PARAMOUNT HEALTH SERVICES & INSURANCE TPA PRIVATE LIMITED (IRDA License No.

006)
[formerly known as PARAMOUNT HEALTH SERVICES (TPA) PVT.LTD]
Plot no.A-442, Road No-28,M.I.D.C Industrial Area, Wagale Estate, Ram Nagar, Vitthal Rukmani Mandir, Thane (W), Mumbai, Pin Code – 400 604
CLAIM ACKNOWLEDGMENT SHEET
Name of Insurer: PHS ID: LMN1234 --- Enter PHS
ABC Insurance Company
ID
Insured Name: Employee No: XYZ890 --- Enter your
XYZ --- Name of person to which policy belongs
Employee No.
Patient Name: PQR --- Name of person who is covered in policy and claiming benefits for. Mobile No: XXXXXXXXXX
Policy No: 12345678 --- Enter policy number Phone (STD): +XX - XXXXXXXX
Name of Corporate:
Type of Claim (To Main Hospitalization / Pre-Post Hospitalization / OPD Claim / Deficiency Retrieval / Critical Illness / Cash Benefit E-Mail ID of
xyz@gmail.com
be ticked) : primary insured:
CLAIM DOCUMENT CHECK LIST
Description Document
Sr. No Remarks
Status(Y/N)
IRDA Claim Form duly signed by the Insured & Hospital Y
Part-A: Duly signed by the insured with Claimed amount, Mobile number & Email ID along with PHS ID Y
1 Part-B: Duly signed and stamped by hospital Y
Declaration form duly signed & stamped by the hospital in case treatment taken is under PPN/GIPSA hospitals.
N

In case of No Intimation / Delay Intimation & Delay in submission of claim, a letter from insured is required stating
2 N
reason for the same.
Original Cancelled Cheque Leaf of Employee/Proposer with the Name of the Account Holder Printed on the Cheque
3 Y
Leaf.
ID Proof of Employee / Primary Insured- Any of one (Passport, Voter ID, Driving License, Or any Government Approved
4 Y
ID ) . If Claim is above 1 lakh- PAN is mandatory with address Proof
5 ID Proof of Patient- Any of one (Passport, Voter ID, Driving License, Or any Government Approved ID ) Y
Original detailed Discharge Summary as per IRDA Format / Day care summary from the hospital (in case of Day Care
6 Treatment) / Death Summary (in Case of Death Claim) N

6.a Copy of the Legal heir certificate (if the claim is for the death of the principle insured) N

6.b Copy of Post Mortem Report & Death Certificate (In Accidental Death cases) N
7 Policy Copy ( if individual policy) N
8 64VB Compliance Certificate ( If individual policy) N
9 Original Final Hospital bill with cost wise breakup of each Item Y
10 Original Payment Receipt of Main Hospital bill ( both Deposit / Refund) Y
Receipt Of Payments made at the Hospital by Credit Card : Please attach the Xerox Copy of the Credit Card Payment Slip
10.a N
as received from the Vendor
Original copy of Implant Invoice along with Payment Receipts & Implant Labels / Stickers for Stents/ Mesh/ IOL
11 N

12 Original bills, original Payment Receipts and investigation / Laboratory Reports Y

Original medicine bills specifying Patient Name and date of purchase along with supporting Prescriptions.
13 Y

14 Original copy of First Consultation letter and subsequent Prescriptions. Y

Hospital Registration certificate issued by Competent authority as per Indian nursing council Act 1947 (If hospital not
15 N
falls in GIPSA/PPN )
16 OTHER DOCUMENTS
Original copy of Obstetric history (Gravida, Para, Living children, Abortions) from treating doctor. (Maternity Claim)
16.a N

16.b Original Sonography Report in case of Maternity Claim N

Original A-Scan Report along with IOL Sticker and Tax paid invoice in case of Cataract
16.c N
Claim
Copy of the First Information Report (FIR) from Police Department / Copy of the Medico-Legal Certificate (MLC) in case
16.d N
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
16.e the Investigation reports/Other related documents reflecting the critical illness diagnosis. (Critical Illness Cases) N

