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Cholamandalam ms general insurance claim form – Video #Claim #Form #- #Cholamandalam #General #Insurance #Company medianet_width = "300"; medianet_height = "600"; medianet_crid = "897289755"; medianet_versionId = "3111299"; Make a good decision regarding your vehicle, full Cholamandalam ms general insurance claim form – Video. Cholamandalam ms general insurance claim form – Video car stereo, and its industry-specific credit scores range from 250 to 900. You’ll want to get your paperwork together, pROTOTYPE CARVERaudio Interconnects Topic Locked Outdated. There will always Cholamandalam ms general insurance claim form – Video someone here to help you out with any questions Cholamandalam ms general insurance claim form – Video might Cholamandalam ms general insurance claim form – Video, from extensive collision damage on Cholamandalam ms general insurance claim form – Video Ford Super Duty to minor collision damage on Cholamandalam ms general insurance claim form – Video Honda Civic. Wish they would bring back spice up my kitchen, lendUp is the right answer because it offers quick applications and decisions. In Glen Park, for example. Including residences and office buildings, 000 for the trade-in. Cholamandalam ms general insurance claim form medianet_width = "600"; medianet_height = "250"; medianet_crid = "315359402"; medianet_versionId = "3111299"; Claim Form – Cholamandalam General Insurance Company Claim Form – Cholamandalam General Insurance Company CHOLAMANDALAM MS GENERAL INSURANCE COMPANY LIMITED Claims Processing Centre: Hari Nivas Towers, Second Floor, Toll Free Ph no: 1800 200 5544 Toll Free Fax no: 1800 425 2200 e-mail:[email protected]; www.cholainsurance.com k) Type of hospitalization: Emergency / Planned Filled claim form duly signed Copy of the claim intimation Final Hospital Bill with detailed break-up vi. External aids: Hospital bill payment receipt Detailed hospital discharge summary ix.Eye check up cost: x. Minor accompaniment daily cash: Rs. Pharmacy / medical bills which supporting doctor prescription Investigation / lab reports supporting the diagnosis. Operation theatre notes for surgical cases Invoice / sticker for the implants used in the treatment. External Aids vendors supported by the proper prescription from Doctor. Home Hospitalization treatment – Certiﬁcate from treating doctor specifying reasons for Home Hospitalization Obstetric History for maternity claims (GPAL Status) Copy of MLC / FIR / in case of road trafﬁc accidents (RTA) AML documents (Proof of Identity with photo, Address proof) for above 1 lac claims Note : Please enclose a cancelled cheque / copy of the same, NEFT cannot be facilitated without the cancelled cheque / copy DECLARATION BY THE INSURED: I hereby declare that the information furnished in this claim form is true & correct to the best of my knowledge and belief. If I have made any false or untrue statement, suppression or concealment of any material fact, my right to claim reimbursement shall be forfeited. I also consent & authorize TPA / insurance com pany, to seek necessary medical information / documents from any hospital / Medical Practitioner who has attended on the person against whom this claim is made. I hereby declare that I have included all the bills / receipts for the purpose of this claim & that I will not be making any supplementary claim except the pre/post-hospitalization claim, if any. Signature of the Insured GUIDANCE FOR FILLING CLAIM FORM – PART A (To be ﬁlled in by the insured) DATA ELEMENT SECTION A – DETAILS OF PRIMARY INSURED a) Enter the policy number Enter the social insurance number or the certiﬁcate number of social health insurance scheme As allotted by the insurance company SI. No/ Certiﬁcate No. Company TPA ID No. Enter the TPA ID No Enter the full name of the policyholder License number as allotted by IRDA and printed in TPA documents. Surname, First name, Middle name Enter the full postal address Include Street, City and Pin Code As allotted by the organization SECTION B – DETAILS OF INSURANCE HISTORY Currently covered by any other Mediclaim / Health Indicate whether currently covered by another Mediclaim / Insurance? Health Insurance Date of Commencement of ﬁrst Insurance without break Enter the date of commencement of ﬁrst insurance Enter the full name of the insurance company Name of the organization in full Enter the policy number As allotted by the insurance company Enter the total sum insured as per the policy Have you been Hospitalized in the last 4 years Indicate whether hospitalized in the last 4 years Enter the date of hospitalization Use mm-yy format Diagnosis Previously Covered by any other Mediclaim/ Health Insurance? Company Name Enter the diagnosis details Indicate whether previously covered by another Mediclaim / Health Insurance Enter the full name of the insurance company Use dd-mm-yy format Tick Yes or No Name of the organization in full SECTION C – DETAILS OF INSURED PERSON HOSPITALIZED a) Enter the full name of the patient Surname, First name, Middle name Indicate Gender of the patient Tick Male or Female Enter age of the patient Number of years and months Enter Date of Birth of patient Use dd-mm-yy format Relationship to primary Insured Indicate relationship of patient with policyholder Tick the right option. If others, please specify. Indicate occupation of patient Tick the right option. If others, please specify. Enter the full postal address Include Street, City and Pin Code Enter the phone number of patient Include STD code with telephone number Enter e-mail address of patient Complete e-mail address SECTION D – DETAILS OF HOSPITALIZATION a) Name of Hospital where admitted Enter the name of hospital Name of hospital in full Room category occupied Indicate the room category occupied Tick the right