{"id":2283,"title":"NMPP Claim Form","purpose":"claim","insurer":{"slug":"national-insurance","name":"National Insurance Company Limited"},"source_pdf":"https://nationalinsurance.nic.co.in/sites/default/files/2026-04/NMPP%20Claim%20Form.pdf","sha256":"2e10068034c6f6aefce8e2aed2eda6e10e5df651eca6298d15e968400b449109","pages":6,"collected":"2026-10-17","instructions":{"about":"This form is used to claim cashless hospitalisation or reimbursement under the National Mediclaim Plus Policy. It is filled by the insured/patient, treating doctor, and hospital.","notes":["Use block letters to fill the form","Original bills only; photocopies may not be accepted","Please fax/scan page 1 only for cashless hospitalisation request","Use dd-mm-yyyy format for dates and hh:mm format for times","Attach all required documents as per checklist","Hospital seal must contain hospital ID","Patient/insured must sign the declaration","For non-network hospitals, additional details must be filled","If injury due to substance abuse/alcohol consumption, attach test reports","If hospitalization is medico-legal, attach MLC report and police FIR","Fill all mandatory fields marked as such"],"title":"NMPP Claim Form","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Details of Third Party Administrator","fields":[{"help":"","type":"text","label":"Name of TPA / Insurance Company:","options":[],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"Toll free phone number:","options":[],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"Toll free Fax:","options":[],"required":null,"pdf_field":""}],"filled_by":""},{"title":"To be filled by the insured / patient","fields":[{"help":"Enter full name of the patient","type":"text","label":"Name of the patient:","options":[],"required":true,"pdf_field":""},{"help":"Tick the appropriate gender","type":"choice","label":"Gender :","options":["Male","Female"],"required":true,"pdf_field":""},{"help":"Enter age in years","type":"number","label":"Age: years","options":[],"required":true,"pdf_field":""},{"help":"Use dd-mm-yyyy format","type":"date","label":"Date of Birth:","options":[],"required":true,"pdf_field":""},{"help":"Include STD code if applicable","type":"phone","label":"Contact number:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Employee ID:","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Insured card ID number:","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Policy number / Name of corporate:","options":[],"required":true,"pdf_field":""},{"help":"If yes to above, provide company name","type":"text","label":"Company Name:","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Do you have a family physician?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"If yes to above, provide name","type":"text","label":"Name of the family physician:","options":[],"required":false,"pdf_field":""},{"help":"Tick to confirm","type":"checkbox","label":"We confirm having read, understood and agreed to the Declaration on the reverse of this form","options":[],"required":true,"pdf_field":""},{"help":"Sign here","type":"signature","label":"Patient / Insured Name & Signature","options":[],"required":true,"pdf_field":""}],"filled_by":"insured / patient"},{"title":"To be filled by the treating doctor / hospital","fields":[{"help":"Full name of doctor","type":"text","label":"Name of the treating doctor:","options":[],"required":true,"pdf_field":""},{"help":"Doctor's qualifications","type":"text","label":"Qualification:","options":[],"required":true,"pdf_field":""},{"help":"Include STD code if applicable","type":"phone","label":"Contact number:","options":[],"required":false,"pdf_field":""},{"help":"Doctor's registration number with state code","type":"text","label":"Registration No. with state code:","options":[],"required":true,"pdf_field":""},{"help":"Preliminary diagnosis","type":"text","label":"Provisional diagnosis:","options":[],"required":true,"pdf_field":""},{"help":"Describe illness and complaints","type":"text","label":"Nature of illness/ disease with presenting complaints","options":[],"required":true,"pdf_field":""},{"help":"Number of days","type":"number","label":"Duration of the present ailment: Days","options":[],"required":true,"pdf_field":""},{"help":"Use dd-mm-yyyy format","type":"date","label":"Date of first consultation:","options":[],"required":true,"pdf_field":""},{"help":"","type":"yes-no","label":"Past history of any chronic illness","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Specify