Health insurance claim form: Part A and Part B, filled in step by step

Part A and Part B at a glance

A reimbursement claim form comes in two parts. You fill in Part A. The hospital fills in Part B. This two-part layout is the standard one, and many insurers use it as it is. Some print their own version, but they ask for the same things, and on some insurers' forms the treating practitioner fills Part B.

Part A, filled in by you

1. Details of the primary insured. The policy number, the TPA or health card ID, your name, address, phone and email, as they are on the policy.
2. Insurance history. Whether you have other health cover, when your first policy started without a break, and any stay in hospital in the last four years.
3. The insured person in hospital. The patient's name, health card number, gender, age, date of birth and relationship to you.
4. The hospital stay. The hospital's name, the room category, whether it was an illness, an injury or maternity, and the dates and times of admission and discharge.
5. The claim. The amounts for costs before, during and after the stay, ambulance and others, with a tick list of the documents you enclose.
6. Bills enclosed. Each bill's number, date, who issued it, what it is for and the amount.
7. Your bank account. The account holder's name as the bank has it, the account number, bank and branch, IFSC and MICR codes, PAN and CKYC number.
8. Declaration. Sign and date it. It says the details are true, and a false statement can forfeit the claim.

Part B, filled in by the hospital

1. Hospital details. The hospital's name and ID, whether it is in the insurer's network, and the treating practitioner's name, qualification, registration number and phone.
2. The patient admitted. The in-patient registration number, the dates and times of admission and discharge, the type of admission, the status at discharge and the total amount claimed.
3. The illness and the procedure. The conditions and procedures with their ICD-10 codes, the pre-authorisation number if there was one, and injury or medico-legal details.
4. Claim documents checklist. The discharge summary, main and break-up bills, operation notes, reports and the pre-authorisation papers.
5. Non-network hospital details. Only when the hospital is not in the network: its address, registration, PAN, beds and facilities.
6. Declaration by the hospital. Signed and sealed by the hospital authority.

Documents to attach

The standard policy wording IRDAI published in July 2020 lists these. Your insurer may ask for more, such as KYC documents when the claim is ₹1 lakh or more (as the example wording puts it), or a legal heir certificate where needed. It may also ask for fewer.

• The completed and signed claim form, both parts.
• Photo identity proof of the patient.
• The written advice to admit the patient.
• Original bills with an itemised break-up, and payment receipts.
• The discharge summary.
• Test and scan reports, with the prescriptions that ordered them.
• Operation notes or the surgeon's certificate, for surgery.
• The sticker or invoice for any implant.
• The medico-legal report and FIR, where one exists.
• A cancelled cheque or bank details for direct credit.

The deadlines

Your policy wording sets your deadlines. Many insurers set a shorter limit, some as little as 7 days. Check your policy and your insurer's page in the table below.

The 2020 figures come from the standard policy wording IRDAI published in July 2020. That is the old standard: the 2024 master circular superseded it, but many current policies still use its wording.

A late claim can still be paid. The 2024 master circular says no claim shall be rejected or closed for delayed intimation or for want of documents. Send it as soon as you can and keep proof of the date.

Filing it, step by step

1. Fill and sign Part A. Use the form from your insurer's or TPA's own website, and write the claim or intimation number on it if you have one.
2. Get Part B from the hospital. Ask the hospital's insurance or billing desk to fill, sign and seal it before discharge.
3. Attach the documents. Add the original bills and receipts, the discharge summary and the reports, and keep a copy of every page.
4. Send it within your policy's time limit. Send it to the insurer or the TPA named on your health card, and keep proof of the date you sent it.

Common mistakes

• Leaving Part B to the patient. Part B must come from the hospital, signed and sealed. Ask the desk for it before discharge.
• Names that do not match. Bills must be in the name of the patient being claimed for, spelled as on the policy.
• Missing the claim number. Write the claim or intimation number on the form if you already have one.
• Sending copies instead of originals. Send original bills and receipts unless the insurer says copies are fine, and keep a copy of every page.
• A bank account in another name. The account in Part A should be the primary insured's, with a cancelled cheque that shows the name.
• Forgetting the implant sticker or the operation notes. These are often the documents a query asks for later.
• Using a form from another website. Download the form only from your insurer's or TPA's own website.
• Not signing and dating the declaration. An unsigned form comes back as a query.

Where to get your insurer's official form

These links go to each insurer's own website. We do not host copies of any form, so you always get the insurer's current one. Your TPA's website may carry the same form.