{"id":601,"title":"OPD - CLAIM FORM","purpose":"claim","insurer":{"slug":"indusind-general-insurance","name":"IndusInd General Insurance Company Limited"},"source_pdf":"https://www.indusindinsurance.com/downloads/opd-claim-form","sha256":"03a5221c44a7c84854344da32a361dd2cd815d0ab67609395f5153cbeba7d458","pages":5,"collected":"2026-10-17","instructions":{"about":"This form is for insured persons to claim reimbursement for outpatient treatment (OPD) expenses under their health insurance policy.","notes":["Fill the form in BLOCK LETTERS.","Attach original bills only.","Any hospitalization from the notified hospital will not be entertained; refer to the notified hospital list on the website.","As per IRDAI, all payments to insured are only through electronic mode.","Attach original cancelled cheque and PAN card copy for bank details verification.","For claims above ₹1 lakh, PAN card/Form 60 is mandatory; below ₹1 lakh, photo identity proof is mandatory.","CTS 2010 compliant cheque is mandatory for NEFT settlements; else submit passbook/bank statement copy with details.","RTGS/NEFT facility activates within 15 days of mandate receipt.","Customer must give 15 days prior written notice to discontinue RTGS/NEFT facility.","Claim form is applicable only for IndusInd Group Mediclaim Policy."],"title":"OPD - CLAIM FORM","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Part A (To be filled by Insured)","fields":[{"help":"","type":"choice","label":"Type of Claim:","options":["Health Checkup","OPD (Outpatient Treatment)"],"required":null,"pdf_field":""},{"help":"","type":"text","label":"*Policy No.:","options":[],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Policy Type:","options":["Group","Individual"],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Group/Company Name","options":[],"required":false,"pdf_field":""},{"help":"","type":"choice","label":"Is this a renewal policy","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"text","label":"If Yes, previous year's policy No.:","options":[],"required":false,"pdf_field":""},{"help":"Name of the insured person for whom claim is made","type":"text","label":"*Name:","options":[],"required":true,"pdf_field":""},{"help":"Age in years","type":"number","label":"Present completed age (in years):","options":[],"required":false,"pdf_field":""},{"help":"","type":"choice","label":"Gender:","options":["M","F"],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Relationship with the Policy Holder","options":[],"required":false,"pdf_field":""},{"help":"Unique Health ID or Card number","type":"text","label":"*Card / UHID No.","options":[],"required":true,"pdf_field":""},{"help":"","type":"amount","label":"Sum Insured `","options":[],"required":false,"pdf_field":""},{"help":"Full current address","type":"text","label":"*Current Residential Address","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"City","options":[],"required":false,"pdf_field":""},{"help":"Postal code","type":"number","label":"*Pin Code","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"State","options":[],"required":false,"pdf_field":""},{"help":"Select if you want to update contact details","type":"choice","label":"Change of the Contact Details:","options":["Yes, I wish to change my contact details","There is no change in my contact details"],"required":false,"pdf_field":""},{"help":"Mobile number for contact","type":"phone","label":"Please update mentioned monile number as primary contact details against my policy. I also hereby confirm to be contacted on the number provided below for Claim Status / Policy Renewal","options":[],"required":false,"pdf_field":""},{"help":"If yes, provide details below","type":"choice","label":"Does the claimant have health insurance policy with any other insurance company?","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Other insurer's name if applicable","type":"text","label":"Name of the Insurance Company","options":[],"required":false,"pdf_field":""},{"help":"Other insurer's policy number","type":"text","label":"Policy No.","options":[],"required":false,"pdf_field":""},{"help":"Sum insured under other policy","type":"amount","label":"Sum Insured `","options":[],"required":false,"pdf_field":""},{"help":"Start date of other policy","type":"date","label":"Policy Start Date","options":[],"required":false,"pdf_field":""},{"help":"End date of other policy","type":"date","label":"Policy End Date","options":[],"required":false,"pdf_field":""},{"help":"Name insured under other policy","type":"text","label":"Name of the Insured","options":[],"required":false,"pdf_field":""},{"help":"Date when injury or illness was first noticed","type":"date","label":"Date of injury sustained or disease / illness first detected","options":[],"required":false,"pdf_field":""},{"help":"Doctor or surgeon's name","type":"text","label":"Name of Treating Physician / Surgeon","options":[],"required":false,"pdf_field":""},{"help":"Doctor's qualification","type":"text","label":"Qualification","options":[],"required":false,"pdf_field":""},{"help":"Doctor's registration number","type":"text","label":"Registration Number","options":[],"required":false,"pdf_field":""},{"help":"Claim form number if any","type":"text","label":"Claim Form No:","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"Details of the amount claimed","fields":[{"help":"Bill number for each expense","type":"text","label":"Bill