Hospitalisation Claim Forms 67119

Policy No.: Claim No.:

Tata AIA Life Insurance Company Limited

(Hereinafter called “Tata AIA” or “the Company”, whichever is applicable) HOSPITALIZATION CLAIM FORM Office ___________________________________ Agency _______________ Code ______________ Agent _______________ Code ______________

PART I (To be completed by Insured/Claimant in BLOCK letters) Please answer all questions, use “not applicable” (N/A) as appropriate instead of leaving it blank. Counter-sign where amendments/alterations are made in the form. The filing of this claim form is not to be construed as an ission of liabilities of our Company. No agent has been or is authorized to it any liabilities on behalf of the Company.

(Note: - Insured’s name should be written in full as the same will appear on the cheque) Policy No. Full Name of Insured

Age

Alias, if any

Sex

Benefits to Claim: (please tick) Daily Hospital Benefit

Post-Hospitalization Benefit

Surgical Benefit

Dismemberment

Insured’s Address

I. D. No.

Phone No.

I. D. Document Type

Bank No. Payment Method (tick the option)

CHEQUE

NEFT

Advance Discharge Voucher submitted - YES Occupation & exact duties

Employer Name & Address

Phone No. Are you claiming from other insurers or institutions (including government/welfare schemes) for the same cause? Yes, for (type & amount) _______________________________ _______________________________

from ___________________________________ from ___________________________________

No

Yes, (state the dates) __________________

No

Did a medical leave certificate filed to Insured’s employer? Claims Details Describe initial symptoms / parts of body injured

Since when does the Insured have these symptoms / bodily injury MM

DD

YYYY

MM

DD

YYYY

Date of first consultation Diagnosis given by doctor

The first doctor consulted (name, address & telephone)

Is the condition due to an accident? Accident Date Accident Details

No.

Yes, details below: Time

MM

DD

(am / pm)

Place

YYYY

Consultation Details

Name, Address & Telephone

Consultation Dates

Disease / Condition

a) Insured’s regular doctor b)

All other doctors consulted for this illness/injury; or similar condition in the past

CLM/P4.9/4.T3 (II) - 29May2003 Corporate Office : Tata AIA Life Insurance Co. Ltd., 2nd Floor, Delphi-B Wing, Arcade Avenue, Hiranandani Business Park, Powai, Mumbai - 400 076. Phone No.: - 022 – 5647 9000. Fax No.: - 022 – 5502 4123. ed Office : Tata AIA Life Insurance Co. Ltd., 6th Floor, Peninsula Corporate Park, G K Marg, Lower Parel, Mumbai- 400 013.

c)

Doctor who referred Insured to hospital

Please give details of any other illness Insured have suffered from in the past. Disease/Condition

Consultation Dates

Doctor consulted (Name, Address & Telephone No.)

Hospitalization Details Details of hospital confinement for the injury/illness. Name of Hospital

Address

Date of consultation(s)

Date & time of ission

Date & time of discharge

Any surgical procedure(s) done during hospitalization? No

Yes, details:

Information of Claimant (if other than the Life Insured) [Note:- Claimant name should be written in full as the same will appear on the cheque] Name in Full ID No. ID Type Sex:

Male

Female

Telephone No.

Age

Address Relationship with the Insured

In what title are you submitting this claim?

Advance Discharge Voucher submitted - YES

Bank no. (tick the option)

Payment Method -

CHEQUE

NEFT

DECLARATION AND AUTHORIZATION

I/We hereby declare that the information given on this accident/hospitalization claim application form is true and complete. /We hereby make claim to Tata AIA by submitting this accident/hospitalization claim application form and agree that the written statements of all the physicians who attended or treated the Insured and all other proofs and ing documents associated with this accident/hospitalization claim application form shall constitute and are hereby made part of this accident/hospitalization claim application form. I/We further agree that the furnishing of this accident/hospitalization claim application form, or of any other forms supplemental hereto by the Company, shall not be deemed an ission of an existence of any assurance in force on the life in question, nor an ission of liabilities or a waiver of any of its rights of defenses. I/We hereby declare and agree that any personal information collected or held by the Company (whether contained in this application or otherwise obtained) is provided and may be held, used, and disclosed by the Company to individuals/organizations associated with the Company or any selected third party (within or outside of India, including reinsurance and claims investigation companies and industry associations/federations) for the purposes of processing this application and providing subsequent services for this and other financial products and services, direct marketing, and data matching, and to communicate with me/us for such purposes. I/We hereby irrevocably authorize: (i) any organization, institution, or individual that has any record or knowledge of my/the Insured’s health and medical history or any treatment or advice and that has been or may hereafter be consulted, other personal information or details of related accident/injury to disclose to the Company such information; (ii) the Company and its approved medical examiners and laboratories to perform medical assessment and tests to evaluate Insured’s health condition, or to perform any autopsy as appropriate.

