{"id":710,"title":"Liberty Health Connect Policy – Claim form","purpose":"claim","insurer":{"slug":"liberty-general-insurance","name":"Liberty General Insurance Limited"},"source_pdf":"https://www.libertyinsurance.in/Docx/Liberty%20Health%20Connect%20-%20Claim%20Form_UIN-LIBHLIP26039V062526_w.e.f_01.07.2025.pdf","sha256":"426274cdba8e8001095c7dc2960e38b7effc03ddff54695e4cff7570035381e0","pages":10,"collected":"2026-10-17","instructions":{"about":"This form is for filing a health insurance claim under the Liberty Health Connect Policy. It is filled by the insured person and the hospital.","notes":["Use block letters to fill the form.","Use original bills only.","Dates should be in dd-mm-yy or dd-mm-yyyy format as specified.","Times should be in hh:mm format.","Tick the appropriate options where applicable.","Attach separate sheets if additional space is needed for bills or details.","Part B of the claim form is to be filled by the hospital.","Preauthorization request form must be included with Part B.","For domiciliary hospitalization claims, provide details on annexure.","If injury is due to substance abuse or alcohol, attach test report if conducted.","If hospital is non-network, fill additional hospital details in Part B."],"title":"Liberty 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 insurer","type":"text","label":"Policy Number:","options":[],"required":null,"pdf_field":""},{"help":"Enter social insurance or claim number if any","type":"text","label":"SL No / Certificate No/ Claim Number (If any):","options":[],"required":false,"pdf_field":""},{"help":"Enter the TPA ID number","type":"text","label":"Company/ TPA ID no","options":[],"required":null,"pdf_field":""},{"help":"Enter full name of the primary insured","type":"text","label":"Name","options":[],"required":true,"pdf_field":""},{"help":"Enter full postal address including street, city, state, 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","type":"phone","label":"Phone No:","options":[],"required":null,"pdf_field":""},{"help":"Enter complete email address","type":"email","label":"Email ID:","options":[],"required":false,"pdf_field":""},{"help":"Enter ABHA ID if available","type":"text","label":"ABHA ID:","options":[],"required":false,"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":true,"pdf_field":""},{"help":"Use dd-mm-yy format","type":"date","label":"Date of commencement of first Insurance without break: dd mm yy","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 of other insurance","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":"Enter health card number if any","type":"text","label":"Health Card Number:","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":true,"pdf_field":""},{"help":"Use mm-yy format","type":"date","label":"DATE : MM YY","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":false,"pdf_field":""},{"help":"Enter company name","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 hospitalized person","type":"text","label":"Name:","options":[],"required":true,"pdf_field":""},{"help":"Tick Male or Female","type":"choice","label":"Gender: Male / Female","options":["Male","Female"],"required":true,"pdf_field":""},{"help":"Enter age in years and months","type":"number","label":"Age: …. Years …. Months","options":[],"required":true,"pdf_field":""},{"help":"Use dd-mm-yy format","type":"date","label":"Date of Birth : DD MM YY","options":[],"required":true,"pdf_field":""},{"help":"Tick the correct option and 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":true,"pdf_field":""},{"help":"Tick the correct option and 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":true,"pdf_field":""},{"help":"Enter full postal address including city, state, 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":true,"pdf_field":""},{"help":"Tick the correct room category","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":true,"pdf_field":""},{"help":"Tick the correct reason","type":"choice","label":"Hospitalization due to : Illness / Injury / Maternity","options":["Illness","Injury","Maternity"],"required":true,"pdf_field":""},{"help":"Use dd-mm-yyyy format","type":"date","label":"Date of Injury / Disease first detected / Date of Delivery: DD MM YYYY","options":[],"required":true,"pdf_field":""},{"help":"Use dd-mm-yy format","type":"date","label":"Date of Admission: DD MM YY","options":[],"required":true,"pdf_field":""},{"help":"Use hh:mm format","type":"text","label":"Time : HH MM","options":[],"required":true,"pdf_field":""},{"help":"Use dd-mm-yy format","type":"date","label":"Date of Discharge: DD MM YY","options":[],"required":true,"pdf_field":""},{"help":"Use hh:mm format","type":"text","label":"Time : HH MM","options":[],"required":true,"pdf_field":""},{"help":"Tick the correct cause if injury","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":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":"MLC report or Police FIR attached: YES / NO","options":["YES","NO"],"required":false,"pdf_field":""},{"help":"Enter system of medicine","type":"text","label":"System of medicine","options":[],"required":false,"pdf_field":""}],"filled_by":"insured person"},{"title":"Section E - Details of Claim","fields":[{"help":"Enter amounts in rupees for: 1. Pre Hospitalization Expenses, 2. Hospitalization Expenses, 3. Post Hospitalization Expenses, 4. Health Check Up cost, 5. Ambulance Charges, 6. Others (Code), and Total","type":"table","label":"Details of Treatment Expenses Claimed","options":[],"required":true,"pdf_field":""},{"help":"Enter number of days","type":"number","label":"Pre Hospitalization Period : _days","options":[],"required":false,"pdf_field":""},{"help":"Enter number of days","type":"number","label":"Hospitalization Period : _days","options":[],"required":false,"pdf_field":""},{"help":"Tick Yes or No; if Yes provide details on annexure","type":"yes-no","label":"Claim for Domiciliary Hospitalization : YES / NO","options":["YES","NO"],"required":false,"pdf_field":""},{"help":"Enter amounts in rupees for Hospital Daily Cash, Surgical cash, Critical Illness, Convalescence, Pre Post Lump Sum, Vector Borne Disease Benefit, EMI Protector Benefit, Other, and Total","type":"table","label":"Detail of Lump Sum cash benefit