No","options":[],"required":false,"pdf_field":""},{"help":"Date of bill","type":"date","label":"Date","options":[],"required":false,"pdf_field":""},{"help":"Name of issuer of bill","type":"text","label":"Issued By (Doctors Name / Lab. Name / Medical Store Name)","options":[],"required":false,"pdf_field":""},{"help":"Select type of expense","type":"choice","label":"Type of Expense","options":["Consultation /Doctor visit bills OPD (Outpatient Treatment)","Investigations /Lab tests /Diagnostic tests bills OPD (Outpatient Treatment)","Pharmacy /Medicine etc bills OPD (Outpatient Treatment)","Any Other bills OPD (Outpatient Treatment)"],"required":false,"pdf_field":""},{"help":"Amount claimed for each bill","type":"amount","label":"Amount (`)","options":[],"required":false,"pdf_field":""},{"help":"Total amount claimed","type":"amount","label":"Total","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"Documents enclosed","fields":[{"help":"Tick Yes if claim form is attached","type":"yes-no","label":"Claim form Duly Filled","options":[],"required":null,"pdf_field":""},{"help":"Tick Yes if investigation reports attached","type":"yes-no","label":"Investigation Reports/Reports Name","options":[],"required":null,"pdf_field":""},{"help":"Tick Yes if consultation bills attached","type":"yes-no","label":"Consultation bills & consultation papers","options":[],"required":null,"pdf_field":""},{"help":"Tick Yes if medicine bills with prescription attached","type":"yes-no","label":"Medicine/Pharmacy Bills with Doctors Prescription","options":[],"required":null,"pdf_field":""},{"help":"Tick Yes if other documents attached","type":"yes-no","label":"Others","options":[],"required":null,"pdf_field":""},{"help":"Total number of pages of all documents attached","type":"number","label":"Total No. of Pages enclosed","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"Policyholder Bank Details","fields":[{"help":"Select title and write full name","type":"choice","label":"Name of the Bank Account Holder","options":["Mr.","Mrs.","Ms."],"required":false,"pdf_field":""},{"help":"Bank account number for claim refund","type":"text","label":"Bank Account No.","options":[],"required":false,"pdf_field":""},{"help":"Type of bank account","type":"choice","label":"Account:","options":["Saving","Current"],"required":false,"pdf_field":""},{"help":"Bank name","type":"text","label":"Name of the Bank","options":[],"required":false,"pdf_field":""},{"help":"Bank branch","type":"text","label":"Branch","options":[],"required":false,"pdf_field":""},{"help":"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":"11 character IFSC code from cheque","type":"text","label":"IFSC Code (11 character code appearing on your cheque leaf)","options":[],"required":false,"pdf_field":""},{"help":"Confirm refund to bank account","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":""}],"filled_by":"insured"},{"title":"Payment Option by Aadhaar Card (For Reimbursement claims)","fields":[{"help":"Provide Aadhaar number and attach self-attested copy","type":"text","label":"Aadhaar Card No.:","options":[],"required":false,"pdf_field":""},{"help":"Consent to receive claim amount in Aadhaar linked bank account","type":"checkbox","label":"I wish to collect claim reimbursement directly in my Bank account linked with my aforementioned Aadhaar Card.","options":[],"required":false,"pdf_field":""},{"help":"Sign here","type":"signature","label":"Signature of Claimant","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"},{"title":"Declaration and PEP Declaration","fields":[{"help":"Place of signing","type":"text","label":"Place:","options":[],"required":false,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date:","options":[],"required":false,"pdf_field":""},{"help":"Sign here","type":"signature","label":"Signature of Claimant","options":[],"required":true,"pdf_field":""},{"help":"Answer if you are a PEP","type":"choice","label":"Are you a Politically Exposed Person (PEP)?","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Position held if PEP","type":"text","label":"If yes, please mention the position held","options":[],"required":false,"pdf_field":""},{"help":"Answer 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":false,"pdf_field":""},{"help":"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":""}],"filled_by":"insured"}],"deadlines":[],"applies_to":"IndusInd Group Mediclaim Policy - OPD (Outpatient Treatment) claims","attachments":["Original cancelled cheque","Copy of PAN card","Self attested Aadhaar card copy (if opting for Aadhaar payment)","Original bills and reports supporting the claim"],"declarations":["The details given are true and correct to the best of my knowledge.","Incorrect information may lead to forfeiture of policy rights.","I agree to provide additional information if required.","I indemnify the company against any loss due to misstatement.","I will make a statutory declaration if required.","I will not receive any rebate other than that mentioned in the prospectus.","I will inform the company if I or my close relatives become politically exposed persons (PEPs).","I consent to receive claim communication on WhatsApp.","I understand and agree to the terms and conditions for payments through RTGS/NEFT.","I agree that refunds and payments will be credited only to the bank account provided."],"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/601-opd-claim-form"}