This internal health insurance claim form helps an employee hand over a complete reimbursement claim under the group health policy to HR, who forwards it to the TPA. It summarises patient, treatment and bill details; the insurer's or TPA's own claim form must still be completed and signed where required.
Important: This form helps HR process your claim. The insurer's or TPA's official claim form must also be completed, signed and attached where required.
1. Employee Details
Employee Name
Employee ID
Department
Mobile Number
Email ID
2. Patient Details
Patient Name
Relationship to Employee
Age
E-card / Member ID
TPA Claim Intimation No. (if any)
3. Treatment Details
Claim Type: Reimbursement / Pre-hospitalisation / Post-hospitalisation / Day Care
Hospital Name and City
Network Hospital: Yes / No
Date of Admission
Date of Discharge
Diagnosis / Ailment
Cashless Denied: Yes / No
4. Expense Summary
Expense Head
Bill No.
Bill Date
Amount (₹)
Hospital Final Bill
[Bill No.]
[DD/MM/YYYY]
[Amount]
Pharmacy
[Bill No.]
[DD/MM/YYYY]
[Amount]
Diagnostics
[Bill No.]
[DD/MM/YYYY]
[Amount]
Consultation
[Bill No.]
[DD/MM/YYYY]
[Amount]
Total Claimed
[Amount]
5. Documents Enclosed
Insurer / TPA claim form, duly signed
Discharge summary
Final hospital bill with itemised breakup and payment receipt
Prescriptions and pharmacy bills
Investigation reports
Copy of e-card and ID proof
Cancelled cheque or bank details of employee
Declaration
I declare that the expenses claimed were actually incurred for the treatment of the patient named above, that I have not claimed these amounts from any other source except as disclosed, and that the documents are genuine. I authorise HR to forward this claim to the insurer/TPA.
Employee [Employee Name] Date: [Date]
HR Claims Desk [HR Name] Forwarded to TPA on: [Date]
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Frequently asked questions
Is this form enough to claim mediclaim reimbursement?+
No. It is an internal cover sheet. You must also complete the insurer's or TPA's claim form and attach the original bills and reports.
What documents are needed for a health insurance reimbursement claim?+
Typically the discharge summary, final bill with breakup, payment receipts, prescriptions, investigation reports, ID and e-card copy, and a cancelled cheque. Your TPA may ask for more.
Who do I submit my group health claim to?+
Usually to HR or the broker's claims desk, who forwards it to the TPA, or directly to the TPA through its portal, as your company process specifies.
Note: This internal form helps HR support your claim. The hospital's pre-authorisation request and the insurer's or TPA's claim form must also be completed where required.
Employee and Patient
Employee Name
Employee ID
Mobile Number
Patient Name
Relationship
E-card / Member ID
Admission Details
Admission Type: Planned / Emergency
Hospital Name and City
Network Hospital: Yes / No
Treating Doctor
Diagnosis / Proposed Procedure
Date of Admission
Expected Length of Stay (days)
Room Category Opted
Room Rent Eligibility as per Policy: ₹[Amount] per day