November 19, 2015

TO ALL OFFICES

HRDD CIRCULAR NO. 723

Medical Insurance Scheme for Officers/Employees in lieu of earlier

Hospitalisation Scheme under Regulations / Bipartite settlement

We refer HRDD Circular No.714 dated 30.9.2015 vide which it was interalia informed that a new Medical Insurance Scheme for Officers / employees is coming into force w.e.f. 1.10.2015. It was further informed that the

operational guidelines of the same shall be circulated separately.

Details of the Medical Insurance Scheme were circulated as Annexure/ Schedule-IV of PAD Circular No.271 dated 9.6.2015 and HRDD Circular No.694 dated 20.6.2015. However, brief details of the same alongwith

operational guidelines containing instructions for seeking reimbursement / availing benefits under the scheme are being circulated herewith as

Annexure. All staff members are advised to go through the provisions of the joint note

dated 25.05.2014 for complete details and the operational guidelines very carefully so that the benefits available can be claimed in a proper manner and within the stipulated time. Please note that these are the operational

guidelines in brief and detailed guidelines will be circulated after the same are received through IBA/UIIC.

(M.C. MADAN)

DY. GENERAL MANAGER

Human Resources Development Division

(Hospitalisation Cell), Head Office: New Delhi Phone No. – 011-26174730

Email – hrdhospitalisation@pnb.co.in FAX – 011-26196491

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ANNEXURE

BRIEF DETAILS OF MEDICAL INSURANCE SCHEME FOR OFFICERS & WORKMEN STAFF

Policy Period 01.10.2015 to 30.09.2016

Plan Type Group Health Policy (Family Floater)

Beneficiary Employee + Spouse + Dependent Children + dependent

parents or parent in laws, (Dependent status should be entered and verified in HRMS)

Total number of lives covered All active employees, spouse & dependents

Sum insured (Annual cover amount)

Cadre Sum insured (Rs.)

Officers 4,00,000/-

Clerical & Sub Staff 3,00,000/-

Critical illness

In case an employee (self only and not dependents)

contracts a critical illness as specified in the scheme, Rs.1,00,000/- shall be paid, as a benefit without any bills, immediately on first detection / diagnosis of the

critical illness. Hospitalisation is not required to claim this benefit.

Officer/ Employee can claim the benefit by submitting medical certificate, prescription and reports in respect of the illness.

Corporate Buffer In case an individual exhausts the sum insured, the balance will be considered from the Corporate Buffer.

However detailed guidelines in this regard shall be circulated separately.

Coverages 1(i) Inpatient Hospitalisation expenses

(ii) Pre/Post hospitalization expenses covered

Pre-hospitalization for 30 days

Post Hospitalization for 90 days: 2. Listed Day Care Procedures

3. Domiciliary treatment in respect of specified diseases.

Room Rent - Room Rent upto to Rs.5,000/- per day. - ICU charges upto Rs.7,500/- per day.

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Ambulance Charges - Ambulance charges upto Rs.1000/- per trip. - Taxi and Auto in actual maximum up to Rs. 750/-

per trip

Maternity benefits - Normal Delivery : Rs.35,000

- Caesarian Delivery : Rs.50,000 - Complications on Maternity would be covered up to

the sum insured plus the Corporate Buffer.

New born baby expenses Covered under the floater sum insured of the family.

Domiciliary Coverage:

Domiciliary treatment shall also be covered under the scheme i.e treatment taken for specified diseases

which may or may not require hospitalization as mentioned herein below:- Medical expenses incurred in case of the following

diseases which need domiciliary hospitalization/ domiciliary treatment, as may be certified by the

recognized hospital authorities and bank‟s medical officer shall be deemed as hospitalization expenses and reimbursement to the extent of 100%.

