STAR HEALTH AND ALLIED INSURANCE COMPANY LIMITED

Regd. & Corporate Office: 1, New Tank Street, Valluvar Kottam High Road, Nungambakkam, Chennai - 600 034.
Corporate Olfi@ - Claims Dept. : KRM Center, 6th Floor, No 2 Harington Road, Chstpet, Chennai - 600 031.
Toll fre Phono No: 1800 425 2255 Toll fce Fax No: 1800 425 5522
.l29
CIN : U66010TN2005F1C055619 Ecal:info@slafiealh.in Website: ww.stafiealfi.if, lRoAl Regn. No:

v.,;,; *-;,; iil;;;."

CLAII\I FOR[4 - PART - A

TO BE FILLED lN

BYfHE INSURED The i$ue orlhis Fom is not lo be taken 33 an admission of

a) Policy No:

b) SI.

liability Claim

NO.

Nd Cgtilieb tlo:

cI Compony/ TPA lO No:

an

t'l

.}

d) Namo

-{

s) Acdrcsr

CilY:

cM

Curenlly

E)

clllys,

by any olher Mediclaim I

Hcalh

lhsurans: Yd l-l

S0h lnsucd (Rs.)

0) PEviouEly

d)

@ve6

No

l_l

bl Osb ol

mlllelffil

of

trE trE

fFl ln$rae wi0wt Mk:

-J

@mpany mme:

by aoy

oth$ Medidaim

H.w

you

v*i:

/ Heallh inEurance

y4ts?

hospitrliz.d h lh. Iad,l

be6

rcl

Diasmas:

ure:

Ye3

trtr

-/-/-

r,llyescmDonyNam

a) Namo:

,.'l[. ] *r"i:-] I:
Famr l- ,
e)RetarimshipbPilma.yinsu'ed: sef
spu*fchldi-l
f) o@paliof,:
s*i* i i soltEmploycd I Hmemk.L_.] sudcn L
blGender.

!) tudre$

{if

Marei-l remaref-...l

_/_/_

d)oatoorBdh

veas

creee

uoer

l-l

Re&ed

Lj

ll
*t *l

ott",

{H6*spain

u
m

(Pieaslsp.ciM

diffdill fM abml

City

.)

Name o!

H6tild f,ioe

hfury, D5t!

d) Oslc ol

No. of lP Beds:

Admilbd:

@pia,,

c*gory

Room

bJ

Em8il lD:

Codi:

Pin

Os6*

oay
fi61

re I

a)

Medim

D*ils

/-

Ies6I ,*-/l_

cf lh6

lBhrdl

n"

xpnss

l_]

Expefres:
Expons:

ii.

HospElEato

iir.

Pod-hosphlizatd

lv.

Heollh.Che*

Ambohoechaqes:

up

Cost

Sil.

Pd-hGpihlzBlis

sl. t{o

Bill

Fiod:

/-

fj

Y6s

*"
-

Nriiso:

c)Hospitaliratjodueio:

,n* fl

[:

u*aniV

Timr
//i- j nmtom.eoamr i : sut*neeu*lAtdrlCoumprio
-l
rl: i Y* I ruo il sislem of Mdicino:
iii. MLC Rcpod& Polie FlRaircrx
J
bi Craim fo lbmiciltsry H6p"li.",iVe
I No 0t yes, proite deroih h annexue) Chid Oodm.tri. Sobmltu4 Ct.ct
:]
f Clain Fm txy signed
cl tlebili ol Lurp sm / 6sh benefil clained:
I Copy otlhc &im iniimtion
i. HospiH oaily Cash:
RsX ficailarM.$n El
E ihcgbl BGk{p 8il1
ii. Slrgft, Gsh:
R5.
I H,r6dlai Bill PryrMt Recol
Rs.
iii. Cridol llhssr Eonefl:
E lh6tihl oirdsle S0ntmary
Rs.
iv Cff6lc6en@:
I Phem&y 8iI

.)