This authorization shall bind my/the Insured’s successors and assigns and remain valid notwithstanding my/the Insured’s heath or incapacity in so far as legally possible. A photocopy of this authorization shall be as valid as the original. Witness Signature ___________________________

Claimant Signature _______________________

Name of the Witness _________________________ (in block letters, family name first)

Date ___________________________________

Address of Witness: _____________________________

Name of Claimant _________________________

Designation: ____________________

Note: Witness should be notary / Gazetted officer / SEM or a person of local standing. \

CLM/P4.9/4.T3 (II) - 29May2003 Corporate Office : Tata AIA Life Insurance Co. Ltd., 2nd Floor, Delphi-B Wing, Arcade Avenue, Hiranandani Business Park, Powai, Mumbai - 400 076. Phone No.: - 022 – 5647 9000. Fax No.: - 022 – 5502 4123. ed Office : Tata AIA Life Insurance Co. Ltd., 6th Floor, Peninsula Corporate Park, G K Marg, Lower Parel, Mumbai- 400 013.

Policy No.: Claim No.:

Tata AIA Life Insurance Company Limited

(Hereinafter called “Tata AIA” or “the Company”, whichever is applicable) CERTIFICATE OF MEDICAL ATTENDANT To be completed in BLOCK letters by a duly qualified and ed medical practitioner at the claimant’s expense. Please answer all questions, use “not applicable” (N/A) as appropriate instead of leaving it blank. Counter-sign where amendments/alterations are made in the form. Patient Name

Age

Patient’s Occupation

I. D. No.

Sex

Patient’s Address

I. D. Document Type

Consultation Details If due to ILLNESS, please provide: Chief complaints & presenting symptoms

If due to ACCIDENT, please provide: Conditions of injury & parts of body involved

Is there external visible evidence of injury at your first consultation: If yes, give details Date symptoms first appeared

Date of injury

Your Diagnosis

Cause of injury

Date of your consultation of this illness/injury First consultation on Last consultation on Past medical history, family history and co-morbid conditions (please give consultation dates & details)

Hospitalization Details

Does this illness/injury necessitate inpatient hospitalization:

No

Yes, details as below:-

Hospital Name

Date & Time of ission

Address

Date & Time of Discharge

Any surgical procedure performed?

No

Yes, details as below:-

Date of operation

Place of operations

Name of surgical procedure

Surgeon Name & Registration No.

Tests & investigations performed?

No

Name of test/investigations

Yes, details as below:Date(s)

Results (please enclose a certified true copy of the test results)

Other treatments istered (medicines, dressing & suturing etc) Discharge summary & treatment plan Dates of follow-up consultations with you after hospital discharge for the same illness/injury Date(s)

Condition

CLM/P4.9/4.T3 (II) - 29May2003 Corporate Office : Tata AIA Life Insurance Co. Ltd., 2nd Floor, Delphi-B Wing, Arcade Avenue, Hiranandani Business Park, Powai, Mumbai - 400 076. Phone No.: - 022 – 5647 9000. Fax No.: - 022 – 5502 4123. ed Office : Tata AIA Life Insurance Co. Ltd., 6th Floor, Peninsula Corporate Park, G K Marg, Lower Parel, Mumbai- 400 013.

Was healing complicated? If yes, state reasons and any special treatment given. Bearing in mind the patient’s occupation, do you feel the illness/injury would have prevented him/her from working at your first consultation at your last consultation If absence from work more than 2 weeks was necessary, please state the reasons. Is the illness/injury related to (a) Physical defects/congenital anomaly (b) Unfavourable past medical history (c) Degenerative changes (d) Alcohol, drug, or nicotine/smoking (e) AIDS or HIV infection (f) Suicide or self-inflicted injury Other doctors/hospitals involved in the care of the patient Name Address

No

Yes, details as below:-

No No

Yes, details: _______________________________ Yes, details: _______________________________

No No No No No No

Yes, details: _______________________________ Yes, details: _______________________________ Yes, details: _______________________________ Yes, details: _______________________________ Yes, details: _______________________________ Yes, details: _______________________________ Telephone No.

