A hospitalization claim form records an in-patient admission from intimation to discharge so HR can support the employee with the TPA. It covers planned and emergency admissions, the cashless or reimbursement route, room category and length of stay; the insurer's own pre-authorisation or claim form must still be filled where required.
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
Claim Route
Cashless: pre-authorisation sent by hospital on [DD/MM/YYYY], status [Approved / Pending / Denied], approved amount ₹[Amount]
Reimbursement: employee to pay hospital and submit originals within [Number] days of discharge
Cost Summary
Item
Estimated (₹)
Final Bill (₹)
Approved / Paid by Insurer (₹)
Room and Nursing
[Amount]
[Amount]
[Amount]
Surgery / Procedure
[Amount]
[Amount]
[Amount]
Medicines and Consumables
[Amount]
[Amount]
[Amount]
Investigations
[Amount]
[Amount]
[Amount]
Total
[Amount]
[Amount]
[Amount]
Discharge Checklist
Discharge summary collected
Final bill with itemised breakup
Payment receipts (for any amount paid by employee)
Investigation reports and prescriptions
Insurer / TPA claim form signed
Post-hospitalisation bills to be submitted later
Declaration
I confirm that the information above is correct and authorise HR to share it with the TPA, insurer and broker to support this claim. I understand that admissibility is decided by the insurer under the policy terms.
Post in 5 minutesDescribe the role in one line — we write the job description.
Verified applicantsEvery applicant has a verified mobile number.
Resume databaseSearch experienced candidates by skill, city and experience.
Frequently asked questions
How do I intimate hospitalisation to the insurer?+
Contact the TPA by its helpline, app or email within the time your policy states, and inform HR. For cashless, the hospital's insurance desk sends the pre-authorisation request.
What is room rent limit in group mediclaim?+
Some policies cap the daily room rent, for example as a percentage of sum insured. If you choose a costlier room, other charges may be reduced proportionately.
Can I switch from cashless to reimbursement?+
If cashless is denied or not available, you can usually pay the hospital and file for reimbursement with all original documents.
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.
Please complete all sections within the enrollment window and return this form to [HR Name], Human Resources. Benefits will be activated only after HR verification.
Section A: Employee Details
Employee Name (as per PAN)
Employee ID
Designation
Department
Date of Joining
Work Location
Date of Birth
Gender
Mobile Number
Personal Email
PAN
Aadhaar (last 4 digits only)
Section B: Statutory Benefits
UAN (if already allotted)
Previous PF Account / Member ID
ESI IP Number (if applicable, for gross wages up to ₹21,000/month)
I opt IN to the group mediclaim for myself and the dependants listed in Part C.
I opt IN for myself only.
I opt OUT of the group mediclaim. I am covered under policy no. [Policy Number] with [Insurer Name]. I understand I cannot claim under the company policy and may rejoin only at renewal, if permitted.