D6rc of

i)lllninydvr@u*:

Im.:

poll@:

3ameuaspcrmml

sh.nng

Rs
Rs.

Rs.
Rs

Rr.

!i.

days
days

Pre,Post

hGpleliatm

orhe6, l__]

Toi.l

Lump

sm

f] l ]

f--i

at
m

sdiiniided

Rs.

Rs.

i@d6):
Tel
!ii. Prc{EEibli4uonpor'od:
s. OrrE

l. Ropo.l6d lo

h)

T{h

[l

/-

claiM

ExFsS:

i. PFhospalizalioo

@eancy

delaled ,D.G ol Dd i,.ry

g)OateofDi$heee:
i.

sngle

lnirry

Mcft.

Rs.

L,-]

opealisTrihNG

Ddods

R&

i_l

RE,

-!
I

Ecc
hHigati@

rcquGl for

3
Ud:

o
m
o
o

{
z

hHrgaljon

Re{tr

ilndoding CT

i MRI / USG /HPE)

Dodods

P@htims

omr
Amdnt (Rs)

ilo

o
o
Io

a
:oi

:.--:---.i.--........-.*.---

ilo:

alpeli
c)

E E rl
-_j

Bak N.me'nd

*ad

I I i-- I I I us*r**n** I I I I [ tr tr [ ] , I I I I f [-,tr tr

;] f l l Il [l -j I [_j I I I I tl I I i-, i: I f] tl l Il I ri tl f tr [ ] t
=

t-,

d)chequa,ooPay,bledeils:e)lFSccdq|-]t.]i]l.-]|--]ili;ItrL.l--=r...1!]|.1].,'.]-3

(tilPoiTAm PLEAE

I Sizo 2r0.00mm r 297.00mm

TUnN OVERI

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I hereby declare thal. the information fumished in this claim form is true & corect to the best of my knowledge and belief. lf I have made any false or untrue slatement,
suppresslon or concealment of any matorial fact, my right to daim reimburs6ment shall bs forteited. I also consent E au'thorize TPA / insuranco company, to seek necessary
medical infomation / 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 lhe 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.

D"t",

i.' li :

l.:iltll

: ii:

:.1

"*",1.......--,
GUIDANCE FOR FILLING CLAIM FORM

DATA ELEiTENT

tnrured)

DESCRIPTION
SECTION

A. DETAILS OF PRIMARY

FORMAT

INSURED

a)
b)

Policy No.

c)
d)

CompanyTPA lD No.

Enter the TPA lD No

Namo

Enter the full nams

e)

Address

Enter th tull postal address

a)

Curehtly covered by any other Mediclaim / Healih

b)
c)

Date of Commencement ot fiGl lnsurance without break

Enter the date of commencmsnt of fiBt insuran@

Use

CompanyNama

Enter th6 full name of th6 insurance @mpany

Name of the organiation in full

Policy No.

Enter the policy numb6r

As al,otted by ih6 insurance c

Sum lnsured

Enter ths total sum InBUred as par ths pollcy

d)

Enter lhe pollcy number

Enter the social insuEnce number
social hoallh insuran@ schomo

Sl. No/ Certilicate No.

Have )rcu been Hospitalizsd in the last 4

As allotted by the rnsurance company

the @rtificate numbor ot

Sumame, FiEt name, Middle name

lnclude Street, City and Pin Code

SECTION B - DETAILS OF INSURANCE HISTORY

lndimte wfiether currBntly coveed by another Mediclaim
H.alth lnsurance

yeas

ir the lasl

lndicate whether hospitalized

Date

Enter the date of hospitalization

Diagnosis

s)

P@iously Covered by any other Mediclaim/ Health

l)

Company Name

Enter the full name

C.

