{"id":2286,"title":"REQUEST FOR CASHLESS HOSPITALISATION FOR MEDICLAIM INSURANCE POLICY","purpose":"claim","insurer":{"slug":"national-insurance","name":"National Insurance Company Limited"},"source_pdf":"https://nationalinsurance.nic.co.in/sites/default/files/2026-04/NYIMP%20Claim%20Form.pdf","sha256":"082d539e2ea62e8251ec1b5e5e8c0ac31acb7a11a7e77012354778da3c2eb0a8","pages":6,"collected":"2026-10-17","instructions":{"about":"This form is used by the insured or patient to request cashless hospitalisation under the Mediclaim insurance policy and by the hospital and treating doctor to provide necessary details for claim processing.","notes":["Fill form in block letters","Use original bills and documents only","Attach all required supporting documents as per checklist","Page 1 only to be faxed/scanned for cashless request","Declaration must be signed by patient/insured and hospital authority","Use dd-mm-yyyy format for dates and include STD codes for phone numbers"],"title":"REQUEST FOR CASHLESS HOSPITALISATION FOR MEDICLAIM INSURANCE POLICY","submit":{"to":"TPA / Insurance Company as per policy","how":"FAX / SCAN PAGE 1 ONLY for cashless request; submit original documents after discharge","address":""},"purpose":"claim","sections":[{"title":"Details of the Third Party Administrator","fields":[{"help":"","type":"text","label":"a) Name of TPA / Insurance Company:","options":[],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"b) Toll free phone number:","options":[],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"c) Toll free Fax:","options":[],"required":null,"pdf_field":""}],"filled_by":""},{"title":"Details of the Patient Admitted","fields":[{"help":"Enter full name in block letters","type":"text","label":"a) Name of the patient:","options":[],"required":true,"pdf_field":""},{"help":"Tick the appropriate gender","type":"choice","label":"b) Gender :","options":["M","F","TG"],"required":true,"pdf_field":""},{"help":"Enter age in years","type":"number","label":"c) Age:  years","options":[],"required":true,"pdf_field":""},{"help":"Use dd/mm/yyyy format","type":"date","label":"d) Date of Birth:","options":[],"required":true,"pdf_field":""},{"help":"Enter contact number of patient or relative","type":"phone","label":"e) Contact number:","options":[],"required":true,"pdf_field":""},{"help":"","type":"phone","label":"f) Contact number of attending relative","options":[],"required":null,"pdf_field":""},{"help":"As per insurance card","type":"text","label":"g) Insured card ID number:","options":[],"required":true,"pdf_field":""},{"help":"Enter policy number or corporate name","type":"text","label":"h) Policy number / Name of corporate:","options":[],"required":true,"pdf_field":""},{"help":"Full postal address","type":"text","label":"n) Current address of insured person","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"o) Occupation of insured person:","options":[],"required":null,"pdf_field":""},{"help":"Use dd/mm/yyyy format","type":"date","label":"a) Date of admission:","options":[],"required":true,"pdf_field":""},{"help":"Enter time of admission","type":"text","label":"b) Time:","options":[],"required":true,"pdf_field":""},{"help":"Tick appropriate option","type":"choice","label":"c) Is this an emergency / a planned hospitalization event?","options":["Emergency","Planned"],"required":true,"pdf_field":""},{"help":"Enter expected duration in days","type":"number","label":"e) Expected no. of days in hospital:","options":[],"required":null,"pdf_field":""},{"help":"Enter number of ICU days if applicable","type":"number","label":"f) Days in ICU:","options":[],"required":null,"pdf_field":""},{"help":"Use dd/mm/yyyy format","type":"date","label":"m) In case of maternity: Expected date of Delivery:","options":[],"required":null,"pdf_field":""},{"help":"Enter provisional diagnosis","type":"text","label":"f) Provisional diagnosis:","options":[],"required":null,"pdf_field":""},{"help":"Describe illness and complaints","type":"text","label":"c) Nature of illness/ disease with presenting complaints","options":[],"required":null,"pdf_field":""},{"help":"Enter duration in days","type":"number","label":"e) Duration of the present ailment:","options":[],"required":null,"pdf_field":""},{"help":"Use dd/mm/yyyy format","type":"date","label":"i. Date of first consultation:","options":[],"required":null,"pdf_field":""},{"help":"Provide