{"id":705,"title":"Liberty Eternia Health Policy Claim Form (UIN -LIBHLIP27040V012627) (Effective from 15.04.2026)","purpose":"claim","insurer":{"slug":"liberty-general-insurance","name":"Liberty General Insurance Limited"},"source_pdf":"https://www.libertyinsurance.in/Docx/Liberty%20Eternia%20Health%20Policy%20-%20Claim%20Form%20(UIN%20-LIBHLIP27040V012627)%20(Effective%20from%2015.04.2026).pdf","sha256":"8adf0f96735a93d385204342ca8a2c38fac7caa29df7c033a11edfc76343c938","pages":6,"collected":"2026-10-17","instructions":{"about":"This form is used by the insured person and hospital to claim health insurance benefits under the Liberty Eternia Health Policy. The insured fills Part A and the hospital fills Part B.","notes":["Use block letters where applicable.","Use dd-mm-yy format for dates and hh:mm format for times.","Attach original bills and documents as listed in the checklist.","For domiciliary hospitalization claims, provide details on annexure.","Original preauthorization request form must be included with Part B.","Hospital to verify and attach copy of photo ID card of patient.","For non-network hospitals, fill additional hospital details section.","The issue of this form is not to be taken as an admission of liability."],"title":"Liberty Eternia Health Policy Claim Form (UIN -LIBHLIP27040V012627) (Effective from 15.04.2026)","submit":{"to":"Liberty General Insurance Ltd., Unit 1501&1502, 15th Floor, Tower 2, One International Center, Senapati Bapat Marg, Prabhadevi, Mumbai – 400013","how":"post / in person / as per insurer instructions","address":"Unit 1501&1502, 15th Floor, Tower 2, One International Center, Senapati Bapat Marg, Prabhadevi, Mumbai – 400013"},"purpose":"claim","sections":[{"title":"SECTION A - DETAILS OF PRIMARY INSURED","fields":[{"help":"Enter the policy number","type":"text","label":"Policy Number","options":[],"required":null,"pdf_field":""},{"help":"Enter the full name of the policyholder","type":"text","label":"Name","options":[],"required":null,"pdf_field":""},{"help":"Tick Male or Female","type":"choice","label":"Gender: Male / Female","options":["Male","Female"],"required":null,"pdf_field":""},{"help":"Enter number of years and months","type":"text","label":"Age","options":[],"required":null,"pdf_field":""},{"help":"Tick the right option. If others, please specify","type":"choice","label":"Relationship of Primary Insured: Self/ Spouse/ Child/ Father/ Mother/ Other (Please Specify)","options":["Self","Spouse","Child","Father","Mother","Other"],"required":null,"pdf_field":""},{"help":"Tick the right option. If others, please specify","type":"choice","label":"Occupation: Service/ Self Employed/ Homemaker/ Student/ Retired/ Other (Please specify)","options":["Service","Self Employed","Homemaker","Student","Retired","Other"],"required":null,"pdf_field":""},{"help":"Use dd-mm-yy format","type":"date","label":"Date of Birth","options":[],"required":null,"pdf_field":""},{"help":"Include Street, City and Pin Code","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"Include STD code with telephone number","type":"phone","label":"Phone No","options":[],"required":null,"pdf_field":""},{"help":"Complete e-mail address","type":"email","label":"Email ID","options":[],"required":null,"pdf_field":""}],"filled_by":"insured person"},{"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? Yes / No","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Use dd-mm-yy format","type":"date","label":"Date of commencement of first Insurance without break","options":[],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"Previously covered by any other Mediclaim / Health Insurance: Yes / No","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter the full name of the insurance company","type":"text","label":"If Yes company name","options":[],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"Have you been hospitalized in the last four years since the inception of the contract? Yes / No","options":["Yes","No"],"required":null,"pdf_field":""}],"filled_by":"insured person"},{"title":"SECTION C - DETAILS OF INSURED PERSON HOSPITALIZED","fields":[{"help":"Enter the full name of the patient","type":"text","label":"Name","options":[],"required":null,"pdf_field":""},{"help":"Tick