Tlck Yes or No

dd{m-yyfomat

ln rupess

4 years

Enter the diagnosis details

lndlcate wlrether previously coveEd by another Medic{aim
Hcalth ln{'rrn.s

SECTION

As allotted by the orgEnization

License number as allotted by IRDA and

ofthe policyholder

Tick Yes or No
Use mm-yy format
Open Text

ofthe insuranca @mpany

Tick Yes or No
Name of the organization in tull

DETAILS OF INSURED PERSON HOSPITALIZED

a)

Naho

Enter the full name ot the patient

Sumam6, FiGt name, Middle

b)

Gsder

lndicate Gender of the patiBnt

Tick Male or Female

c)
d)

Age

Enter age of the patiBnt

Number of yoaB and months

e)
0

g)
h)
i)

ofBidh

Use dd-mm-yy

Relationship to primary lnsured

lndicate relationship ot patient with pollcyholder

Tick the dght option. lf otheE, please specify.

fomat

Ocdpation

lndiEts occupstion of patient

Tick the dght option. ll otheB, please Bpecity,

Address

Enter the full postal addross

lnclude Street. City and Pin Code

Phon No

Entor the phone number of patient

lnclud STD code with telephone number

E-mail lD

Enter e-nrail address ot patient

Complete e-mail address

$EcnoN

a)
b)
c)
d)

Name of Hospill where admitted

Room

HosptrAltzATtoN

Enter lhe name of hospital

tegory oc@piod

Hospitalizalion due to
Date of lnjury/Date Disease liGt detected/ Date
Delivery

D . DETA|LS oF

of

Name ot hospital in tull

lndiHt th6 rcom etegory ocapied

Tick the dght option

lndl@ts rsason of hospitalization

Tick tha right eption

Enlsr th8 relevanl date

Usc dd-mm-yyfomat

e)
0

Oate of admission

Enter date ofadmisEion

Use dd-mm-yy

Time

Enter time of admission

Use hh:mm format

g)
h)

Date of discharge

Enter dat ot discharge

Use dd-mm-yy

Time

Enter time ofdisdlarge

Use hh:mm lormat

i)

i)

nahe

Enter Date of Birth of patient

Oare

fomat
lomat

lflnjurygiv cause

lndlcate caus6 of injury

Tlck lhe dght option

lf Medico legal

lndi@te whether injury is mdi@ legal

Tick

Reported to Poli@

lndlte whether police rcport was filed

Tlck Yes or No

MLC Report & Police FIR anadred

lndicate whethor MLC report and Policc FIR attachcd

Tick Yos or No

SFlem of Medicine

Enter th s)6tem of medicino followed in lreatlng the patient

Open Text

Y$

or No

SECTION E . DETAILS OF CLAIM

a)
b)
c)
d)

Oelgils ofTreatment Expenses

Entet the amount claimed as keEtment expenses

ln rupees (Do not enter paise valuss)

Clalm tor Domiciliary H6pltalization

lndit whethr claim

Tlck Y6s or No

Details of Lump sum/ cash benelit claimed

Entor the amount claimed as lump sum/ cash benefit

ln rupees (Do not enter paise

Claim Doements Submitted-Check List

lndicate which suppotting documents ar Eubmitted

Tlck the right option

i6 for domicillary hospitallzation

wlues)

SECTION F . DETAILS OF BILLS ENCLOSEO

lndicate which bills are enciosed with the amounts in rupees
SECTION G -

a)

PAN

b) A@rt
c)
d)
e)

