Reimbursement Claim Form Part A and B - Summary
Reimbursement claim form Part A and Part B is the standard health insurance claim document prescribed by the Insurance Regulatory and Development Authority of India (IRDAI) for filing mediclaim reimbursement. Policyholders submit this form to insurance companies or Third Party Administrators (TPAs) to claim medical expenses incurred during hospital treatment.
This claim form has two main sections. Part A is filled and signed by the policyholder with policy numbers, patient information, hospitalization dates, expense breakdown, and bank account details for direct payment. Part B is filled, signed, and stamped by the treating doctor and hospital administration with diagnostic codes, treatment details, and admission records. Policyholders using specific providers can also refer to the Medi Assist reimbursement claim form or the Star Health reimbursement form for company-specific guidelines.
Reimbursement claim form structure and parts
To avoid rejection or delays, claimants must submit the completed form along with original hospital records.
- Original discharge summary with complete admission notes and doctor advice
- Itemized hospital final bill with breakdown of room rent, nursing, and medicines
- Original paid receipts and payment vouchers showing payment settlement
- Prescriptions, pharmacy bills, and diagnostic test reports with doctor advice
- Cancelled cheque of the primary policyholder for electronic bank transfer
How to fill and submit the claim form
STEP 1 – Print Part A and Part B of the form on clean A4 paper.
STEP 2 – Fill Part A with your policy number, patient details, expense breakdown, and bank account details.
STEP 3 – Hand over Part B to the hospital billing desk at the time of discharge for the doctor to fill and stamp.
STEP 4 – Gather original hospital bills, payment receipts, discharge card, and doctor prescriptions.
STEP 5 – Attach self-attested copies of your Aadhaar card, PAN card, and a cancelled cheque.
STEP 6 – Submit the completed claim set to your insurer or TPA office within 30 days of discharge.
