{"id":593,"title":"HEALTH INSURANCE POLICIES OTHER THAN TRAVEL AND PERSONAL ACCIDENT - 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-tpa-claim-form-b","sha256":"3d261d82325fa0b4f7074e46e09528f68307dfb522c0d90c77bc5dfabc58b4ca","pages":4,"collected":"2026-10-17","instructions":{"about":"This form is used by the insured to claim health insurance benefits for hospitalisation under health insurance policies other than travel and personal accident. The insured or hospital fills it.","notes":["Fill the form in BLOCK LETTERS.","Include the original preauthorization request form in lieu of PART A.","If hospital is non-network, fill SECTION E.","Attach original bills and relevant documents as per checklist.","Politically Exposed Persons (PEPs) are defined as per Prevention of Money Laundering Rules, 2005.","Signatures required from proposer and hospital authority.","Use the contact numbers or email for queries or submission."],"title":"HEALTH INSURANCE POLICIES OTHER THAN TRAVEL AND PERSONAL ACCIDENT - 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":"post / e-mail","address":"No.1-89/3/B/40 to 42/ks/301, 3rd floor, Krishe Block, Krishe Sapphire, Madhapur, Hyderabad - 500081; Email: healthcare@indusindinsurance.com"},"purpose":"claim","sections":[{"title":"SECTION A - DETAILS OF HOSPITAL","fields":[{"help":"","type":"text","label":"Name of the Hospital","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Hospital ID","options":[],"required":null,"pdf_field":""},{"help":"Select one","type":"choice","label":"Type of Hospital","options":["Network","Non Network (if non network fill section E)"],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Name of the treating doctor","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Qualification","options":[],"required":null,"pdf_field":""},{"help":"Doctor's registration number including state code","type":"text","label":"Registration No with state code","options":[],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"Phone No","options":[],"required":null,"pdf_field":""},{"help":"","type":"email","label":"Email Id:","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"SECTION B - DETAILS OF PATIENT ADMITTED","fields":[{"help":"","type":"text","label":"Name of the patient","options":[],"required":null,"pdf_field":""},{"help":"Inpatient registration number at hospital","type":"text","label":"IP Registration Number","options":[],"required":null,"pdf_field":""},{"help":"Select one","type":"choice","label":"Gender","options":["Male","Female"],"required":null,"pdf_field":""},{"help":"Enter years and months","type":"number","label":"Age","options":[],"required":null,"pdf_field":""},{"help":"DD/MM/YYYY","type":"date","label":"Date of birth","options":[],"required":null,"pdf_field":""},{"help":"DD/MM/YYYY","type":"date","label":"Date of Admission","options":[],"required":null,"pdf_field":""},{"help":"HH/MM AM/PM","type":"text","label":"Time","options":[],"required":null,"pdf_field":""},{"help":"DD/MM/YYYY","type":"date","label":"Date of Discharge","options":[],"required":null,"pdf_field":""},{"help":"HH/MM AM/PM","type":"text","label":"Time","options":[],"required":null,"pdf_field":""},{"help":"Select one","type":"choice","label":"Type of admission","options":["Emergency","Planned","Day care","Maternity"],"required":null,"pdf_field":""},{"help":"Select one","type":"choice","label":"Status at time of discharge","options":["Discharge to home","Discharge to another hospital","Deceased"],"required":null,"pdf_field":""},{"help":"Enter amount claimed in INR","type":"amount","label":"Total claimed amount","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"SECTION C - DETAILS OF AILMENT DIAGNOSED (PRIMARY) - PART B","fields":[{"help":"Describe the procedures performed","type":"text","label":"Details of procedure","options":[],"required":null,"pdf_field":""},{"help":"Select one","type":"choice","label":"Pre - authorization obtained","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Fill if pre-authorization obtained","type":"text","label":"Pre - authorization number","options":[],"required":false,"pdf_field":""},{"help":"Explain reason if no authorization from network hospital","type":"text","label":"If authorization by network hospital not obtained, give reason","options":[],"required":false,"pdf_field":""},{"help":"Select one","type":"choice","label":"Hospitalization due to injury","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Select cause if injury is yes","type":"choice","label":"If Yes, give cause","options":["Self inflicted","Road traffic accident","Substance abuse/alcohol consumption"],"required":false,"pdf_field":""},{"help":"Select if test was done; attach reports if yes","type":"choice","label":"If injury due to Substance abuse/alcohol consumption, Test conducted to establish this","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Select if case is medico legal","type":"choice","label":"If Medico Legal","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Select if reported to police","type":"choice","label":"Reported to police","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Fill FIR number if reported","type":"text","label":"FIR No","options":[],"required":false,"pdf_field":""},{"help":"Explain reason if not reported","type":"text","label":"If not reported to police, give reason","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"CLAIM DOCUMENTS