Cancer, Leukemia, Thalassemia, Tuberculosis, Paralysis, Cardiac Ailment, Pleurisy, Leprosy, Kidney Ailment, All Seizure disorder, Parkinson‟s diseases,

Psychiatric disorder including schizophrenia and psychotherapy, Diabetes and its complications, hypertension, Asthme, Hepatitis-B, Hepatitis-C,

Hemophilia, Myasthenia gravis, Wilson‟s disease, Ulcerative Colitis, Epidermolysis, bullosa, Venous

Thrombosis (not caused by smoking) Aplastic Anaemia, Psoriasis, Third Degree burns, Arthritis, Hypothyroidism, Hyperthyroidism, expenses incurred

on radiotherapy and chemotherapy in the treatment of cancer and leukemia, Glaucoma, Tumor, Diphtheria, Malaria, Non-Alcoholic Cirrhosis of Liver, Purpura,

Thphoid, Accident of Serious Nature, Cerebral Palsy, Polio, All strokes leading to

Paralysis, Hemorrhage caused by accident, all animal/reptile/insect bite or string, chronic pancreatitis, Immuno suppressants, multiple

sclerosis/motor neuron disease, status asthamaticus, sequalea of meningitis, osteoporosis, muscular

dystrophies, sleep apnea syndrome (not related to obesity), any organ related (chronic) condition, stickle cell disease, systemic lupus erythematous (SLE), any

connective tissue disorder, varicose veins, thrombo

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embolism venous thrombosis/venous thrombo embolism(VTE), growth disorder, Graves‟ disease,

Chronic Pulmonary Disease, Chronic Bronchitis, Physiotherapy and swine flu shall be considered for reimbursement under domiciliary treatment.

The cost of medicines, medical reports and visiting charges, in respect of domiciliary treatment shall be

reimbursed for the period stated in the Specialist's prescription. If no period is stated, the prescription for the purpose of reimbursement shall be valid for a

period not exceeding 90 days.

Congenital internal /

external diseases / defects/ anomalies

Covered in the policy.

Pre-existing diseases coverage

Covered in the policy.

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OPERATIONAL GUIDELINES

TPA CARD i. The scheme is being operationalised by United India Insurance Company through Raksha TPA and all the

claims under the scheme are to be processed by the TPA. ii. Each employee and their dependents are to be issued

separate TPA ID card containing the photo of the insured.

iii. Circle Offices to obtain photographs of all employees and

their dependents for the purpose of issuing TPA ID cards. In the meantime the TPA ID card without

photograph can be downloaded through website (rakshatpa.com) and / or through mobile app as below

iv. For downloading TPA ID Card through website, the

employees are advised to follow the path >> visit Raksha TPA web site www.rakshatpa.com >> click on IBA >> click

PNB. System will ask you to fill the ID card No. where the following is to be filled:-

“UIC545(Employee PF Number) PNBA” eg. If PF number is 70065, the text to be filled shall be “UIC54570065PNBA” >> click on search button. New

screen will appear with all details. If details are correct, click PRINT E-CARD and save the same for records and

future reference. For downloading TPA ID card through mobile app, use smart mobile phone for the facility. Download the Mobile

App. „Raksha TPA‟, on the application. System will show many options, click on „Request E-card‟ and enter the

particulars as advised above, then click on search button. New screen will appear with all details. If details are correct, click PRINT E-CARD and save the same for

record and future reference.

INTIMATION OF CLAIM IN CASE OF ALL HOSPITALISATION

(CASHLESS OR OTHERWISE)

i. The reimbursement claims are required to be intimated to Raksha TPA within 24 hours of hospitalization and original documents are to be submitted within 30 days

of discharge from the hospital. ii. In case of planned hospitalization, the TPA is to be

informed at least two days before hospitalization, but in any case within 24 hours of hospitalization.

iii. Intimation has to be sent along with the following

particulars:- a. Member ID b. Patient‟s Name

c. Name and address of the Hospital d. Disease / ailment and Treatment given

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e. Date of admission f. Requested amount

iv. Intimation can be sent by the insured / relatives / office

where the employee is posted through any of the

following methods:- a. Through e-mail to Raksha TPA at email id

“helpIBA@rakshatpa.com”, “claimintimation@rakshatpa.com”

b. Through phone by calling any of the following 24

hours toll free No./Call Center and providing above information

a) 0129 4289999 – Delhi b) 1800 180 1444 – Delhi c) 1800 220 456 - Mumbai

d) 1800 425 8910 – Bangalore

c. On line Registration by following the undernoted

procedure:

1. login to www.rakshatpa.com 2. click on claim intimation link 3. Punch in desired details like Member id, date of

admission, name of hospital etc. 4. Acknowledgement No. (i.e. your claim no.) shall be

reflected, a copy of which may be retained

SUBMISSION &

PAYMENT OF MEDICAL BILLS

(OTHER THAN ON CASHLESS BASIS)

i. All claims are to be submitted on the prescribed format

of the insurance company. Proforma of the claim form is enclosed.