In case of claims where the insured has submitted documents to another insurance co./TPA, he needs to submit
16.f attested Photocopies of all the documents along with detailed claim settlement letter from the TPA and any unpaid bills N
and receipt for the same in originals.
Claims Submitted by : Insured / Corporate / Agent / Broker / Insurer / Hospital
XXXXXXXXXX – Number
Claim Submitted by: Mobile No.
XYZ – The person who fills the claim form and submits the claim of the person who will
submit the claim
Date of Claim PHS Executive Name of the person to
Submission: DD/MM/YYYY HH:MM --- Format of Date & Time Name: whom you submitted the
claim at PHS office.
Claim Submitted at: Signature: Sign of the person who
PHS - (Location) / Help Desk – Enter location where you will submit the claim
submits the claim
Important Points to Remember:-
1. Please mark either √ or × against respective check box
2. Date of File Received will be considered as next working day for Claim Files picked up at Help Desk
3. Claim Need to be Submitted within 7 Working Days from Date of Discharge from Hospital
4. 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. Please visit us at www.paramounttpa.com to check Online Claim Status or download Paramount Mobile App
6. 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
7. Corrections in any documents are not allowed, otherwise it will not be entertained during adjudication.
CLAIM FORM - PART A' to 'CLAIM FORM FOR HEALTH INSURANCE POLICIES OTHER THAN TRAVEL AND PERSONAL ACCIDENT - PART A
TO BE FILLED BY THE INSURED (To be Filled in block letters)
The issue of this Form is not to be taken as an admission of liablity

DETAILS OF PRIMARY INSURED:

a) Policy No.: 1 2 3 4 5 6 7 8 b) Sl. No/ Certificate no.

c) Company/ TPA ID No: L M N 1 2 3 4

SECTION A
d) Name: X Y Z S U R N A M E F I R S T N A M E M I D D L E N A M E

e) Address: A D D R E S S

City: M A H A R A S H T R A State:

Pin Code 4 0 0 0 0 1 Phone No: X x x x x x x x x x x x Email ID: xyz@gmail.com

x
DETAILS OF INSURANCE HISTORY:

a) Currently covered by any other Mediclaim / Health Insurance: Yes No b) Date of commencement of first Insurance without break: D D M M Y Y Y Y

SECTION B
c) If yes, company name: Policy No.

Sum insured (Rs.) d) Have you been hospitalized in the last four years since inception of the contract? Yes No Date: M M Y Y

Diagnosis: e) Previously covered by any other Mediclaim /Health insurance: : Yes No

f) If yes, company name:

DETAILS OF INSURED PERSON HOSPITALIZED: :

a) Name: P Q R S U R N A M E F I R S T N A M E M I D D L E N A M E
N A M
b) Gender E Male Female c) Age years Y Months M M d) Date of Birth D D M M Y Y Y Y

e) Relationship to Primary insured: Self Spouse Child Father Mother Other (Please Specify)

SECTION C
f) Occupation Service Self Employed Home Maker Student Retired Other (Please Specify)

g) Address (if diffrent from above) :

City: State:

Pin Code Phone No: Email ID:

DETAILS OF HOSPITALIZATION: :

a) Name of Hospital where Admited: H O S P I T A L N A M E

b) Room Category occupied: Day care Single occupancy Twin sharing 3 or more beds per room

SECTION D
c) Hospitalization due to: Injury Illness Maternity d) Date of injury / Date Disease first detected /Date of Delivery: D D M M Y Y Y Y

e) Date of Admission: D D M M Y Y f) Time H H M H g) Date of Discharge: D D M M Y Y h) Time: H H : M H

I) If injury give cause: Self inflicted Road Traffic Accident Substance Abuse / Alcohol Consumption I) If Medico legal Yes No

ii) Reported to Police iii. MLC Report & Police FIR attached Yes No j) System of Medicine:

DETAILS OF CLAIM:

a) Details of the Treatment expenses claimed

Claim Documents Submitted - Check List:
I. Pre -hospitalization expenses Rs. 7 0 0 0 ii. Hospitalization expenses Rs. 1 1 0 0 0 Claim form duly signed
Copy of the claim intimation, if any
iii. Post-hospitalization expenses Rs. 5 0 0 iv. Health-Check up cost: Rs.
Hospital Main Bill
v. Ambulance Charges: Rs. 1 0 0 0 vi. Others (code): Rs.
Hospital Break-up Bill

SECTION E
Total Rs. 1 9 5 0 0 Hospital Bill Payment Receipt
vii. Pre -hospitalization period: days 0 7 viii. Post -hospitalization period: days
Hospital Discharge Summary
b) Claim for Domiciliary Hospitalization: Yes No (If yes, provide details in annexure) Pharmacy Bill

c) Details of Lump sum / cash benefit claimed: Operation Theater Notes

i. Hospital Daily cash: Rs. ii. Surgical Cash: Rs. ECG

Doctor’s request for investigation
iii. Critical Illness benefit: Rs. iv. Convalescence: Rs.
Investigation Reports (Including CT
v. Pre/Post hospitalization Lump sum benefit: Rs. vi. Others: Rs. / MRI / USG / HPE)
Doctor’s Prescriptions
Total Rs.
Others
DETAILS OF BILLS ENCLOSED:

Sl. No. Bill No. Date Issued by Towards Amount (Rs)

1. xxxxxx 0 9 0 8 2 2 Hospital main Bill 1 1 0 0 0
2. xxxxxx 0 6 0 8 2 2 Pre-hospitalization Bills: Nos 7 0 0 0
SECTION F

3. xxxxxx 1 3 0 8 2 2 Post-hospitalization Bills: Nos 5 0 0

4. xxxxxx 1 5 0 8 2 2 Pharmacy Bills 1 0 0 0
5. D D M M Y Y
6. D D M M Y Y
7. D D M M Y Y
8. D D M M Y Y
9. D D M M Y Y
10. D D M M Y Y

DETAILS OF PRIMARY INSURED’S BANK ACCOUNT::

SECTION G

a) PAN: A B C D E F 5 5 5 5 b) Account Number: 5 x x x x x x x x x x x x x x x x x

c) Bank Name and Branch: A B C D E F G H I J

d) Cheque / DD Payable details: e) IFSC Code: x x x x x x x x x x x x x x x x

(IMPORTANT: PLEASE TURN OVER)

 DECLARATION BY THE INSURED:

I hereby declare that the information furnished in the claim form is true & correct to the best of my knowledge and belief. If I have made any false or untrue statement, suppression
or concealent of any material fact with respect to questions asked in relation to this claim, my right to claim reimbrusement shall be forfeited, I also consent & authorize TPA /
Insurance Company, to seek necessary medical information / 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 the bills / receipts for the purpose of this claim & that I will not be making any supplementary claim except the pre/post-hospitalization

SECTION H
claim, if any.

