{"id":596,"title":"HEALTH INSURANCE POLICIES OTHER THAN TRAVEL AND PERSONAL ACCIDENT - PART A - 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-a","sha256":"c28601f6b61394ab2e7a112ff9ac55613a21d024f888f218a39ff39e73e52330","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 the claim, hospitalization, and related expenses.","notes":["Fill the form in BLOCK LETTERS.","The issue of this form is not an admission of liability.","Attach original bills and documents as per the checklist.","All payments to the insured will be made only through electronic mode as per IRDAI regulations.","The company reserves the right to have the insured examined by a doctor appointed by it for verification.","Use the annexure to provide details if claiming for domiciliary hospitalization.","Politically Exposed Persons (PEPs) are defined as per Prevention of Money Laundering Rules, 2005."],"title":"HEALTH INSURANCE POLICIES OTHER THAN TRAVEL AND PERSONAL ACCIDENT - PART A - 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. Email: healthcare@indusindinsurance.com"},"purpose":"claim","sections":[{"title":"SECTION A - DETAILS OF PRIMARY INSURED","fields":[{"help":"Select the type of claim being made","type":"choice","label":"Type of claim","options":["Hospitalization","Pre Hospitalization","Post Hospitalization","Health check-up","OPD"],"required":null,"pdf_field":""},{"help":"Indicate if pre-authorization was obtained","type":"choice","label":"Pre authorization obtained","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Specify the period end date if applicable","type":"text","label":"Period To","options":[],"required":false,"pdf_field":""},{"help":"Select policy type","type":"choice","label":"Policy type","options":["Individual","Group"],"required":null,"pdf_field":""},{"help":"Enter group or company name if applicable","type":"text","label":"Group/Company name","options":[],"required":false,"pdf_field":""},{"help":"Enter your policy number","type":"text","label":"Policy No","options":[],"required":true,"pdf_field":""},{"help":"Enter serial or certificate number if applicable","type":"text","label":"Sl. No/Certificate No","options":[],"required":false,"pdf_field":""},{"help":"Enter company or TPA ID number","type":"text","label":"Company/TPA ID No.","options":[],"required":false,"pdf_field":""},{"help":"Enter full name of the primary insured","type":"text","label":"Name","options":[],"required":true,"pdf_field":""},{"help":"Enter full address","type":"text","label":"Address","options":[],"required":false,"pdf_field":""},{"help":"Enter city","type":"text","label":"City","options":[],"required":false,"pdf_field":""},{"help":"Enter state","type":"text","label":"State","options":[],"required":false,"pdf_field":""},{"help":"Enter postal code","type":"number","label":"Pincode","options":[],"required":false,"pdf_field":""},{"help":"Enter phone number","type":"phone","label":"Phone No","options":[],"required":false,"pdf_field":""},{"help":"Enter email address","type":"email","label":"E-mail Id","options":[],"required":false,"pdf_field":""},{"help":"Enter PAN number","type":"text","label":"PAN No.","options":[],"required":false,"pdf_field":""},{"help":"Select monthly income range","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":""}],"filled_by":"insured"},{"title":"SECTION B - DETAILS OF INSURANCE HISTORY","fields":[{"help":"Indicate if currently covered by other health insurance","type":"choice","label":"Currently covered by any other Mediclaim/Health Insurance","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter date in DD/MM/YYYY format","type":"date","label":"Date of commencement of first insurance without break","options":[],"required":false,"pdf_field":""},{"help":"Enter other insurance company name if applicable","type":"text","label":"If yes, Company Name","options":[],"required":false,"pdf_field":""},{"help":"Enter policy number of other insurance","type":"text","label":"Policy No","options":[],"required":false,"pdf_field":""},{"help":"Enter sum insured amount","type":"amount","label":"Sum Insured `","options":[],"required":false,"pdf_field":""},{"help":"Indicate if hospitalized in last 4 years","type":"choice","label":"Have you been hospitalized in the last four years since inception of the contact?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter date of hospitalization in 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":"Indicate if previously covered by other health insurance","type":"choice","label":"Previously covered by any other Mediclaim/Health Insurance","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter previous insurance company name if applicable","type":"text","label":"If yes, Company Name","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"SECTION C - DETAILS OF INSURED PERSON HOSPITALIZED","fields":[{"help":"Enter name of the person hospitalized","type":"text","label":"Name","options":[],"required":true,"pdf_field":""},{"help":"Select gender","type":"choice","label":"Gender","options":["Male","Female"],"required":null,"pdf_field":""},{"help":"Enter age in years and months","type":"text","label":"Age","options":[],"required":false,"pdf_field":""},{"help":"Enter date of birth in DD/MM/YYYY format","type":"date","label":"Date of Birth","options":[],"required":false,"pdf_field":""},{"help":"Select relationship and specify if Other","type":"choice","label":"Relationship to Primary insured","options":["Self","Spouse","Child","Father","Mother","Other - Please