month and year","type":"text","label":"If Yes, since (month / year)","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Any other Ailment, give details:","options":[],"required":false,"pdf_field":""},{"help":"Total expected cost in rupees","type":"amount","label":"Sum Total, expected cost of hospitalization:","options":[],"required":true,"pdf_field":""},{"help":"Daily charges in rupees","type":"amount","label":"Per Day Room Rent + Nursing & Service Charges + Patient's Diet:","options":[],"required":false,"pdf_field":""},{"help":"Expected cost in rupees","type":"amount","label":"Expected cost of investigation + diagnostics:","options":[],"required":false,"pdf_field":""},{"help":"Tick applicable treatment","type":"choice","label":"Proposed line of treatment:","options":["Medical Management","Surgical Management","Intensive Care","Investigation"],"required":true,"pdf_field":""},{"help":"Name of surgery if applicable","type":"text","label":"If Surgical, name of surgery:","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"If other treatments, provide details","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Route of drug administration:","options":[],"required":false,"pdf_field":""},{"help":"International Classification of Diseases code","type":"text","label":"ICD 10 Code if any","options":[],"required":false,"pdf_field":""},{"help":"Procedure coding system code","type":"text","label":"ICD 10 PCS Code","options":[],"required":false,"pdf_field":""},{"help":"Fill details below if applicable","type":"section","label":"In case of accident:","options":[],"required":null,"pdf_field":""},{"help":"Road Traffic Accident","type":"yes-no","label":"Is it RTA?","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Use dd-mm-yyyy format","type":"date","label":"Date of injury:","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Reported to Police:","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"First Information Report number","type":"text","label":"FIR No.:","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Injury / Disease caused due to substance abuse / alcohol consumption:","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Attach test reports if yes","type":"yes-no","label":"Test conducted to establish this? (If yes attach reports)","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Total package charges in rupees","type":"amount","label":"All inclusive package charges, if any applicable:","options":[],"required":false,"pdf_field":""},{"help":"Use dd-mm-yyyy format","type":"date","label":"Date of admission:","options":[],"required":true,"pdf_field":""},{"help":"Use hh:mm format","type":"text","label":"Time:","options":[],"required":true,"pdf_field":""},{"help":"Tick applicable","type":"choice","label":"Is this an emergency / a planned hospitalization event?","options":["Emergency","Planned"],"required":true,"pdf_field":""},{"help":"Number of days expected","type":"number","label":"Expected no. of days in hospital: Days","options":[],"required":true,"pdf_field":""},{"help":"Specify room type","type":"text","label":"Room Type:","options":[],"required":true,"pdf_field":""},{"help":"Charges in rupees","type":"amount","label":"ICU Charges:","options":[],"required":false,"pdf_field":""},{"help":"Operation Theatre charges in rupees","type":"amount","label":"OT Charges:","options":[],"required":false,"pdf_field":""},{"help":"Total professional fees in rupees","type":"amount","label":"Professional fees Surgeon + Anesthetist Fees + consultation charges:","options":[],"required":false,"pdf_field":""},{"help":"Fill details below if applicable","type":"section","label":"In case of maternity:","options":[],"required":false,"pdf_field":""},{"help":"Use dd-mm-yyyy format","type":"date","label":"Date of Delivery:","options":[],"required":false,"pdf_field":""},{"help":"Total cost in rupees","type":"amount","label":"Medicines + Consumables + Cost of implants (if applicable, please specify), other hospital expenses, if any:","options":[],"required":false,"pdf_field":""},{"help":"Hospital official seal and signature","type":"signature","label":"Hospital Seal (must contain hospital ID)","options":[],"required":true,"pdf_field":""},{"help":"Signature of treating doctor","type":"signature","label":"Doctor's Signature","options":[],"required":true,"pdf_field":""}],"filled_by":"treating doctor / hospital"},{"title":"Details of Primary Insured (Claim Form - Part A)","fields":[{"help":"Enter policy number","type":"text","label":"Policy