D D M M Y Y Y Y Place: Mumbai Signature of the Insured

Date

GUIDANCE FOR FILLING CLAIM FORM - PART A (To be filled in by the insured)
DATA ELEMENT DESCRIPTION FORMAT
SECTION A - DETAILS OF PRIMARY INSURED
a) Policy No. Enter the policy number As allotted by the Insurance Company
Enter the social Insurance number or the certificate number of
b) Sl. No/ Certificate No. social health insurance scheme As allotted by the oraganization
Licence number as allotted by IRDA and printed in
c) Company TPA ID No. Enter the TPA ID No. TPA documents.
d) Name Enter the full name of the policyholder Surname, First name, Middle name
e) Address Enter the full postal address Include Street, City and Pin code
SECTION B -DETAILS OF INSURANCE HISTORY
a) Currently covered by any other Mediclaim / Health Indicate whether currently covered by another Mediclaim /
Tick Yes or No
Insurance? Health Insurance
b) Date of commencement of first Insurance without break Enter the date of commencement of first Insurance Use dd-mm-yy-forrmat
c) Company Name Enter the full name of the Insurance Company Name of the organization in full
Policy No. Enter the policy number As allotted by the Insurance Company
Sum insured Enter the total sum insured as per the policy In rupees
d) Have you been Hospitalized in the last four years since Tick Yes or No
Indicate whether hospitalized in the last four years
Inception of the contract?
Date Enter the date of Hospitalization Use mm-yy format
Diagnosis Enter the diagnosis details Open Text
e) Previously covered by any other Mediclaim / Health Indicate whether previously covered by another mediclaim /
Tick Yes or No
Insurance? Health Insurance
f) Company Name Enter the full name of the Insurance Company Name of the organization in full
SECTION C -DETAILS OF INSURED PERSON HOSPITALIZED
a) Name Enter the full name of the patient Surname, First name, Middle name
b) Gender Indicate Gender of the patient Tick Male or Female
c) Age Enter age of the patient Number of years and months
d) Date of Birth Enter Date of Birth of patient Use dd-mm-yy format
e) Relationship to primary Insured Indicate relationship of patient with policyholder Tick the right option, if others, please specify

f) Occupation indicate occupation of patient Tick the right option. If others, please specify.
g) Address Enter the full postal address Include Street, City and Pin code
h) Phone No Enter the phone number of patient Include STD code with telephone number
1) E-mail ID Enter e-mail address of patient Complete e-mail address
SECTION D - DETAILS OF HOSPITALIZATION
a) Name of Hospital where admited Enter the name of hospital Name of hospital in full
b) Room category occupied indicate the room category occupied Tick the right option
c) Hospitalization due to indicate reason of hospitalization Tick the right option
d) Date of injury/Date Disease first detected / Date of
Enter the relevant date Use dd-mm-yy format
Delivery
e) Date of admission Enter date of admission Use dd-mm-yy format
f) Time Enter time of admission Use hh-mm- format
g) Date of discharge Enter date of discharge Use dd-mm-yy format
h) Time Enter time of discharge Use hh-mm- format
I) If injury give cause indicate cause of injury Tick the right option

If Medico legal indicate whether injury is medico legal Tick Yes or No

Reported to Police indicate whether police report was filed Tick Yes or No
MLC Report & Police FIR attached indicate whether MLC report and Police FIR attached Tick Yes or No
j) System of Medicene Enter the system of medicine followed in treating the patient Open Text
SECTION E - DETAILS OF CLAIM
a) Details of Treatment Expences Enter the amount claimed as treatment expences In rupees (Do not enter paise values)
b) Claim for Domiciliary Hospitalization indicate whether claim is for domiciliary hospitalization Tick Yes or No
c) Details of Lump sum/ Cash benifit claimed Enter the amount claimed as lump sum / cash benefit In rupees (Do not enter paise values)
d) Claim documents Submitted-Check List indicate which supporting documents are submitted Tick the right option
SECTION F - DETAILS OF BILLS ENCLOSED
Indicate which bills are enclosed with the amount in rupees
SECTION G - DETAILS OF PRIMARY INSURED’s BANK ACCOUNT
a) PAN Enter the permanent account number As allotted by the Income Tax Department
b) Account Number Enter the Bank account number As allotted by the Bank
c) Bank Name and Branch Enter the Bank name along with the branch Name of the Bank in full
Enter the name of the beneficiary the cheque / DD should be
c) Cheque/ DD payable details Name of the individual / organization in full
made out to
c) IFSC Code Enter the IFSC code of the Bank branch IFSC code of the Bank branch in full
SECTION H - DECLARATION BY THE INSURED
Read declaration carefully and mention date (in dd:mm:yy format), place (open text) and sign.
 CLAIM FORM - PART B
TO BE FILLED IN BY THE HOSPITAL
The issue of this Form is not to be taken as an admission of liability (To be Filled in block letters)
Please include the original preauthorization request form in lieu of PART A
DETAILS OF HOSPITAL

a) Name of the hospital:

SECTION A
a) Hospital ID: c) Type of Hospital: Network : Non Network : (if non network fill section E)

c) Name of the treating doctor: S U R N A M E F I R S T N A M E M I D D L E N A M E

e) Qualification: f) Registration No. with State Code: g) Phone No.