past management details","type":"text","label":"ii. Past history of Management, provide details","options":[],"required":null,"pdf_field":""},{"help":"Specify route","type":"text","label":"i. Route of drug administration:","options":[],"required":null,"pdf_field":""},{"help":"Tick all applicable","type":"choice","label":"g) Proposed line of treatment:","options":["Medical Management","Surgical Management","Intensive Care","Investigation"],"required":null,"pdf_field":""},{"help":"Provide details","type":"text","label":"h) If investigation & / or Medical present ailment,","options":[],"required":null,"pdf_field":""},{"help":"Provide accident details","type":"text","label":"l) In case of accident:","options":[],"required":null,"pdf_field":""},{"help":"Tick yes or no","type":"yes-no","label":"i. Is it RTA?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Use dd/mm/yyyy format","type":"date","label":"ii. Date of injury:","options":[],"required":null,"pdf_field":""},{"help":"Tick yes or no","type":"yes-no","label":"iii. Reported to Police:","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter FIR number if applicable","type":"text","label":"iv. FIR No.:","options":[],"required":null,"pdf_field":""},{"help":"Tick yes or no","type":"yes-no","label":"v. Injury / Disease caused due to substance abuse / alcohol consumption:","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter surgery name if applicable","type":"text","label":"i) If Surgical, name of surgery:","options":[],"required":null,"pdf_field":""},{"help":"Provide details of other treatments","type":"text","label":"j) If other treatments, provide details","options":[],"required":null,"pdf_field":""},{"help":"Describe cause of injury","type":"text","label":"k) How did the injury occur?","options":[],"required":null,"pdf_field":""},{"help":"Tick yes or no","type":"yes-no","label":"k) Do you have a family physician?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter name if applicable","type":"text","label":"l) Name of the family physician:","options":[],"required":null,"pdf_field":""},{"help":"Enter contact number if applicable","type":"phone","label":"m) Contact number, if any:","options":[],"required":null,"pdf_field":""},{"help":"Enter employee ID if applicable","type":"text","label":"i) Employee ID:","options":[],"required":null,"pdf_field":""}],"filled_by":"insured / patient"},{"title":"Details of Charges and Expenses","fields":[{"help":"Enter amount in INR","type":"amount","label":"i) Expected cost of investigation + diagnostics:","options":[],"required":null,"pdf_field":""},{"help":"Enter amount in INR","type":"amount","label":"j) ICU Charges:","options":[],"required":null,"pdf_field":""},{"help":"Enter amount in INR","type":"amount","label":"k) OT Charges:","options":[],"required":null,"pdf_field":""},{"help":"Enter amount in INR","type":"amount","label":"l) Professional fees Surgeon + Anesthetist Fees + consultation charges:","options":[],"required":null,"pdf_field":""},{"help":"Enter amount in INR","type":"amount","label":"m) Medicines + Consumables + Cost of implants (if applicable, please specify):","options":[],"required":null,"pdf_field":""},{"help":"Enter amount in INR","type":"amount","label":"n) Other hospital expenses, if any:","options":[],"required":null,"pdf_field":""},{"help":"Enter amount in INR","type":"amount","label":"o) All inclusive package charges, if any applicable:","options":[],"required":null,"pdf_field":""}],"filled_by":"hospital / treating doctor"},{"title":"Declaration by Patient / Insured","fields":[{"help":"Sign to confirm declaration","type":"signature","label":"Patient / Insured Name & Signature","options":[],"required":true,"pdf_field":""}],"filled_by":"insured / patient"},{"title":"Declaration by Hospital","fields":[{"help":"Stamp with hospital seal","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":""},{"help":"Date of signing","type":"date","label":"Date:","options":[],"required":true,"pdf_field":""},{"help":"Time of signing","type":"text","label":"Time:","options":[],"required":true,"pdf_field":""}],"filled_by":"hospital"},{"title":"Claim Form - Part A: Details of Primary Insured and Hospitalization","fields":[{"help":"Enter policy number","type":"text","label":"a) Policy no:","options":[],"required":true,"pdf_field":""},{"help":"Name of primary