no:","options":[],"required":true,"pdf_field":""},{"help":"Full name of primary insured","type":"text","label":"Name:","options":[],"required":true,"pdf_field":""},{"help":"Tick applicable and specify if Other","type":"choice","label":"Relationship to Primary Insured:","options":["Self","Spouse","Child","Father","Mother","Other (Please specify)"],"required":true,"pdf_field":""},{"help":"Full postal address including city, state, pin code","type":"text","label":"Address:","options":[],"required":true,"pdf_field":""},{"help":"Include STD code if applicable","type":"phone","label":"Phone No:","options":[],"required":false,"pdf_field":""},{"help":"","type":"email","label":"Email ID:","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"Details of Insured Person Hospitalized","fields":[{"help":"Full name of hospitalized person","type":"text","label":"Name:","options":[],"required":true,"pdf_field":""},{"help":"Tick applicable","type":"choice","label":"Gender:","options":["Male","Female"],"required":true,"pdf_field":""},{"help":"Use dd-mm-yyyy format","type":"date","label":"Date of Birth:","options":[],"required":true,"pdf_field":""},{"help":"Sum insured as per policy","type":"amount","label":"Sum insured:","options":[],"required":true,"pdf_field":""},{"help":"Tick applicable and specify if Other","type":"choice","label":"Occupation:","options":["Service","Self Employed","Homemaker","Student","Retired","Other (Please specify)"],"required":false,"pdf_field":""},{"help":"Full postal address if different","type":"text","label":"Address (if different from above):","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"Details of Hospitalization","fields":[{"help":"Full name of hospital","type":"text","label":"Name of Hospital where Admitted:","options":[],"required":true,"pdf_field":""},{"help":"Tick applicable","type":"choice","label":"Room category occupied:","options":["Suite","Deluxe room","Single occupancy","Twin occupancy","3 or more occupancy"],"required":true,"pdf_field":""},{"help":"Tick applicable","type":"choice","label":"Hospitalization due to:","options":["Injury","Illness","Accident"],"required":true,"pdf_field":""},{"help":"Use dd-mm-yyyy format","type":"date","label":"Date of injury/ Date Disease first detected:","options":[],"required":false,"pdf_field":""},{"help":"Use dd-mm-yyyy format","type":"date","label":"Date of Admission:","options":[],"required":true,"pdf_field":""},{"help":"Use hh:mm format","type":"text","label":"Time:","options":[],"required":true,"pdf_field":""},{"help":"Use dd-mm-yyyy format","type":"date","label":"Date of Discharge:","options":[],"required":true,"pdf_field":""},{"help":"Use hh:mm format","type":"text","label":"Time:","options":[],"required":true,"pdf_field":""},{"help":"Tick applicable","type":"choice","label":"If injury, give cause:","options":["Self inflicted","Road Traffic Accident","Substance abuse / Alcohol Consumption"],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"If Medico Legal:","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Reported to police:","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Attach if applicable","type":"yes-no","label":"MLC Report & Police FIR attached:","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Tick applicable and specify if AYUSH","type":"choice","label":"System of medicine:","options":["Allopathy","AYUSH (Please Specify)"],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"Details of Claim","fields":[{"help":"Enter amount claimed in rupees","type":"amount","label":"Details of treatment expenses claimed","options":[],"required":true,"pdf_field":""},{"help":"Tick all documents submitted","type":"checkbox","label":"Claim Documents Submitted - Check List","options":["Copy of the claim intimation, if any","Claim Form Duly signed","Hospital Main Bill","Pre hospitalization Bills","Post hospitalization Bills","Pharmacy Bills","Health checkup","Doctor's Prescription","Investigation Reports (including CT / MRI / USG / HPE)","Hospital Discharge Summary","Operation Theatre Notes","MLC report & Police FIR","Original Pre-authorization request","Copy of the Pre-authorization approval letter","Doctor's reference slip"],"required":true,"pdf_field":""}],"filled_by":"insured"},{"title":"Details of Bills Enclosed","fields":[{"help":"Columns: Bill No., Date, Issued By, Amount (₹)","type":"table","label":"Bill Towards","options":[],"required":true,"pdf_field":""},{"help":"Number of bills for each category","type":"number","label":"No. of