claimed","options":[],"required":false,"pdf_field":""}],"filled_by":"insured person"},{"title":"Section F - Details of Bills Enclosed","fields":[{"help":"Provide Sl. No, Bill No, Date, Issued by, Towards, Amount for Hospital Main Bill, Pre Hospitalization, Post Hospitalization, Pharmacy Bills, and Total. Attach separate sheet if needed.","type":"table","label":"Details of bills enclosed","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":false,"pdf_field":""},{"help":"Enter bank account number","type":"text","label":"Account Number","options":[],"required":true,"pdf_field":""},{"help":"Enter full bank name and branch","type":"text","label":"Bank Name/ Branch:","options":[],"required":true,"pdf_field":""},{"help":"Enter name to whom payment is payable","type":"text","label":"Payable details: Cheque/ DD/NEFT* Payable to:","options":[],"required":true,"pdf_field":""},{"help":"Enter IFSC code of the bank branch","type":"text","label":"IFSC Code:","options":[],"required":true,"pdf_field":""}],"filled_by":"insured person"},{"title":"Section H - Declaration by the Insured","fields":[{"help":"Enter date of signing in dd:mm:yy format","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 the form","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 full hospital name","type":"text","label":"Name of the Hospital","options":[],"required":true,"pdf_field":""},{"help":"Enter hospital ID","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":"Fill section E if hospital is non-network","type":"text","label":"If Non Network fill sec E","options":[],"required":false,"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":false,"pdf_field":""},{"help":"Enter registration number with state code","type":"text","label":"Registration No with State Code:","options":[],"required":false,"pdf_field":""},{"help":"Enter phone number","type":"phone","label":"Phone No:","options":[],"required":false,"pdf_field":""},{"help":"Enter inpatient registration number","type":"text","label":"IP Registration Number","options":[],"required":false,"pdf_field":""},{"help":"Tick Male or Female","type":"choice","label":"Gender: Male/ Female","options":["Male","Female"],"required":true,"pdf_field":""},{"help":"Enter age","type":"number","label":"Age","options":[],"required":true,"pdf_field":""},{"help":"Use dd-mm-yyyy format","type":"date","label":"Date of Birth: DD MM YYYY","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":"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":"Enter date of delivery if maternity","type":"date","label":"If Maternity Date of delivery","options":[],"required":false,"pdf_field":""},{"help":"Enter gravida status","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":"Enter primary ailment diagnosed","type":"text","label":"Ailment Diagnosed (Primary)","options":[],"required":true,"pdf_field":""},{"help":"Enter ICD 10 code","type":"text","label":"ICD 10 Code","options":[],"required":false,"pdf_field":""},{"help":"Enter diagnosis description","type":"text","label":"Diagnosis Description","options":[],"required":false,"pdf_field":""},{"help":"Enter details of procedures done","type":"text","label":"Details of Procedure/s done","options":[],"required":false,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"Pre authorization YES/ NO","options":["YES","NO"],"required":false,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"Hospitalization Yes/ No","options":["YES","NO"],"required":false,"pdf_field":""},{"help":"Tick correct cause","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":"Enter FIR number if applicable","type":"text","label":"FIR No","options":[],"required":false,"pdf_field":""},{"help":"Explain reason if police not informed","type":"text","label":"If not reported to police, give reasons","options":[],"required":false,"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 to establish this? If YES please attach Report YES/ NO","options":["YES","NO"],"required":false,"pdf_field":""},{"help":"Explain reason if preauthorization not obtained","type":"text","label":"If authorization by network hospital not obtained, give reason","options":[],"required":false,"pdf_field":""},{"help":"Fill address, city, state, pin code, phone no, registration no, hospital PAN, number of inpatient beds, and facilities","type":"text","label":"Details in case of Non network Hospital (only fill in case of non –network hospital)","options":[],"required":false,"pdf_field":""},{"help":"Tick applicable facilities","type":"checkbox","label":"Facilities in the Hospital OT □ Yes □ No ICU □ Yes □ No Others","options":["OT","ICU","Others"],"required":false,"pdf_field":""}],"filled_by":"hospital"},{"title":"Declaration by the Hospital","fields":[{"help":"Hospital authority to sign and seal","type":"signature","label":"SEAL & SIGNATURE OF THE HOSPITAL AUTHORITY","options":[],"required":true,"pdf_field":""},{"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":""}],"filled_by":"hospital"}],"deadlines":[],"applies_to":"Health insurance claims under Liberty Health Connect Policy","attachments":["Copy of the Claim Intimation, if any","Hospital Main Bill","Hospital Break Up Bill","Payment Receipt","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 (if applicable)","Original Death Summary from Hospital where applicable","Original Preauthorization Request Form (for Part B)","Copy of Pre-Authorisation Approval Letter","Copy of Photo Id Card of Patient verified by the Hospital"],"declarations":["The information furnished in this claim form is true and correct to the best of my knowledge and belief.","False or untrue statements or concealment of material facts will forfeit the right to claim reimbursement.","Consent is given to 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 is given to Liberty General Insurance Limited to process/share personal information with group companies or service providers for insurance and related products.","The hospital declares that the information furnished is true and correct to the best of their knowledge and belief.","False or untrue statements or concealment of material facts by the hospital will forfeit the right to claim under the policy."],"dropped_labels":3},"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/710-liberty-health-connect-policy-claim-form"}