Customer City

Customer State

Customer Pincode

Plantype * Family Floater Group

Choose Plan * Select a Plan * Silver Gold Diamond

Sum Insured *

Provider Name *

ProviderID *

Provider City

Provider State

Provider Pincode

Claim Type

Claim Number

Claim Date

Primary Diagnosis*

Primary Diagnosis code

Secondary Diagnosis

Secondary Diagnosis code

Tertiary Diagnosis

Tertiary Diagnosis Code

Date of Admission *

Date of Discharge *

Billed Amount *

Medical expenses

Room & Nursing expenses

Consultation fees

Non Hospital expenses

Pre Hospitalization expenses

Post Hospitalization expenses

Misc Expenses

Previous Claims

Claims TPA Decision

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