bills","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"Details of Primary Insured's Bank Account","fields":[{"help":"Permanent Account Number","type":"text","label":"PAN:","options":[],"required":true,"pdf_field":""},{"help":"Bank account number","type":"text","label":"Account Number:","options":[],"required":true,"pdf_field":""},{"help":"Full name of bank","type":"text","label":"Bank Name:","options":[],"required":true,"pdf_field":""},{"help":"Full name of bank branch","type":"text","label":"Bank Branch:","options":[],"required":true,"pdf_field":""},{"help":"Name of beneficiary for cheque/DD","type":"text","label":"Cheque/ DD Payable details:","options":[],"required":true,"pdf_field":""},{"help":"IFSC code of bank branch","type":"text","label":"IFSC Code:","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"},{"title":"Declaration by the Insured","fields":[{"help":"Use dd-mm-yyyy format","type":"date","label":"Date:","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Place:","options":[],"required":true,"pdf_field":""},{"help":"Sign here","type":"signature","label":"Signature of the insured:","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"},{"title":"Details of Hospital (Claim Form - Part B)","fields":[{"help":"Full name of hospital","type":"text","label":"Name of Hospital:","options":[],"required":true,"pdf_field":""},{"help":"ID number allocated by TPA","type":"text","label":"Hospital ID:","options":[],"required":false,"pdf_field":""},{"help":"Tick applicable","type":"choice","label":"Type of Hospital:","options":["Network","Non Network"],"required":true,"pdf_field":""},{"help":"Full postal address including city, state, pin code","type":"text","label":"Address of the hospital:","options":[],"required":true,"pdf_field":""},{"help":"Include STD code if applicable","type":"phone","label":"Phone No:","options":[],"required":false,"pdf_field":""},{"help":"Hospital registration number with state code","type":"text","label":"Registration No. with state code:","options":[],"required":true,"pdf_field":""},{"help":"Permanent Account Number of hospital","type":"text","label":"Hospital PAN:","options":[],"required":false,"pdf_field":""},{"help":"Number of beds available","type":"number","label":"Number of inpatient beds:","options":[],"required":false,"pdf_field":""},{"help":"Tick applicable facilities","type":"checkbox","label":"Facilities available in the hospital:","options":["OT","ICU","Others (Please specify)"],"required":false,"pdf_field":""}],"filled_by":"hospital"},{"title":"Details of Patient Admitted","fields":[{"help":"Full name of patient","type":"text","label":"Name of Patient:","options":[],"required":true,"pdf_field":""},{"help":"Insurance provider registration number","type":"text","label":"IP Registration No.:","options":[],"required":false,"pdf_field":""},{"help":"Tick applicable","type":"choice","label":"Gender:","options":["Male","Female"],"required":true,"pdf_field":""},{"help":"Enter years and months","type":"text","label":"Age: years months","options":[],"required":true,"pdf_field":""},{"help":"Use dd-mm-yyyy format","type":"date","label":"Date of Admission:","options":[],"required":true,"pdf_field":""},{"help":"Use hh:mm format","type":"text","label":"Time:","options":[],"required":true,"pdf_field":""},{"help":"Use dd-mm-yyyy format","type":"date","label":"Date of Discharge:","options":[],"required":true,"pdf_field":""},{"help":"Use hh:mm format","type":"text","label":"Time:","options":[],"required":true,"pdf_field":""},{"help":"Tick applicable","type":"choice","label":"Type of Admission:","options":["Emergency","Planned","Day Care","Maternity"],"required":true,"pdf_field":""},{"help":"Fill details below if applicable","type":"section","label":"If Maternity:","options":[],"required":false,"pdf_field":""},{"help":"Use dd-mm-yyyy format","type":"date","label":"Date of Delivery:","options":[],"required":false,"pdf_field":""},{"help":"Enter gravida status","type":"text","label":"Gravida Status:","options":[],"required":false,"pdf_field":""},{"help":"Tick applicable","type":"choice","label":"Status at time of discharge:","options":["Discharged to home","Discharged to another hospital","Deceased"],"required":true,"pdf_field":""},{"help":"Total amount claimed in rupees","type":"amount","label":"Total claimed amount:","options":[],"required":true,"pdf_field":""}],"filled_by":"hospital"},{"title":"Details of Treating Doctor","fields":[{"help":"Full name","type":"text","label":"Name of the treating