CHECKLIST FOR REIMBURSEMENT UNDER IBA CORPORATE
1. Claim form duly filled in all respects provided by IRDA (available in our website), clearly mentioning the
amount claimed, policy no, card no, name of hospital, date of admission and discharge, contact no, mail ID
and signature (mandatory).
2. Original Discharge summary duly signed and stamped by treating doctor.
3. Original Final bill with detailed breakup under different heads(Pre numbered final bill).
4. All investigation reports in original with reports.
5. All receipts in original for the claim amount for which the claim has been lodged (Pre number receipts against
the final bill incase payment is done by cheque & claims with amount more then 1lakh bank statement
supporting cheque clearance / online payment also required.
6. In case of surgery where implant has been used, original sticker and invoice of the implant.
7. In case claimed amount is more than 2 lac IPD (Indoor patient sheet) / OT notes.
8. FIR, MLC copy in case of injury/RTA. In all accidental cases details narration of incidence (How, When, Where)
verified from treating doctor and history of alcohol influence at the time of injury verified from treating doctor
also required.
9. In case of part settlement, all photocopy documents by first claim processing TPA, duly signed and stamped
by the concerned authorities, claim settlement voucher and complete breakup details of deductions.
10. In case original documents are lost the photocopy documents dully attested by nodal officer of the bank
along with notary attested affidavit on Rs.100 stamp paper.
11. In case of demise of proposer (main insured), succession certificate is required.
12. All bill / receipts for purchase of medicine upon which a claim is made shall bear the valid GST no. of the
issue of such bills, receipts, etc. or declaration with sign & stamp of pharmacy if exempted verified by nodal
officer of the concerned.
13. All report should duly sign and stamped (MD Pathologist, X-ray, CT reports Sign & stamped by Radiologist).
14. Registration certificate of the treating facility/hospital on case to case basis.
15. GOVT. approved ID Proof showing age similar to policy.
16. PAN card copy of proposer in case of claims above 1 Lac.
17. For self-bank id card/Aadhar card & any one of the KYC documents for dependents & addition of new baby.
18. Cancelled cheque bearing the name of proposer. If the cancelled cheque is not bearing the name of the
proposer, photocopy of first page of passbook showing the account details of proposer unless the details of
insured provided by the nodal officer as one-time exercise.
***These are the documents that are NORMALLY REQUIRED while processing the reimbursement
claims.Apart from this there can be other queries for particular claim DEPENDING ON THE REQUIREMENT
and also AFTER RECEIVING QUERY REPLIES.
CHECKLIST FOR DOMICILIARY CLAIMS UNDER IBA CORPORATE
1. Domiciliary claim form or Claim Form PART A
2. FINAL DIAGNOSIS on Prescription
3. All original bills & receipts claimed (All bills should be pre-numbered).
4. Name of patient on all bills, documents.
5. Original Investigation report & films supporting the documents.
6. Original doctor’s prescription supporting the medicines /Investigation/Consultations/Physiotherapy
Etc.
7. Medicines bills must have GST number or declaration with sign &stamp of pharmacy if exempted
verified by nodal officer of the concerned.
8. GOVT. approved ID Proof showing age similar to policy.
9. A copy of cancel cheque bearing the name of Proposer/A copy of first page of Bank’s Passbook
unless the details of insured provided by the nodal officer as one-time exercise.
10. All report should duly sign and stamped (MD Pathologist, X-ray, CT reports Sign & stamped by
Radiologist).
*Please keep Scanned or photocopy of all submitted documents for your reference before submission.
*Documents can be submitted either at any of the branch office or HO of the TPA.
Safeway Insurance TPA Pvt. Ltd.
815, VishwaSadan, Distt.CentreJanakpuri, NewDelhi-110058 E- Phone: 011 - 4142 5671, 45451300 (100 lines),
Mail:
[email protected], Website:www.safewaytpa.in Fax: +91-11 - 4142 5672 CIN: U67200DL2004PTC129929
