{"id":751,"title":"Claim Form (Part B) – Saksham Health Insurance","purpose":"claim","insurer":{"slug":"magma-general-insurance","name":"Magma General Insurance Limited"},"source_pdf":"https://www.magmainsurance.com/documents/5553002/0/Claim+Form+%28Part+B%29+%E2%80%93+Saksham+Health+Insurance.pdf/c44624d0-58bb-bb1c-897f-0afcdda07428?t=1789044412347","sha256":"7454d9e44a0fabd2de4c04334c90c8d4ebea962bd87f09113b5661811e92ecab","pages":4,"collected":"2026-10-17","instructions":{"about":"This form is for hospital use to provide detailed information about the patient, hospital, diagnosis, and treatment for processing a health insurance claim under Saksham Health Insurance.","notes":["Please include the original pre-authorisation request form in lieu of PART A.","Use block letters to fill the form.","Use dd-mm-yyyy format for dates and hh:mm format for times.","Attach all relevant investigation reports and documents as per the checklist.","Authorisation Letter is mandatory and must be signed by proposer and patient.","This form is to be filled by the hospital only."],"title":"Claim Form (Part B) – Saksham Health Insurance","submit":{"to":"Family Health Plan Insurance TPA Limited","how":"post","address":"Srinilaya - cyber spazio suite, 101,102,Ground Floor, Road No. 2, Banjara Hills, Hyderabad, Telangana 500034"},"purpose":"claim","sections":[{"title":"SECTION A - DETAILS OF HOSPITAL","fields":[{"help":"Enter the full name of the hospital","type":"text","label":"a) Name of the hospital:","options":[],"required":null,"pdf_field":""},{"help":"Enter the hospital ID as allocated by the TPA","type":"text","label":"b) Hospital ID:","options":[],"required":null,"pdf_field":""},{"help":"Tick the appropriate option","type":"choice","label":"c) Type of Hospital:","options":["Network","Non-Network"],"required":null,"pdf_field":""},{"help":"Enter the full name of the treating doctor","type":"text","label":"d) Name of the treating doctor:","options":[],"required":null,"pdf_field":""},{"help":"Enter the educational qualifications of the doctor","type":"text","label":"e) Qualification:","options":[],"required":null,"pdf_field":""},{"help":"Enter the doctor's registration number with state code as allocated by Medical Council of India","type":"text","label":"f) Registration No. with State Code:","options":[],"required":null,"pdf_field":""},{"help":"Include STD code with telephone number","type":"phone","label":"g) Phone No.:","options":[],"required":null,"pdf_field":""}],"filled_by":"hospital"},{"title":"SECTION B - DETAILS OF THE PATIENT ADMITTED","fields":[{"help":"Enter the full name of the patient","type":"text","label":"a) Name of the Patient:","options":[],"required":null,"pdf_field":""},{"help":"Enter the insurance provider registration number allotted by the insurer","type":"text","label":"b) IP Registration Number:","options":[],"required":null,"pdf_field":""},{"help":"Tick the appropriate gender","type":"choice","label":"c) Gender:","options":["Male","Female"],"required":null,"pdf_field":""},{"help":"Enter age in years and months","type":"text","label":"d) Age:","options":[],"required":null,"pdf_field":""},{"help":"Use dd-mm-yyyy format","type":"date","label":"e) Date of birth:","options":[],"required":null,"pdf_field":""},{"help":"Use dd-mm-yyyy format","type":"date","label":"f) Date of Admission:","options":[],"required":null,"pdf_field":""},{"help":"Use hh:mm format","type":"text","label":"g) Time:","options":[],"required":null,"pdf_field":""},{"help":"Use dd-mm-yyyy format","type":"date","label":"h) Date of Discharge:","options":[],"required":null,"pdf_field":""},{"help":"Use hh:mm format","type":"text","label":"I) Time:","options":[],"required":null,"pdf_field":""},{"help":"Enter date of delivery if maternity case, use dd-mm-yyyy format","type":"date","label":"k) If Maternity: i. Date of Delivery:","options":[],"required":null,"pdf_field":""},{"help":"Tick the appropriate status","type":"choice","label":"l) Status at time of discharge:","options":["Discharge to home","Discharge to another hospital","Deceased"],"required":null,"pdf_field":""},{"help":"Enter total amount claimed in rupees (no paise)","type":"amount","label":"m) Total amount claimed:","options":[],"required":null,"pdf_field":""}],"filled_by":"hospital"},{"title":"SECTION C - DETAILS OF AILMENT DIAGNOSED (PRIMARY)","fields":[{"help":"Enter ICD 10 Code and description of primary