DETAILS OF THE PATIENT ADMITTED

a) Name of the Patient: F I R S T N A M E M I D D L E N A M E

b) IP Registration Number: c) Gender: Male Female d) Age: Years Y Y Months M M e) Date of birth: D D M M Y Y

SECTION B
MM D D M M H H

To BE FILLED BY HOSPITAL
f) Date of Admission: D D M M Y Y g) Time: H H h) Date of Discharge: Y Y M M

j) Type of Admission: Emergency Planned Day Care Maternity k) If Maternity i) Date of Delivery: D D M M Y Y ii) Gravida Status: :

I) Status at time of discharge: Discharge to home Discharge to another hospital Deceased m) Total claimed amount

DETAILS OF AILMENT DIAGNOSED (PRIMARY)

a) ICD 10 Codes Description b) ICD 10 PCS Description

I. Primary Diagnosis i. Procedure 1:

ii. Additional Diagnosis: ii. Procedure 2:

iii. Co-morbidities: iii. Procedure 3:

To BE FILLED BY HOSPITAL

SECTION C
iv. Co-morbidities: iv. Details of Procedure:

c) Pre-authorization obtained: Yes No d) Pre-authorization Number:

e) If authorization by network hospital not obtained, give reason:

f) Hospitalization due to injury: Yes No I. If Yes, give cause Self-inflicted Road Traffic Accident Substance abuse / alcohol consumption

ii) If injury due to substance abuse / alcohol consumption, Test conducted to establish this: Yes No (If Yes, attach reports) iii. If Medico legal: Yes No iv. Reported to Police Yes No

v. FIR No. vi. If not reported to police give reason:

To BE FILLED BY HOSPITAL
CLAIM DOCUMENTS SUBMITTED - CHECK LIST

Claim Form duly signed Investigation reports

Original Pre-authorization request CT/MR/USG/HPE investigation reports

Copy of the Pre-authorization approval letter Doctor’s reference slip for investigation

SECTION D
Copy of Photo ID Card of patient Verified by hospital ECG

Hospital Discharge summary Pharmacy bills

Operation Theatre Notes MLC reports & Police FIR

Hospital main bill Original death summary from hospital where applicable
Hospital break-up bill Any other, please specify

ADDITIONAL DETAILS IN CASE OF NON NETWORK HOSPITAL (ONLY FILL IN CASE OF NON-NETWORK HOSPITAL)

a) Address of the Hospital

To BE FILLED BY HOSPITAL City: State:

SECTION E

Pin Code: b) Phone No. c) Registration No. with State Code:

d) Hospital PAN: e) Number of inpatient beds f) Facilities available in the hospital i. OT Yes No ii. ICU Yes No

iii. Others:

DECLARATION BY THE HOSPITAL (PLEASE READ VERY CAREFULLY)

We hereby declare that the information furnished in this Claim Form is true & correct to the best of our knowledge and belief. If we have made any false or untrue statement, suppression or concealment of any material fact,
our right to claim under this claim shall be forfeited.
SECTION F

Date: D D M M Y Y

Place: Signature and Seal of the Hospital Authority:

 GUIDANCE FOR FILLING CLAIM FORM - PART B (To be filled in by the hospital)

