","label":"Type of Admission:","options":["Planned","Emergency"],"required":null,"pdf_field":""},{"help":"Format DD/MM/YYYY","type":"date","label":"Expected DOA:","options":[],"required":null,"pdf_field":""},{"help":"Number of days","type":"number","label":"Length of Stay:","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Package Rate:","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"amount","label":"If Yes, Package Charges:","options":[],"required":false,"pdf_field":""},{"help":"","type":"amount","label":"Implant Charges:","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Remarks (if Any):","options":[],"required":false,"pdf_field":""},{"help":"Fill below charges","type":"text","label":"If Package not applicable,","options":[],"required":false,"pdf_field":""},{"help":"","type":"amount","label":"Room Rent + Nursing Charges","options":[],"required":false,"pdf_field":""},{"help":"","type":"amount","label":"Surgeon / Assistant Surgeon Charges","options":[],"required":false,"pdf_field":""},{"help":"","type":"amount","label":"Anesthesia / Anesthetist Charges","options":[],"required":false,"pdf_field":""},{"help":"","type":"amount","label":"Operation theatre Charges","options":[],"required":false,"pdf_field":""},{"help":"","type":"amount","label":"Doctor's Visit Charges","options":[],"required":false,"pdf_field":""},{"help":"","type":"amount","label":"Investigation Charges","options":[],"required":false,"pdf_field":""},{"help":"","type":"amount","label":"Pharmacy Charges","options":[],"required":false,"pdf_field":""},{"help":"","type":"amount","label":"Implant Cost (if any)","options":[],"required":false,"pdf_field":""},{"help":"","type":"amount","label":"Total Cost of Hospitalization","options":[],"required":null,"pdf_field":""}],"filled_by":"hospital"},{"title":"CONSENT AND SIGNATURES","fields":[{"help":"","type":"signature","label":"Patient Signature","options":[],"required":null,"pdf_field":""},{"help":"","type":"signature","label":"Treating Doctor's Signature","options":[],"required":null,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date:","options":[],"required":null,"pdf_field":""},{"help":"Hospital stamp","type":"attachment","label":"Stamp of Hospital","options":[],"required":null,"pdf_field":""}],"filled_by":"patient and treating doctor"},{"title":"PEP DECLARATION","fields":[{"help":"","type":"yes-no","label":"Are you a Politically Exposed Person (PEP)?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"text","label":"If yes, please mention the position held","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Is any of your close relation or family member a PEP?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"text","label":"If yes, please mention the name and relation and the position held by such close relative/family member.","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Place:","options":[],"required":false,"pdf_field":""},{"help":"","type":"date","label":"Date:","options":[],"required":false,"pdf_field":""},{"help":"","type":"signature","label":"Signature of Proposer","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer/insured"},{"title":"AML GUIDELINES DECLARATION","fields":[{"help":"","type":"text","label":"Place:","options":[],"required":false,"pdf_field":""},{"help":"","type":"date","label":"Date:","options":[],"required":false,"pdf_field":""},{"help":"","type":"signature","label":"Signature of Proposer","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer/insured"},{"title":"FINAL DECLARATION","fields":[{"help":"","type":"text","label":"Place:","options":[],"required":false,"pdf_field":""},{"help":"","type":"date","label":"Date:","options":[],"required":false,"pdf_field":""},{"help":"","type":"signature","label":"Signature of Claimant","options":[],"required":null,"pdf_field":""}],"filled_by":"claimant"}],"deadlines":["Completed Pre-authorization Request Form should reach at least 4 days prior to likely date of admission","In case of emergency admission, form should be sent within 4 hours of admission","Request for authorisation/enhancement will not be entertained after discharge of the patient","All queries raised need to be replied within 24 hours"],"applies_to":"","attachments":["Copy of MLC (Medico Legal Case) if applicable","Copy of FIR if applicable","Copy of Pl if applicable","PAN card/form 60 of the insured/Policy holder/Proposer if claimed amount above 1 lac","Photo identity proof (e.g. Aadhar card, Driving license, Election card, Passport etc) if claimed amount below 1 lac"],"declarations":["Cashless facility is not automatically guaranteed by IGICL and hospital visits and document collection are authorized","Information provided is accurate to the best knowledge and cost is payable if authorization becomes null due to incorrect info","If proposer or relatives become Politically Exposed Persons (PEP), they must inform the insurer","Premiums are paid from bonafide sources and insurer may verify source of funds","Insurance contract may be cancelled if found guilty under money laundering laws","Insurer will verify KYC and PAN details and proposer consents to issue policy with proposal form details despite mismatches","Statements in claim form are true and complete; false or withheld info voids policy and claim","Consent given to insurer to seek medical info from any hospital or medical practitioner"],"dropped_labels":1},"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/584-pre-authorization-health-claim-form"}