{"id":724,"title":"CLAIM FORM FOR HEALTH INSURANCE POLICIES OTHER THAN TRAVEL AND PERSONAL ACCIDENT - PART A TO BE FILLED IN BY THE INSURED","purpose":"claim","insurer":{"slug":"magma-general-insurance","name":"Magma General Insurance Limited"},"source_pdf":"https://www.magmainsurance.com/documents/5553002/42694151/Claim+Form+%28Part+A%29_OneHealth+10.0.pdf/89d72e79-4284-60f4-d41e-bf05de4e8864?t=1789042555559","sha256":"6c7e78008607e14ba8b8b663b4bdc781f4ceb9ed4edcd89d31dbad47dd666fb7","pages":4,"collected":"2026-10-17","instructions":{"about":"This form is for filing health insurance claims by the insured person under policies other than travel and personal accident insurance.","notes":["Fill the form in block letters.","Provide active email ID only as claims correspondence will be sent to this email.","Attach original documents except for Hospital Cash benefit where photocopies are acceptable.","Attach cancelled cheque leaf of bank account in the name of primary insured without fail.","For new born baby cover, separate claim form to be filled and submitted.","For Fitness Reward points, fill separate form available on website.","Benefits under Cumulative Bonus, Early joining Benefit, Restoration of Sum Insured are automatic and need not be claimed separately.","Use dd-mm-yyyy format for dates and hh:mm format for times.","Retain copy of complete set of claim documents for your records."],"title":"CLAIM FORM FOR HEALTH INSURANCE POLICIES OTHER THAN TRAVEL AND PERSONAL ACCIDENT - PART A TO BE FILLED IN BY THE INSURED","submit":{"to":"Family Health Plan Insurance TPA Limited, Srinilaya - cyber spazio suite, 101,102, Ground Floor, Road No. 2, Banjara Hills, Hyderabad, Telangana 500034","how":"post","address":"Family Health Plan Insurance TPA Limited, Srinilaya - cyber spazio suite, 101,102, Ground Floor, Road No. 2, Banjara Hills, Hyderabad, Telangana 500034"},"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 No:","options":[],"required":null,"pdf_field":""},{"help":"Enter the social insurance or certificate number as allotted by the organisation","type":"text","label":"SI. No/ Certicate No:","options":[],"required":null,"pdf_field":""},{"help":"Enter the TPA ID number as per TPA documents","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, 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":"","type":"phone","label":"Landline (With STD Code):","options":[],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"Mobile No:","options":[],"required":null,"pdf_field":""},{"help":"Provide active email ID only as claims correspondence will be sent here","type":"email","label":"Email ID:","options":[],"required":null,"pdf_field":""},{"help":"","type":"email","label":"Alternate Email ID:","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"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:","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Tick the applicable policy type","type":"choice","label":"If yes, Policy Type:","options":["Individual","Group"],"required":false,"pdf_field":""},{"help":"Enter full name of the insurance company","type":"text","label":"Company Name:","options":[],"required":false,"pdf_field":""},{"help":"Enter policy number","type":"text","label":"Policy No.:","options":[],"required":false,"pdf_field":""},{"help":"Use dd-mm-yyyy format","type":"date","label":"Date of commencement of rst Insurance without break:","options":[],"required":false,"pdf_field":""},{"help":"Enter total sum insured in rupees","type":"amount","label":"Sum Insured (Rs.):","options":[],"required":false,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"Have you been hospitalised in the last four years since inception of the contract?","options":["Yes","No"],"required":null,"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:","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"},{"title":"SECTION C - DETAILS OF INSURED PERSON HOSPITALISED","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:","options":["Male","Female"],"required":null,"pdf_field":""},{"help":"Enter age in years","type":"number","label":"Age: Years","options":[],"required":null,"pdf_field":""},{"help":"Enter age in months","type":"number","label":"Months","options":[],"required":null,"pdf_field":""},{"help":"Use dd-mm-yyyy format","type":"date","label":"Date of Birth:","options":[],"required":null,"pdf_field":""},{"help":"Tick the applicable option 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":"Enter full postal address including