ii. Employees/officers posted within the jurisdiction of Circle Offices shall lodge claim to their Circle Offices.

iii. FGM Office Employees/officers shall lodge their Claims

to their concerned Circle Offices. iv. Head Office Employees/officers shall lodge their Claims

to HRD Division (Hospitalization cell) through their Divisional Heads.

v. Circle Offices and HRD Division HO (Hospitalisation Cell)

will submit these bills to TPA on daily basis, after keeping proper record.

vi. All reimbursements shall be credited in Employees‟ Bank

account directly.

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PROCEDURE & TIME SCHEDULE FOR

SUBMISSION OF MEDICAL CLAIMS

All supporting documents in original, i.e Discharge Card, Medical Prescription, Medicine Bills, related Reports, X-rays,

ECG strips, CT scan pictures and other documents relating to the claim must be submitted with the claim form within 30 days from the date of discharge from the hospital. In case of

post-hospitalization treatment (limited to 90 days), all claim documents should be submitted within 30 days after completion of such treatment.

HOSPITALISATION CLAIMS -

(CASHLESS BASIS)

i. The benefit of cashless hospitalisation facility is available in many hospitals on provider‟s network. The list of such

hospitals can be accessed on PNB Parivar and Raksha TPA‟s website.

ii. Officers/employees are advised to contact TPA counter of the hospital along with TPA ID Card and a Govt. Photo ID proof of the patient for seeking cashless

hospitalization claim. iii. On production of ID card, the TPA desk of the hospital

shall inform the TPA, the requisite particulars of

employee, the patient admitted, reason for hospitalization etc. and seek initial approval of the

estimated hospitalization expenses.

iv. Some hospitals have a policy of seeking an advance for

treatment to start. The same is refundable once the cashless approval is received.

v. After treatment, the hospital‟s TPA desk will submit the

bills to the TPA and on receipt of sanction, the patient

shall be discharged. Claim amount shall be paid by Insurance Company through TPA directly to the hospital concerned.

vi. Any amount not admissible under the scheme and not

sanctioned by the TPA shall have to be paid by the officer/ employee to the hospital at the time of discharge of patient.

vii. In case of post-hospitalisation treatment, all claim

documents should be submitted within 30 days after

completion of such treatment.

EMERGENCY

HOSPITALISATION

In case of an emergency admission to a hospital which is not

in PP Network, the officers / employees can approach the TPA for cashless treatment by intimating the Third Party

Administrator, call centre number (0129-4289999, 1800-180-1444(Delhi), 1800-220-456(Mumbai), 1800-425-8910(Bangalore), mentioning his ID card No and name. The

hospital authorities would fax / mail the details of

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hospitalisation to the Third Party Administrator, who would again revert by fax / mail a confirmation to the hospital to

proceed with the claim.

IF HOSPITAL IS NOT IN

THE APPROVED LIST OF TPA

Wherever the hospital is not in the approved list of Third Party

Administrator, the Third Party Administrator will take necessary action for considering addition of such hospital on their network hospital list in consultation with bank. In an

emergency the claim payment would be made to the hospital account and empanelment of the hospital would be

considered.

DOMICILIARY CLAIMS

Treatment taken from clinics of Specialist Doctors are eligible

for reimbursement. The cost of Medicines, Investigations, and consultations, etc. in respect of domiciliary treatment shall be

reimbursed for the period stated by the specialist and / or the attending doctor and / or the Bank‟s Medical Officer. If no period is stated, the prescription, for the purpose of

reimbursement shall be valid for a period not exceeding 90 days. All prescriptions for consultations must specify the

disease, and should be signed & stamped by the treating doctor. Claims should be submitted on the prescribed format enclosed along with original bills and related prescriptions for

consultation.