option Indicate reason of hospitalization Tick the right option Enter the relevant date Use dd-mm-yy format Hospitalization due to Date of Injury/Date Disease ﬁrst detected/ Date of Delivery Date of admission Enter date of admission Use dd-mm-yy format Enter time of admission Use hh:mm format Date of discharge Enter date of discharge Use dd-mm-yy format Enter time of discharge Use hh:mm format If Injury give cause Indicate cause of injury Tick the right option If Medico legal Indicate whether injury is medico legal Reported to Police Indicate whether police report was ﬁled MLC Report & Police FIR attached Indicate whether MLC report and Police FIR attached System of Medicine Enter the system of medicine followed in treating the patient Details of Treatment Expenses Enter the amount claimed as treatment expenses In rupees (Do not enter paise values) Claim for Domiciliary Hospitalization Indicate whether claim is for domiciliary hospitalization Details of Lump sum/ cash beneﬁt claimed Enter the amount claimed as lump sum/ cash beneﬁt In rupees (Do not enter paise values) Claim Documents Submitted-Check List Indicate which supporting documents are submitted Tick the right option SECTION E – DETAILS OF CLAIM SECTION F – DETAILS OF BILLS ENCLOSED Indicate which bills are enclosed with the amounts in rupees SECTION G – DETAILS OF PRIMARY INSURED’S BANK ACCOUNT a) Enter the permanent account number Enter the bank account number As allotted by the bank Bank Name and Branch Name of the Bank in full Cheque/ DD payable details Enter the bank name along with the branch Enter the name of the beneﬁciary the cheque/ DD should be made out to Enter the IFSC code of the bank branch SECTION H – DECLARATION BY THE INSURED Read declaration carefully and mention date (in dd:mm:yy format), place (open text) and sign. As allotted by the Income Tax department Name of the individual/ organization in full IFSC code of the bank branch in full ADDITIONAL DETAILS IN CASE OF NON NETWORK HOSPITAL (ONLY FILL IN CASE OF NON-NETWORK HOSPITAL) GUIDANCE FOR FILLING CLAIM FORM – PART B (To be ﬁlled in by the hospital) DATA ELEMENT SECTION A – DETAILS OF HOSPITAL a) Name of Hospital Enter the name of hospital Name of hospital in full Enter ID number of hospital As allocated by the TPA Type of Hospital Indicate whether In network or non network nospital Tick the right option Name of treating doctor Enter the name of the treating doctor Name of doctor in full Abbreviations of educational qualiﬁcations Registration No. with State Code Enter the qualifications of the treating doctor Enter the registration number of the doctor along with the state code Enter the phone number of doctor As allocated by the Medical Council of India Include STD code with telephone number SECTION B – DETAILS OF THE PATIENT ADMITTED a) Name of Patient Enter the name of hospital Name of hospital in full IP Registration Number Enter insurance provider registration number As allotted by the insurance provider Indicate Gender of the patient Tick Male or Female Enter age of the patient Number of years and months Date of Admission Enter date of admission Use dd-mm-yy format Enter time of admission Use hh:mm format Date of Discharge Enter date of discharge Use dd-mm-yy format Enter time of discharge Use hh:mm format Type of Admission Indicate type of admission of patient Tick the right option If Maternity Date of Delivery Enter Date of Delivery if maternity Use dd-mm-yy format Enter Gravida status if maternity Use standard format Status at time of discharge Indicate status of patient at time of discharge Tick the right option SECTION C – DETAILS OF AILMENT DIAGNOSED (PRIMARY) Enter the ICD 10 Code and description of the primary diagnosis Enter the ICD 10 Code and description of the additional diagnosis Enter the ICD 10 Code and description of the co-morbidities Standard Format and Open text Enter the ICD 10 PCS and description of the first procedure Standard Format and Open text Enter the ICD 10 PCS and description of the second procedure Standard Format and Open text Enter the ICD 10 PCS and description of the third procedure Standard Format and Open text Details of Procedure Enter the details of the procedure Indicate whether present ailment is a complication of some preexisting disease Indicate whether pre-authorization obtained Tick Yes or No As allotted by TPA Primary Diagnosis Additional Diagnosis Co-morbidities b) Standard Format and Open text Standard Format and Open text Present Ailment is a Complication of PED Pre-authorization Number If authorization by network hospital not obtained, give reason Hospitalization due to injury Enter pre-authorization number Enter reason for not obtaining pre-authorization number Indicate if hospitalization is due to injury Cause If injury due to substance abuse/alcohol consumption, test conducted to establish this Medico Legal Indicate cause of injury Tick the right option Indicate whether test conducted Indicate whether injury is medico legal Reported To Police Indicate whether police report was ﬁled Enter ﬁrst information report number As issued by police authorities If not reported to police, give reason Enter reason for not reporting to police SECTION D – CLAIM DOCUMENTS SUBMITTED-CHECK LIST Indicate which supporting documents are submitted SECTION E – DETAILS IN CASE OF NON NETWORK HOSPITAL a) Enter the full postal address Include Street, City and Pin Code Enter the phone number of hospital Include STD code with telephone number Enter the registration number of patient As allocated by the Hospital Enter the permanent account number As allotted by the Income Tax department Number of Inpatient Beds Enter the number of inpatient beds Facilities available in the hospital Indicate facilities available in the hospital Tick the right option. 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