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Insurers and third party administrators must use the revised Part C form and the new Part D cashless authorization letter format. All insurers and third party administrators ensure that every network provider receives the Part D authorization letter and notify the policyholder simultaneously. Insurers and third party administrators also notify the policyholder when they issue any supplementary authorization or final approval. All forms must use a font size of Times New Roman 10 or larger. This circular takes effect on July 1, 2019.
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भारतीय बीमा विनियामक और विकास प्राधिकरण INSURANCE REGULATORY AND DEVELOPMENT AUTHORITY OF INDIA
Ref: IRDAI/HLT/REG/CIR/86/05/2019
27.05.2019
To All Insurers and TPAs,
Re: Modification of existing format for "Request for Cashless Hospitalization for Health Insurance Policy (Part C)" and introduction of Standard Cashless Authorization Letter Format (Part D)
Page 1 of 11
सर्वे नं. 115/1, फाइनेंशियल डिस्ट्रिक्ट, नानकरामगुडा, हैदराबाद-500 032, भारत Survey No. 115/1, Financial District, Nanakramguda, Hyderabad-500 032, India (क) : +91-40-2020 4000, फैक्स : +91-40-2020 4555 : +91-40-2020 4000, Fax : +91-40-2020 4555 वेबसाइट : www.irdai.gov.in Website : www.irdai.gov.in
(DVS Ramesh) General Manager (Health)
Encl: Part - C & Part - D
REQUEST FOR CASHLESS HOSPITALISATION FOR HEALTH INSURANCE POLICY PART – C (Revised) (TO BE FILLED IN BLOCK LETTERS)
DETAILS OF THE THIRD PARTY ADMINISTRATOR/ INSURER/ HOSPITAL:
a. Name of TPA/Insurance company: b. Toll free phone number: c. Toll free fax: d. Name of Hospital:
TO BE FILLED BY INSURED/PATIENT
A. Name of the Patient: B. Gender: [ ] Male [ ] Female [ ] Third Gender C. Age: (Years) / (Month) D. Date of Birth: (DD/MM/YYYY) E. Contact number: F. Contact number of attending Relative: G. Insured Card ID number: H. Policy number/Name of Corporate: I. Employee ID: J. Currently do you have any other mediclaim /health insurance: [ ] Yes [ ] No
(PLEASE COMPLETE DECLARATION OF THIS FORM)
Page 3 of 11
TO BE FILLED BY TREATING DOCTOR/HOSPITAL
A: Name of the treating Doctor: B: Contact number: C: Nature of Illness/Disease with presenting complaint: D: Relevant Critical Findings: E: Duration of the present ailment Days
H: If investigation and/or Medical Management, provide details
m. In case of Maternity
Page 4 of 11
DETAILS OF PATIENT ADMITTED
A. Date of admission: (DD/MM/YYYY) B. Time of admission: (HH : MM) C. Is this an emergency/planned hospitalization event: Emergency [ ] Planned [ ] D. Mandatory Past History of any chronic illness: If yes (Since month/year)
E. Expected number of Days/stay in hospital: Days F. Days in ICU: Days G. Room Type: H. Per day room rent+nursing and service charges+ patients diet: I. Expected cost of investigation + diagnostic: J. ICU charges: K. OT charges: L. Professional fees Surgeon + Anesthetist Fees + consultation Charges: M. Medicines + Consumables + Cost of Implants (if applicable please specify): N. Other hospital expenses if any: O. All-inclusive package charges if any applicable: P. Sum Total expected cost of hospitalization:
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DECLARATION (Please read very carefully)
We confirm having read understood and agreed to the Declarations of this form
a. Name of the treating doctor: b. Qualification: c. Registration number with State code:
[ Hospital Seal ] (Must include Hospital ID)
[ Patient/Insured Name and Sign ]
Page 6 of 11
DECLARATION BY THE PATIENT / REPRESENTATIVE
a. I agree to allow the hospital to submit all original documents pertaining to hospitalization to the Insurer/T.P.A after the discharge. I agree to sign on the Final Bill & the Discharge Summary, before my discharge. b. Payment to hospital is governed by the terms and conditions of the policy. In case the Insurer / TPA is not liable to settle the hospital bill, I undertake to settle the bill as per the terms and conditions of the policy. c. All non-medical expenses and expenses not relevant to current hospitalization and the amounts over & above the limit authorized by the Insurer/T.P.A not governed by the terms and conditions of the policy will be paid by me. d. I hereby declare to abide by the terms and conditions of the policy and if at any time the facts disclosed by me are found to be false or incorrect I forfeit my claim and agree to indemnify the Insurer / T.P.A e. I agree and understand that T.P.A is in no way warranting the service of the hospital & that the Insurer / TPA is in no way guaranteeing that the services provided by the hospital will be of a particular quality or standard. f. I hereby warrant the truth of the forgoing particulars in every respect and I agree that if I have made or shall make any false or untrue statement, suppression or concealment with respect to the claim, my right to claim reimbursement of the said expenses shall be absolutely forfeited. g. I agree to indemnify the hospital against all expenses incurred on my behalf, which are not reimbursed by the Insurer / TPA. h. "I/We authorize Insurance Company/TPA to contact me/us through mobile/email for any update on this claim".