DATA ELEMENT DESCRIPTION FORMAT

SECTION A - DETAILS OF HOSPITAL

a) Name of the hospital: Enter the name of hospital Name of the hospital in full

b) Hospital ID Enter ID number of hospital As allocated by the TPA

c) Type of Hospital Indicate whether in network or non network hospital Tick the right option

c) Name of treating doctor Enter the name of the treating doctor Name of doctor in full
e) Qualification Enter the qualification of the treating doctor Abbreviations of educational qualifications
f) Registration No. with State Code Enter the registration number of the doctor along with the state code As allocated by the Medical Council of India

g) Phone No. Enter the phone number of doctor Include STD code with telephone number
SECTION B - DETAILS OF THE PATIENT ADMITTED

To BE FILLED BY HOSPITAL
a) Name of Patient Enter the name of patient Name of patient in full

b) IP registration Number Enter insurance provider registration number As allotted by the insurance provider
c) Gender Indicate Gender of the patient Tick Male or Female

d) Age Enter age of the patient Number of years and months

e) Date of Birth Enter date of birth Use dd-mm-yy format

f) Date of Admission Enter date of admission Use dd-mm-yy format

g) Time Enter Time of admission Use hh:mm format
h) Date of Discharge Enter date of Discharge Use dd-mm-yy format

i) Time Enter time of Discharge Use hh:mm format

j) Type of Admission Indicate type of admission of patient Tick the right option
k) If Maternity
Date of Delivery Enter Date of Delivery if maternity Use dd-mm-yy format
Gravida Status Enter Gravida status if maternity Use standard format

l) Status at time of discharge Indicate status of patient at time of discharge Tick the right option

M) Total claimed amount Indicate the total claimed amount In rupees (Do not enter paise values)
SECTION C - DETAILS OF AILMENT DIAGNOSED (PRIMARY)

To BE FILLED BY HOSPITAL
a) ICD 10 Code

Primary Diagnosis Enter the ICD 10 Code and description of the primary diagnosis
Standard Format and Open text
Additional Diagnosis Enter the ICD 10 Code and description of the additional diagnosis Standard Format and Open text
Co-morbidities Enter the ICD 10 Code and description of the Co-morbidities Standard Format and Open text

b) ICD 10 PCS

Procedure 1 Enter the ICD 10 Code and description of the first procedure Standard Format and Open text
Procedure 2 Enter the ICD 10 Code and description of the second procedure Standard Format and Open text
Procedure 3 Enter the ICD 10 Code and description of the third procedure Standard Format and Open text
Details of Procedure Enter the details of the procedure Open text

c) Pre-authorization obtained Indicate whether pre-authorization obtained Tick Yes or No

d) Pre-authorization Number Enter pre-authorization number As allotted by TPA

e) If authorization by network hospital not obtained, give reason Enter reason for not obtaining pre-authorization number Open text

f) Hospitalization due to injury Indicate if hospitalization is due to injury Tick Yes or No

Cause Indicate cause of injury Tick the right option
If injury due to substance abuse/alcohol consumption test
conducted to establish this Indicate whether test conducted Tick Yes or No

Medico Legal Indicate whether injury is medico legal Tick Yes or No

Reported to Police Indicate whether police report was filed Tick Yes or No
FIR No. Enter first information report number As issued by police authrities
If not reported to police, give reason Enter reason for not reporting to police Open text
SECTION D - CLAIM DOCUMENTS SUBMITTED-CHECK LIST
Indicate which supporting documents are submitted
SECTION E - DETAILS IN CASE OF NON NETWORK HOSPITAL

a) Address Enter the full postal address Include Street, City and Pin Code
b) Phone No. Enter the phone number of hospital Include STD code with telephone number
Enter the registration number of the Hospital obtained from local body
c) Registration No. with State Code As allocated by the City Corporation / Municipality
like City Corporation / Municipality
d) Hospital PAN Enter the permanent account number As allocated by the Income Tax Department
e) Number of Inpatient beds Enter the number of inpatient beds Digits
f) Facilities available in the hospital Indicate facilities available in the hospital Tick the right option. If others, please specify

SECTION F - DECLARATION BY THE HOSPITAL

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