Declaration by the Attending Physician/Specialist I declare that the answers given are true and complete. I declare I am duly licensed and ed to practice western medicine (allopathy) in India (if outside India, please state where ______ ) Certification by Hospital itted, that 1)

The Hospital is duly licensed and ed as a Hospital to provide treatment in western medicine (allopathy) in India (if outside India, state where ___________) for the care and treatment of sick and injured persons as ed in-patients, fully equipped with facilities for diagnosis and major surgery which are under the constant supervision of one or more ed Medical Practitioners, and which have 24-hour a day full time professional nursing services; And

2)

Maintains proper medical and patient records and quality health care to the standards as required under the prevailing laws and regulations in the geographical area it is located; And

3)

Is not an institution operated as a convalescent or rest home, a hotel, a home for the aged, a place for alcoholics or drug addicts, or Custodial Care, or for any similar purpose.

4)

The Hospital has on the following facility and resource (please state) No. of in-patient beds : ___________________ No. of qualified ed resident doctors: ___________________ No. of qualified ed full time nurses : ___________________

__________________________________________________ Signature of Attending Physician/Specialist (with qualifications)

___________________________________________________ Signature of authorized Hospital

[Name in Block:

[Name in Block:

]

_____________________________________________

]

_____________________________________________

Registration No. & Place

Name of Hospital

__________________________________________________ Address & Official Stamp

___________________________________________________ Registration No. & Place

__________________________________________________ Telephone

___________________________________________________ Address & Official Stamp

__________________________________________________ Mobile No.

__________________________ Telephone

__________________________________________________ Email Address

___________________________________________________ Email Address

___________________________________________________ Date

___________________________________________________ Date

_______________________ Fax No.

CLM/P4.9/4.T3 (II) - 29May2003 Corporate Office : Tata AIA Life Insurance Co. Ltd., 2nd Floor, Delphi-B Wing, Arcade Avenue, Hiranandani Business Park, Powai, Mumbai - 400 076. Phone No.: - 022 – 5647 9000. Fax No.: - 022 – 5502 4123. ed Office : Tata AIA Life Insurance Co. Ltd., 6th Floor, Peninsula Corporate Park, G K Marg, Lower Parel, Mumbai- 400 013.

Hospital Information Sheet

Please provide your answers in the right column and return it to us at the following address for our database: Tata AIA Life Insurance Co. Ltd. 2nd Floor, Delphi-B Wing, Arcade Avenue, Hiranandani Business Park, Powai, Mumbai - 400 076. Attn: Claims Department Name of hospital : Registration no. & ing authority & Place : Address : Tel. No. : Fax no. : Web site : Name of person : Designation : Telephone no. : Email address : Name of Owner (if different from person above) : The Hospital provide treatment in (tick as appropriate) :

western medicines (allopathy) alternate medicines (state details) ________________________

Specialties available (e.g. Paediatrics, Orthopaedics, ENT etc) If yes, please state details: No. of in-patient beds: No. of qualified ed resident doctors : For government hospitals, please also state No. of Professor doctors: No. of Assistant Professor doctors: No. of Lecturer doctors: No. of qualified ed full time nurses : In House facility available [please state Yes in the right column if available] Pathology Lab. : Oxygen : -

Central supply :

-

Cylinder :

E. C. G. : X Ray : Ultrasonography : C. T. Scan : M. R. I. Scan : CLM/P4.9/4.T3 (III) - 29May2003 Corporate Office : Tata AIA Life Insurance Co. Ltd., 2nd Floor, Delphi-B Wing, Arcade Avenue, Hiranandani Business Park, Powai, Mumbai - 400 076. Phone No.: - 022 – 5647 9000. Fax No.: - 022 – 5502 4123. ed Office : Tata AIA Life Insurance Co. Ltd., 6th Floor, Peninsula Corporate Park, G. K. Marg, Lower Parel, Mumbai – 400 013

Pathology : Blood Bank : Operation Theatre : Labour room / delivery room : I. C. C. U.: Cardiac monitor : Defibrillator : Ventilator : Emergency Room : Day Care Centre : Outpatient consultation : Computerized access to patient records : Other facilities – please state details :

The above information is certified to be true and complete.

______________________________________ Date

__________________________________________________________________ Signature of Hospital [Name in Block:

]

__________________________________________________________________ Hospital Name & Official Stamp

CLM/P4.9/4.T3 (III) - 29May2003 Corporate Office : Tata AIA Life Insurance Co. Ltd., 2nd Floor, Delphi-B Wing, Arcade Avenue, Hiranandani Business Park, Powai, Mumbai - 400 076. Phone No.: - 022 – 5647 9000. Fax No.: - 022 – 5502 4123. ed Office : Tata AIA Life Insurance Co. Ltd., 6th Floor, Peninsula Corporate Park, G. K. Marg, Lower Parel, Mumbai – 400 013