{"id":732,"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/5553002/0/Claim+Form+%28Part+A%29+%E2%80%93+OneHealth+Extra+Cover.pdf/eb176a91-231e-e9f3-2619-a42e57bd7fba?t=1789044328180","sha256":"3f848d15784bf0626bc86a633fa6c49499813358270bbef75b55d1b75437a537","pages":4,"collected":"2026-10-17","instructions":{"about":"This form is for filing health insurance claims under policies other than travel and personal accident. It is to be filled by the insured person or policyholder.","notes":["Fill the form in block letters.","Use original bills only 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 'Fitness reward earning claim form' available on website.","Benefits under Cumulative Bonus, Early joining Benefit, Restoration of Sum Insured are provided automatically; no separate claim needed.","If claim is for accidental injuries, provide details of date, time and circumstances of accident event.","Use dd-mm-yy format for dates and hh:mm format for times."],"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 number or certificate number of social health insurance scheme","type":"text","label":"SI. No/ Certicate No:","options":[],"required":null,"pdf_field":""},{"help":"Enter the TPA ID number as allotted by IRDA and printed in TPA documents","type":"text","label":"Company/ TPA ID No:","options":[],"required":null,"pdf_field":""},{"help":"Enter the full name of the policyholder (Surname, First name, Middle name)","type":"text","label":"Name:","options":[],"required":null,"pdf_field":""},{"help":"Enter the 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 with telephone number","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 to this email ID","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 appropriate policy type if currently covered","type":"choice","label":"If yes, Policy Type:","options":["Individual","Group"],"required":false,"pdf_field":""},{"help":"Enter the full name of the insurance company if currently covered","type":"text","label":"Company Name:","options":[],"required":false,"pdf_field":""},{"help":"Enter the policy number if currently covered","type":"text","label":"Policy No.:","options":[],"required":false,"pdf_field":""},{"help":"Enter the total sum insured as per the policy in rupees","type":"amount","label":"Sum Insured (Rs.):","options":[],"required":null,"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 if hospitalised in last four years","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 the full name of the insurance company if previously covered","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 (Surname, First name, Middle name)","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 and months","type":"number","label":"Age: Years Months","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 appropriate 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 with telephone number","type":"phone","label":"Phone No:","options":[],"required":false,"pdf_field":""},{"help":"Complete e-mail address","type":"email","label":"Email ID:","options":[],"required":false,"pdf_field":""},{"help":"Tick the appropriate option or specify if Other","type":"choice","label":"Occupation:","options":["Service","Self Employed","Homemaker","Student","Retired","Other (Please specify)"],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Name of Employer/ Firm's Name:","options":[],"required":false,"pdf_field":""},{"help":"Include Street, City and Pin Code","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 appropriate 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 appropriate reason","type":"choice","label":"Hospitalisation due to:","options":["Injury","Illness","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:","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:","options":[],"required":null,"pdf_field":""},{"help":"Enter Gravida Status","type":"text","label":"Gravida Status:","options":[],"required":false,"pdf_field":""},{"help":"Tick the appropriate cause","type":"choice","label":"If injury give cause:","options":["Self-inflicted","Road Traffic 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 the system of medicine followed in treating the patient","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 as treatment expenses in rupees (no paise)","type":"amount","label":"Details of the other treatment expenses 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 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 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; attach separate sheet if necessary","type":"table","label":"Hospital Main Bill Payment Receipts only - Receipt No., Date, Amount (Rs)","options":[],"required":false,"pdf_field":""},{"help":"Provide details of all bills including pre-hospitalisation, post-hospitalisation and pharmacy bills; attach additional sheets if needed","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 the Permanent Account Number as allotted by the Income Tax department","type":"text","label":"PAN:","options":[],"required":null,"pdf_field":""},{"help":"Enter the bank account number","type":"text","label":"Account Number:","options":[],"required":null,"pdf_field":""},{"help":"Enter the bank name along with the branch","type":"text","label":"Bank Name and Branch:","options":[],"required":null,"pdf_field":""},{"help":"Enter the IFSC code of the bank branch","type":"text","label":"IFSC Code:","options":[],"required":null,"pdf_field":""},{"help":"Enter cheque or demand draft payable details if applicable","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-yy 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 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)"],"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 suppressed or concealed, the right to claim shall be forfeited.","Consent and authorisation is given to TPA / insurance company to seek necessary medical information/documents from any hospital or medical practitioner who attended the person for whom this claim is made.","All bills and receipts for the purpose of this claim are included and no supplementary claim will be made except pre/post hospitalization claim and for additional covers, if any."],"dropped_labels":8},"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/732-claim-form-for-health-insurance-policies-other-than-travel-and-personal-accident"}