GRIEVANCE REDRESSAL In the event of any grievance relating to the insurance, the insured Person may raise query and grievance in writing to

the TPA, through its website www.rakshatpa.com link online grievance. The insured person may also submit in writing to the

Policy Issuing Office or Grievance Cells at the Regional Office of the United India Insurance on https://uiic.co.in link online complaint

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PROFORMA FOR CAPTURING OF DEPENDENT DETAILS

Name of employee _________________PF number ________Branch/office _____________ Circle Office_____ SB/CA A/C number ____________________________IFSC code__________________________

1. SELF NAME____________________ D.O.B. ____________GENDER _________________

2. DEPENDENTS NAME____________________ D.O.B. ____________GENDER _________________ RELATION : ______________ NAME____________________ D.O.B. ____________GENDER ________ RELATION : ______________ NAME____________________ D.O.B. ____________GENDER _________________ RELATION : ______________ NAME____________________ D.O.B. ____________GENDER ________ RELATION : ______________

SIGNATURES OF THE EMPLOYEE SIGNATURES OF THE INCUMBENT INCHARGE The scheme covers Self+Spouse+ dependent children + any two of the dependent parents/parents in law. No age limit for dependents, Dependent will be considered only if his/her monthly income does not exceed Rs 10000.00. Brother and sisters are dependents only if they are physically challenged with 40 % or more disability. Widowed daughter/divorced/separated/daughter/sister including unmarried/ divorced/abandoned or separated from husband/widowed sister and crippled child shall be considered as dependent for the purpose of this policy

CLAIM FORM - PART ATO BE FILLED IN BY THE INSURED

(To be filled in block letters)DETAILS OF PRIMARY INSURED

a) Policy no:

c) Company/ TPA ID No: SECTION Ad) Name: SECTION A

e) Address:

City: State:

Pin Code: Phone No: Email ID:

DETAILS OF INSURANCE HISTORY

Yes No b) Date of commencement of first insurance without break:

SECTION B

c) If yes, company name: Policy No:

d) Have you been hospitalized in the last four years since inception of the contract? Yes No Date:

Diagnosis: Yes No

f) If yes, Company Name :

DETAILS OF INSURED PERSON HOSPITALIZED

a) Name :

b) Gender : Male Female c) Age: years months d) Date of Birth:

Self Spouse Child Father Mother Other (Please specify)

SECTION C

f) Occupation: Service Self Employed Homemaker Student Retired Other (Please specify)

g) Address (if different from above):

City: State:

Pin Code: Phone No: Email ID:

DETAILS OF HOSPITALIZATION

a) Name of Hospital where Admitted:

b) Room category occupied: Day Care Single occupancy Twin sharing 3 or more beds per room

SECTION D

c) Hospitalization due to: Injury Illness Maternity d) Date of injury/ Date Disease first detected/ Date of Delivery:

e) Date of Admission: f) Time: : g) Date of Discharge: h) Time: :

i) If injury, give cause: Self inflicted Road Traffic Accident Substance abuse / Alcohol Consumption i. If Medico Legal: Yes No

ii. Reported to police: Yes No iii. MLC Report & Police FIR attached: Yes No j) System of medicine:

DETAILS OF CLAIM

a) Details of treatment expenses claimed Claim Documents Submitted- Check List:

` ii. Hospitalization Expenses `

iii. Post Hospitalization Expenses ` iv. Health Check up Cost ` Copy of the claim intimation, if any

v. Ambulance Charges ` vi. Others (code): ` Hospital Main bill

Total ` Hospital Break-up bill

SECTION E

days days Hospital Discharge Summary

b) Claim for Domiciliary Hospitalization: Yes No Pharmacy Bill

c) Details of Lump sum / cash benefit claimed:

i. Hospital Daily Cash: ` ii. Surgical Cash: ` ECG

iii. Critical Illness Benefit: ` iv. Convalescence: ` Doctor's request for investigation

` vi. Others: ` Investigation Reports (including CT / MRI / USG / HPE)

Total ` Doctor's Prescription

Others

DETAILS OF BILLS ENCLOSED

Bill No. Date Issued By Towards1 Hospital Main Bill

234 Pharmacy Bills: SECTION F

5678910

DETAILS OF PRIMARY INSURED'S BANK ACCOUNT

a) PAN: b) Account Number:

SECTION G

c) Bank Name and Branch

The issue of theis form is not to be taken as admission of liability

b) Sl. No/ Certificate No:

a) Currently covered by any other Mediclaim/ Health Insurance:

Sum Insured (`):

e) Previously covered by any other Mediclaim/ Health Insurance :

e) Relatuionship to Primary Insured:

i. Pre Hospitalization Expenses Claim FormDuly signed

vi. Pre hospitalization period: vii. Pre hospitalization period:

(if yes, provide details in annexure)

Operation Theatre Notes

v. Pre/Post hosp. Lump sum benefit:

Sl. No. Amount (`)

Pre hospitalisation Bills: ___ NosPost hospitalisation Bills: ___ Nos

UNITED INDIA INSURANCE COMPANY LIMITED

REGISTERED & HEAD OFFICE: 24, WHITES ROAD, CHENNAI-600014

e) IFSC Code:

SECTION G

DECLARATION BY THE INSURED

SECTION H

Date: Place: Signature of the insured:

GUIDANCE FOR FILLING CLAIM FORM – PART A (To be filled in by the insured)DATA ELEMENT DESCRIPTION FORMAT

SECTION A - DETAILS OF PRIMARY INSUREDa) Policy No. Enter the policy number As allotted by the insurance company

b) SI. No/ Certificate No. As allotted by the organization

c) Company TPA ID No. Enter the TPA ID No

d) Name Enter the full name of the policyholder Surname, First name, Middle namee) Address Enter the full postal address Include Street, City and Pin Code

SECTION B - DETAILS OF INSURANCE HISTORY

Tick Yes or No

b) Date of Commencement of first Insurance without break Enter the date of commencement of first insurancec) Company Name Enter the full name of the insurance company Name of the organization in fullPolicy No. Enter the policy number As allotted by the insurance companySum Insured Enter the total sum insured as per the policy In rupeesd) Have you been Hospitalized in the last 4 years since inception of the contract? Indicate whether hospitalized in the last 4 years Tick Yes or NoDate Enter the date of hospitalizationDiagnosis Enter the diagnosis details Open Text

Tick Yes or No

f) Company Name Enter the full name of the insurance company Name of the organization in fullSECTION C - DETAILS OF INSURED PERSON HOSPITALIZED

a) Name Enter the full name of the patient Surname, First name, Middle nameb) Gender Indicate Gender of the patient Tick Male or Femalec) Age Enter age of the patient Number of years and monthsd) Date of Birth Enter Date of Birth of patiente) Relationship to primary Insured Indicate relationship of patient with policyholder Tick the right option. If others, please specify.f) Occupation Indicate occupation of patient Tick the right option. If others, please specify.g) Address Enter the full postal address Include Street, City and Pin Codeh) Phone No Enter the phone number of patient Include STD code with telephone numberi) E-mail ID Enter e-mail address of patient Complete e-mail address

SECTION D - DETAILS OF HOSPITALIZATIONa) Name of Hospital where admitted Enter the name of hospital Name of hospital in fullb) Room category occupied Indicate the room category occupied Tick the right optionc) Hospitalization due to Indicate reason of hospitalization Tick the right optiond) Date of Injury/Date Disease first detected/ Date of Delivery Enter the relevant datee) Date of admission Enter date of admissionf) Time Enter time of admissiong) Date of discharge Enter date of dischargeh) Time Enter time of dischargei) If Injury give cause Indicate cause of injury Tick the right optionIf Medico legal Indicate whether injury is medico legal Tick Yes or NoReported to Police Indicate whether police report was filed Tick Yes or NoMLC Report & Police FIR attached Indicate whether MLC report and Police FIR attached Tick Yes or Noj) System of Medicine Enter the system of medicine followed in treating the patient Open Text

SECTION E - DETAILS OF CLAIMa) Details of Treatment Expenses Enter the amount claimed as treatment expensesb) Claim for Domiciliary Hospitalization Indicate whether claim is for domiciliary hospitalization Tick Yes or Noc) Details of Lump sum/ cash benefit claimed Enter the amount claimed as lump sum/ cash benefitd) Claim Documents Submitted-Check List Indicate which supporting documents are submitted Tick the right option

SECTION F - DETAILS OF BILLS ENCLOSEDIndicate which bills are enclosed with the amounts in rupees

SECTION G - DETAILS OF PRIMARY INSURED’S BANK ACCOUNTa) PAN Enter the permanent account number As allotted by the Income Tax departmentb) Account Number Enter the bank account number As allotted by the bankc) Bank Name and Branch Enter the bank name along with the branch Name of the Bank in full

Name of the individual/ organization in fulle) IFSC Code Enter the IFSC code of the bank branch IFSC code of the bank branch in full

SECTION H - DECLARATION BY THE INSURED

d) Cheque/ DD Payable details:

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 with respect to questions asked in relation to this claim, my right to claim reimbursement shall be forfeited. I also consent & authorize TPA / insurance company, 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.

Enter the social insurance number or the certificate number of social health insurance scheme

License number as allotted by IRDA and printed in TPA documents.

a) Currently covered by any other Mediclaim / Health Insurance? Indicate whether currently covered by another Mediclaim / Health Insurance

Use dd-mm-yy format

Use mm-yy format

e) Previously Covered by any other Mediclaim/ Health Insurance? Indicate whether previously covered by another Mediclaim / Health Insurance

Use dd-mm-yy format

Use dd-mm-yy format

Use dd-mm-yy format

Use hh:mm format

Use dd-mm-yy format

Use hh:mm format

In rupees (Do not enter paise values)

In rupees (Do not enter paise values)

d) Cheque/ DD payable details Enter the name of the beneficiary the cheque/ DD should be made out to

Read declaration carefully and mention date (in dd:mm:yy format), place (open text) and sign.

CLAIM FORM - PART BTO BE FILLED IN BY THE HOSPITAL

(To be filled in block letters)DETAILS OF HOSPITAL

a) Name of the Hospital:

SECTION A

c) Hospital ID: c) Type of Hospital: Network Non Network (if non network, fill Section E)

d) Name of the treating doctor:

e) Qualification: f) Registration No. with state code: g) Phone No.

DETAILS OF PATIENT ADMITTED

a) Name of Patient:

b) IP Registration No.: c) Gender : Male Female d) Age: years months e) Date of Birth: SECTION B

f) Date of Admission: g) Time: : h) Date of Discharge: i) Time: :

j) Type of Admission: Emergency Planned Day Care Maternity k) If Maternity: i. Date of Delivery:

l) Status at time of discharge: Discharged to home Discharged to another hospital Deceased m) Total claimed amount

DETAILS OF AILMENT DIAGNOSED (PRIMARY)

a) ICD 10 Codes Description b) ICD 10 PCS Description

i. Primary Diagnosis : i. Procedure 1 :

ii. Additional Diagnosis : ii. Procedure 2 :

iii. Co-morbidities : iii. Procedure 3 :

SECTION C

iv. Co-morbidities : iv. Details of Procedure :

Yes No

e) If authorization by network hospital not obtained, give reason:

f) Hospitalization due to injury: Yes No i. If yes, give cause Self inflicted Road Traffic Accident Substance abuse / alcohol consumption

Yes No (if yes, attach reports) iii. If Medico Legal: Yes No iv. Reported to Police: Yes No

v. FIR No. vi. If not reported to police, give reason:

CLAIM DOCUMENTS SUBMITTED - CHECKLIST

Claim Form duly signed Investigation reports

CT/ MRI/ USG/ HPE/ Investigation reports

SECTION D

Copy of photo ID card of patient verified by hospital ECG

Hospital discharge summary Pharmacy bills

MLC report & Police FIR

Hospital main bill Original death summary from hospital, where applicable

Hospital break-up bill Any other, please specify

a) Address of the hospital:

SECTION E

City: State:

Pin Code: b) Phone No: c) Registration No. with State Code:

d) Hospital PAN e) Number of inpatient beds f) Facilities available in the hospital: i. OT: Yes No ii. ICU: Yes No

iii. Others:

DECLARATION BY THE HOSPITAL (Please read very carefully)

SECTION FDate:

Place: Signature of the insured:

GUIDANCE FOR FILLING CLAIM FORM – PART B (To be filled in by the hospital)

DATA ELEMENT DESCRIPTION FORMATSECTION A - DETAILS OF HOSPITAL

a) Name of Hospital Enter the name of hospital Name of hospital in fullb) Hospital ID Enter ID number of hospital As allocated by the TPAc) Type of Hospital Tick the right optiond) Name of treating doctor Enter the name of the treating doctor Name of doctor in fulle) Qualification Enter the qualifications of the treating doctor Abbreviations of educational qualificationsf) Registration No. with State Code Enter the registration number of the doctor along with the state code As allocated by the Medical Council of Indiag) Phone No. Enter the phone number of doctor 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