DETAITS OF PRIMARY INSURED's BANK ACCOUNT

Enter the pemanent

Number

smunt

number

As allolted by the lncome Tax department

Enter the bank a@ount number

As allotted by the bank

Bank Name and Branch

Enter the bank name along with the branctt

Name ot the Bank in full

Cheque/ DD payable dctails

Enter the name otthe beneliciary the cheque/ DD should be

IFSC Code

Enter the IFSC code of the bank branch

Name of

o
J
o
2
I

Signature of the lnsured

PART A (To be fltled ln by the

U,

tte individual/ organizatim in full

IFSC code of the b6nk bEnch in full

STAR HEALTH AND ALLIED INSURANCE COMPANY LIMITED

-/\

,.\-,:,=

Regd. & corpoEte Oflice: 1. New Tank Street, Valluvar Kottam High Road, Nungambakkam, Chennai - 600 034.
Corporats Otti@ - Claims DBpt. : KRM Center, 6ih Floor, No 2 Harington Road, Chetpet, Chennai - 600 031.
Toll fee Phone No: 1800 425 2255 Toll frse Fax No: 1800 425 5522
CIN : U6601 0TN2005PLC0566,19 EmEi*info@stsrir6lth.h Web6ilE: w.starheahh.in IRDAI Regn. No: 'l 29

?,,--: i ll'.",H...

TO BE FILLED IN BY THE HOSPITAL

Th. iE*! dthrs Fom

a)

Na@ ol ils h8dlal

bl

li6pit8l

rd b b 6tr illn dhbds dli.thl H.r.! i@d6 h cgill EUhcEb

c) Typ. of

Shis Hcpital l0:

lD:

i.lieu dPMT A

Host,lal:

x"tr* [__..1

rEU..t

rilh

([

non

ndwk

ltll

$dim

o
m
o
Io

E)

.)Ouaffelid:

d) N8@ ol tro lreating do.lor:

0 Regist"alion No.

H*o* I

Hon

h) Email lD:

Stale Code:

THE PABEI{T AD]'TflED

a)

Nr@

ot

Ur

Pelient:

b)lPRegiitsationNumb6ceru,!*ri I fr.*"al I
disda.ge: Oiscna.lclohom6 I

ilTrDeorMmission:
l)Sbtusallimoof

glTire:-

,/-

r/-

0thlofAdilission:

c)Gender: Mao

lhyCm.

Femah

aon",

u-nr[]

i--

r)fMffiitv

,/-

'1r*, [[
-/-,/-

]itr trtr

trI

i.Ddeorootsry

O** f

o
m
o

e)Dahoftin:

r/-

h)D.teof oisderge:

uarunlry

Di*,lrargcuaotrahept

,*[[

ii c6,idashh6:

Jo

,[[

i ]i li

DETAILS OF AILTEI{T

i.

:r:nn'rr
=ltr ItrNI

ftmary Diagmis:

ii Addili(ftlaagGis:
ni.

-n:l[]irrti
l-'-uL_f]I[

Conuhdili.s.

iv Comdbiditi6

v Oudim d

lllness:

d)p*rdtatonobhind, v*
by

ned( lEdlal d

g)HGrruiatboduebri4r

i I !i I

l_l

n"

[_]

oblained, giw

v* lj

n"

---

=-X

i.ry6,giw@s

Pc-.ufvialkl

Copy of the
Copy

s*r,niauo

I-l

no

erd

ij

ll

ufi6d

by

a)

MdE$ of

t,

{
o
o
o

----

--

,i_-.1l--il-

subBla@abu$ialc.trlonsumorim

V*

iii.fti4di@logd:

fl

l,/o

lnwstgatfi

t_..

CTrlrRli,SGfi PE hvesligatkn repdls

i-

Doffi's

f
il

hct lrl

Ih6lE mks

brBl({p

--

i---1

l]l
t* n *

ivRepodedbkiie:

[--.]

vi.rrndopldbldicesi**w,

Hospihl roin bill

Hospilal

([Y*.aedrropofi

$mmry

Hspilal Disdrrge
opelion

:L--

-------_

epp@al ledcr

oi pa'ief,i

Pr@due

R@dTafrcAcidal

requesl

P6&lhdizad.n

photo lD

iu D6uils ol

- U|-ltr,l

a)p*ursizatmNumb.r

M*, i--

[l

---

Fm dult signed

Gbinal

ll li i

1ol_(1,Y6.,5porydohik)

