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    Insurance Claim Checklist

    Uploaded by

    Badal Bhattacharya
    The document provides a checklist for submitting an insurance claim. It lists 15 items that must be arranged and provided in order, including claim forms, hospital bills and receipts, investigation reports, discharge summaries, and any other supporting documents. It notes that investigation reports and receipts over Rs. 5000 must include revenue stamps. The checklist also includes fields to be filled out by the employee such as patient and policy details, claim amount, and contact information.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Insurance Claim Checklist

    Uploaded by

    Badal Bhattacharya
    230 views1 page
    The document provides a checklist for submitting an insurance claim. It lists 15 items that must be arranged and provided in order, including claim forms, hospital bills and receipts, investigation reports, discharge summaries, and any other supporting documents. It notes that investigation reports and receipts over Rs. 5000 must include revenue stamps. The checklist also includes fields to be filled out by the employee such as patient and policy details, claim amount, and contact information.

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    The document provides a checklist for submitting an insurance claim. It lists 15 items that must be arranged and provided in order, including claim forms, hospital bills and receipts, investigation reports, discharge summaries, and any other supporting documents. It notes that investigation reports and receipts over Rs. 5000 must include revenue stamps. The checklist also includes fields to be filled out by the employee such as patient and policy details, claim amount, and contact information.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    230 views1 page

    Insurance Claim Checklist

    Uploaded by

    Badal Bhattacharya
    The document provides a checklist for submitting an insurance claim. It lists 15 items that must be arranged and provided in order, including claim forms, hospital bills and receipts, investigation reports, discharge summaries, and any other supporting documents. It notes that investigation reports and receipts over Rs. 5000 must include revenue stamps. The checklist also includes fields to be filled out by the employee such as patient and policy details, claim amount, and contact information.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    Claim Submission Check list

    Dear Sir/Madam,

    We request you to arrange your documents in the following order before claim submission:
               

    1) Claim Intimation

    2) Duly filled & signed claim form by the Insured

    3) Original Discharge Card/Discharge Summary

    4) Original Main hospital bill & receipts with breakup of charges

    5) Original medicine bills (with the Insured’s name, date) with supporting prescriptions

    6) Original investigation reports with bills, receipts & prescriptions

    7) Any other supporting document which may be Important to the hospitalization

    8) Maintain a copy of Investigation reports and discharge card before claim submission

    (For point no: (5, 6) if any documents are found missing, the corresponding amount shall be
    deducted.)
    Note-: * All Receipts above Rs-5000/- must be Revenue Stamped.
    * Notes by the Employee: _______________________________________________________
    _____________________________________________________________________________
    _____________________________________________________________________________

    To be filled by employee:
    1. Company Name : _____________________________________________________________
    2. Policy Number : ___________________________________________________ _________
    3. Member ID : ______________________________________________________ __________
    4. Employee ID : _______________________________________________________________
    5. Name of Employee : __________________________________________________________
    6. Name of Patient : ____________________________________________________________
    7. Relationship with Employee: ____________________________________________________
    8. Age of Patient : ______________________________________________________________
    9. Date of Admission : ___________________________________________________________
    10. Date of Discharge : __________________________________________________________
    11. Claim Amount : _____________________________________________________________
    12. Claim Towards : _____________________________________________________________
    13. Contact No of Employee: ______________________________________________________
    (Mobile Number for SMS alerts)
    14. Email Id : __________________________________________________________________
    15. Signature of Employee: _______________________________________________________

    * * * * * Assuring you best of our Services always * * * * *


    * * * * * * Wish you to stay healthier * * * * * *
    Alliance Insurance Brokers Pvt. Ltd.

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