Male or Female","type":"choice","label":"Gender: Male / Female","options":["Male","Female"],"required":null,"pdf_field":""},{"help":"Enter age of the patient","type":"text","label":"Age","options":[],"required":null,"pdf_field":""},{"help":"Tick the right option. If others, please specify","type":"choice","label":"Relationship to primary Insured","options":["Self","Spouse","Child","Father","Mother","Other"],"required":null,"pdf_field":""},{"help":"Tick the right option. If others, please specify","type":"choice","label":"Occupation","options":["Service","Self Employed","Homemaker","Student","Retired","Other"],"required":null,"pdf_field":""},{"help":"Use dd-mm-yy format","type":"date","label":"Date of Birth","options":[],"required":null,"pdf_field":""},{"help":"Include STD code with telephone number","type":"phone","label":"Phone No","options":[],"required":null,"pdf_field":""},{"help":"Complete e-mail address","type":"email","label":"E-mail ID","options":[],"required":null,"pdf_field":""},{"help":"Include Street, City and Pin Code","type":"text","label":"Address","options":[],"required":null,"pdf_field":""}],"filled_by":"insured person"},{"title":"SECTION D - DETAILS OF HOSPITALIZATION","fields":[{"help":"Enter the name of hospital in full","type":"text","label":"Name of Hospital where admitted","options":[],"required":null,"pdf_field":""},{"help":"Tick the right option","type":"choice","label":"Room category occupied","options":["Day care","Single occupancy","Twin sharing","3 or more"],"required":null,"pdf_field":""},{"help":"Tick the right option","type":"choice","label":"Hospitalization due to: Illness / Injury / Maternity","options":["Illness","Injury","Maternity"],"required":null,"pdf_field":""},{"help":"Use dd-mm-yy format","type":"date","label":"Date of Admission","options":[],"required":null,"pdf_field":""},{"help":"Use hh:mm format","type":"text","label":"Time of Admission","options":[],"required":null,"pdf_field":""},{"help":"Use dd-mm-yy format","type":"date","label":"Date of Injury / Date Disease first detected / Date of Delivery","options":[],"required":null,"pdf_field":""},{"help":"Use dd-mm-yy format","type":"date","label":"Date of Discharge","options":[],"required":null,"pdf_field":""},{"help":"Use hh:mm format","type":"text","label":"Time of Discharge","options":[],"required":null,"pdf_field":""},{"help":"Tick the right option","type":"choice","label":"If injury, give cause: Self Inflicted / Road Traffic Accident / Substance Abuse or Alcohol Consumption","options":["Self Inflicted","Road Traffic Accident","Substance Abuse or Alcohol Consumption"],"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 person"},{"title":"SECTION E - DETAILS OF CLAIM","fields":[{"help":"Enter amounts in rupees (do not enter paise)","type":"amount","label":"Details of Treatment Expenses Claimed","options":[],"required":null,"pdf_field":""},{"help":"Enter amount in rupees","type":"amount","label":"Detail of Lump Sum cash benefit claimed","options":[],"required":null,"pdf_field":""},{"help":"Tick the documents submitted","type":"checkbox","label":"Claim Documents Submitted - Check List","options":["Claim Form Duly Filled","Claim Documents Submitted Check List","Copy of the Claim Intimation, if any","Hospital Main Bill","Hospital Break Up Bill","Hospital Bill Payment Receipt","Hospital Discharge Summary","Pharmacy Bill","Operation Theater Notes","ECG","Doctor’s request for investigation","Investigation Reports (Including CT/MRI/USG/HPE)","Doctor’s Prescription","Others"],"required":null,"pdf_field":""}],"filled_by":"insured person"},{"title":"SECTION F - DETAILS OF BILLS ENCLOSED","fields":[{"help":"Attach separate sheet for additional bills/receipt details with these columns","type":"table","label":"Sl. No, Bill No, Date, Issued by, Amount, Towards","options":[],"required":null,"pdf_field":""}],"filled_by":"insured person"},{"title":"SECTION G - DETAILS OF PRIMARY INSURED'S BANK ACCOUNT","fields":[{"help":"Enter permanent account number","type":"text","label":"PAN No","options":[],"required":null,"pdf_field":""},{"help":"Enter bank account number","type":"text","label":"Account Number","options":[],"required":null,"pdf_field":""},{"help":"Enter