{"id":2303,"title":"CLAIM FORM – PART A","purpose":"claim","insurer":{"slug":"navi-general-insurance","name":"Navi General Insurance Limited"},"source_pdf":"https://public-navi-docs.s3.ap-south-1.amazonaws.com/Navi%20Health-Claim%20Form-Reimbursement.pdf","sha256":"e6332367b9af336b534612256bf94f7bbec1d99e7da1c5fe5791e0378c5dd584","pages":8,"collected":"2026-10-17","instructions":{"about":"This form is for submitting a health insurance claim reimbursement and is filled by the insured person and the hospital.","notes":["Fill the form in block letters.","Use original bills only.","Use specified date formats (dd-mm-yy, hh:mm).","Tick the appropriate options clearly.","Include all required documents as per checklist.","Part A is filled by the insured; Part B is filled by the hospital.","The issue of this form is not an admission of liability."],"title":"CLAIM FORM – PART A","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"DETAILS OF PRIMARY INSURED","fields":[{"help":"Enter the policy number as allotted by the Insurance Company","type":"text","label":"Policy No.:","options":[],"required":null,"pdf_field":""},{"help":"Enter the Social Insurance number or certificate number","type":"text","label":"Sl. No./Certificate No.:","options":[],"required":null,"pdf_field":""},{"help":"Enter the TPA ID number","type":"text","label":"Company/TPA Id No.:","options":[],"required":null,"pdf_field":""},{"help":"Enter full name of the policyholder","type":"text","label":"Name:","options":[],"required":null,"pdf_field":""},{"help":"Enter full postal address including city and pin code","type":"text","label":"Address:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"City:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"State:","options":[],"required":null,"pdf_field":""},{"help":"","type":"number","label":"Pin Code:","options":[],"required":null,"pdf_field":""},{"help":"Enter complete email address","type":"email","label":"Email ID:","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"DETAILS OF INSURANCE HISTORY","fields":[{"help":"Tick Yes or No","type":"choice","label":"Currently covered by any other Mediclaim/Health Insurance:","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Use dd-mm-yy format","type":"date","label":"Date of commencement of first Insurance without break:","options":[],"required":null,"pdf_field":""},{"help":"Enter full name of the Insurance Company","type":"text","label":"If yes, Company Name:","options":[],"required":null,"pdf_field":""},{"help":"Enter the Policy Number","type":"text","label":"Policy No.:","options":[],"required":null,"pdf_field":""},{"help":"Enter total Sum Insured in rupees","type":"amount","label":"Sum Insured (₹):","options":[],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"choice","label":"Have you been hospitalised in the last four years since inception of the contract?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Use mm-yy format","type":"date","label":"Date:","options":[],"required":null,"pdf_field":""},{"help":"Enter diagnosis details","type":"text","label":"Diagnosis:","options":[],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"choice","label":"Previously covered by any other Mediclaim/Health Insurance:","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter full name of the Insurance Company","type":"text","label":"If Yes, Company Name:","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"DETAILS OF INSURED PERSON HOSPITALISED","fields":[{"help":"Enter full name of the patient","type":"text","label":"Name:","options":[],"required":null,"pdf_field":""},{"help":"Tick Male or Female","type":"choice","label":"Gender:","options":["Male","Female"],"required":null,"pdf_field":""},{"help":"Enter age in years and months","type":"number","label":"Age:","options":[],"required":null,"pdf_field":""},{"help":"Use dd-mm-yyyy format","type":"date","label":"Date of Birth:","options":[],"required":null,"pdf_field":""},{"help":"Tick the correct option or specify if Other","type":"choice","label":"Relation with Primary Insured:","options":["Self","Spouse","Child","Father","Mother","Other (Please Specify)"],"required":null,"pdf_field":""},{"help":"Tick the correct option or specify if Other","type":"choice","label":"Occupation:","options":["Self","Spouse","Child","Father","Mother","Other (Please Specify)"],"required":null,"pdf_field":""},{"help":"Enter full postal address including city and pin code","type":"text","label":"Address:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"City:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"State:","options":[],"required":null,"pdf_field":""},{"help":"","type":"number","label":"Pin Code:","options":[],"required":null,"pdf_field":""},{"help":"Enter complete email address","type":"email","label":"Email ID:","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"DETAILS OF HOSPITALISATION","fields":[{"help":"Enter full name of hospital","type":"text","label":"Name of Hospital where admitted:","options":[],"required":null,"pdf_field":""},{"help":"Tick the correct