Claim Form
AMHI/PR/H/0018
We would be happy to assist you. For any help contact us at: E-mail : customerservice@apollomunichinsurance.com Toll Free : 1800-102-0333
Apollo Munich Health Insurance Co. Ltd. • 2
nd
& 3
rd
Floor, iLABS Centre, Plot No. 404-405, Udyog Vihar, Phase-III, Gurgaon-122016, Haryana • Corp. Off. 1
st
Floor, SCF-19, Sector-14,
Gurgaon-122001, Haryana • Reg. Off. Apollo Hospitals Complex, Jubilee Hills, Hyderabad-500033, Andhra Pradesh • Insurance is the subject matter of solicitation • For more details on risk
factors, terms and conditions, please read sales brochure carefully before concluding a sale • IRDA Registration Number - 131 • Corporate Identity Number: U66030AP2006PLC051760
www.apollomunichinsurance.com
In-patient Treatment /Day Care Procedures
q Duly filled and signed Claim Form.
q Photocopy of ID card / Photocopy of current year policy.
q Original Detailed Discharge Summary / Day care summary from the
hospital.
q Original consolidated hospital bill with break up of each Item, duly signed
by the insured.
q Original payment Receipt of the hospital bill.
q First Consultation letter and subsequent Prescriptions.
q Original bills, original payment receipts and Reports for investigation.
q Original medicine bills and receipts with corresponding Prescriptions.
q Original invoice/bills for Implants (viz. Stent /PHS Mesh / IOL etc.) with
original payment receipts.
Road Traffic Accident
In addition to the In-patient Treatment documents:
q Copy of the First Information Report from Police Department / Copy of the
Medico-Legal Certificate.
In Non Medico legal cases
q Treating Doctor’s Certificate giving details of injuries (How, when and
where injury sustained)
In Accidental Death cases
q Copy of Post Mortem Report & Death Certificate
For Death Cases
In addition to the In-patient Treatment documents:
q Original Death Summary from the hospital.
q Copy of the Death certificate from treating doctor or the hospital authority.
q Copy of the Legal heir certificate, if the claim is for the death of the
principle insured.
Pre and Post-hospitalisation expenses
q Duly filled and signed Claim Form.
q Photocopy of ID card / Photocopy of current year policy.
q Original Medicine bills, original payment receipt with prescriptions.
q Original Investigations bills, original payment receipt with prescriptions
and report.
q Original Consultation bills, original payment receipt with prescription.
q Copy of the Discharge Summary of the main claim.
Outpatient Benefit/Dental
q Duly filled and signed Claim Form.
q Photocopy of ID card / Photocopy of current year policy.
q Original Medicine bills, original payment receipt.
q Original Investigations bills, original payment receipt with report.
q Original Consultation bills, original payment receipt with prescription.
q Details of any Outpatient Procedures, If any
q Dental X-ray film.
Daily Cash Benefit
q Duly filled and signed Claim Form.
q Photocopy of ID card / Photocopy of current year policy.
Organ Donation/Transplantation
In addition to the documents of general hospitalization
q Organ Function test / blood test proving organ failure.
q Treatment Certificate issued by the Transplant Surgeon of the hospital
concerned.
Ambulance Benefit
q Duly filled and signed Claim Form.
q Photocopy of ID card / Photocopy of current year policy.
q Original Bill with Original Payment Receipt.
q Treating Doctor’s consultation prescription indicating Emergency
Hospitalization.
Maternity Expenses
In addition to the In-patient Treatment documents:
q Obstetric history (Gravida, Para, Living children, Abortions) from treating
doctor.
Critical Illness Benefit
q Duly filled and signed Claim Form.
q Photocopy of ID card / Photocopy of current year policy.
q A medical certificate confirming the diagnosis of critical illness from a
doctor not less qualified than MD/MS.
q Investigation reports/ other related documents reflecting the critical
illness diagnosis.
Health Check up
q Duly filled and signed Claim Form.
q Photocopy of ID card / Photocopy of current year policy.
q Original Investigation bills, original payment receipts with Reports.
q Original Consultation bills and original payment receipts with prescription.
Expenses for spectacles/contact lenses, hearing aids
q Duly filled and signed Claim Form.
q Photocopy of ID card / Photocopy of current year policy.
q Prescription of the Treating Doctor.
q Original Invoice/bills, original payment receipt of the device, appliances,
lens etc.
CHECK LIST OF ENCLOSURES FOR SUBMISSION OF CLAIM