insured","type":"text","label":"c) Name:","options":[],"required":true,"pdf_field":""},{"help":"Full hospital name","type":"text","label":"a) Name of Hospital where Admitted:","options":[],"required":true,"pdf_field":""},{"help":"Hospital address","type":"text","label":"d) Address:","options":[],"required":true,"pdf_field":""},{"help":"Tick yes or no","type":"yes-no","label":"a) Currently covered by any other Mediclaim/ Health Insurance:","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Use dd-mm-yyyy format","type":"date","label":"b) Date of commencement of first insurance without break:","options":[],"required":null,"pdf_field":""},{"help":"Name of other insurance company","type":"text","label":"c) If yes, company name:","options":[],"required":null,"pdf_field":""},{"help":"Tick yes or no","type":"yes-no","label":"d) Have you been hospitalized in the last four years since inception of the contract?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Name of insured person hospitalized","type":"text","label":"a) Name :","options":[],"required":true,"pdf_field":""},{"help":"Tick appropriate gender","type":"choice","label":"b) Gender :","options":["M","F","TG"],"required":true,"pdf_field":""},{"help":"Tick appropriate occupation","type":"choice","label":"g) Occupation:","options":["Service","Self Employed","Homemaker","Student","Retired","Other (Please specify)"],"required":null,"pdf_field":""},{"help":"Enter alternate address if any","type":"text","label":"h) Address (if different from above):","options":[],"required":false,"pdf_field":""},{"help":"Tick appropriate reason","type":"choice","label":"c) Hospitalization due to:","options":["Injury","Illness","Accident"],"required":true,"pdf_field":""},{"help":"Use dd-mm-yyyy format","type":"date","label":"d) Date of injury/ Date Disease first detected:","options":[],"required":null,"pdf_field":""},{"help":"Use dd-mm-yyyy format","type":"date","label":"e) Date of Admission:","options":[],"required":true,"pdf_field":""},{"help":"Enter time of admission","type":"text","label":"f) Time:","options":[],"required":true,"pdf_field":""},{"help":"Use dd-mm-yyyy format","type":"date","label":"g) Date of Discharge:","options":[],"required":true,"pdf_field":""},{"help":"Enter time of discharge","type":"text","label":"h) Time:","options":[],"required":true,"pdf_field":""},{"help":"Tick appropriate cause","type":"choice","label":"i) If injury, give cause:","options":["Self inflicted","Road Traffic Accident","Substance abuse / Alcohol Consumption"],"required":null,"pdf_field":""},{"help":"Tick yes or no","type":"yes-no","label":"i) If Medico Legal:","options":["Yes","No"],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Details of Bills Enclosed","fields":[{"help":"List number of bills for Hospital Main Bill, Pre hospitalisation, Post hospitalisation, Pharmacy Bills, Others","type":"table","label":"Bill Towards","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"Details of Primary Insured's Bank Account","fields":[{"help":"Enter Permanent Account Number","type":"text","label":"a) PAN:","options":[],"required":true,"pdf_field":""},{"help":"Enter bank account number","type":"text","label":"b) Account Number:","options":[],"required":true,"pdf_field":""},{"help":"Enter bank name","type":"text","label":"c) Bank Name","options":[],"required":true,"pdf_field":""},{"help":"Enter bank branch name","type":"text","label":"d) Bank Branch","options":[],"required":true,"pdf_field":""},{"help":"Name of beneficiary for cheque/DD","type":"text","label":"e) Cheque/ DD Payable details:","options":[],"required":true,"pdf_field":""},{"help":"Enter IFSC code of bank branch","type":"text","label":"f) IFSC Code:","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"},{"title":"Declaration by the Insured","fields":[{"help":"Date of signing","type":"date","label":"Date:","options":[],"required":true,"pdf_field":""},{"help":"Place of signing","type":"text","label":"Place:","options":[],"required":true,"pdf_field":""},{"help":"Sign to confirm declaration","type":"signature","label":"Signature of the insured:","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"},{"title":"Claim Form - Part B: To be filled by the Hospital","fields":[{"help":"Full hospital name","type":"text","label":"a) Name of the Hospital:","options":[],"required":true,"pdf_field":""},{"help":"Hospital identification number","type":"text","label":"b) Hospital