option","type":"choice","label":"Room Category Occupied:","options":["Day care","Single Occupancy","Twin Sharing","3 or more beds per room"],"required":null,"pdf_field":""},{"help":"Tick the correct option","type":"choice","label":"Hospitalisation due to:","options":["Injury","Illness","Maternity"],"required":null,"pdf_field":""},{"help":"Use dd-mm-yy format","type":"date","label":"Date of injury/Date of disease first detected/Date of Delivery:","options":[],"required":null,"pdf_field":""},{"help":"Use dd-mm-yy format","type":"date","label":"Date of Admission:","options":[],"required":null,"pdf_field":""},{"help":"Use hh:mm format","type":"text","label":"Time:","options":[],"required":null,"pdf_field":""},{"help":"Use dd-mm-yy format","type":"date","label":"Date of Discharge:","options":[],"required":null,"pdf_field":""},{"help":"Use hh:mm format","type":"text","label":"Time:","options":[],"required":null,"pdf_field":""},{"help":"Tick the correct option","type":"choice","label":"If injury, give cause:","options":["Self-Inflicted","Road Traffic Accident","Substance Abuse/Alcohol Consumption"],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"choice","label":"If medico legal:","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"choice","label":"Reported to Police:","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"choice","label":"MLC Report & Police FIR attached:","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter system of medicine used","type":"text","label":"System of Medicine:","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"DETAILS OF CLAIM","fields":[{"help":"Enter amounts in rupees, do not enter paise","type":"amount","label":"Details of Treatment expenses claimed (in Rupees):","options":[],"required":null,"pdf_field":""},{"help":"","type":"amount","label":"Pre-hospitalisation Expenses:","options":[],"required":null,"pdf_field":""},{"help":"","type":"amount","label":"Hospitalisation Expenses:","options":[],"required":null,"pdf_field":""},{"help":"","type":"amount","label":"Post-hospitalisation Expenses:","options":[],"required":null,"pdf_field":""},{"help":"","type":"amount","label":"Health-Check up cost:","options":[],"required":null,"pdf_field":""},{"help":"","type":"amount","label":"Ambulance Charges:","options":[],"required":null,"pdf_field":""},{"help":"","type":"amount","label":"Others (code):","options":[],"required":null,"pdf_field":""},{"help":"","type":"amount","label":"Total:","options":[],"required":null,"pdf_field":""},{"help":"","type":"number","label":"Pre-hospitalisation Period: days","options":[],"required":null,"pdf_field":""},{"help":"","type":"number","label":"Post-hospitalisation Period: days","options":[],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"choice","label":"Claim for domiciliary hospitalisation:","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter amounts in rupees, do not enter paise","type":"amount","label":"Details of Lump sum / cash benefit claimed (in Rupees):","options":[],"required":null,"pdf_field":""},{"help":"","type":"amount","label":"Hospital Daily Cash:","options":[],"required":null,"pdf_field":""},{"help":"","type":"amount","label":"Surgical Cash:","options":[],"required":null,"pdf_field":""},{"help":"","type":"amount","label":"Critical Illness Benefit:","options":[],"required":null,"pdf_field":""},{"help":"","type":"amount","label":"Convalescence:","options":[],"required":null,"pdf_field":""},{"help":"","type":"amount","label":"Pre/Post hospitalisation Lump sum benefit:","options":[],"required":null,"pdf_field":""},{"help":"","type":"amount","label":"Others:","options":[],"required":null,"pdf_field":""},{"help":"","type":"amount","label":"Total:","options":[],"required":null,"pdf_field":""},{"help":"Tick the documents you are submitting","type":"checkbox","label":"Claims Documents Submitted – Check List","options":["Claim form duly signed","Operation Theatre Notes","Copy of the claim intimation, if any","ECG","Hospital Main Bill","Doctor’s request for investigation","Hospital Break-up Bill","Investigation Reports (Including CT/MRI/UCG/HPE)","Hospital Bill Payment Receipt","Doctor’s Prescriptions","Hospital Discharge Summary","Others","Pharmacy Bill"],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"DETAILS OF PRIMARY INSURED’S BANK ACCOUNT","fields":[{"help":"Enter Permanent Account Number","type":"text","label":"PAN:","options":[],"required":null,"pdf_field":""},{"help":"Enter bank account number","type":"text","label":"Account Number:","options":[],"required":null,"pdf_field":""},{"help":"Enter bank name and branch","type":"text","label":"Bank Name and Branch:","options":[],"required":null,"pdf_field":""},{"help":"Enter name of beneficiary for cheque/DD","type":"text","label":"Cheque/DD Payable details:","options":[],"required":null,"pdf_field":""},{"help":"Enter IFSC code of bank branch","type":"text","label":"IFSC Code:","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"DECLARATION BY THE INSURED","fields":[{"help":"Use dd-mm-yy