bank name and branch","type":"text","label":"Bank Name/ Branch","options":[],"required":null,"pdf_field":""},{"help":"Enter name of beneficiary for payment","type":"text","label":"Cheque/ DD/ NEFT Payable to","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 person"},{"title":"SECTION H - DECLARATION BY THE INSURED","fields":[{"help":"Enter date of signing","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Enter place of signing","type":"text","label":"Place","options":[],"required":true,"pdf_field":""},{"help":"Sign here","type":"signature","label":"Signature of the Insured","options":[],"required":true,"pdf_field":""}],"filled_by":"insured person"},{"title":"CLAIM FORM – PART B (To be filled by the hospital)","fields":[{"help":"Enter hospital name in full","type":"text","label":"Name of the Hospital","options":[],"required":null,"pdf_field":""},{"help":"Enter full name","type":"text","label":"Name of the treating Doctor","options":[],"required":null,"pdf_field":""},{"help":"Enter qualification","type":"text","label":"Qualification","options":[],"required":null,"pdf_field":""},{"help":"Enter patient name","type":"text","label":"Name of the patient","options":[],"required":null,"pdf_field":""},{"help":"Tick Male or Female","type":"choice","label":"Gender","options":["Male","Female"],"required":null,"pdf_field":""},{"help":"Use dd-mm-yy format","type":"date","label":"If Maternity Date of delivery","options":[],"required":null,"pdf_field":""},{"help":"Use dd-mm-yy format","type":"date","label":"Date of Admission","options":[],"required":null,"pdf_field":""},{"help":"Use dd-mm-yy format","type":"date","label":"Date of Discharge","options":[],"required":null,"pdf_field":""},{"help":"Enter FIR number if applicable","type":"text","label":"FIR No","options":[],"required":null,"pdf_field":""},{"help":"Tick Yes or No and attach report if Yes","type":"yes-no","label":"If injury due to Substance Abuse/ Alcohol consumption test conducted: Yes / No","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Tick the right option","type":"choice","label":"Status at the time of Discharge: Discharge to Home / Discharge to another Hospital / Deceased","options":["Discharge to Home","Discharge to another Hospital","Deceased"],"required":null,"pdf_field":""},{"help":"Explain reasons if not reported","type":"text","label":"If not reported to police, give reasons","options":[],"required":null,"pdf_field":""},{"help":"Hospital authority to sign and seal","type":"signature","label":"SEAL & SIGNATURE OF THE HOSPITAL AUTHORITY","options":[],"required":true,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Place of signing","type":"text","label":"Place","options":[],"required":true,"pdf_field":""}],"filled_by":"hospital"}],"deadlines":[],"applies_to":"Health insurance claims under Liberty Eternia Health Policy","attachments":["Claim Form Duly Filled","Claim Documents Submitted Check List","Copy of the Claim Intimation, if any","Hospital Main Bill","Hospital Break Up Bill","Hospital Bill Payment Receipt","Hospital Discharge Summary","Pharmacy Bill","Operation Theater Notes","ECG","Doctor’s request for investigation","Investigation Reports (Including CT/MRI/USG/HPE)","Doctor’s Prescription","MLC report & Police FIR","Original Pre-Authorisation Request","Copy of Pre-Authorisation Approval Letter","Copy of Photo Id Card of Patient verified by the Hospital","Original Death Summary from Hospital where applicable","Any other, please specify"],"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 hospitals or medical practitioners.","All bills and receipts for the claim are included and no supplementary claim will be made except pre/post-hospitalization claims.","Consent to process/share personal information and data with group companies or service providers for insurance and related products.","Hospital declares that information furnished is true and correct and any false statement will forfeit claim rights."],"dropped_labels":13},"pdf_fields":null,"fillable_pdf":false,"send_to":[],"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/liberty-general-insurance/705-liberty-eternia-health-policy-claim-form-uin-libhlip27040v012627-effective-from-"}