{"id":72,"title":"Health Claim Form","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_Kannada_0.pdf","sha256":"181909075fcc3e43591e43e57d5fe66c6bd7d36a56f5520dfad4a9281447ed4d","pages":11,"collected":"2026-10-17","instructions":{"about":"This form is used by the insured person to claim health insurance benefits from Bandhan Life. It collects details about the insured, insurance history, hospitalization, treatment, and claim expenses.","notes":["Form to be filled in block letters.","The issue of this form is not an admission of liability.","Please include the original preauthorization request form in lieu of PART A for Part B submission.","Use original bills only.","Attach all relevant documents as per the checklist.","Provide dates in DD/MM/YYYY format and times in HH:MM format.","Fill all applicable sections completely and accurately."],"title":"Health Claim Form","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Details Of Primary Insured","fields":[{"help":"","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":"6 digit postal code","type":"number","label":"Pincode","options":[],"required":null,"pdf_field":""},{"help":"Full postal address","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"Include STD code if applicable","type":"phone","label":"Phone No.","options":[],"required":null,"pdf_field":""},{"help":"","type":"email","label":"Email ID","options":[],"required":null,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Currently covered by any other Mediclaim/ Health Insurance","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Date in DD/MM/YYYY format","type":"date","label":"Date of commencement of first insurance without break","options":[],"required":null,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Previously covered by any other Mediclaim / Health Insurance","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Have you been hospitalized in last four years since inception of the contract?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide details of previous hospitalization","type":"text","label":"If yes, Please provide details","options":[],"required":null,"pdf_field":""},{"help":"Name of previous insurer if applicable","type":"text","label":"Company Name","options":[],"required":null,"pdf_field":""},{"help":"Previous policy number if applicable","type":"text","label":"Policy no.","options":[],"required":null,"pdf_field":""},{"help":"Sum assured amount in INR","type":"amount","label":"Sum Assured","options":[],"required":null,"pdf_field":""},{"help":"Date in DD/MM/YYYY format","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Diagnosis details","type":"text","label":"Diagnosis","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Details Of Hospitalisation","fields":[{"help":"Select 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":"Provide relevant date in DD/MM/YYYY format","type":"date","label":"Date of Injury/ Date Disease first detected/ Date of Delivery","options":[],"required":null,"pdf_field":""},{"help":"Select reason for hospitalization","type":"choice","label":"Hospitalization due to","options":["Injury","Illness","Maternity"],"required":null,"pdf_field":""},{"help":"Describe cause of injury","type":"text","label":"If Injury, give cause","options":[],"required":null,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Self Inflicted","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Road Traffic Accident","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Substance Abuse/ Alcohol Consumption","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"If Medico-Legal","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Reported to Police","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Attach MLC report and FIR if applicable","type":"yes-no","label":"MLC Report & Police FIR Attached","options":["Yes","No"],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Details Of Insured Person Hospitalised","fields":[{"help":"Name of the hospitalized insured person","type":"text","label":"Name","options":[],"required":null,"pdf_field":""},{"help":"Select gender","type":"choice","label":"Gender","options":["Male","Female","Third Gender"],"required":null,"pdf_field":""},{"help":"Date in DD/MM/YYYY format","type":"date","label":"Date of birth","options":[],"required":null,"pdf_field":""},{"help":"Age in completed years","type":"number","label":"Age (In Years)","options":[],"required":null,"pdf_field":""},{"help":"Select relationship or specify","type":"choice","label":"Relationship to Primary Insured","options":["Self","Spouse","Child","Father","Mother","Other (Please Specify)"],"required":null,"pdf_field":""},{"help":"Include STD code if applicable","type":"phone","label":"Phone No.","options":[],"required":null,"pdf_field":""},{"help":"","type":"email","label":"Email ID","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Details Of Hospitalization","fields":[{"help":"Full hospital name","type":"text","label":"Name of Hospital where admitted","options":[],"required":null,"pdf_field":""},{"help":"Date in DD/MM/YYYY format","type":"date","label":"Date of admission","options":[],"required":null,"pdf_field":""},{"help":"Date in DD/MM/YYYY format","type":"date","label":"Date of discharge","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Details Of Claim","fields":[{"help":"Amount in INR","type":"amount","label":"Pre-hospitalization Expenses","options":[],"required":null,"pdf_field":""},{"help":"Amount in INR","type":"amount","label":"Hospitalization Expenses","options":[],"required":null,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Claim for Domiciliary Hospitalization","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide details if domiciliary hospitalization claimed","type":"text","label":"If