IRDAI Claim Form Part A

The claim form is the basic and mandatory requirement for registering a healthcare claim. The claim form helps understand the details of the healthcare condition as well as the rationale of the treatment and justifies the expenses claimed. The claim forms can be downloaded from the Medi Assist website. 

Significance of Claim Form in Healthcare Claims:

A claim form is an application requesting the Insurance Company for financial coverage on any hospitalisation or treatment as per your policy’s specification on the timeline. The claim form helps the TPA/Insurer understand:

For whom the claim is being requested;

The exact value of the amount that is being claimed;

If the claim is being registered within the stipulated period

Understanding the Claim Form:

Each claim form has eight sections requesting details about the primary policyholder, patient, hospitalisation, expenses claimed, and a final acknowledgement along with the remittance information. Each section has paramount importance to the claim process. By missing out on any field in the form, there can be delays in the claim process. Thus, every field in the form must be filled out accurately. 

The following are the components of the Claim Form Part A:

Section A – Policyholder’s Basic Information

This section primarily involves enlisting the basic information of the Primary Policyholder. It is crucial to fill out the policy number, employee ID/TPA ID, name and the communication address of the primary policyholder. It is important to mention the official email registered with the policy/corporate.

Section B – Policy Details

This second section is of utmost significance as vital information like details of the healthcare policy,  including the date since when the policy has been active, name of the Insurer (for Retail) or the Corporate (for Group Mediclaim Policy), past healthcare insurance plans, and hospitalisation history is notified. The details provided are critical especially when utilising coverage from multiple policies.  

Section C – Patient Information

The patient’s basic information must be provided in this section, including but not limited to name, age, date of birth, relationship with the primary policyholder, and communication address. It is best to fill in the communication address, even if it’s the same as the primary policyholder, along with the email ID and phone number that is registered at the policy level.

Section D – Hospitalisation details

Comprehensive information on hospitalisation must be provided in this section. This includes the hospital’s complete name, room occupancy, the reason for hospitalisation, history of the condition/cause including the nature of the trauma, date and time of the admission & discharge, and the nature of the treatment.  

Sections E and F – Reports, Documents, Bills and Other Hospitalisation Related Information

Explicit details of the claim, including details of the documents attached, must be provided in Section E. This helps identify any pending documents required. 

Enlist every hospitalisation bill received in Section F. In case there are numerous bills enclosed, attach a separate list with complete details of the bill. 

Additionally, the total amount must be entered under “Hospitalisation expenses” of Section E and “Hospital Main Bill” of Section F as this will be the amount processed. This is key when claiming only a partial amount. 

Note: Ensure to submit the attested copies and the settlement letter of the settled claim from other TPAs/Insurers along with the original cash paid receipts for the difference amount claimed with us.

Section G – Bank Account Information

Remittance information of the Primary Policyholder, that is, active bank account details must be provided in this section, including the PAN card number. Ensure to cross-verify the accuracy of the account number and the IFSC code provided. Please note that every claim settlement is done via NEFT transfers, input “NA” under cheque/DD-related information.

Section H – Signed Declaration

This section requires a declaration by the Primary Policyholder. This is crucial as it acknowledges that the information is accurate and thorough. 

How does the Claim Form look:

Some useful information:

Make use of the following tips  to avoid delays in claim processing:

• Verify the details to ensure the form is accurate and thorough with precise information. 
• Every hospitalisation or treatment requires a new claim form.
• The second page of the claim form contains information on how to fill the form to help clarify immediate confusion. 
• File a separate claim to reimburse any Pre-hospitalisation and Post-hospitalisation expenses by following the same guidelines.

Important Point to Note:

IRDAI has mandated the Part B claim form as a non-negotiable requisite to completing the claim registration. It is recommended that you ensure to have the hospital complete the form to ensure successful claim registration. I

For any non-network hospital, it is advised to attach an attested copy of the hospital’s registration certificate while providing other mandatory documents.

Conclusion:

Following the guidelines for filling out the Claim Form accurately and thoroughly is pivotal. Information furnished for a claim registration helps ensure the claim is registered successfully for further evaluation. Please note that incomplete or incorrect claim forms will lead to non-registration of the claim and delayed claim processing.