{"id":707,"title":"Secure Health Connect Policy – Claim Form","purpose":"claim","insurer":{"slug":"liberty-general-insurance","name":"Liberty General Insurance Limited"},"source_pdf":"https://www.libertyinsurance.in/Docx/Secure%20Health%20Connect%20-%20Claim%20Form%20(UIN%20-%20LIBHLIP27042V032627)(Effective%20from%2031.08.2026).pdf","sha256":"bdb407038f8d2fc0fb99662d4733883977662e9c54f55d195db596f3eadd9b41","pages":6,"collected":"2026-10-17","instructions":{"about":"This form is used by the insured person to claim health insurance benefits under the Secure Health Connect Policy. The insured fills Part A, and the hospital fills Part B.","notes":["Use block letters to fill the form.","Use original bills and receipts only.","Dates should be in dd-mm-yy or dd-mm-yyyy format as specified.","Time should be in hh:mm format.","Include STD code with phone numbers.","Attach separate sheet if bills or receipts exceed space provided.","For non-network hospitals, additional hospital details must be provided.","Preauthorization request form must be included with Part B.","Refer to checklist for claim documents to be submitted."],"title":"Secure Health Connect Policy – Claim Form","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Section A - Details of Primary Insured","fields":[{"help":"Enter the policy number as allotted by the insurance company","type":"text","label":"Policy Number","options":[],"required":null,"pdf_field":""},{"help":"Enter the social insurance or certificate number as allotted","type":"text","label":"SL No / Certificate No/ Claim Number (If any)","options":[],"required":null,"pdf_field":""},{"help":"Enter the TPA ID number as per IRDA license","type":"text","label":"Company/ TPA ID no","options":[],"required":null,"pdf_field":""},{"help":"Enter full name of the policyholder (Surname, First name, Middle name)","type":"text","label":"Name","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":"text","label":"City","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"State","options":[],"required":null,"pdf_field":""},{"help":"","type":"number","label":"Pin Code","options":[],"required":null,"pdf_field":""},{"help":"Include STD code with telephone number","type":"phone","label":"Phone No","options":[],"required":null,"pdf_field":""},{"help":"Enter complete email address","type":"email","label":"Email ID","options":[],"required":null,"pdf_field":""},{"help":"Enter ABHA ID if available","type":"text","label":"ABHA 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":"Enter full name of the insurance company","type":"text","label":"If YES, - Company Name","options":[],"required":false,"pdf_field":""},{"help":"Enter policy number as allotted","type":"text","label":"Policy Number","options":[],"required":false,"pdf_field":""},{"help":"Enter sum insured in rupees","type":"amount","label":"Sum Insured","options":[],"required":false,"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":""},{"help":"Use mm-yy format","type":"date","label":"DATE","options":[],"required":false,"pdf_field":""},{"help":"Enter diagnosis details","type":"text","label":"Diagnosis","options":[],"required":false,"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 full name of the insurance company","type":"text","label":"If Yes company name","options":[],"required":false,"pdf_field":""}],"filled_by":"insured person"},{"title":"Section C - Details of Insured Person Hospitalized","fields":[{"help":"Enter 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 in years and months","type":"number","label":"Age","options":[],"required":null,"pdf_field":""},{"help":"Use dd-mm-yy format","type":"date","label":"Date of Birth","options":[],"required":null,"pdf_field":""},{"help":"Tick the correct option or specify if Other","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 correct option or specify if Other","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":"Enter full postal address including street, city, and pin code","type":"text","label":"Address (If different from above)","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"City","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"State","options":[],"required":false,"pdf_field":""},{"help":"","type":"number","label":"Pin Code","options":[],"required":false,"pdf_field":""},{"help":"Include STD code","type":"phone","label":"Phone No","options":[],"required":false,"pdf_field":""},{"help":"Enter complete email address","type":"email","label":"Email ID","options":[],"required":false,"pdf_field":""}],"filled_by":"insured person"},{"title":"Section D - Details of Hospitalization","fields":[{"help":"Enter full hospital name","type":"text","label":"Name of the Hospital where admitted","options":[],"required":null,"pdf_field":""},{"help":"Tick the correct option","type":"choice","label":"Room Category Occupied: Day care / Single occupancy / Twin sharing / 3 or more","options":["Day care","Single occupancy","Twin sharing","3 or more"],"required":null,"pdf_field":""},{"help":"Tick the correct option","type":"choice","label":"Hospitalization due to: Illness / Injury","options":["Illness","Injury"],"required":null,"pdf_field":""},{"help":"Use dd-mm-yyyy format","type":"date","label":"Date of Injury / Disease first detected / 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 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 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 correct 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":false,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"If Medico legal: YES/ NO","options":["YES","NO"],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"Reported to Police: YES/ NO","options":["YES","NO"],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"MLC report or Police FIR attached: YES / NO","options":["YES","NO"],"required":null,"pdf_field":""},{"help":"Enter system of medicine followed","type":"text","label":"System of medicine","options":[],"required":false,"pdf_field":""},{"help":"Specify the source if applicable","type":"text","label":"Please specify if the hospitalization was arranged/referred through any of the following: Digital healthcare platform (Name), TPA/Insurance helpline / call centre (Name), Agent / intermediary, Direct hospital approach, Others (Please specify)","options":[],"required":false,"pdf_field":""}],"filled_by":"insured person"},{"title":"Section E - 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":"Enter amount in rupees","type":"amount","label":"Post Hospitalization Expenses","options":[],"required":null,"pdf_field":""},{"help":"Enter amount in rupees","type":"amount","label":"Health Check Up cost","options":[],"required":null,"pdf_field":""},{"help":"Enter amount in rupees","type":"amount","label":"Ambulance