Ia trItrItrtrtrI

Oaim

lt__lT:

i_--...]--1-----li--ii-

irihi4/dEhsu*taGsb@i8lcohd6$mpto,T6rcddudrdtoshuidrris: vs
r:rtRno

l-I

i___l:i

.....

c,PEslailMlisa@dsrisofpD? v"sl--i

auhdiatim

i:

i. ProeduE

vi. Past Medil Hi3tory

0 ll

r,:iJrnr

b)

aafd6nc6 dip for

an

hEsiJalon

o
I
o
o

ECG

Phamcy blls

T'

iJLC

Oigind dcah su,Wry

mp.(

& Pdi@ FIR

lM

hostihi

tllm

arplicade

Ary dh6r ple6$ 6ps.ilY

t.....

bill

rcpona

lhc Hcp{al:

U,

{
o
o
m

c)

d)pr:
ir.

i_

,, ]t

it -.ll

]-l|_..]tl]lJ

etNunterorrnoariarusll i--1

Reiisfalion No.:

|)Faciririssewr.breiolhohqrrei:

i.or: v* -l

ro

l__] ii.rcu, v* i_l m [

O(Ec

]
i
I

DECLARAnoil BYTli HOSPr L

our dght to claim

unds

** EE

ll

this daim shall bo

fdtoil6d.

llr II

T16 signatuts of th6 insurcd is taken

m his fom ater Claim Fom

B is fully

o
m
o
o

lill6d up by us.

{
Signatl,rc and Seal of

tt

Hospilat &rt1dity.

0IIPORI xl:

PLEASE

TUn[

OVER)

j
,.\--;:F.=,-.:111",,",1*"."
Not to be Faxed
GUIDANCE FOR FILLING CLAIU FORM
DATA ELEMENT

A.

FORTAT

DETAILS OF HOSPITAL

Name of Hospital

Enter the name ol hospital

Name o, hospital in full

Hospital lD

Ehter lD number of hospital

As allocated by the TPA

Type ofHospital

lndicate whether ln network or non network nospital

Tick the right option

Name of heating doctor

Enterthe name ofthe treating doclor

Name of doctor in tull

Qualitication

Enter the qualilications

Abbreviations of educational qualifi cations

Registration No. with Slate Codo

Enterthe regishation number of the doctor 6long with the state

code

As allocated

Phone No.

Enter the phone number ol doctor

lnclude STD code with tslephone number

SECTION B

a)
b)
c)
d)
e)
0
g)
h)
i)
j)

PART B Oo bc fllled ln bytho hospital)

DESCRIPI1ON
SECTION

a)
b)
c)
d)
e)
f)
g)

Scanned

ofthe treating doctor

bythe Mediml Council of lndia

DETAILS OF THE PATIENT ADMITTED

Name of Paticnt

Enter the name of hospital

Name of hospital in full

lP Registration Number

Enter insurance providor rogistration number

As allottod by the insurance provider

Gender

lndicato Gender ofthe patient

Tick Male or Female

Age

Enter age of the patient

Number of years and

Date ofAdmission

Enter date of admission

Use dd-mm.yy format

Time

Enter time of admission

Uss hh:mm

Date of Discharge

Enter date of discharge

Use dd-mm-yy

Time

Enter time of discharge

Us6 hh:mm

lndimt8 type of admission of patienl

Tick the right option

Tpe

of Admission

fomat
fomat

fomal

ll Matemity
Date of Delivery

Enter Date of Delivery if maternity

Use dd-mm-yy format

Gravida Status

Ent6r Gravida status if maternity

Use standard

k)

Status at time of discharge

lndicate slatus of patienl at time ofdischarge

Tick the right option

a)