ID:","options":[],"required":true,"pdf_field":""},{"help":"Tick appropriate type","type":"choice","label":"c) Type of Hospital:","options":["Network","Non Network"],"required":true,"pdf_field":""},{"help":"Registration number of hospital with state code","type":"text","label":"f) Registration No. with state code:","options":[],"required":true,"pdf_field":""},{"help":"Hospital phone number with STD code","type":"phone","label":"g) Phone No.","options":[],"required":true,"pdf_field":""},{"help":"Full name of treating doctor","type":"text","label":"a) Name of the treating doctor:","options":[],"required":true,"pdf_field":""},{"help":"Doctor's educational qualifications","type":"text","label":"b) Qualification:","options":[],"required":true,"pdf_field":""},{"help":"Tick appropriate gender","type":"choice","label":"c) Gender :","options":["M","F","TG"],"required":true,"pdf_field":""},{"help":"Doctor's age in years","type":"number","label":"d) Age:  years","options":[],"required":true,"pdf_field":""},{"help":"Doctor's date of birth","type":"date","label":"e) Date of Birth:","options":[],"required":true,"pdf_field":""},{"help":"Patient's full name","type":"text","label":"a) Name of Patient:","options":[],"required":true,"pdf_field":""},{"help":"Insurance provider registration number","type":"text","label":"b) IP Registration No.:","options":[],"required":true,"pdf_field":""},{"help":"Use dd-mm-yyyy format","type":"date","label":"f) Date of Admission:","options":[],"required":true,"pdf_field":""},{"help":"Time of admission","type":"text","label":"g) Time:","options":[],"required":true,"pdf_field":""},{"help":"Use dd-mm-yyyy format","type":"date","label":"h) Date of Discharge:","options":[],"required":true,"pdf_field":""},{"help":"Time of discharge","type":"text","label":"i) Time:","options":[],"required":true,"pdf_field":""},{"help":"Tick appropriate type","type":"choice","label":"j) Type of Admission:","options":["Emergency","Planned","Day Care","Maternity"],"required":true,"pdf_field":""},{"help":"Enter details if maternity","type":"text","label":"k) If Maternity:","options":[],"required":null,"pdf_field":""},{"help":"Use dd-mm-yyyy format","type":"date","label":"i. Date of Delivery:","options":[],"required":null,"pdf_field":""},{"help":"Enter gravida status","type":"text","label":"ii. Gravida Status:","options":[],"required":null,"pdf_field":""},{"help":"Enter ICD 10 code and description","type":"text","label":"i. Primary Diagnosis :","options":[],"required":true,"pdf_field":""},{"help":"Enter ICD 10 code and description if any","type":"text","label":"ii. Additional Diagnosis :","options":[],"required":false,"pdf_field":""},{"help":"Enter ICD 10 code and description if any","type":"text","label":"iii. Co-morbidities :","options":[],"required":false,"pdf_field":""},{"help":"Enter ICD 10 PCS code and description","type":"text","label":"i. Procedure 1 :","options":[],"required":false,"pdf_field":""},{"help":"Enter ICD 10 PCS code and description if any","type":"text","label":"ii. Procedure 2 :","options":[],"required":false,"pdf_field":""},{"help":"Enter ICD 10 PCS code and description if any","type":"text","label":"iii. Procedure 3 :","options":[],"required":false,"pdf_field":""},{"help":"Provide details of procedures","type":"text","label":"iv. Details of Procedure :","options":[],"required":false,"pdf_field":""},{"help":"Tick yes or no","type":"yes-no","label":"c) Pre authorization obtained:","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Enter pre-authorization number if obtained","type":"text","label":"d) Pre-authorization number:","options":[],"required":false,"pdf_field":""},{"help":"Provide reason if no authorization","type":"text","label":"e) If authorization by network hospital not obtained, give reason:","options":[],"required":false,"pdf_field":""},{"help":"Tick yes or no","type":"yes-no","label":"f) Hospitalization due to injury:","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Tick appropriate cause","type":"choice","label":"i. If yes, give cause:","options":["Self inflicted","Road Traffic Accident","Substance abuse / alcohol consumption"],"required":false,"pdf_field":""},{"help":"Tick yes or no and attach reports if yes","type":"yes-no","label":"ii. If injury due to Substance abuse / alcohol consumption, Test Conducted to establish this:","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Tick yes or