Specify"],"required":null,"pdf_field":""},{"help":"Select occupation and specify if Other","type":"choice","label":"Occupation","options":["Service","Self Employed","Homemaker","Student","Retired","Other - Please Specify"],"required":null,"pdf_field":""},{"help":"Enter address if different from primary insured","type":"text","label":"Address (if different from above)","options":[],"required":false,"pdf_field":""},{"help":"Enter city","type":"text","label":"City","options":[],"required":false,"pdf_field":""},{"help":"Enter state","type":"text","label":"State","options":[],"required":false,"pdf_field":""},{"help":"Enter postal code","type":"number","label":"Pin Code","options":[],"required":false,"pdf_field":""},{"help":"Enter phone number","type":"phone","label":"Phone No","options":[],"required":false,"pdf_field":""},{"help":"Enter email address","type":"email","label":"Email Id","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"SECTION D - DETAILS OF HOSPITALIZATION","fields":[{"help":"Enter hospital name","type":"text","label":"Name of Hospital where admitted","options":[],"required":true,"pdf_field":""},{"help":"Select room category","type":"choice","label":"Room Category occupied","options":["Day care","Single occupancy","Twin sharing","3 or more beds per room"],"required":null,"pdf_field":""},{"help":"Select reason for hospitalization","type":"choice","label":"Hospitalization due to","options":["Injury","Illness","Maternity"],"required":null,"pdf_field":""},{"help":"Enter date in DD/MM/YYYY format","type":"date","label":"Date of Injury/Date disease first detected /Date of delivery","options":[],"required":false,"pdf_field":""},{"help":"Enter admission date in DD/MM/YYYY format","type":"date","label":"Date of Admission","options":[],"required":true,"pdf_field":""},{"help":"Enter admission time with AM/PM","type":"text","label":"Time","options":[],"required":false,"pdf_field":""},{"help":"Enter discharge date in DD/MM/YYYY format","type":"date","label":"Date of Discharge","options":[],"required":true,"pdf_field":""},{"help":"Enter discharge time with AM/PM","type":"text","label":"Time","options":[],"required":false,"pdf_field":""},{"help":"Select cause if injury","type":"choice","label":"If injury give cause","options":["Self inflicted","Road traffic accident","Substance abuse /Alcohol consumption"],"required":false,"pdf_field":""},{"help":"Indicate if case is medico legal","type":"choice","label":"If Medico legal","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Indicate if reported to police","type":"choice","label":"Reported to police","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Indicate if medico legal case report and FIR are attached","type":"choice","label":"MLC report & Police FIR attached","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Specify system of medicine (e.g. Allopathy, Ayurveda)","type":"text","label":"System of medicine","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"SECTION E - DETAILS OF CLAIM","fields":[{"help":"Fill amounts for Pre hospitalization expenses, Hospitalization expenses, Post hospitalization expenses, Health check up cost, Ambulance charges, Others (code), and total","type":"table","label":"Details of treatment expenses claimed","options":[],"required":false,"pdf_field":""},{"help":"Enter amount for pre hospitalization expenses","type":"amount","label":"Pre hospitalization expenses `","options":[],"required":false,"pdf_field":""},{"help":"Enter amount for hospitalization expenses","type":"amount","label":"Hospitalization expenses `","options":[],"required":false,"pdf_field":""},{"help":"Enter amount for post hospitalization expenses","type":"amount","label":"Post hospitalization expenses `","options":[],"required":false,"pdf_field":""},{"help":"Enter health check up cost","type":"amount","label":"Health check up cost `","options":[],"required":false,"pdf_field":""},{"help":"Enter ambulance charges","type":"amount","label":"Ambulance charges `","options":[],"required":false,"pdf_field":""},{"help":"Enter other expenses with code","type":"amount","label":"Others (code) `","options":[],"required":false,"pdf_field":""},{"help":"Enter total amount claimed","type":"amount","label":"TOTAL `","options":[],"required":false,"pdf_field":""},{"help":"Enter number of days for pre hospitalization","type":"number","label":"Pre hospitalization period","options":[],"required":false,"pdf_field":""},{"help":"Enter number of days for post hospitalization","type":"number","label":"Post hospitalization period","options":[],"required":false,"pdf_field":""},{"help":"Indicate if claim is for domiciliary hospitalization; if yes, provide details in annexure","type":"choice","label":"Claim for Domiciliary Hospitalization","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Fill amounts for Hospital Daily Cash, Surgical cash, Critical illness benefit, Convalescence, Pre/Post hospitalization Lump sum benefit, Others, and total","type":"table","label":"Details of Lump sum/cash benefit claimed","options":[],"required":false,"pdf_field":""},{"help":"Enter hospital daily cash amount claimed","type":"amount","label":"Hospital Daily Cash `","options":[],"required":false,"pdf_field":""},{"help":"Enter surgical cash amount claimed","type":"amount","label":"Surgical cash `","options":[],"required":false,"pdf_field":""},{"help":"Enter critical illness benefit amount claimed","type":"amount","label":"Critical illness benefit `","options":[],"required":false,"pdf_field":""},{"help":"Enter