diagnosis","type":"text","label":"Primary Diagnosis:","options":[],"required":null,"pdf_field":""},{"help":"Enter ICD 10 Code and description of additional diagnosis","type":"text","label":"Additional Diagnosis:","options":[],"required":null,"pdf_field":""},{"help":"Enter ICD 10 Code and description of co-morbidities","type":"text","label":"Co-morbidities:","options":[],"required":null,"pdf_field":""},{"help":"Enter ICD 10 PCS code and description of first procedure","type":"text","label":"Procedure 1:","options":[],"required":null,"pdf_field":""},{"help":"Enter ICD 10 PCS code and description of second procedure","type":"text","label":"Procedure 2:","options":[],"required":null,"pdf_field":""},{"help":"Enter ICD 10 PCS code and description of third procedure","type":"text","label":"Procedure 3:","options":[],"required":null,"pdf_field":""},{"help":"Enter details of the procedure","type":"text","label":"Details of Procedure:","options":[],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"Whether pre-authorisation obtained:","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter pre-authorisation number allotted by TPA","type":"text","label":"If Yes, pre-authorisation Number:","options":[],"required":null,"pdf_field":""},{"help":"Enter reason for not obtaining pre-authorisation","type":"text","label":"If authorisation by network hospital not obtained, give reason:","options":[],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"Hospitalisation due to injury:","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Tick the appropriate cause","type":"choice","label":"If Yes, give cause:","options":["Self-inflicted","Road Traffic Accident","Substance abuse / alcohol consumption","Other"],"required":null,"pdf_field":""},{"help":"Tick Yes or No and attach reports if Yes","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":"Tick Yes or No","type":"yes-no","label":"If Medico Legal:","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"Reported to the police:","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter FIR number if applicable","type":"text","label":"FIR No.:","options":[],"required":null,"pdf_field":""},{"help":"Enter reason if police report not filed","type":"text","label":"If not reported to the police, give reason:","options":[],"required":null,"pdf_field":""},{"help":"Enter date in dd-mm-yyyy format","type":"date","label":"When did the patient start suffering of the complaint: Date of first consultation:","options":[],"required":null,"pdf_field":""},{"help":"Enter previous medical history","type":"text","label":"Please give previous medical history of the patient:","options":[],"required":null,"pdf_field":""},{"help":"For each disease, indicate Yes/No and duration in years and months","type":"table","label":"Is the patient suffering from any of the following diseases? If \"Yes\" Please mention the duration below.","options":[],"required":null,"pdf_field":""},{"help":"Tick Yes or No and provide details if Yes","type":"yes-no","label":"Is the ailment a complication / sequel of a pre-existing disease or condition?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Tick Yes or No; if Yes, state number of years and quantity consumed per day","type":"yes-no","label":"History of alcoholism","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Tick Yes or No; if Yes, state number of years and units consumed per day","type":"yes-no","label":"History of smoking / tobacco chewing:","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Tick the appropriate type of admission","type":"choice","label":"Type of Admission:","options":["Emergency","Planned","Day Care","Maternity"],"required":null,"pdf_field":""}],"filled_by":"hospital"},{"title":"SECTION E - ADDITIONAL DETAILS IN CASE OF NON-NETWORK HOSPITAL","fields":[{"help":"Enter full postal address including city, state, and pincode","type":"text","label":"a) Address of the hospital:","options":[],"required":null,"pdf_field":""},{"help":"Enter city","type":"text","label":"City:","options":[],"required":null,"pdf_field":""},{"help":"Enter state","type":"text","label":"State:","options":[],"required":null,"pdf_field":""},{"help":"Enter postal pincode","type":"number","label":"Pincode:","options":[],"required":null,"pdf_field":""},{"help":"Include STD code with telephone number","type":"phone","label":"b) Phone No:","options":[],"required":null,"pdf_field":""},{"help":"Enter