Health Insurance Claim Form (Pakistan)

A Health Insurance Claim Form in Pakistan captures the information the relevant authority needs for the matter it concerns and creates a dated written record of what was submitted.

The Insurance Ordinance 2000 replaced the Insurance Act 1938 and established a thorough regulatory framework for life and non-life insurance in Pakistan. Section 4 of the Insurance Ordinance 2000 requires all insurers operating in Pakistan to be registered with the SECP. Health insurance is classified as a non-life insurance product in Pakistan and is offered by general insurance companies licensed under Section 12 of the Insurance Ordinance 2000. The SECP's Insurance Division, functioning under the SECP Act 1997, issues regulations and circulars governing policy terms, claim settlement timelines, dispute resolution, and consumer protection for health insurance policyholders.

Health insurance in Pakistan operates through several structures: individual health policies sold directly to policyholders; group health insurance schemes provided by employers to their workforce as an employment benefit, often forming part of the compensation package governed by the Employment Contract and the applicable labour laws; and government-sponsored health insurance schemes including the Sehat Sahulat Programme administered by the State Life Insurance Corporation of Pakistan (SLIC) and provincial social health protection initiatives in Punjab and Khyber Pakhtunkhwa targeting lower-income households.

The Insurance Ordinance 2000 Section 76 establishes the Insurance Ombudsman as an independent forum for resolving consumer complaints against insurers — where an insurer wrongfully rejects or delays settlement of a health insurance claim, the policyholder may file a complaint with the Insurance Ombudsman without paying any court fee or lawyer's fee, making it an accessible alternative dispute resolution mechanism. The Federal Ombudsman (Wafaqi Mohtasib) established under the Establishment of the Office of Wafaqi Mohtasib (Ombudsman) Order 1983 also has concurrent jurisdiction over complaints against government-affiliated insurance entities including SLIC.

The SECP has issued Health Insurance Regulations and multiple circulars governing minimum mandatory benefits, pre-authorisation requirements, Third Party Administrator (TPA) services, claim settlement timelines (typically 30 days for complete claims under SECP guidelines), and mandatory provision of a policy summary document (Key Facts Statement) to policyholders. These regulations directly affect the content and processing of Health Insurance Claim Forms submitted to Pakistani insurers.

The legal framework governing the Health Insurance Claim Form (Pakistan) in Pakistan draws on several key statutes and regulatory bodies. Under Pakistani law, the Muslim Family Laws Ordinance 1961 governs Muslim marriage (nikah), divorce (talaq), maintenance, and dower (mehr). The Family Courts Act 1964 establishes Family Courts with jurisdiction over matrimonial disputes. The National Database and Registration Authority (NADRA) issues CNIC, NICOP, and birth/death certificates. The Guardian and Wards Act 1890 governs child custody. The Federal Shariat Court reviews laws for Islamic compliance. Parties executing a Health Insurance Claim Form (Pakistan) in Pakistan should confirm the document reflects current law, including any amendments enacted since the original drafting date. The Insurance Ordinance 2000 sets the foundational requirements.

A Health Insurance Claim Form in Pakistan is required whenever a policyholder or beneficiary seeks to exercise their rights under a health insurance policy to recover medical expenses or obtain direct payment of hospital charges.

A Health Insurance Claim Form is needed when a policyholder is hospitalised — whether through planned admission (elective surgery, maternity care) or emergency admission (accident, acute illness) — at a hospital not in the insurer's cashless panel network, and must pay the hospital bill directly before seeking reimbursement from the insurance company. SECP regulations require insurers to settle complete reimbursement claims within 30 days of receiving all required documents.

A Health Insurance Claim Form is required when a policyholder undergoes outpatient treatment — diagnostic tests, specialist consultations, physiotherapy, pharmacy purchases — that falls within the outpatient benefit limits of the health policy, requiring submission of original receipts, prescriptions, and laboratory reports for reimbursement.

A Health Insurance Claim Form is needed when a group health insurance policyholder — an employee covered under an employer-sponsored group medical scheme — requires treatment at a non-panel hospital and must submit individual claim documents to the Third Party Administrator (TPA) appointed by the employer's insurer to process group claims.

A Health Insurance Claim Form is required when a beneficiary named in a family health floater policy — typically the spouse or children of the primary insured — incurs medical expenses and the primary policyholder must file on their behalf, establishing the beneficiary's relationship and the policy's coverage extension to family members.