SUBMITTED CHECK LIST","fields":[{"help":"","type":"checkbox","label":"Claim form duly signed","options":[],"required":null,"pdf_field":""},{"help":"Include original pre-authorization request form in lieu of Part A","type":"checkbox","label":"Original pre authorization request","options":[],"required":null,"pdf_field":""},{"help":"","type":"checkbox","label":"Copy of pre - authorization approval letter","options":[],"required":null,"pdf_field":""},{"help":"Attach copy of photo ID card verified by hospital","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":"Attach original hospital main bill","type":"checkbox","label":"Hospital main bill","options":[],"required":null,"pdf_field":""},{"help":"Attach hospital break up bill","type":"checkbox","label":"Hospital break up bill","options":[],"required":null,"pdf_field":""},{"help":"","type":"checkbox","label":"Investigation reports","options":[],"required":null,"pdf_field":""},{"help":"Attach relevant investigation reports","type":"checkbox","label":"CT/MRI/USG/HPE investigation reports","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":"Attach pharmacy bills","type":"checkbox","label":"Pharmacy bills","options":[],"required":null,"pdf_field":""},{"help":"Attach medico legal case report and police FIR if applicable","type":"checkbox","label":"MLC report & police FIR","options":[],"required":null,"pdf_field":""},{"help":"Attach original death summary if applicable","type":"checkbox","label":"Original death summary from hospital where applicable","options":[],"required":null,"pdf_field":""},{"help":"Specify any other documents attached","type":"text","label":"Any other, please specify","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"SECTION E - DETAILS IN CASE OF NON NETWORK HOSPITAL","fields":[{"help":"Include City, State, Pin Code","type":"text","label":"Address of the Hospital","options":[],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"Phone No","options":[],"required":null,"pdf_field":""},{"help":"Hospital registration number including state code","type":"text","label":"Registration No with state code","options":[],"required":null,"pdf_field":""},{"help":"Hospital PAN number","type":"text","label":"Hospital PAN","options":[],"required":null,"pdf_field":""},{"help":"Number of inpatient beds in hospital","type":"number","label":"Number of Inpatients bed","options":[],"required":null,"pdf_field":""},{"help":"Tick facilities available; specify others","type":"checkbox","label":"Facilities available in the hospital","options":["OT: Yes","OT: No","ICU: Yes","ICU: No","Others: specify"],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"PEP DECLARATION","fields":[{"help":"Select one","type":"choice","label":"Are you a Politically Exposed Person (PEP)?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Fill if answered yes above","type":"text","label":"If yes, please mention the position held","options":[],"required":false,"pdf_field":""},{"help":"Select one","type":"choice","label":"Is any of your close relation or family member a PEP?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Fill if answered yes above","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":"Location where form is signed","type":"text","label":"Place","options":[],"required":null,"pdf_field":""},{"help":"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":"insured"},{"title":"GENERAL DECLARATION","fields":[{"help":"Location where form is signed","type":"text","label":"Place","options":[],"required":null,"pdf_field":""},{"help":"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":"insured"},{"title":"SECTION F - DECLARATION BY THE HOSPITAL","fields":[{"help":"Date of signing","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Location where form is signed","type":"text","label":"Place","options":[],"required":null,"pdf_field":""},{"help":"Hospital authority to sign and seal","type":"signature","label":"Signature & Seal of Hospital Authority","options":[],"required":null,"pdf_field":""}],"filled_by":"hospital"}],"deadlines":[],"applies_to":"Health Insurance Policies Other Than Travel And Personal Accident - Part - B","attachments":["Original preauthorization request form","Copy of pre-authorization approval letter","Copy of photo ID card of patient verified by hospital","Hospital discharge summary","Operation theatre notes","Hospital main bill","Hospital break up bill","Investigation reports","CT/MRI/USG/HPE investigation reports","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":["The issue of this form is not to be taken as an admission of liability.","I hereby declare that if I or my close relatives attain a position of Politically Exposed Person (PEP) in future, I shall inform IndusInd General Insurance Co. Ltd.","I confirm that all premiums have been/will be paid from bonafide sources and not from proceeds of crime.","The company may call for documents to establish sources of funds.","The company may cancel the insurance contract if found guilty under money laundering laws.","I understand that IndusInd General Insurance Co. Ltd will verify my KYC and PAN details and I accept responsibility for any mismatch.","Hospital declares that information furnished is true and correct and any false statement will forfeit claim rights."],"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/593-health-insurance-policies-other-than-travel-and-personal-accident-part-b-claim-f"}