City, State 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":"Complete email address","type":"email","label":"Email ID:","options":[],"required":false,"pdf_field":""},{"help":"Tick the applicable option or specify if Other","type":"choice","label":"Occupation:","options":["Service","Self Employed","Homemaker","Student","Retired","Other (Please specify)"],"required":null,"pdf_field":""},{"help":"Enter employer or firm name","type":"text","label":"Name of Employer/ Firm's Name:","options":[],"required":false,"pdf_field":""},{"help":"Enter full address of employer or firm","type":"text","label":"Address of the Employer/Firm:","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"SECTION D - DETAILS OF HOSPITALISATION","fields":[{"help":"Enter full name and address of hospital including City, State, Pin Code and Landmark","type":"text","label":"Name & Address of Hospital where Admitted:","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":"","type":"text","label":"Landmark:","options":[],"required":false,"pdf_field":""},{"help":"Tick the applicable room category or specify if Other","type":"choice","label":"Room Category occupied:","options":["Day care","Single occupancy","Twin sharing","3 or more beds per room","Other (Please specify)"],"required":null,"pdf_field":""},{"help":"Tick the applicable reason","type":"choice","label":"Hospitalisation due to:","options":["Injury","Illness","Maternity"],"required":null,"pdf_field":""},{"help":"Use dd-mm-yyyy format","type":"date","label":"Date of Injury / Date Disease rst detected / Date of Delivery:","options":[],"required":null,"pdf_field":""},{"help":"Use dd-mm-yyyy format","type":"date","label":"Date of Admission:","options":[],"required":null,"pdf_field":""},{"help":"Use hh:mm format","type":"text","label":"Time:","options":[],"required":null,"pdf_field":""},{"help":"Use dd-mm-yyyy format","type":"date","label":"Date of Discharge:","options":[],"required":null,"pdf_field":""},{"help":"Use hh:mm format","type":"text","label":"Time:","options":[],"required":null,"pdf_field":""},{"help":"Enter gravida status","type":"text","label":"Gravida Status:","options":[],"required":false,"pdf_field":""},{"help":"Tick the applicable cause","type":"choice","label":"If injury give cause:","options":["Self-inicted","Road Trafc Accident","Substance Abuse / Alcohol Consumption"],"required":false,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"If Medico Legal:","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"Reported to police:","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"MLC Report & Police FIR attached:","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Enter system of medicine followed in treatment","type":"text","label":"System of Medicine:","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"SECTION E - DETAILS OF CLAIM","fields":[{"help":"Enter amount claimed for treatment expenses in rupees","type":"amount","label":"Details of the other treatment expenses claimed","options":[],"required":false,"pdf_field":""},{"help":"Enter amount claimed for lump sum or cash benefit in rupees","type":"amount","label":"Details of Lump sum / cash benet claimed","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"SECTION F - DETAILS OF BILLS ENCLOSED","fields":[{"help":"Tick the relevant boxes and attach original documents except for Hospital Cash benefit where photocopies are acceptable","type":"checkbox","label":"Check List of Claim Documents to be submitted (In original)* - Please (P) tick relevant box","options":["Claim Form duly lled and signed","Copy of the Claim Intimation, if any","Hospital Bill Payment receipt","Hospital Main Bill","Hospital Break-up Bill","Doctor's request for investigation","Hospital Discharge Summary","Pharmacy Bill","Operation Theatre Notes","Investigation Reports (Including CT / MRI / USG / HPE / ECG)","Test report and prescription relating to rst consultation for the Illness","Doctor's prescription for medicines purchased outside the hospital","FIR / MLC in case of accident injury and English translation of the same if it is in any other language","KYC document (Address proof, ID proof only for claims exceeding `1 Lakh)","Original Death Summary (Wherever applicable)","Cancelled cheque leaf of the bank account held in the name of the primary insured (Mandatory)","Any Other"],"required":true,"pdf_field":""},{"help":"Provide receipt number, date and amount for each hospital main bill payment receipt","type":"table","label":"Hospital