The issue of theis form is not to be taken as admission of liability

Please include the original preauthorization request form in lieu of PART A

ii. Gravida Status:

c) Pre authorization obtained: d) Pre-authorization number:

ii. If injurydue to Substance abuse / alcohol consumption, Test Conducted to establish this:

Original Pre-authorization request

Copy of the Pre-authorization approval letter Doctor's referance slip

Oparation Theatre Notes

DETAILS IN CASE OF NON NETWORK HOSPITAL (ONLY FILL IN CASE OF NON NETWORK HOSPITAL)

We hereby declare that the information furnished in this Claim Form is true & correct to the best of our knowledge and belief. If we have made any false or untrue statement, suppress or concealment of anu material fact, our right to claim under this claim shall be forfeited.

Indicate whether In network or non network nospital

UNITED INDIA INSURANCE COMPANY LIMITED

REGISTERED & HEAD OFFICE: 24, WHITES ROAD, CHENNAI-600014

b) IP Registration Number Enter insurance provider registration number As allotted by the insurance providerc) Gender Indicate Gender of the patient Tick Male or Femaled) Age Enter age of the patient Number of years and monthse) Date of Admission Enter date of admissionf) Time Enter time of admissiong) Date of Discharge Enter date of dischargeh) Time Enter time of dischargei) Type of Admission Indicate type of admission of patient Tick the right optionj) If Maternity

Date of Delivery Enter Date of Delivery if maternityUse standard format

k) Status at time of discharge Indicate status of patient at time of discharge Tick the right optionSECTION C – DETAILS OF AILMENT DIAGNOSED (PRIMARY)

a) ICD 10 Code

Primary Diagnosis Enter the ICD 10 Code and description of the primary diagnosis Standard Format and Open textAdditional Diagnosis Enter the ICD 10 Code and description of the additional diagnosis Standard Format and Open textCo-morbidities Enter the ICD 10 Code and description of the co-morbidities Standard Format and Open text

b) ICD 10 PCS

Procedure 1 Enter the ICD 10 PCS and description of the first procedure Standard Format and Open textProcedure 2 Enter the ICD 10 PCS and description of the second procedure Standard Format and Open textProcedure 3 Enter the ICD 10 PCS and description of the third procedure Standard Format and Open textDetails of Procedure Enter the details of the procedure Open text

Tick Yes or No

As allotted by TPAe) If authorization by network hospital not obtained, give reason Open textf) Hospitalization due to injury Indicate if hospitalization is due to injury Tick Yes or No

Cause Indicate cause of injury Tick the right option

Indicate whether test conducted Tick Yes or NoMedico Legal Indicate whether injury is medico legal Tick Yes or NoReported To Police Indicate whether police report was filed Tick Yes or NoFIR No. Enter first information report number As issued by police authoritiesIf not reported to police, give reason Enter reason for not reporting to police Open Text

SECTION D – CLAIM DOCUMENTS SUBMITTED-CHECK LIST

Indicate which supporting documents are submitted

SECTION E – DETAILS IN CASE OF NON NETWORK HOSPITAL

a) Address Enter the full postal address Include Street, City and Pin Codeb) Phone No. Enter the phone number of hospital Include STD code with telephone numberc) Registration No. with State Code Enter the registration number of the doctor along with the state code As allocated by the Medical Council of Indiad) Hospital PAN Enter the permanent account number As allotted by the Income Tax departmente) Number of Inpatient Beds Enter the number of inpatient beds Digitsf) Facilities available in the hospital Indicate facilities available in the hospital Tick the right option. If others, please specify

SECTION F - DECLARATION BY THE INSURED

Use dd-mm-yy format

Use hh:mm formatUse dd-mm-yy format

Use hh:mm format

Use dd-mm-yy formatGravida Status Enter Gravida status if maternity

c) Pre-authorization obtained Indicate whether pre-authorization obtainedd) Pre-authorization Number Enter pre-authorization number

Enter reason for not obtaining pre-authorization number

If injury due to substance abuse/alcohol consumption, test conducted to establish this

Read declaration carefully and mention date (in dd:mm:yy format), place (open text) and sign.