yes, provide details in annexure","options":[],"required":null,"pdf_field":""},{"help":"Amount in INR","type":"amount","label":"Post-hospitalization Expenses","options":[],"required":null,"pdf_field":""},{"help":"Amount in INR","type":"amount","label":"Health-Checkup Cost","options":[],"required":null,"pdf_field":""},{"help":"Amount in INR","type":"amount","label":"Ambulance Charges","options":[],"required":null,"pdf_field":""},{"help":"Specify code and amount","type":"amount","label":"Others (code)","options":[],"required":null,"pdf_field":""},{"help":"Number of days","type":"number","label":"Pre-hospitalization Period (Days)","options":[],"required":null,"pdf_field":""},{"help":"Number of days","type":"number","label":"Post-hospitalization Period (Days)","options":[],"required":null,"pdf_field":""},{"help":"Total amount in INR","type":"amount","label":"Total","options":[],"required":null,"pdf_field":""},{"help":"Include Hospital Daily Cash, Surgical Cash, Critical Illness benefit, Convalescence, Pre/Post Hospitalization Lump sum benefit, Others with amounts","type":"table","label":"Details of Lump sum/Cash benefit claimed","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Details Of Bills Enclosed","fields":[{"help":"Columns: 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":"Details Of Primary Insured’s Bank Accounts","fields":[{"help":"Permanent Account Number","type":"text","label":"PAN","options":[],"required":null,"pdf_field":""},{"help":"Bank account number for claim payment","type":"text","label":"Account Number","options":[],"required":null,"pdf_field":""},{"help":"Name of the bank","type":"text","label":"Bank Name","options":[],"required":null,"pdf_field":""},{"help":"Branch of the bank","type":"text","label":"Bank Branch","options":[],"required":null,"pdf_field":""},{"help":"Details of cheque or demand draft if applicable","type":"text","label":"Cheque/ DD Payable Details","options":[],"required":null,"pdf_field":""},{"help":"IFSC code of the 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":"Date of signing in DD/MM/YYYY format","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Place of signing","type":"text","label":"Place","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"},{"title":"Details Of Hospital (Part B)","fields":[{"help":"Select hospital type","type":"choice","label":"Type of Hospital","options":["Network","Non-Network"],"required":null,"pdf_field":""},{"help":"Hospital name","type":"text","label":"Name of the Hospital","options":[],"required":null,"pdf_field":""},{"help":"Hospital identification number","type":"text","label":"Hospital ID","options":[],"required":null,"pdf_field":""},{"help":"Doctor's name","type":"text","label":"Name of the Treating Doctor","options":[],"required":null,"pdf_field":""},{"help":"Doctor's qualification","type":"text","label":"Qualification","options":[],"required":null,"pdf_field":""},{"help":"Doctor's registration number with state code","type":"text","label":"Registration No. with State Code","options":[],"required":null,"pdf_field":""},{"help":"Doctor's phone number","type":"phone","label":"Phone No.","options":[],"required":null,"pdf_field":""}],"filled_by":"hospital"},{"title":"Details Of Patient Admitted (Part B)","fields":[{"help":"Patient's full name","type":"text","label":"Name of the Patient","options":[],"required":null,"pdf_field":""},{"help":"Inpatient registration number","type":"text","label":"IP Registration Number","options":[],"required":null,"pdf_field":""},{"help":"Date in DD/MM/YYYY format","type":"date","label":"Date of Admission","options":[],"required":null,"pdf_field":""},{"help":"Date in DD/MM/YYYY format","type":"date","label":"Date of Discharge","options":[],"required":null,"pdf_field":""},{"help":"Time in HH:MM format","type":"text","label":"Time of Discharge","options":[],"required":null,"pdf_field":""},{"help":"Age in years","type":"number","label":"Age","options":[],"required":null,"pdf_field":""},{"help":"Select gender","type":"choice","label":"Gender","options":["Male","Female"],"required":null,"pdf_field":""},{"help":"Select admission type","type":"choice","label":"Type of Admission","options":["Emergency","Planned","Daycare","Maternity"],"required":null,"pdf_field":""},{"help":"Select discharge status","type":"choice","label":"Status at time of discharge","options":["Discharge to home","Deceased","Discharge to another hospital"],"required":null,"pdf_field":""},{"help":"Specify gravida status","type":"text","label":"If Maternity - Gravida Status","options":[],"required":null,"pdf_field":""},{"help":"Date in DD/MM/YYYY format","type":"date","label":"Date of Delivery","options":[],"required":null,"pdf_field":""}],"filled_by":"hospital"},{"title":"Details Of Ailment Diagnosed (Primary)","fields":[{"help":"ICD 10 diagnostic codes","type":"text","label":"ICD 10 Codes","options":[],"required":null,"pdf_field":""},{"help":"Primary diagnosis description","type":"text","label":"Primary Diagnosis","options":[],"required":null,"pdf_field":""},{"help":"First procedure description","type":"text","label":"Procedure 1","options":[],"required":null,"pdf_field":""},{"help":"Second procedure description","type":"text","label":"Procedure 2","options":[],"required":null,"pdf_field":""},{"help":"Third procedure description","type":"text","label":"Procedure 3","options":[],"required":null,"pdf_field":""},{"help":"Select if pre-authorization obtained","type":"yes-no","label":"Pre-authorization obtained","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Pre-authorization reference number","type":"text","label":"Pre-authorization Number","options":[],"required":null,"pdf_field":""},{"help":"Explain reason for no authorization","type":"text","label":"If authorization by