no","type":"yes-no","label":"iii. If Medico Legal:","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Tick yes or no","type":"yes-no","label":"iv. Reported to Police:","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Enter FIR number if applicable","type":"text","label":"v. FIR No.:","options":[],"required":false,"pdf_field":""},{"help":"Provide reason if not reported","type":"text","label":"vi. If not reported to police, give reason:","options":[],"required":false,"pdf_field":""},{"help":"Enter hospital PAN number","type":"text","label":"d) Hospital PAN","options":[],"required":false,"pdf_field":""},{"help":"Enter number of inpatient beds","type":"number","label":"e) Number of inpatient beds","options":[],"required":false,"pdf_field":""},{"help":"Tick available facilities","type":"choice","label":"f) Facilities available in the hospital:","options":["OT","ICU","Others (Please specify)"],"required":false,"pdf_field":""},{"help":"Tick appropriate status","type":"choice","label":"l) Status at time of discharge:","options":["Discharged to home","Discharged to another hospital","Deceased"],"required":true,"pdf_field":""},{"help":"Enter total claim amount in INR","type":"amount","label":"m) Total claimed amount","options":[],"required":true,"pdf_field":""}],"filled_by":"hospital"},{"title":"Claim Documents Submitted - Checklist","fields":[{"help":"Tick if submitted","type":"checkbox","label":"Claim Form duly signed","options":[],"required":true,"pdf_field":""},{"help":"Tick if submitted","type":"checkbox","label":"Investigation reports","options":[],"required":null,"pdf_field":""},{"help":"Tick if submitted","type":"checkbox","label":"Original Pre-authorization request","options":[],"required":null,"pdf_field":""},{"help":"Tick if submitted","type":"checkbox","label":"CT/ MRI/ USG/ HPE/ Investigation reports","options":[],"required":null,"pdf_field":""},{"help":"Tick if submitted","type":"checkbox","label":"Copy of the Pre-authorization approval letter","options":[],"required":null,"pdf_field":""},{"help":"Tick if submitted","type":"checkbox","label":"Hospital main bill","options":[],"required":true,"pdf_field":""},{"help":"Tick if applicable and submitted","type":"checkbox","label":"Original death summary from hospital, where applicable","options":[],"required":null,"pdf_field":""},{"help":"Tick if submitted","type":"checkbox","label":"Hospital break-up bill","options":[],"required":true,"pdf_field":""},{"help":"Specify other documents submitted","type":"text","label":"Any other, please specify","options":[],"required":false,"pdf_field":""}],"filled_by":"hospital"}],"deadlines":["Hospital to send all valid original documents duly countersigned by the insured / patient within 7 days of the patient's discharge"],"applies_to":"National Young India Mediclaim Policy","attachments":["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","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"],"declarations":["The insured declares that the information furnished is true and correct to the best of their knowledge","The insured agrees that false or untrue statements will forfeit the right to claim reimbursement","The insured authorizes TPA / insurance company to seek medical information from hospitals or doctors","The insured agrees to indemnify the hospital against expenses not reimbursed by insurer/TPA","The hospital declares that the information furnished is true and correct to the best of their knowledge","The hospital agrees to send all original documents to TPA / Insurance Company and provide clarifications as needed","The insured agrees to allow hospital to submit all original documents pertaining to hospitalization to Insurer/TPA after discharge","Payment to hospital is governed by terms and conditions of the policy; insured undertakes to settle bill if insurer/TPA is not liable","Non-medical expenses and amounts over authorized limits will be paid by insured","TPA / Insurance Company is not guaranteeing quality or standard of hospital services","No additional amount will be collected from insured in excess of agreed package rates except for non-admissible amounts","Unauthorized recovery of additional amounts from insured may lead to recovery action against hospital"],"dropped_labels":5},"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/2286-request-for-cashless-hospitalisation-for-mediclaim-insurance-policy"}