Checklist PDF

Toll Free No: 1800220102
crm@healthindiatpa.com
HEALTHINDIA INSURANCE TPA SERVICES PVT LTD

NeelKanth Corporate Park
406-412, 4th Floor, Kirol Road / Village
Vidya Vihar Society, Vidyavihar,
Mumbai – 400086
Web: www.healthindiatpa.com
CHECKLIST OF ENCLOSURES FOR SUBMISSION OF CLAIM
[Please tick the appropriate [ ] box]
Name of the claimant: …………………………………………………………. Employee Code: ……………………………………….

CARD No:…………………………………………………………….. Policy No: …………………………………………………
No of Enclosures: …………………………… Date of Submission:………………………………….
GENERAL
1. Duly filled & Signed claim form(Part A and B) 13. Cancelled cheque with name printed and NEFT details
by insured [ ] or a copy of the pass book and front page bank statement
[ ]
2. Photo copy of E Card/ health Card [ ] 14. Indoor case papers/IPD is mandatory.
3. Photo copy of Government ID Proof [ ] FOR DEATH CASES

1. Attested copy of death summary of the hospital duly
4. Original copy of consolidated final bill of hospital signed by the treating doctor with hospital seal and
with breakup details [ ] registration number [ ]
5. Original copy of payment receipt with pre-printed 2. Attested copy of death certificate from competent
receipt number mentioned on it [ ] authorities [ ]
6. All original prescription for bill attached [ ] 3. Legal Heir certificate/ letter from the underwriting office
to settle the claim in the name of nominee/ dependents
7. All original investigation /pathological/reports [ ]
along with films/CD. [ ] FOR MATERNITY CASE
8. Original discharge summary of hospital duly 1. Original copy of treating doctor’s certificate regarding
Signed by the treating doctor with hospital obstetric history (Gravida, Para, Living Children,
Seal/Stamp and registration number. [ ] Abortions, Death) [ ]
9. Original Sticker and invoice of implants (viz Stents/ FOR RTA CASE
PHS mesh/IOL etc) [ ] 1. Attested copy of MLC Report [ ]
10. First consultation letter for the presenting 2. Attested Copy of FIR [ ]
Complaints. [ ]
3. Original copy of treating doctor’s certificate with
11. Pre/Post hospitalization bills/receipts/ reports in circumstances and injuries sustained due to RTA [ ]
original pertaining to the incidence for which
hospitalization has happened [ ] 4. Original copy of Treating doctors certificate for any
evidence of influence of Alcohol/ other Narcotics
12. Original prescription/doctors notes of previous substance during the accident [ ]
treatment for the presenting complaints [ ]
Checklist of Enclosures for submission of

claim
Toll Free No: 1800220102
crm@healthindiatpa.com
Under Taking:
I / We hereby confirm that the above mentioned documents in support of the claimed amount have been
submitted in full and final. No other documents would be submitted on a later date that will alter and
enhance the claim value.
Date: ……………………………………………………… Signature

Place: …………………………………………………….
Name: …………………………………………………….
Address: ……………………………………………………………………………………………………………………………
City: ………………………………………………….. Pin: …………………………………………………..
Mobile No: ………………………………………………. Email ID: …………………………………………………..
Disclaimer:
We acknowledge receipt of your claim and confirm that it has been registered with us on the basis of above
documents. However the above acknowledgement does not guarantee settlement/ payment of claimed
amount. This claim will be subject to pass through medical and commercial scrutiny, which may
Call for additional document that needs to be submitted within the stipulated time frame on intimation.
Date: Name of Claimant Signature for Healthindia
Place:
*Photo Copy of ID card: –

 Any Govt. Issued ID card (PAN card, Passport Copy, AADHAR card, Voter Id proof etc)
 In case of new born babies – the identity proof of the mother and the hospital authorization
letter/Discharge Card/Municipal Birth Certificate (if available)
 In case of children- School Identity Card along with Guardian’s ID proof

Checklist of Enclosures for submission of

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Toll Free No: 1800220102

HEALTHINDIA INSURANCE TPA SERVICES PVT LTD

Name of the claimant: …………………………………………………………. Employee Code: ……………………………………….

3. Photo copy of Government ID Proof [ ] FOR DEATH CASES

Checklist of Enclosures for submission of

Date: ……………………………………………………… Signature

Date: Name of Claimant Signature for Healthindia

*Photo Copy of ID card: –

Checklist of Enclosures for submission of

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