Claim Intimation Lodging
Details Not Available :
Source Type*
Online Portal
Name :*
Mobile No.*
Relation*
Email Id*
Consignment Number*
Claim Type
IPD
OPD
Suminsured Type
Normal
Critical Illness
User Type
Individual
Corporate
Insurance Company Name *
Select
Care Health Insurance(Formaly AS Religare)
National Insurance Co. Ltd.
United India Insurance Co. Ltd.
NEW India Assurance Co. Ltd.
The Oriental Insurance Co Ltd
Religare Health Insurance
Iffco Tokio General Insurance
TATA AIG General Insurance Co. Ltd.
Corporate
Select
Emp. Code*
Policy No. *
Please select card No. OR Employee Code for corporate Policies
Card No.*
Patient Name*
Intimation Date*
Please Select Intimation Date
Intimation Date cann't be less then 30 day and greater then 45 Days from current date
Hospital Name*
Hospital Not In System
Hospital Address
Hospital Type*
PPN / Non PPN*
PPN
Non PPN
Yes
No
PPN And Network Both
Non PPN And Non Network
Contact No
Please fill
Email ID
Fill valid email id
Date of Admission*
Please Select
Time of Admission (Time Format-HH:MM)
Hrs
Min
Please Select
Expected No of days stay in hospital*
Select
0
0
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Please Select
Days
Please Select
Time of Discharge (Time Format-HH:MM)
Hrs
Min
Please Select
Provisional Diagnosis
*Please fill diagnosis
ICD 10 Code
*Please fill diagnosis code
Proposed line of treatment*
( Required Note : Please select either Medical Management Or Surgical Management. )
Medical Management
Surgical Management
Intensive Care
Investigation
Non Allopathic Treatment
*Please select atleast one from medical/surgical management
Intimation Letter/Email pdf
Nature of the illness/disease with presenting complaints
*Please fill
Services
Amount Breakup(Calculation)
Request Amount
Total Requested Amount*
Please fill valid claimed amount
* Claimed amount exceeded limit of SI/ balance.
Hospital Information
Hospital Type*
Please fill valid hospital type
Bed Capacity
Please fill valid claimed amount
Hospital Name*
Please fill valid claimed amount
Hospital Address*
Please fill valid claimed amount
State*
Select State
ANDAMAN NICOBAR
ANDHRA PRADESH
ARUNACHAL PRADESH
ASSAM
BIHAR
CHANDIGARH
CHHATISGARH
DELHI
GOA
Gujarat
HARYANA
Himachal Pradesh
JAMMU KASHMIR
JHARKHAND
KARNATAKA
KERALA
LAKSHDEEP
Madhya Pradesh
Maharashtra
MANIPUR
MEGHALAYA
MIZORAM
NAGALAND
NEPAL
ORISSA
PONDICHERRY
PUNJAB
RAJASTHAN
SKKIM
Tamil Nadu
TELANGANA
TRIPURA
UTTAR PRADESH
UTTRAKHAND
Uttrakhand
WEST BENGAL
Please state
City*
Select City
Please Select city
Name of Corporate
Pending preauthorizations to process. Please process
OK