Scribd
Upload
30 views2 pages

Check List

This document provides a checklist for submitting a claim for hospitalization expenses. It lists 18 required documents, including claim forms, ID proofs, medical records like discharge summaries and bills. It notes that documents marked with an asterisk are mandatory. It provides instructions to arrange documents in the listed order and retain copies for reference. It also lists points about receiving email updates on claim status and providing bank details for electronic claim funds transfer.

Uploaded by

pk
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
30 views2 pages

Check List

This document provides a checklist for submitting a claim for hospitalization expenses. It lists 18 required documents, including claim forms, ID proofs, medical records like discharge summaries and bills. It notes that documents marked with an asterisk are mandatory. It provides instructions to arrange documents in the listed order and retain copies for reference. It also lists points about receiving email updates on claim status and providing bank details for electronic claim funds transfer.

Uploaded by

pk
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 2

CHECKLIST FOR CLAIM SUBMISSION

EmployeeName:

Employee No.: Claim No.:

CompanyName:

Mobile No.: Alternate Contact No.:

Email ID:

DOCUMENTS REQUIRED FOR CLAIMING


HOSPITALIZATIONEXPENSES
1) *Claim Form – Part A: Duly completed by the insured on the prescribed format–
Original
2) *Claim Form – Part B: Duly completed and signed by the hospital authorities–
Original
3) *EWA TPA ID Card – Photocopy
4) *Employee photo ID proof (Employee ID card, Aadhar card & Pan Card
mandatory) –
Photocopy
5) *Cancelled Cheque of Employee’s Bank Account – Original

6) (Cancelled Cheque, with Employee name printed under place ofsignature)


*Discharge Card/Summary – Original
7) (Gives the summary of diagnosis and treatment in hospital)
*Death Summary (Instead of Discharge Summary)– Original
8) (Only in case of death of patient during Hospital stay)
Indoor Case Papers (ICP)
9) *Hospital Main Bill with bill no. & break up – Original
10) (With detailed break up of various heads like Room Rent/OT charges/Nursing etc.)
*Hospital Payment receipt with receipt number – Original (With seal & signature of
hospital)
11) *All Payment Receipts with receipt number – Original
12) (For consultation/surgeon charges, if charged outside the main hospitalbill)
*Investigation bills cum receipt – Original
13) *Prescriptions – Original
14) (On Doctor’s letterhead, mentioning duration and dosage for medicines and advice for
diagnostictests)
*Pharmacy bills cum receipt/Cash Memo – Original
15) *Investigation Reports – Original
16) (Reports for all tests done along with images like USG, X-Ray, ECG, etc. and Blood
reports –
Laboratory reports can be counter signed by only a registered Medical Practitioner with a
post graduate qualification in Pathology)
*Barcode Sticker for the Implants used, along with supportinginvoice – Original

18) (For Implants used in Cataract, Heart Valve, CABG, Abdominal, Knee replacement
surgeries)
Kindly mark against the documents you are submitting
Kindly mark X against the documents you are not submitting
Not Applicable NA
Note: All documents marked with (*) are mandatory for claim processing.

Signatureof Employee:
Points to remember

1) Do not forget to attach this checklist with the Claim file.


2) Arrange the documents in the same order as in the checklist.
3) Please retain copies of all the documents submitted to us for future reference.
4) Please retain a POD copy of the courier for tracking your consignment in case of any delay
etc.
5) 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 claimdocuments.
6) Please note that you will receive following email communication at different stages
of claim processing:
Receipt of your claim email to acknowledge receipt of your claim file
Acknowledgement for Claim email to update claim status
8) Please enter your Bank Account details online for Electronic Fund Transfer of
your medical claim directly into your bank account. Please ensure that you
mention the correct account number for the fund transfer since the claim credit
will be processed solely based on the account number providedby you. Kindly
logon at https://www.ewatpa.com/

You might also like

pFad - Phonifier reborn

Pfad - The Proxy pFad of © 2024 Garber Painting. All rights reserved.

Note: This service is not intended for secure transactions such as banking, social media, email, or purchasing. Use at your own risk. We assume no liability whatsoever for broken pages.


Alternative Proxies:

Alternative Proxy

pFad Proxy

pFad v3 Proxy

pFad v4 Proxy