ICD 10 Code

SECTION C

Ccmorbidities

ofthe primary

Slandard Format and Open text

diaonosis

Standard Fomat and Open ten

Enter the ICD 10 Code and descrlption of lhe ccmorbidities

Standard Format and Open txl

lcD 10 Pcs
Pmcedure

g)

fomat

DETAILS OF AILMENT DIAGNOSED (PRIMARY}

Ent6r the ICD 10 Code and description ot the additional

Additional Diagnosis

c)
d)
e)
0

Enter the ICD 10 Code and description

diadnnsiq

Primary Diagnosis

b)

monhs

Enter tho ICD 1 0 PCS and description

ofthe first procedure

Standard Fomat and Open text

Procedure 2

Enter the ICD 10 PCS and descrlption

ofthe second procedure

Standard Format and Open text

Procedure 3

Enter the ICD 10 PCS and description ofthe third procedure

Details of Procedure

Enter the details

ofthe pmcedure

lndicate whether presenl ailment is a complication of some pre-

Present Ailment is a Complimtion of PED

existinq diseas6

Standard Fomat and Open text

Open text
Tick Yes or No

PrFauthorizationobtained

lndicate wh6th6r pre-authorization obtained

Tick Yes or No

Pre-authorizetionNumber

Enter pre.authorization number

As allotted by

Enter reason for not obtaining pre-authorization numbet

Open text

Hospitalization due to iniury

lndicate if hospitalization is due lo injury

Tick Yes or No

Cause

lndicate cause of inlury

Tick the right option

lf injury du to substance abus8/alcohol consumption,

test conducied lo establish this

lndicate whether test conducted

Tick Yes or No

Medico Legal

lndicate whether iniury is medico legal

Tick Yes or No

Reported To Police

lndicate whether police report was filed

Tick Yes or No

FIR No.

Enter fir$t infomgtion report number

As issued by police aulhorities

lf not reported to police, give rsason

Enter reason for not reporting to police

Open Tcxt

lf authorization by net$/ork hospital not obtained, givo

SECTION D

IPA

CTAIM DOCUMENTS SUBMTTTED4HECK LIST

lndicate which suppoding documents are submitted

SECTION E

a)
b)
c)
d)
e)
f)

DETAILS IN CASE OF NOl{ NETWORK HOSPITAL

Address

Enter the full postal address

lncludo Street, Clty and Pin Code

Phone No.

Enter the phone number of hospitrl

lncludo STD code with tolephone number

Registration No.

Enterth6 rogistration number of patienl

As allocated by lhe Hospital

PAN

Enter the pemanent accounl number

As allotled by the lnmme Tax dspartment

Number of lnpatient Beds

Enter lhe number of inpatient beds

Digits

Facilities available in lhe hospital

lndicate facilities available in the hospital

Tick the right option. lf others, please specify

:I

SECTION F. DECLARATION BY THE HOSPITAL

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

o
o

t*r**
lf\$...;,;,i;,i

Star Heal$ And Allied lnsurance Company Limited

t, Nex Tan* Street, Valtuvar Kottam Fiigh Road, Nungarnbakkar:T

(hennai * 6OS034. Phime - 044 * 28188800, Telefax * 282SS062
eorporate dlaims Departrnent, 6rh Flo6r- ltBM Centre, No. 2, t{arrir}gton Road, Chetpet,
Chennai - 600 031 Phone - 044 - 4347 8337 . www.starhealth in

ReSd and Corporate Office :

for {Eiame.ofttrro }iocpital S Addrcss}

'Date:

Dear Sirs,
ft

g AUTIBft

I have

}$ATION TO STAR

f ALTH AN DALTISD INSUfi ANCE CO. LI D.,

undergone treatment for................-......,...!,.n.....,.,..,.,...."............................................

herebyauthoriae M/s Stsr Fleafth and Alliad lnsuranee Company Ltd., who is my Health lnsurerto seek any

medicel in{ormotion/r"ecords frcrn you or {rom the Medical Practitioners who have artended on me in

connectionwhh the above ailment and the treatmentgiven.

ln case they seek any such information/records kindly oblige.

Thanking you,
Yours fuithfully,

iSBnat!rre <lf the e laimant)

Addre:s ofthe lnsufed:

tuflent Adrriissinn No: