{"id":66,"title":"Health Claim Form / दावा ʛपʕ","purpose":"claim","insurer":{"slug":"bandhan-life-insurance","name":"Bandhan Life Insurance Limited"},"source_pdf":"https://www.bandhanlife.com/sites/default/files/asset/2026-04/Claim%20Form%20-%20Health_Hindi_0.pdf","sha256":"83c8d359fc66b7516b6502967e5ccaa88083d45b2e1d6a351f09e739b48ec6cf","pages":11,"collected":"2026-10-17","instructions":{"about":"This form is for filing a health insurance claim and is to be filled by the insured person and the hospital.","notes":["Form to be filled in block letters.","The issue of this Form is not to be taken as an admission of liability.","Use DD-MM-YYYY format for dates and HH:MM format for times.","Attach original pre-authorization request form in lieu of PART A for hospital section.","Use original bills only for claim submission.","Fill all sections applicable carefully and completely.","Hospital section to be filled by hospital only."],"title":"Health Claim Form / दावा ʛपʕ","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Details Of Primary Insured","fields":[{"help":"","type":"text","label":"Company/TPA ID No.","options":[],"required":null,"pdf_field":""},{"help":"Enter Social Insurance Number or certificate number","type":"text","label":"Sl. no./ Certificate no.","options":[],"required":null,"pdf_field":""},{"help":"Enter Policy Number allotted by Insurance Company","type":"text","label":"Policy no.","options":[],"required":null,"pdf_field":""},{"help":"Enter full name of Policy Holder (Surname, First name, Middle name)","type":"text","label":"Name","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":"Pincode","options":[],"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":"phone","label":"Phone No.","options":[],"required":null,"pdf_field":""},{"help":"","type":"email","label":"Email ID","options":[],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"choice","label":"Currently covered by any other Mediclaim/ Health Insurance","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":"Tick Yes or No","type":"choice","label":"Previously covered by any other Mediclaim / Health Insurance","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"choice","label":"Have you been hospitalized in last four years since inception of the contract?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide Company Name, Policy no., Sum Assured, Date, Diagnosis","type":"table","label":"If yes, Please provide details","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Details Of Insured Person Hospitalised","fields":[{"help":"","type":"checkbox","label":"Student","options":[],"required":null,"pdf_field":""},{"help":"Tick the appropriate occupation or specify if Other","type":"choice","label":"Occupation","options":["Service","Self Employed","Homemaker","Retired","Other (Please Specify)"],"required":null,"pdf_field":""},{"help":"Tick the room category occupied","type":"choice","label":"Room Category Occupied","options":["Day Care","Single Occupancy","Twin Sharing","3 or more beds per room"],"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":"Tick the reason for hospitalization","type":"choice","label":"Hospitalization due to","options":["Injury","Illness","Maternity"],"required":null,"pdf_field":""},{"help":"Tick the cause if injury","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":"choice","label":"If Medico-Legal","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"choice","label":"Reported to Police","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"choice","label":"MLC Report & Police FIR Attached","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter full postal address if different","type":"text","label":"Address (if different from above)","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":"Pincode","options":[],"required":null,"pdf_field":""},{"help":"Enter system of medicine followed","type":"text","label":"System of Medicine","options":[],"required":null,"pdf_field":""},{"help":"Tick the gender","type":"choice","label":"Gender","options":["Male","Female","Third Gender"],"required":null,"pdf_field":""},{"help":"Use DD-MM-YYYY format","type":"date","label":"Date of birth","options":[],"required":null,"pdf_field":""},{"help":"","type":"number","label":"Age (In Years)","options":[],"required":null,"pdf_field":""},{"help":"Tick the relationship or specify if Other","type":"choice","label":"Relationship to Primary Insured","options":["Self","Spouse","Child","Father","Mother","Other (Please Specify)"],"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":""},{"help":"Enter full hospital name","type":"text","label":"Name of Hospital where admitted","options":[],"required":null,"pdf_field":""},{"help":"Use DD-MM-YYYY format","type":"date","label":"Date of admission","options":[],"required":null,"pdf_field":""},{"help":"Use DD-MM-YYYY format","type":"date","label":"Date of discharge","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Details Of Claim","fields":[{"help":"Enter amount in rupees","type":"amount","label":"Pre-hospitalization Expenses","options":[],"required":null,"pdf_field":""},{"help":"Enter amount in rupees","type":"amount","label":"Hospitalization Expenses","options":[],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"choice","label":"Claim for Domiciliary Hospitalization","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter amount in rupees","type":"amount","label":"Post-hospitalization Expenses","options":[],"required":null,"pdf_field":""},{"help":"Enter amount in rupees","type":"amount","label":"Health-Checkup Cost","options":[],"required":null,"pdf_field":""},{"help":"Enter amount in rupees","type":"amount","label":"Ambulance Charges","options":[],"required":null,"pdf_field":""},{"help":"Enter amount in rupees with code","type":"amount","label":"Others (code)","options":[],"required":null,"pdf_field":""},{"help":"Enter number of days","type":"number","label":"Pre-hospitalization Period (Days)","options":[],"required":null,"pdf_field":""},{"help":"Enter number of days","type":"number","label":"Post-hospitalization Period (Days)","options":[],"required":null,"pdf_field":""},{"help":"Total amount claimed in rupees","type":"amount","label":"Total","options":[],"required":null,"pdf_field":""},{"help":"Enter amounts for Hospital Daily Cash, Surgical Cash, Critical Illness benefit, Convalescence, Pre/Post Hospitalization Lump sum benefit, Others","type":"table","label":"Details of Lump sum/Cash benefit claimed","options":[],"required":null,"pdf_field":""},{"help":"Sign the claim form","type":"signature","label":"Claim Form Duly Signed","options":[],"required":true,"pdf_field":""},{"help":"List bills with Sl. no., Bill no., Date, Issued by, Towards, Amount","type":"table","label":"Details Of Bills Enclosed","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Attachments","fields":[{"help":"Attach if available","type":"attachment","label":"Copy of the Claim Intimation (if any)","options":[],"required":false,"pdf_field":""},{"help":"Attach hospital break-up bill","type":"attachment","label":"Hospital Break-up Bill","options":[],"required":false,"pdf_field":""},{"help":"Attach payment receipt","type":"attachment","label":"Hospital Bill Payment Receipt","options":[],"required":false,"pdf_field":""},{"help":"Attach discharge summary","type":"attachment","label":"Hospital Discharge Summary","options":[],"required":false,"pdf_field":""},{"help":"Attach pharmacy bills","type":"attachment","label":"Pharmacy Bill","options":[],"required":false,"pdf_field":""},{"help":"Attach operation theatre notes","type":"attachment","label":"Operation Theatre Notes","options":[],"required":false,"pdf_field":""},{"help":"Attach doctor's request","type":"attachment","label":"Doctor’s Request for Investigation","options":[],"required":false,"pdf_field":""},{"help":"Attach ECG report","type":"attachment","label":"ECG","options":[],"required":false,"pdf_field":""},{"help":"Attach investigation reports","type":"attachment","label":"Investigation Reports (Including CT/ MRI/ USG/ HPE)","options":[],"required":false,"pdf_field":""},{"help":"Attach prescriptions","type":"attachment","label":"Doctor’s Prescriptions","options":[],"required":false,"pdf_field":""},{"help":"Attach any other relevant documents","type":"attachment","label":"Others","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"Details Of Primary Insured’s Bank Accounts","fields":[{"help":"Enter Permanent Account Number","type":"text","label":"PAN","options":[],"required":null,"pdf_field":""},{"help":"Enter bank account number","type":"text","label":"Account Number","options":[],"required":null,"pdf_field":""},{"help":"Enter bank name","type":"text","label":"Bank Name","options":[],"required":null,"pdf_field":""},{"help":"Enter bank branch","type":"text","label":"Bank Branch","options":[],"required":null,"pdf_field":""},{"help":"Enter name of beneficiary for cheque/DD","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":"Declaration By The Insured","fields":[{"help":"Sign the form","type":"signature","label":"Signature of Insured","options":[],"required":true,"pdf_field":""},{"help":"Enter date in DD-MM-YYYY format","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Enter place","type":"text","label":"Place","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"},{"title":"Hospital Section (Part B)","fields":[{"help":"Enter full hospital name","type":"text","label":"Name of Hospital","options":[],"required":true,"pdf_field":""},{"help":"Enter hospital ID allotted by TPA","type":"text","label":"Hospital ID","options":[],"required":true,"pdf_field":""},{"help":"Tick appropriate option","type":"choice","label":"Type of Hospital","options":["Network","Non-Network"],"required":true,"pdf_field":""},{"help":"Enter full name of treating doctor","type":"text","label":"Name of the Treating Doctor","options":[],"required":true,"pdf_field":""},{"help":"Enter doctor's qualification","type":"text","label":"Qualification","options":[],"required":true,"pdf_field":""},{"help":"Enter registration number with state code","type":"text","label":"Registration No. with State Code","options":[],"required":true,"pdf_field":""},{"help":"Enter phone number with STD code","type":"phone","label":"Phone No.","options":[],"required":true,"pdf_field":""},{"help":"Enter full name of patient","type":"text","label":"Name of the Patient","options":[],"required":true,"pdf_field":""},{"help":"Enter insurance provider's registration number","type":"text","label":"IP Registration Number","options":[],"required":true,"pdf_field":""},{"help":"Use DD-MM-YYYY format","type":"date","label":"Date of Admission","options":[],"required":true,"pdf_field":""},{"help":"Use HH:MM format","type":"text","label":"Time of Admission","options":[],"required":true,"pdf_field":""},{"help":"Use DD-MM-YYYY format","type":"date","label":"Date of Discharge","options":[],"required":true,"pdf_field":""},{"help":"Use HH:MM format","type":"text","label":"Time of Discharge","options":[],"required":true,"pdf_field":""},{"help":"Enter age in years and months","type":"number","label":"Age","options":[],"required":true,"pdf_field":""},{"help":"Tick gender","type":"choice","label":"Gender","options":["Male","Female"],"required":true,"pdf_field":""},{"help":"Tick type of admission","type":"choice","label":"Type of Admission","options":["Emergency","Planned","Daycare","Maternity"],"required":true,"pdf_field":""},{"help":"Tick status at discharge","type":"choice","label":"Status at time of discharge","options":["Discharge to home","Deceased","Discharge to another hospital"],"required":true,"pdf_field":""},{"help":"Enter gravida status if maternity","type":"text","label":"Gravida Status (if Maternity)","options":[],"required":false,"pdf_field":""},{"help":"Use DD-MM-YYYY format","type":"date","label":"Date of Delivery (if Maternity)","options":[],"required":false,"pdf_field":""},{"help":"Enter ICD 10 code and description","type":"text","label":"Additional Diagnosis","options":[],"required":false,"pdf_field":""},{"help":"Enter ICD 10 code and description","type":"text","label":"Co-morbidities","options":[],"required":false,"pdf_field":""},{"help":"Enter ICD 10 PCS code and description","type":"text","label":"Procedure 1","options":[],"required":false,"pdf_field":""},{"help":"Enter ICD 10 PCS code and description","type":"text","label":"Procedure 2","options":[],"required":false,"pdf_field":""},{"help":"Enter ICD 10 PCS code and description","type":"text","label":"Procedure 3","options":[],"required":false,"pdf_field":""},{"help":"Enter details of procedure","type":"text","label":"Details of Procedure","options":[],"required":false,"pdf_field":""},{"help":"Tick Yes or No","type":"choice","label":"Pre-authorization obtained","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Enter pre-authorization number","type":"text","label":"Pre-authorization Number","options":[],"required":false,"pdf_field":""},{"help":"Enter reason","type":"text","label":"If authorization by network hospital not obtained, give reason","options":[],"required":false,"pdf_field":""},{"help":"Tick Yes or No","type":"choice","label":"Hospitalization due to injury","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Tick cause","type":"choice","label":"If yes, give cause","options":["Self Inflicted","Road traffic accident","Substance abuse/ alcohol consumption"],"required":false,"pdf_field":""},{"help":"Tick Yes or No","type":"choice","label":"If injury due to Substance Abuse / Alcohol Consumption, Test Conducted to establish this","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Tick Yes or No","type":"choice","label":"If Medico-Legal","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Tick Yes or No","type":"choice","label":"Reported to Police","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Enter FIR number","type":"text","label":"FIR No.","options":[],"required":false,"pdf_field":""},{"help":"Enter reason","type":"text","label":"If not reported to Police, give reason","options":[],"required":false,"pdf_field":""},{"help":"Tick the documents submitted","type":"checkbox","label":"Claim Documents Submitted - Check List","options":["Claim Form Duly Signed","Copy of the Pre-authorization Approval Letter","Original Pre-authorization request","Copy of Photo ID Card of Patient Verified by Hospital","Investigation Reports","CT / MRI / USG / HPE Investigation Reports","Doctor’s Reference Slip for Investigation ECG","Pharmacy Bill"],"required":null,"pdf_field":""},{"help":"Enter date in DD-MM-YYYY format","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Enter place","type":"text","label":"Place","options":[],"required":true,"pdf_field":""}],"filled_by":"hospital"}],"deadlines":[],"applies_to":"","attachments":["Copy of the Claim Intimation (if any)","Hospital Break-up Bill","Hospital Bill Payment Receipt","Hospital Discharge Summary","Pharmacy Bill","Operation Theatre Notes","Doctor’s Request for Investigation","ECG","Investigation Reports (Including CT/ MRI/ USG/ HPE)","Doctor’s Prescriptions","Others","Copy of the Pre-authorization Approval Letter","Original Pre-authorization request","Copy of Photo ID Card of Patient Verified by Hospital"],"declarations":["The information furnished in this claim form is true and correct to the best of my 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.","Consent and authorize TPA/ Insurance company to seek necessary medical information from any hospital or medical practitioner.","All bills/ receipts for the claim have been included and no supplementary claim will be made except pre/post-hospitalization claim if any.","Hospital declares that information furnished is true and correct to the best of their knowledge and belief.","If hospital makes any false or untrue statement or conceals material fact, their right to claim under this claim shall be forfeited."],"dropped_labels":3},"pdf_fields":null,"fillable_pdf":false,"send_to":[{"purpose":"claim","channel":"address","value":"submit duly completed claim forms and other documents at the nearest Bandhan Life Branch Office or at our Head Office","label":"Claim Intimation and Registration","level":null,"hours":null,"applies_to":"life","source_url":"https://www.bandhanlife.com/customer-service/claims-process","quote":"nes can use the amount when they need it most.\nClaim Intimation and Registration\nFor Claims intimation to Bandhan Life, submit duly completed claim forms and other documents at the nearest Bandhan Life Branch Office or at our Head Office. Please click on the below links to see/ download the requirement list, claim forms and to locate our nearest branch of","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/bandhan-life-insurance/66-health-claim-form"}