{"id":589,"title":"CLAIM FORM FOR HEALTH INSURANCE POLICIES OTHER THAN TRAVEL AND PERSONAL ACCIDENT – PART A","purpose":"claim","insurer":{"slug":"indusind-general-insurance","name":"IndusInd General Insurance Company Limited"},"source_pdf":"https://www.indusindinsurance.com/downloads/indusind-health-infinity-claim-form-a-new","sha256":"32a56f45c01b6ae6a984dffe70ca55a0b3088d6bad881db54d4f331fd81354f4","pages":5,"collected":"2026-10-17","instructions":{"about":"This form is used by the insured person to claim health insurance benefits under policies other than travel and personal accident. The insured fills this form to provide details about themselves, the insured person hospitalized, hospitalization, and claim details.","notes":["Fill the form in BLOCK LETTERS.","Use dd/mm/yyyy format for dates and hh:mm format for times.","Include STD code with telephone numbers.","Attach original bills and receipts as required.","Refer to the sales brochure, prospectus and policy wordings for complete details on benefits, coverage, terms & conditions and exclusions."],"title":"CLAIM FORM FOR HEALTH INSURANCE POLICIES OTHER THAN TRAVEL AND PERSONAL ACCIDENT – PART A","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"SECTION A: 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":["Mr.","Mrs.","Ms."],"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":"","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":"Include STD code with telephone number","type":"phone","label":"Phone Number:","options":[],"required":null,"pdf_field":""},{"help":"Enter complete e-mail address","type":"email","label":"Email ID","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"SECTION B: 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":"Tick Yes or No","type":"yes-no","label":"Claimed in other policy:","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Use dd/mm/yyyy format","type":"date","label":"Date of commencement of first Insurance without break:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Claim No and Insurance Company:","options":[],"required":false,"pdf_field":""},{"help":"Enter full name of the insurance company","type":"text","label":"If yes, company name:","options":[],"required":false,"pdf_field":""},{"help":"Enter policy number as allotted by the insurance company","type":"text","label":"Policy No.:","options":[],"required":false,"pdf_field":""},{"help":"Enter total sum insured in rupees","type":"amount","label":"Sum Insured (Rs.):","options":[],"required":false,"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 dd/mm/yyyy format","type":"date","label":"Date:","options":[],"required":false,"pdf_field":""},{"help":"Enter diagnosis details","type":"text","label":"Diagnosis:","options":[],"required":false,"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":false,"pdf_field":""}],"filled_by":"insured"},{"title":"SECTION C: DETAILS OF INSURED PERSON HOSPITALISED","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 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":"Enter odometer reading if applicable","type":"text","label":"Odometer reading on Accident Date:","options":[],"required":false,"pdf_field":""},{"help":"Tick the appropriate option or specify if Other","type":"choice","label":"Relationship with Primary Insured:","options":["Self","Spouse","Child","Father","Mother","Other (Please Specify)"],"required":null,"pdf_field":""},{"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":""},{"help":"Enter full postal address including City, State and Pin Code","type":"text","label":"Address (if different from above):","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"City:","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"State:","options":[],"required":false,"pdf_field":""},{"help":"","type":"number","label":"Pin Code:","options":[],"required":false,"pdf_field":""},{"help":"Include STD code with telephone number","type":"phone","label":"Phone Number:","options":[],"required":false,"pdf_field":""},{"help":"Enter complete e-mail address","type":"email","label":"Email ID","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"SECTION D: DETAILS OF HOSPITALISATION","fields":[{"help":"Enter full name of hospital","type":"text","label":"Name of Hospital where admitted:","options":[],"required":null,"pdf_field":""},{"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":""},{"help":"Tick the appropriate option","type":"choice","label":"Hospitalisation due to:","options":["Injury","Illness","Maternity"],"required":null,"pdf_field":""},{"help":"Use dd/mm/yyyy format","type":"date","label":"Date of injury / Date disease first detected / Date of delivery:","options":[],"required":null,"pdf_field":""},{"help":"Use dd/mm/yyyy 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/yyyy 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 appropriate option","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":"SECTION E: DETAILS OF CLAIM","fields":[{"help":"Enter amounts in rupees for: Pre-hospitalisation expenses, Hospitalisation expenses, Post-hospitalisation expenses, Health Check-up cost, Ambulance charges, Others (code and amount), Total, Pre-hospitalisation period, Post-hospitalisation period (days)","type":"table","label":"Details of the Treatment Expenses claimed:","options":[],"required":null,"pdf_field":""},{"help":"Tick Yes or No. If yes, provide details in annexure","type":"yes-no","label":"Claim for Domiciliary hospitalisation:","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter amounts in rupees for: Hospital daily cash, Surgical cash, Critical illness benefit, Convalescence, Pre/Post hospitalisation lump sum benefit, Others (code and amount), Total","type":"table","label":"Details of Lump Sum / cash benefit claimed:","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Claim Documents Submitted – Checklist","fields":[{"help":"Tick Yes or No","type":"yes-no","label":"Claim form Duly signed","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"Copy of the claim intimation, if any","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"Hospital Main bill","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"Hospital Break-up bill","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"Hospital Bill Payment Receipt","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"Hospital Discharge Summary","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"Operation Theatre Notes","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"Pharmacy bill","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"ECG","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"Doctor’s request for investigation","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"Investigation on reports (including CT/MRI/USG/HPE)","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"Doctor’s prescriptions","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Tick Yes or No and specify if Yes","type":"yes-no","label":"Others:","options":["Yes","No"],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"SECTION G: 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 to whom cheque/DD should be made payable","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"},{"title":"SECTION H: DECLARATION BY THE INSURED","fields":[{"help":"Enter place of signing","type":"text","label":"Place:","options":[],"required":true,"pdf_field":""},{"help":"Enter date in dd/mm/yyyy format","type":"date","label":"Date:","options":[],"required":true,"pdf_field":""},{"help":"Sign the form","type":"signature","label":"Signature of Insured","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"}],"deadlines":[],"applies_to":"Health insurance policies other than travel and personal accident","attachments":["Claim form Duly signed","Copy of the claim intimation, if any","Hospital Main bill","Hospital Break-up bill","Hospital Bill Payment Receipt","Hospital Discharge Summary","Operation Theatre Notes","Pharmacy bill","ECG","Doctor’s request for investigation","Investigation on reports (including CT/MRI/USG/HPE)","Doctor’s prescriptions","Others (if any)"],"declarations":["The information furnished in this claim form is true and correct to the best of the insured's 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.","The insured consents and authorizes TPA/insurance company to seek necessary medical information/documents from any hospital or medical practitioner who attended the person against whom this claim is made.","The insured declares that all bills/receipts for the claim are included and no supplementary claim will be made except for pre/post-hospitalization claims, if any."],"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/589-claim-form-for-health-insurance-policies-other-than-travel-and-personal-accident"}