Common use of CLAIM DOCUMENTS Clause in Contracts

CLAIM DOCUMENTS. We shall be provided the following necessary information and documentation in respect of all Claims within 30 days of the Insured Person’s discharge from Hospital. For Claims under which the use of Cashless Facility has been approved, We will be provided with these documents by the Network Provider immediately following the Insured Person’s discharge from Hospital: (a) Xxxx completed Claim form signed by You and the Medical Practitioner (only for reimbursement claims); (b) Original Pre – authorization request (c) Copy of Pre – authorization approval letter (d) Copy of the photo identity document of the Insured Person; (e) Original bills, receipts and discharge certificate/card from the Hospital/Medical Practitioner; (f) Original bills from chemists supported by proper prescription; (g) Original investigation test reports (including CT/MR/USG/ECG, as applicable) and payment receipts; (h) Indoor case papers (if available); (i) Medical Practitioner’s referral letter advising Hospitalization in non-Accident cases and referral slip for all investigations carried out; (j) Hospital discharge summary; (k) FIR (if done) or MLC (if conducted) for Accident cases (l) Post mortem report (if applicable and conducted); (m) Any other document as required by Us or Our TPA to investigate the Claim or Our obligation to make payment for it.

CLAIM DOCUMENTS. We shall be provided the following necessary information and documentation in respect of all Claims within 30 days of the Insured Person’s 's discharge from Hospital. For Claims under which the use of Cashless Facility has been approved, We will be provided with these documents by the Network Provider immediately following the Insured Person’s 's discharge from Hospital: (a) Xxxx completed Claim form signed by You and the Medical Practitioner (only for reimbursement claims); (b) Original Pre – authorization request (c) Copy of Pre – authorization approval letterletter Kotak Health Care UIN: IRDAI / HLT / KMGI / P - H / V.I / 28 / 2015 - 16 (d) Copy of the photo identity document of the Insured Person; (e) Original bills, receipts and discharge certificate/card from the Hospital/Medical Practitioner; (f) Original bills from chemists supported by proper prescription; (g) Original investigation test reports (including CT/MR/USG/ECG, as applicable) and payment receipts; (h) Indoor case papers (if available)papers; (i) Medical Practitioner’s 's referral letter advising Hospitalization Hospitalisation in non-Accident cases and referral slip for all investigations carried out; (j) Hospital discharge summary; (k) FIR (if done) or MLC (if conducted) for Accident cases; (l) Post mortem report (if applicable and conducted); (m) Any other document as required by Us or Our TPA to investigate the Claim or Our obligation to make payment for it.

CLAIM DOCUMENTS. We shall be provided the following necessary information and documentation in respect of all Claims within 30 days of the Insured Person’s 's discharge from Hospital. For Claims under which the use of Cashless Facility has been approved, We will be provided with these documents by the Network Provider immediately following the Insured Person’s 's discharge from Hospital: (a) Xxxx completed Claim form signed by You and the Medical Practitioner (only for reimbursement claims); (b) Original Pre – authorization request (c) Copy of Pre – authorization approval letter (d) Copy of the photo identity document of the Insured Person; (e) Original bills, receipts and discharge certificate/card from the Hospital/Medical Practitioner; (f) Original bills from chemists supported by proper prescription; (g) Original investigation test reports (including CT/MR/USG/ECG, as applicable) and payment receipts; (h) Indoor case papers (if available)papers; (i) Medical Practitioner’s 's referral letter advising Hospitalization Hospitalisation in non-non- Accident cases and referral slip for all investigations carried out; (j) Hospital discharge summary; (k) FIR (if done) or MLC (if conducted) for Accident cases; (l) Post mortem report (if applicable and conducted); (m) Any other document as required by Us or Our TPA to investigate the Claim or Our obligation to make payment for it.. Kotak Health Care UIN: IRDAI / HLT / KMGI / P - H / V.I / 28 / 2015 - 16

CLAIM DOCUMENTS. We shall be provided the following necessary information and documentation in respect of all Claims within 30 days of the Insured Person’s discharge from Hospital. For Claims under which the use of Cashless Facility has been approved, We will be provided with these documents by the Network Provider immediately following the Insured Person’s discharge from Hospital: (a) Xxxx completed Claim form signed by You and the Medical Practitioner (only for reimbursement claims); (b) Original Pre – authorization requestHospital discharge summary; (c) Copy of Pre – authorization approval letterFirst consultation and follow up treatment papers; (d) Copy of the photo identity document of the Insured Person; (e) Original bills, bills and receipts and discharge certificate/card from the Hospital/Medical Practitioner; (fe) Original bills from chemists supported by proper prescription; (gf) Original investigation test reports (including CT/MR/USG/ECG, as applicable) and payment receipts; (hg) Indoor case papers (papers, if available); (h) Implant Invoice/ Sticker, if available; (i) Medical Practitioner’s referral letter advising Hospitalization in non-Accident cases and referral slip for all investigations carried outAmbulance Invoice, if applicable; (j) Hospital discharge summary; (k) FIR (if done) or MLC (if conducted) for Accident casescases ; (lk) Post mortem report (if applicable and conducted); (l) KYC documents viz. Photo ID and address proof along with duly completed form. (m) Any other document as required by Us or Our TPA to investigate the Claim or Our obligation to make payment for it. For claims under which cashless facility has been approved, following documents will be provided by the Network hospital along with the above: (n) Original Pre – authorization request (o) Copy of Pre – authorization approval letter (p) Copy of the photo identity document of the Insured Person; (q) KYC documents obtained at the time of cashless facility.