Professional Documents
Culture Documents
Check
Particulars Type of Document
No. Box
Original Detailed Discharge Summary / Day care summary from the hospital
6 Original
in case of Day Care Treatment/Death Summary in Case of Death Claim
a) Copy of the Legal heir certificate, if the claim is for the death of the
Copy
principle insured.
b) Copy of Post Mortem Report & Death Certificate (In Accidental Death
Copy
cases)
7 Original Final Hospital bill with breakup of each Item. Original
8 Original Payment Receipt of Main Hospital bill (both Deposit & Refund) Original
a) Receipt Of Payments Made At The Hospital By Credit Card :
Please Attach The Xerox Copy Of The Credit Card Payment Slip As Received
Copy
From The Vendor
Implant Invoice along with Payment Receipts & Implant Labels / Stickers for
9 Original
Stents/Mesh/IOL
Original medicine bills with Patient Name and date of purchase with
11 Original
corresponding Prescriptions.
12 First Consultation letter and subsequent Prescriptions. Original
In case of No intimation/Delay submission of files letter from the insured
13
required stating reason for the same.
14 OTHERS
Obstetric history (Gravida, Para, Living children, Abortions) from treating
a Original
doctor. (Maternity Claim)
b One Sonography Report in case of Maternity Claim Original
A Scan' Report along with IOL sticker and tax paid invoice in case of Cataract
c Original
Claim
Copy of the First Information Report (FIR) from Police Department / Copy of
d Copy
the Medico-Legal Certificate (MLC) in case of Road Traffic Accident (RTA)
A medical certificate from a doctor not less qualified than MD/MS confirming
the diagnosis of critical illness along with the Investigation reports/Other
e Original
related documents reflecting the critical illness diagnosis. (Critical Illness
Cases)
In case of claims where the insured has submitted documents to another
Settlement Letter In Original.
insurance co /TPA he needs to submit attested Photocopies of all the
f Unpaid Bills And Receipt In
documents along with detailed claim settlement letter from the TPA and any
Original
unpaid bills and receipt for the same in originals.
Important Notes:
2. Date of File Received will be considered as next working day for Claim Files picked up at Help
Desk.
3. The above list of documents is indicative. In case of any other document requirement as specified
by the Insurance Company, our document recovery team will contact you on receipt of your claim
documents by us.
5. Member is advised to keep photocopies of all the papers since Insurer requires all the above
documents in original. Documents once submitted will not returned unless approved & agreed by
Insurer.
A. DETAILS OF INSURED/CLAIMANT
Building Locality
Street
City District
State Pincode
Email ID
B. DETAILS OF ILLNESS/ACCIDENT
2. Nature of disease/illness/injury
3. Diagnosis of illness
4. When did you first notice D D M M Y Y Y Y 5. When did you first consult D D M M Y Y Y Y
signs and symptoms of the illness? your doctor for the illness?
the Doctor
E-mail Id
1
Corporate & Registered Office: ‘Natraj’, 101, 201 & 301, Junction of Western Express Highway & Andheri - Kurla Road, Andheri (East), Mumbai - 400 069.
IRDA Reg. No. 144 dated 15/12/2009 | Insurance is the subject matter of the solicitation.
11. Type of Admission Emergency Planned Daycare
12. Type of Claim Hospitalization - Illness Hospitalization - Accidental Hospitalization - Domiciliary Pre Hospitalization
Post Hospitalization Parental Care Benefit Child Care Benefit Convalescence Benefit
Road Area
City District
State Pincode
E-mail Id
Name of Insurer
Policy Number
Name of TPA
1. Please tick (ü
) specifying nature of claim as follows along with the expense details:
A Hospitalization Expenses
B Pre-hospitalization Expenses
C Post-hospitalization Expenses
F Maternity Expenses
2
Please provide break up of expenses incurred by claimant
Investigations Expense
Medicines Expense
Surgeon Expense
Anesthetist Expense
Consumables Expense
Ambulance Expenses
Convalescence Benefit
GRAND TOTAL
F. ENCLOSURE CHECKLIST
Claim Form duly filled & signed Policy Copy Discharge Card / Certificate Hospitalization Bills
Medicine Bills Investigation Bills Valid Photo Identity Card Medical Certificate
FIR/ MLC copy Death Certificate (if applicable) Investigation Reports Doctor's Prescription
G PAYEE DETAILS
1. Name of Proposer
2. Payable Details Cheque NEFT
Note: It is agreed that the Policyholder/Claimant will intimate in writing to SBI General about any change in bank account details. Please attach a cancelled cheque
pertaining to the same account.
If 'Yes', specify
3
I/We, the above named, do hereby warrant the truth of foregoing statements in every respect and to the best of my/our knowledge and belief. I/We agree that if I /We
have made or make any further declaration (that the Company may require in respect of the said claim) any false of fraudulent statement or any suppression or
concealment, my/our Claim shall be absolutely forfeited and the Policy shall be null and void and my/our all rights uin respect of past or future loss/accident shall be
forfeited.
IP Registration No.
Description
a. Primary Diagnosis
b. Additional Diagnosis
c. Procedure 1
d. Procedure 2
e. Procedure 3
f. Details of Procedure
If authorization is not
obtained by network hospital
please give reason
FIR No.
I certify that I have examined the above named insured, the above statements are correct and that the above named insured is necessarily suffered from the illness
mentioned.