doctor:","options":[],"required":true,"pdf_field":""},{"help":"Doctor's qualifications","type":"text","label":"Qualification:","options":[],"required":true,"pdf_field":""},{"help":"Doctor's registration number with state code","type":"text","label":"Registration No. with State Code:","options":[],"required":true,"pdf_field":""},{"help":"Include STD code if applicable","type":"phone","label":"Phone No:","options":[],"required":false,"pdf_field":""},{"help":"Use dd-mm-yyyy format","type":"date","label":"Date of Birth:","options":[],"required":false,"pdf_field":""}],"filled_by":"hospital"},{"title":"Declaration by the Hospital","fields":[{"help":"Use dd-mm-yyyy format","type":"date","label":"Date:","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Place:","options":[],"required":true,"pdf_field":""},{"help":"Signature and official seal","type":"signature","label":"Signature and seal of the hospital authority:","options":[],"required":true,"pdf_field":""}],"filled_by":"hospital"}],"deadlines":["All valid original documents duly countersigned by the insured / patient as per the checklist below will be sent to TPA / Insurance Company within 7 days of the patient's discharge"],"applies_to":"National Mediclaim Plus Policy claims including cashless hospitalisation and reimbursement claims","attachments":["Detailed Discharge Summary and all Bills from the hospital","Cash Memos from the Hospitals / Chemists supported by proper prescription","Receipts and Pathological Test Reports from Pathologists, supported by note from the attending Medical Practitioner / Surgeon recommending such pathological Tests","Surgeon's Certificate stating nature of operation performed and Surgeon's Bill and Receipt","Certificates from attending Medical Practitioner / Surgeon that the patient is fully cured","Copy of the claim intimation, if any","Claim Form Duly signed","Hospital Main Bill","Pre hospitalization Bills","Post hospitalization Bills","Pharmacy Bills","Health checkup","Doctor's Prescription","Investigation Reports (including CT / MRI / USG / HPE)","Hospital Discharge Summary","Operation Theatre Notes","MLC report & Police FIR","Original Pre-authorization request","Copy of the Pre-authorization approval letter","Doctor's reference slip"],"declarations":["The insured declares that the information furnished is true and correct to the best of their knowledge and belief","False or untrue statements, suppression or concealment of material facts will forfeit the right to claim reimbursement","The insured consents and authorizes TPA / insurance company to seek necessary medical information from hospitals or medical practitioners","The insured declares that all bills and receipts for the claim are included and no supplementary claim except pre/post-hospitalization will be made","The hospital declares that the information furnished is true and correct to the best of their knowledge and belief","False or untrue statements by the hospital will forfeit their right to claim under this claim","The hospital agrees to provide clarifications for queries raised regarding hospitalization and takes responsibility for any delay","The hospital confirms the patient declaration was signed in their presence","The insured agrees to allow the hospital to submit all original documents pertaining to hospitalization to the Insurer/TPA after discharge","Payment to hospital is governed by the terms and conditions of the policy; if insurer/TPA is not liable, the insured undertakes to settle the bill","All non-medical expenses and expenses not relevant to current hospitalization or amounts over authorized limits will be paid by the insured","The insured agrees to indemnify the hospital against all expenses not reimbursed by the Insurer/TPA","The insured agrees to abide by the terms and conditions of the policy and indemnify the Insurer/TPA if facts disclosed are false or incorrect","TPA/Insurance Company is not liable for payment in case of discrepancies between form and discharge summary or other documents","TPA is not guaranteeing the quality or standard of hospital services"],"dropped_labels":7},"pdf_fields":null,"fillable_pdf":false,"send_to":[],"how_to_use":"Ask the user for each field in order, in plain words; never invent an answer. Labels are as printed. If fillable_pdf is true, pdf_fields gives the PDF's own field names so the file can be filled directly. The printed form decides if anything differs.","url":"https://indiainsurances.com/forms/national-insurance/2283-nmpp-claim-form"}