format","type":"date","label":"Date:","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Place:","options":[],"required":true,"pdf_field":""},{"help":"","type":"signature","label":"Signature of Insured","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"},{"title":"DETAILS OF HOSPITAL (PART B)","fields":[{"help":"Enter full hospital name","type":"text","label":"Name of the Hospital:","options":[],"required":null,"pdf_field":""},{"help":"Enter hospital ID as allocated by TPA","type":"text","label":"Hospital ID:","options":[],"required":null,"pdf_field":""},{"help":"Tick the correct option","type":"choice","label":"Type of Hospital:","options":["Network","Non Network"],"required":null,"pdf_field":""},{"help":"Enter full name of treating doctor","type":"text","label":"Name of the treating doctor:","options":[],"required":null,"pdf_field":""},{"help":"Enter doctor's qualification","type":"text","label":"Qualification:","options":[],"required":null,"pdf_field":""},{"help":"Enter registration number with state code","type":"text","label":"Registration No. with state code:","options":[],"required":null,"pdf_field":""},{"help":"Include STD code","type":"phone","label":"Phone No.:","options":[],"required":null,"pdf_field":""}],"filled_by":"hospital"},{"title":"DETAILS OF THE PATIENT ADMITTED (PART B)","fields":[{"help":"Enter full name of patient","type":"text","label":"Name of the Patient:","options":[],"required":null,"pdf_field":""},{"help":"Enter insurance provider registration number","type":"text","label":"IP Registration Number:","options":[],"required":null,"pdf_field":""},{"help":"Tick Male or Female","type":"choice","label":"Gender:","options":["Male","Female"],"required":null,"pdf_field":""},{"help":"Enter age in years and months","type":"number","label":"Age:","options":[],"required":null,"pdf_field":""},{"help":"Use dd-mm-yy format","type":"date","label":"Date of Birth:","options":[],"required":null,"pdf_field":""},{"help":"Use dd-mm-yy format","type":"date","label":"Date of Admission:","options":[],"required":null,"pdf_field":""},{"help":"Use hh:mm format","type":"text","label":"Time:","options":[],"required":null,"pdf_field":""},{"help":"Use dd-mm-yy format","type":"date","label":"Date of Discharge:","options":[],"required":null,"pdf_field":""},{"help":"Use hh:mm format","type":"text","label":"Time:","options":[],"required":null,"pdf_field":""},{"help":"Tick the correct option","type":"choice","label":"Type of Admission:","options":["Emergency","Planned","Day Care","Maternity"],"required":null,"pdf_field":""},{"help":"Use dd-mm-yy format","type":"date","label":"If Maternity - Date of Delivery:","options":[],"required":null,"pdf_field":""},{"help":"Enter gravida status","type":"text","label":"Gravida Status:","options":[],"required":null,"pdf_field":""},{"help":"Tick the correct option","type":"choice","label":"Status at time of Discharge:","options":["Discharge to home","Discharge to another hospital","Deceased"],"required":null,"pdf_field":""},{"help":"Enter amount in rupees","type":"amount","label":"Total claimed amount:","options":[],"required":null,"pdf_field":""}],"filled_by":"hospital"},{"title":"DETAILS OF AILMENT DIAGNOSED (PRIMARY) (PART B)","fields":[{"help":"Enter ICD 10 PCS code and description","type":"text","label":"ICD 10 PCS - Procedure 1:","options":[],"required":null,"pdf_field":""},{"help":"Enter details of procedure","type":"text","label":"Details of Procedure:","options":[],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"choice","label":"Pre-authorisation obtained:","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter pre-authorisation number","type":"text","label":"Pre-authorisation number:","options":[],"required":null,"pdf_field":""},{"help":"Enter reason","type":"text","label":"If authorisation by network hospital not obtained, give reason:","options":[],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"choice","label":"Hospitalisation due to injury:","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Tick the correct option","type":"choice","label":"If yes, give cause:","options":["Self-inflicted","Road Traffic Accident","Substance abuse/alcohol consumption"],"required":null,"pdf_field":""},{"help":"Tick Yes or No and attach reports if Yes","type":"choice","label":"If injury due to Substance abuse/alcohol consumption, test conducted to establish this:","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"choice","label":"If Medico legal:","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"choice","label":"Reported to Police:","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter FIR number","type":"text","label":"FIR No.:","options":[],"required":null,"pdf_field":""},{"help":"Enter reason","type":"text","label":"If not reported to Police give reason:","options":[],"required":null,"pdf_field":""}],"filled_by":"hospital"},{"title":"ADDITIONAL DETAILS IN CASE OF NON NETWORK HOSPITAL (PART B)","fields":[{"help":"Enter full postal address including city and pin