Charges","options":[],"required":null,"pdf_field":""},{"help":"Enter amount and code if applicable","type":"amount","label":"Others (Code)","options":[],"required":false,"pdf_field":""},{"help":"Enter total amount claimed","type":"amount","label":"Total","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":"Tick Yes or No","type":"yes-no","label":"Claim for Domiciliary Hospitalization: YES / NO","options":["YES","NO"],"required":null,"pdf_field":""},{"help":"Enter amount in rupees","type":"amount","label":"Detail of Lump Sum cash benefit claimed - Hospital Daily Cash","options":[],"required":false,"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 full bank name and branch","type":"text","label":"Bank Name/ Branch","options":[],"required":null,"pdf_field":""},{"help":"Enter name of beneficiary","type":"text","label":"Payable details: 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":"Use dd:mm:yy format","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Place","options":[],"required":true,"pdf_field":""},{"help":"Sign to confirm declaration","type":"signature","label":"Signature of the Insured","options":[],"required":true,"pdf_field":""}],"filled_by":"insured person"},{"title":"Part B - To be filled by the Hospital","fields":[{"help":"Enter full hospital name","type":"text","label":"Name of the Hospital","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Hospital ID","options":[],"required":false,"pdf_field":""},{"help":"Tick the correct option","type":"choice","label":"Type of Hospital: Network / Non Network","options":["Network","Non Network"],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Name of the treating Doctor","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Qualification","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Registration No with State Code","options":[],"required":false,"pdf_field":""},{"help":"","type":"phone","label":"Phone No","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Name of the patient","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"IP Registration Number","options":[],"required":false,"pdf_field":""},{"help":"","type":"choice","label":"Gender: Male/ Female","options":["Male","Female"],"required":true,"pdf_field":""},{"help":"","type":"number","label":"Age","options":[],"required":false,"pdf_field":""},{"help":"Use DD MM YYYY format","type":"date","label":"Date of Birth","options":[],"required":false,"pdf_field":""},{"help":"","type":"date","label":"Date of Admission","options":[],"required":true,"pdf_field":""},{"help":"Use hh:mm format","type":"text","label":"Time of Admission","options":[],"required":false,"pdf_field":""},{"help":"","type":"date","label":"Date of Discharge","options":[],"required":true,"pdf_field":""},{"help":"Use hh:mm format","type":"text","label":"Time of Discharge","options":[],"required":false,"pdf_field":""},{"help":"Tick the correct option","type":"choice","label":"Type of Admission: Emergency / Planned / Day-care / Maternity","options":["Emergency","Planned","Day-care","Maternity"],"required":true,"pdf_field":""},{"help":"","type":"date","label":"If Maternity Date of delivery","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Gravida Status","options":[],"required":false,"pdf_field":""},{"help":"Tick the correct 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":true,"pdf_field":""},{"help":"Enter total claimed amount in rupees","type":"amount","label":"Total Claimed Amount","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Ailment Diagnosed (Primary)","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"ICD 10 Code - Primary Diagnosis","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Details of Procedure/s done","options":[],"required":false,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"Pre authorization Obtained: YES/ NO","options":["YES","NO"],"required":true,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"Hospitalization due to Injury: Yes/ No","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Tick the correct option","type":"choice","label":"If Yes Give cause: Self-Inflicted / Road Traffic Accident / Substance Abuse / Alcohol Consumption","options":["Self-Inflicted","Road Traffic Accident","Substance Abuse","Alcohol Consumption"],"required":false,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"Reported to police: YES / NO","options":["YES","NO"],"required":false,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"Medico Legal: YES / NO","options":["YES","NO"],"required":false,"pdf_field":""},{"help":"","type":"text","label":"FIR No","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"If not reported to police, give reasons","options":[],"required":false,"pdf_field":""},{"help":"Attach report if Yes","type":"yes-no","label":"If injury due to Substance Abuse/ Alcohol consumption test conducted to establish this? YES/ NO","options":["YES","NO"],"required":false,"pdf_field":""},{"help":"","type":"text","label":"If authorization by network hospital not obtained, give reason","options":[],"required":false,"pdf_field":""},{"help":"Fill all applicable details","type":"text","label":"Details in case of Non network Hospital (only fill in case of non –network hospital): Address, City, State, Pin Code, Phone No, Registration no with state code, Hospital PAN, No of Inpatient Beds, Facilities in the Hospital (OT, ICU, Others)","options":[],"required":false,"pdf_field":""}],"filled_by":"hospital"}],"deadlines":[],"applies_to":"Health insurance claims under Secure Health Connect Policy","attachments":["Pharmacy Bill","Copy of the Claim Intimation, if any","Operation Theater Notes","Hospital Main Bill","ECG","Hospital Break Up Bill","Doctor’s request for investigation","Hospital Bill Payment Receipt","Investigation Reports (Including CT/MRI/USG/HPE)","Hospital Discharge Summary","Doctor’s Prescription","MLC report & Police FIR (if applicable)","Copy of Photo Id Card of Patient verified by the Hospital","Original Death Summary from Hospital where applicable","Original Preauthorization Request Form (for Part B)"],"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 authorization is given to TPA/insurance company to seek necessary medical information from hospitals or medical practitioners.","All bills and receipts for the claim have been included and no supplementary claims will be made.","This claim has not been or also been lodged with other insurers; total claim amount across all insurers shall not exceed actual admissible expenses.","Hospital declares that information furnished is true and correct; false statements will forfeit claim rights."],"dropped_labels":8},"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/707-secure-health-connect-policy-claim-form"}