convalescence amount claimed","type":"amount","label":"Convalescence `","options":[],"required":false,"pdf_field":""},{"help":"Enter pre/post hospitalization lump sum benefit amount claimed","type":"amount","label":"Pre/Post hospitalization Lump sum benefit `","options":[],"required":false,"pdf_field":""},{"help":"Enter other lump sum/cash benefits claimed","type":"amount","label":"Others `","options":[],"required":false,"pdf_field":""},{"help":"Enter total lump sum/cash benefit claimed","type":"amount","label":"TOTAL `","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"SECTION F - DETAILS OF BILLS ENCLOSED","fields":[{"help":"Fill serial number, bill number, date, issued by, towards, and amount for each bill type including hospital main bill, pre/post hospitalization bills, home care treatment bills, pharmacy bills, other expenses","type":"table","label":"Details of bills enclosed","options":[],"required":false,"pdf_field":""},{"help":"Tick the documents submitted with the claim","type":"checkbox","label":"CLAIM DOCUMENTS SUBMITTED CHECK LIST","options":["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","Pharmacy bill","Operation theatre notes","ECG","Doctor’s request for investigation","Investigation reports (including CT/MRI/USG/HPE)","Doctor’s prescriptions","Others"],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"SECTION G - DETAILS OF PRIMARY INSURED’S BANK ACCOUNT","fields":[{"help":"Enter full name of bank account holder with title (Mr./Mrs./Ms.)","type":"text","label":"Name of the Bank Account Holder","options":[],"required":true,"pdf_field":""},{"help":"Enter bank account number","type":"text","label":"Bank Account No.:","options":[],"required":true,"pdf_field":""},{"help":"Select account type","type":"choice","label":"Account","options":["Saving","Current","Other"],"required":true,"pdf_field":""},{"help":"Enter bank name","type":"text","label":"Name of the Bank","options":[],"required":true,"pdf_field":""},{"help":"Enter bank branch","type":"text","label":"Branch","options":[],"required":true,"pdf_field":""},{"help":"Enter 9 digit MICR code from cheque","type":"text","label":"MICR Code (9 digit MICR code number of the bank and branch appearing on the cheque issued by the bank)","options":[],"required":false,"pdf_field":""},{"help":"Enter 11 character IFSC code from cheque leaf","type":"text","label":"IFSC Code (11 character code appearing on your cheque leaf)","options":[],"required":true,"pdf_field":""},{"help":"Acknowledge electronic payment mandate","type":"checkbox","label":"I understand that any refund due on the premium payment / any payment / claims to be directly credited to my aforesaid Bank Account.*","options":[],"required":true,"pdf_field":""},{"help":"Indicate if you are a PEP","type":"choice","label":"Are you a Politically Exposed Person (PEP)?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Specify position if PEP","type":"text","label":"If yes, please mention the position held","options":[],"required":false,"pdf_field":""},{"help":"Indicate if any close relative is a PEP","type":"choice","label":"Is any of your close relation or family member a PEP?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Provide details of relative who is a PEP","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":"Enter place of signing","type":"text","label":"Place","options":[],"required":true,"pdf_field":""},{"help":"Enter date of signing in DD/MM/YYYY format","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Sign the form","type":"signature","label":"Signature of Proposer","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"},{"title":"SECTION H - DECLARATION BY THE INSURED","fields":[{"help":"Enter date of declaration in DD/MM/YYYY format","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Enter place of declaration","type":"text","label":"Place","options":[],"required":true,"pdf_field":""},{"help":"Sign the declaration","type":"signature","label":"Signature of the 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","Pharmacy bill","Operation theatre notes","ECG","Doctor’s request for investigation","Investigation reports (including CT/MRI/USG/HPE)","Doctor’s prescriptions","Others"],"declarations":["The information furnished in this claim form is true and correct to the best of my knowledge and belief.","False or untrue statements, suppression or concealment of material facts will forfeit the right to claim reimbursement.","Consent and authorize TPA/Insurance Company to seek necessary medical information/documents from hospitals or medical practitioners.","All bills/receipts for this claim are included and no supplementary claim will be made except pre/post hospitalization claims.","I understand that any refund or payment will be credited directly to my bank account as per IRDAI mandate.","I declare that if I or my close relatives become Politically Exposed Persons (PEP) in future, I will inform the insurer.","I confirm that premiums are paid from bonafide sources and not from proceeds of crime as per AML guidelines.","The insurer has the right to verify sources of funds and cancel the contract if found guilty under money laundering laws.","I agree and consent that in case of mismatch in KYC or PAN details, the policy will be issued as per proposal form and I am responsible for consequences."],"dropped_labels":0},"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/596-health-insurance-policies-other-than-travel-and-personal-accident-part-a-claim-f"}