code","type":"text","label":"Address:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"City:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"State:","options":[],"required":null,"pdf_field":""},{"help":"","type":"number","label":"Pin Code:","options":[],"required":null,"pdf_field":""},{"help":"Include STD code","type":"phone","label":"Phone No.:","options":[],"required":null,"pdf_field":""},{"help":"Enter registration number from local body","type":"text","label":"Registration No. with state code:","options":[],"required":null,"pdf_field":""},{"help":"Enter Permanent Account Number","type":"text","label":"Hospital PAN:","options":[],"required":null,"pdf_field":""},{"help":"Enter number of inpatient beds","type":"number","label":"Number of inpatient beds:","options":[],"required":null,"pdf_field":""},{"help":"Tick available facilities; specify others if any","type":"checkbox","label":"Facilities available in the Hospital:","options":["OT","ICU","Others"],"required":null,"pdf_field":""}],"filled_by":"hospital"},{"title":"DECLARATION BY THE HOSPITAL","fields":[{"help":"Use dd-mm-yy format","type":"date","label":"Date:","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Place:","options":[],"required":true,"pdf_field":""},{"help":"","type":"signature","label":"Treating Doctor’s Signature and Seal of the Hospital Authority:","options":[],"required":true,"pdf_field":""}],"filled_by":"hospital"}],"deadlines":[],"applies_to":"health insurance reimbursement claims","attachments":["Operation Theatre Notes","Copy of the claim intimation, if any","ECG","Hospital Main Bill","Doctor’s request for investigation","Hospital Break-up Bill","Investigation Reports (Including CT/MRI/UCG/HPE)","Hospital Bill Payment Receipt","Doctor’s Prescriptions","Hospital Discharge Summary","Pharmacy Bill","Original Pre-authorisation request form","Copy of the Pre-authorisation approval letter","MLC reports and Police FIR","Copy of the photo ID card of the patient verified by Hospital","Original death summary from hospital where applicable","Hospital break-up bill"],"declarations":["The information furnished in the claim form is true and correct to the best of my knowledge and belief.","False or untrue statements or concealment of material facts will forfeit the right to claim reimbursement.","Consent is given to TPA/Insurance Company to seek medical information from hospitals or doctors.","All bills/receipts for the claim are included and no supplementary claim will be made except pre/post-hospitalisation claims.","The hospital declares that the information furnished is true and correct to the best of their knowledge and belief.","False or untrue statements or concealment of material facts by the hospital will forfeit the right to claim."],"dropped_labels":7},"pdf_fields":null,"fillable_pdf":false,"send_to":[{"purpose":"claim","channel":"email","value":"insurance.help@navi.com","label":"Claims intimation","level":1,"hours":null,"applies_to":"all","source_url":"https://public-navi-docs.s3.ap-south-1.amazonaws.com/NaviCommercialVehicleLiabilityOnlyInsurance%20CIS.pdf","quote":"own damage claim\n12 | Policy Servicing Claim Intimation and Processing | 1. Call Us: Toll Free 1800 123 0004 2. Email: insurance.help@navi.com 3. Email for Senior Citizens- seniorcare@navi.com 4. Visit our website: https://www.naviinsurance.com/service/ 5. Walk","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"email","value":"seniorcare@navi.com","label":"Email for Senior Citizens","level":1,"hours":null,"applies_to":"all","source_url":"https://public-navi-docs.s3.ap-south-1.amazonaws.com/NaviCommercialVehicleLiabilityOnlyInsurance%20CIS.pdf","quote":"on and Processing | 1. Call Us: Toll Free 1800 123 0004 2. Email: insurance.help@navi.com 3. Email for Senior Citizens- seniorcare@navi.com 4. Visit our website: https://www.naviinsurance.com/service/ 5. Walk in for assistance 6. Dispatch your letters to us a","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"1800 123 0004","label":"Toll Free","level":1,"hours":null,"applies_to":"all","source_url":"https://public-navi-docs.s3.ap-south-1.amazonaws.com/NaviCommercialVehicleLiabilityOnlyInsurance%20CIS.pdf","quote":"nses - paid amount under own damage claim\n12 | Policy Servicing Claim Intimation and Processing | 1. Call Us: Toll Free 1800 123 0004 2. Email: insurance.help@navi.com 3. Email for Senior Citizens- seniorcare@navi.com 4. Visit our website: https://www.n","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"url","value":"https://www.naviinsurance.com/service/","label":"Customer Portal on website","level":1,"hours":null,"applies_to":"all","source_url":"https://public-navi-docs.s3.ap-south-1.amazonaws.com/NaviCommercialVehicleLiabilityOnlyInsurance%20CIS.pdf","quote":"1800 123 0004 2. Email: insurance.help@navi.com 3. Email for Senior Citizens- seniorcare@navi.com 4. Visit our website: https://www.naviinsurance.com/service/ 5. Walk in for assistance 6. Dispatch your letters to us at – Corporate Office: Navi General Insurance Limited, Vaishna","fetched_at":"2026-10-20"}],"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/navi-general-insurance/2303-claim-form-part-a"}