A Health Insurance Claim Form is needed when a policyholder who received cashless treatment at a panel hospital discovers that the insurer's TPA did not settle the full bill — the remaining balance (due to policy limits, co-payment provisions, or non-covered items) must be settled by the policyholder and can then be claimed for reimbursement where the policy permits.

A Health Insurance Claim Form is required when a policyholder covered under the Sehat Sahulat Programme or a provincial health insurance scheme receives treatment at an empanelled secondary or tertiary care hospital and the hospital's health management information system requires formal claim documentation for government reimbursement processing.

A valid Health Insurance Claim Form in Pakistan under the Insurance Ordinance 2000 and SECP Health Insurance Regulations must contain the following essential elements to support successful and timely claim processing.

Policyholder and Patient Identification: Full name of the policyholder exactly as it appears on the NADRA Computerised National Identity Card (CNIC), CNIC number in 13-digit format (XXXXX-XXXXXXX-X), policy number issued by the insurance company, and group scheme certificate number (for group insurance). If the patient is a beneficiary other than the primary policyholder, the patient's full name, CNIC or NADRA B-Form number, date of birth, and relationship to the primary insured must be stated.

Insurer and Policy Details: Name of the insurance company licensed under the Insurance Ordinance 2000 with its SECP registration number, name and CNIC of the Third Party Administrator (TPA) if applicable, policy type (individual, family floater, or group), policy commencement date, policy expiry date, and sum insured amount in Pakistani Rupees (PKR). The claim must be submitted within the time limit specified in the policy — most Pakistani health policies require claims to be filed within 30 to 90 days of discharge or treatment.

Medical Details: Date(s) of treatment, name and address of the hospital or clinic, name of the treating doctor and their Pakistan Medical Commission (PMC) registration number, diagnosis (using ICD-10 code if available), nature of illness or injury (whether illness, accident, or maternity), and whether the admission was pre-authorised by the insurer or TPA under a pre-authorisation (PA) number.

Expense Summary: An itemised list of medical expenses claimed — hospital room charges (ward, semi-private, or private room as per policy coverage), surgeon's fee, anaesthesiologist fee, operating theatre charges, intensive care unit (ICU) charges, diagnostic test charges (X-ray, MRI, CT scan, blood tests), pharmacy charges (with original receipts), physiotherapy charges, and ambulance charges. Each item must be supported by original bills, receipts, and discharge summary.

Bank Account Details: Name of bank, branch address, IBAN (International Bank Account Number) of the policyholder for direct credit of reimbursement under the State Bank of Pakistan (SBP) IBFT or RAAST instant payment system. All reimbursements above PKR 25,000 are required to be made by bank transfer under SBP financial inclusion guidelines.

Declaration of Truth: A signed declaration by the policyholder that all information in the claim form is true and correct, that the expenses were actually incurred for the treatment of the named patient, that no other insurance claim has been or will be filed for the same expenses with another insurer, and that the policyholder consents to the insurer or TPA verifying information with the treating hospital and doctors under the Medical Practitioners and Dentists Act 1963 and the PMC regulations.

Pre-existing Condition Disclosure: A specific declaration regarding whether the condition treated is related to a pre-existing ailment disclosed at the time of policy issuance or subject to a waiting period under the policy terms. SECP regulations require insurers to clearly define pre-existing condition exclusions in the policy document — misrepresentation at this stage voids the claim under Section 18 of the Insurance Ordinance 2000.

Required Attachments Checklist: Attested copies of CNIC of policyholder and patient; original hospital discharge summary signed by the treating doctor; original itemised hospital bill and payment receipt; original diagnostic reports (lab reports, X-rays, MRI films or CD); original pharmacy receipts with doctor's prescription; pre-authorisation letter from TPA (if obtained); and referral letter from general practitioner to specialist (where applicable).

Forms-legal.com provides this Health Insurance Claim Form (Pakistan) template to help policyholders organise and submit complete, compliant claims to their health insurers. Policyholders whose claims are wrongly rejected should first appeal to the insurer's internal grievance cell, then escalate to the SECP Insurance Division or the Insurance Ombudsman established under Section 76 of the Insurance Ordinance 2000 for independent resolution.