Claim Form - Group Health Insurance

Claim form - What is it?

A claim form in health insurance is a standard document provided by the health insurance company or the TPA. By filling this out, the policyholder or the insured can raise a claim to the health insurance company and claim the hospitalisation expenses.

The claim form comes into play when the insured has opted for a reimbursement claim. A reimbursement claim is where the insured pays out of his/her pocket for the hospitalisation expenses. After that, he/she applies for a reimbursement claim to the health insurance company.

Claim form part A and B

The claim form has two parts, of which the first one is called the Claim Form Part - A and the second is the Claim Form Part - B. The first part is filled out by the policyholder and the second part is filled out by the hospital.

Claim form part A and how to fill claim form - part A?

The insured/policyholder duly fills out the claim form part A.

This part of the claim form holds all the required information about the policy, details of the policyholder, details of hospitalisation, and others.

Let us see them one by one.

1. The first section asks for information about the policyholder, also known as the primary insured. The claim number, the policy number, the TPA Id number, and personal details of the policyholder are also filled in along with the phone number.
2. The next section is about details of the insurance history. This section requires information about other health insurance policies covering the policyholder if any. However, this section is not mandatory as it is to be filled in case there are other policies covering him/her.
3. The next section is about details of the insured person hospitalised. This section has queries on his/her details, occupation and the type of relationship with the primary insured.
4. After this section, the details of hospitalization are asked next. This includes details on the name of the hospital, the type of room occupied, the type of hospitalisation, and details about the reports to the police in case of any accidents.
5. The next requires information about the details of the claim. Here you are asked to fill in details of pre and post hospitalisation expenses, in-hospitalisation expenses, ambulance charges, and others. Here you are also required to mention if it's a domiciliary hospitalisation, if daily hospital cash benefit is applicable, and other information required according to the terms and conditions of the policy.
6. In the above section, there will be a checklist of documents to be attached to the reimbursement claim. Those documents are to be enclosed and their details are provided in the next section of the claim form. The total amount against different types of hospital bills is also mentioned in this section.
7. The last section is about details of the bank account of the primary insured/policyholder. The details required are the pan number, the bank account number and bank name, with IFSC code and cheque/DD details.
8. At the end of the claim form part A, the insured is to submit a declaration mentioning the above details are correct.

Claim form part B

The claim for part B is the second part of the claim form. This is duly filled by the hospital where the treatment was taken. Hence, the policyholder need not worry about filling this part B of the reimbursement claim form.

Reimbursement claim form - Who provides it?

The claim form, also known as the reimbursement claim form is provided by the health insurance company, the TPA, or by the IRDAI. The health insurance company provides the reimbursement claim form if the claim is to be processed by the internal TPA of the insurance company.

In case, the claim is being processed by the external TPA of the health insurance company, the claim form mentioning the TPA’s name can be used.

Then there is the IRDA claim form which is provided by the Insurance Regulatory and Development Authority. This claim form for health insurance can be used across any health insurance company or the TPA.

However, please note that all the details mentioned above about the claim form part A and B do not change with respect to the claim form. In other words, the details asked for in any claim form are universal.

Documents required to file a reimbursement claim for your group health insurance

The following are the necessary documents required to file a reimbursement claim for your group health insurance policy.

1. A duly filled claim form
2. Copy of photo Id card of the patient verified by the hospital 
3. Discharge summary from the hospital
4. Main bill from the hospital
5. Hospital break-up bill
6. Medical reports 
7. Reference slip from the doctor in charge
8. Pharmacy bills
9. Medico-Legal certificate (MLC) and police FIR copy
10. All other relevant documents

Health insurance claim form filled out sample

‍