network hospital not obtained, give reason","options":[],"required":null,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Hospitalization due to injury","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Cause of injury","type":"text","label":"If yes, give cause","options":[],"required":null,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Self Inflicted","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Road traffic accident","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Substance abuse / alcohol consumption","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"If injury due to Substance Abuse / Alcohol Consumption, Test Conducted to establish this","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"If Medico-Legal","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Select Yes or No","type":"yes-no","label":"Reported to Police","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Police FIR number","type":"text","label":"FIR No","options":[],"required":null,"pdf_field":""},{"help":"Reason for not reporting","type":"text","label":"If not reported to Police, give reason","options":[],"required":null,"pdf_field":""}],"filled_by":"hospital"},{"title":"Claim Documents Submitted - Check List","fields":[{"help":"Tick if signed","type":"checkbox","label":"Claim Form Duly Signed","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Attach if available","type":"checkbox","label":"Copy of the Claim Intimation (if any)","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Attach main hospital bill","type":"checkbox","label":"Hospital Main Bill","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Attach break-up bill","type":"checkbox","label":"Hospital Break-up Bill","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Attach payment receipt","type":"checkbox","label":"Hospital Bill Payment Receipt","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Attach discharge summary","type":"checkbox","label":"Hospital Discharge Summary","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Attach pharmacy bills","type":"checkbox","label":"Pharmacy Bill","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Attach operation theatre notes","type":"checkbox","label":"Operation Theatre Notes","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Attach doctor's investigation request","type":"checkbox","label":"Doctor’s Request for Investigation","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Attach ECG report","type":"checkbox","label":"ECG","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Attach investigation reports","type":"checkbox","label":"Investigation Reports (Including CT/ MRI/ USG/ HPE)","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Attach prescriptions","type":"checkbox","label":"Doctor’s Prescriptions","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Specify other documents attached","type":"text","label":"Others","options":[],"required":null,"pdf_field":""}],"filled_by":"insured / hospital"},{"title":"Declaration By The Hospital","fields":[{"help":"Authorized signatory's signature and seal","type":"signature","label":"Signature and Seal of the Hospital Authority","options":[],"required":true,"pdf_field":""},{"help":"Date of signing in DD/MM/YYYY format","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"},{"title":"Details In Case Of Non Network Hospital","fields":[{"help":"City of hospital","type":"text","label":"City","options":[],"required":null,"pdf_field":""},{"help":"State of hospital","type":"text","label":"State","options":[],"required":null,"pdf_field":""},{"help":"6 digit postal code","type":"number","label":"Pincode","options":[],"required":null,"pdf_field":""},{"help":"Full hospital address","type":"text","label":"Address of the Hospital","options":[],"required":null,"pdf_field":""},{"help":"Hospital phone number","type":"phone","label":"Phone No.","options":[],"required":null,"pdf_field":""},{"help":"Permanent Account Number of hospital","type":"text","label":"Hospital PAN","options":[],"required":null,"pdf_field":""},{"help":"Number of inpatient beds in hospital","type":"number","label":"Number of inpatient beds","options":[],"required":null,"pdf_field":""},{"help":"Hospital registration number with state code","type":"text","label":"Registration No. with State Code","options":[],"required":null,"pdf_field":""},{"help":"Tick available facilities","type":"checkbox","label":"Facilities available in the hospital","options":["OT","ICU","Others"],"required":null,"pdf_field":""}],"filled_by":"hospital"}],"deadlines":[],"applies_to":"","attachments":["MLC Report & Police FIR if applicable","Hospital Main Bill","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","Copy of the Claim Intimation (if any)","Copy of the Pre-authorization Approval Letter","Original Pre-authorization request","Copy of Photo ID Card of Patient Verified by Hospital","Original Death Summary from Hospital Where Applicable"],"declarations":["The information furnished in this claim form is true and correct to the best of the insured's knowledge and belief.","False or untrue statements, suppression or concealment of material facts will forfeit the right to claim reimbursement.","Consent and authorization is given to TPA/Insurance company to seek necessary medical information from hospitals or medical practitioners.","All bills/receipts for the claim are included and no supplementary claim will be made except pre/post-hospitalization claims if any.","The hospital declares that the information furnished is true and correct to the best of their knowledge and belief.","False or untrue statements by the hospital will forfeit their right to claim under this claim."],"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/72-health-claim-form"}