Main Bill Payment Receipts only","options":[],"required":false,"pdf_field":""},{"help":"List all bills with details; attach additional sheets if necessary","type":"table","label":"Sl. No, Bill No, Date, Issued by, Towards, Amount (Rs)","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"SECTION G - DETAILS OF PRIMARY INSURED's BANK ACCOUNT","fields":[{"help":"Enter Permanent Account Number as allotted by Income Tax department","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 full bank name and branch","type":"text","label":"Bank Name and Branch:","options":[],"required":null,"pdf_field":""},{"help":"Enter IFSC code of bank branch","type":"text","label":"IFSC Code:","options":[],"required":null,"pdf_field":""},{"help":"Enter cheque or demand draft payable details","type":"text","label":"Cheque/ DD Payable Details:","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"SECTION H - DECLARATION BY THE INSURED","fields":[{"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":""},{"help":"Sign the form","type":"signature","label":"Signature of the Insured:","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"}],"deadlines":[],"applies_to":"Health insurance policies other than travel and personal accident","attachments":["Claim Form duly filled and signed","Copy of the Claim Intimation, if any","Hospital Bill Payment receipt","Hospital Main Bill","Hospital Break-up Bill","Doctor's request for investigation","Hospital Discharge Summary","Pharmacy Bill","Operation Theatre Notes","Investigation Reports (Including CT / MRI / USG / HPE / ECG)","Test report and prescription relating to first consultation for the Illness","Doctor's prescription for medicines purchased outside the hospital","FIR / MLC in case of accident injury and English translation if in other language","KYC document (Address proof, ID proof only for claims exceeding ₹1 Lakh)","Original Death Summary (Wherever applicable)","Cancelled cheque leaf of the bank account held in the name of the primary insured (Mandatory)"],"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 is made or material fact is concealed, the right to claim shall be forfeited.","I consent and authorise TPA / insurance company to seek necessary medical information from any hospital or medical practitioner.","I declare that all bills and receipts for this claim are included and no supplementary claim will be made except for pre/post hospitalization and additional covers."],"dropped_labels":3},"pdf_fields":null,"fillable_pdf":false,"send_to":[{"purpose":"claim","channel":"address","value":"Magma General Insurance Limited (Claims Hub), Srinilaya Cyber Spazio Suite 101, 102, Ground Floor, Road No. 2, Banjara Hills, Hyderabad, Telangana – 500034","label":"Claims Hub Address","level":null,"hours":null,"applies_to":"health","source_url":"https://www.magmainsurance.com/learn-about-claims","quote":"fe takes an unexpected turn. When that moment comes, a clear and dependable claims process makes all the difference. At Magma General Insurance, our aim is to make the process simple to understand, transparent to follow, and supportive at every step. This page explains how claims work across Health, Motor and Non‑Motor policies.\nClaim is easy at Magma General Insurance.\nRegister Claim\nHealth","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"email","value":"customercare@magmainsurance.com","label":"Customer Care Email","level":null,"hours":null,"applies_to":"all","source_url":"https://www.magmainsurance.com/web/magmainsurance/claims","quote":"ma HDI General Insurance Company Limited) | All Rights Reserved\n| IRDAI Reg. No. 149 |\nwww.magmainsurance.com\n| E-mail:\ncustomercare@magmainsurance.com\n| Registered & Corporate Office: Equinox Business Park, Tower 3, Ambedkar Nagar, 2\nnd\nFloor, Unit Number 1B & 2B, LBS M","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"1800 266 3202","label":"Claims Intimation Toll Free Number","level":null,"hours":null,"applies_to":"all","source_url":"https://www.magmainsurance.com/web/magmainsurance/claims","quote":"surance Claims - Motor & Health Insurance Claim Process - Magma Insurance - Magma\nSkip to Content\nOne-Line-Hearder-Test\n1800 266 3202\nNavigation\nCustomer Service\nSenior Citizen Services\nRoad side Assistance\nAnnual Health Check-up\nPolicy Servicing assist","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/magma-general-insurance/724-claim-form-for-health-insurance-policies-other-than-travel-and-personal-accident"}