CHECKLIST & DOCUMENTS | KNK SHIP MANAGEMENT

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Checklist for Reimbursement Claims

Claim Form Part A employee sign (to be filled by employee with total claim amount)
Download Form Part A
Claim Form Part B (to be filled by Hospital)
Download Form Part B
KYC document of employee & patient – PAN Card & Aadhaar Card (photocopies are required)
Original Discharge Card / Discharge Summary / Day Care Summary duly signed by treating doctor and with hospital stamp
Original Hospital Final Bill – duly sealed & signed, with break-up details with serial numbers
Original Advance Receipt & payment done to hospital
Original pre-numbered hospital payment receipt duly sealed & signed (with revenue stamp)
If medicine and consumables are charged in the hospital, a detailed break-up should be given (name of medicine / consumables with charges)
Original Prescriptions / Consultation Papers with consultation receipts
Original Pharmacy Bills (please make sure patient name is mentioned on the bill)
Original Investigation Reports along with original bills & payment receipts for investigations done within & outside hospitals
All X-Ray, CT Scan, MRI Films, ECG Strips, Doppler / Angiogram reports & CD etc. (in case of fracture & heart surgery)
Current year Hospital Registration Certificate with total number of beds (Form C) – photocopy
All other original documents related to the claim
MLC Copy / FIR in case of accidental cases (in case of accidental cases, fall from bike, fall at home, etc.)
Detailed narration of the incidence of injury from employee
Letter from treating doctor – No Alcohol Certificate from treating doctor (in case of accidental cases, fall from bike, fall at home, etc.)
Original cancelled cheque with IFSC code and printed name of employee
If employee has availed a cashless claim but the same was not utilized, a letter from the hospital mentioning the same with GIPSA PPN form
In case of Maternity claims, obstetric history of the patient (GPLA Status) certificate from the treating doctor
USG Report (Ultrasonography Report) – mandatory for maternity cases
For Cataract claims, IOL sticker & purchase invoice copy of the sticker is mandatory
For Surgery (Replacement / PTCA), invoice copy / sticker is mandatory

Please read carefully

Important Note

Give all the above requirements within 5 days after discharge.
Submit / courier all original papers for the claim on the Mumbai address.

Address

Mezzanine floor, Ballard House, Adi Marzban path, Ballard estate, Bearing CTS number 1185, Fort, Mumbai 400001

Please keep a copy of all documents and papers for your record.
Original papers once submitted will not be returned.

You are required to courier all the necessary documents directly to the Client Servicing Officer yourself. If your claim is delayed despite submitting all the required documents, please contact your Site Supervisor for assistance and follow-up.