hospital registration number with state code","type":"text","label":"c) Registration No. with State Code:","options":[],"required":null,"pdf_field":""},{"help":"Enter hospital Permanent Account Number","type":"text","label":"d) Hospital PAN:","options":[],"required":null,"pdf_field":""},{"help":"Enter number of inpatient beds","type":"number","label":"e) Number of Inpatient beds:","options":[],"required":null,"pdf_field":""},{"help":"Tick all applicable facilities; specify others if any","type":"checkbox","label":"f) Facilities available in the hospital:","options":["OT","ICU","Round the clock Doctor / Nurses","Maintains daily record of patients","Others"],"required":null,"pdf_field":""}],"filled_by":"hospital"},{"title":"SECTION F - DECLARATION BY THE HOSPITAL","fields":[{"help":"Enter date in dd-mm-yyyy 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 and stamp the form","type":"signature","label":"Signature and Seal of the Hospital Authority:","options":[],"required":true,"pdf_field":""}],"filled_by":"hospital"},{"title":"SECTION D - CLAIM DOCUMENTS SUBMITTED - CHECK LIST","fields":[{"help":"Tick if submitted","type":"checkbox","label":"Claim Form duly signed","options":[],"required":null,"pdf_field":""},{"help":"Tick if submitted","type":"checkbox","label":"Investigation reports","options":[],"required":null,"pdf_field":""},{"help":"Tick if submitted","type":"checkbox","label":"Original pre-authorisation request","options":[],"required":null,"pdf_field":""},{"help":"Tick if submitted","type":"checkbox","label":"CT/MR/USG/HPE investigation reports","options":[],"required":null,"pdf_field":""},{"help":"Tick if submitted","type":"checkbox","label":"Copy of the pre-authorisation approval letter","options":[],"required":null,"pdf_field":""},{"help":"Tick if submitted","type":"checkbox","label":"Doctor's reference slip for investigation","options":[],"required":null,"pdf_field":""},{"help":"Tick if submitted","type":"checkbox","label":"Copy of photo ID card of patient verified by hospital","options":[],"required":null,"pdf_field":""},{"help":"Tick if submitted","type":"checkbox","label":"ECG","options":[],"required":null,"pdf_field":""},{"help":"Tick if submitted","type":"checkbox","label":"Hospital discharge summary","options":[],"required":null,"pdf_field":""},{"help":"Tick if submitted","type":"checkbox","label":"Pharmacy bills","options":[],"required":null,"pdf_field":""},{"help":"Tick if submitted","type":"checkbox","label":"Operation theatre notes","options":[],"required":null,"pdf_field":""},{"help":"Tick if submitted","type":"checkbox","label":"MLC report & Police FIR","options":[],"required":null,"pdf_field":""},{"help":"Tick if submitted","type":"checkbox","label":"Hospital main bill","options":[],"required":null,"pdf_field":""},{"help":"Tick if submitted","type":"checkbox","label":"Original death summary from hospital where applicable","options":[],"required":null,"pdf_field":""},{"help":"Tick if submitted","type":"checkbox","label":"Hospital break-up bill","options":[],"required":null,"pdf_field":""},{"help":"Specify any other documents submitted","type":"text","label":"Other, please specify","options":[],"required":false,"pdf_field":""}],"filled_by":"hospital"}],"deadlines":[],"applies_to":"","attachments":["Claim Form duly signed","Investigation reports","Original pre-authorisation request","CT/MR/USG/HPE investigation reports","Copy of the pre-authorisation approval letter","Doctor's reference slip for investigation","Copy of photo ID card of patient verified by hospital","ECG","Hospital discharge summary","Pharmacy bills","Operation theatre notes","MLC report & Police FIR","Hospital main bill","Original death summary from hospital where applicable","Hospital break-up bill"],"declarations":["The information furnished in this Claim Form is true and correct to the best of our knowledge and belief.","If any false or untrue statement is made or material fact is concealed, the right to claim under this claim shall be forfeited.","The issuance of this Form is not to be taken as an admission of liability.","I consent and authorise M/s Magma General Insurance Limited and their Authorised Service Providers to seek medical information from the hospital and share relevant medical records."],"dropped_labels":1},"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/751-claim-form-part-b-saksham-health-insurance"}