{"id":2304,"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/Health-%20Claim%20Form%20-%20Reimbursement.pdf","sha256":"96e8237d5630efd114058a2cd1e3d93dc3be55ab0aaa91a485636c1676ad7b8c","pages":8,"collected":"2026-10-17","instructions":{"about":"This form is for submitting a health insurance claim reimbursement and is to be filled by the insured person and the hospital.","notes":["Fill the form in block letters.","Use original bills only.","Use dd-mm-yy format for dates unless otherwise specified.","Use hh:mm format for time fields.","Tick the appropriate boxes where applicable.","Attach all relevant supporting documents as per the checklist.","Part A is to be filled by the insured; Part B is to be filled by the hospital.","Include the original pre-authorisation request form with Part B.","If claim is for domiciliary hospitalisation, provide details in annexure.","If hospital is non-network, fill the additional details section."],"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 of social health insurance scheme","type":"text","label":"Sl. No./Certificate No.","options":[],"required":null,"pdf_field":""},{"help":"Enter the TPA ID No. as allocated by IRDAI and printed in TPA documents","type":"text","label":"Company/TPA Id No.","options":[],"required":null,"pdf_field":""},{"help":"Enter the full name of the policyholder (Surname, First name, middle name)","type":"text","label":"Name","options":[],"required":null,"pdf_field":""},{"help":"Enter the full postal address including Street, 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":"text","label":"Pin Code","options":[],"required":null,"pdf_field":""},{"help":"Enter complete e-mail address","type":"email","label":"Email ID","options":[],"required":false,"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 the full name of the Insurance Company","type":"text","label":"If yes, Company Name","options":[],"required":false,"pdf_field":""},{"help":"Enter the Policy Number as allotted by the Insurance Company","type":"text","label":"Policy No.","options":[],"required":false,"pdf_field":""},{"help":"Enter the total Sum Insured as per the Policy in rupees","type":"amount","label":"Sum Insured (₹)","options":[],"required":false,"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":false,"pdf_field":""},{"help":"Enter the diagnosis details","type":"text","label":"Diagnosis","options":[],"required":false,"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 the full name of the Insurance Company","type":"text","label":"If Yes, Company Name","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"DETAILS OF INSURED PERSON HOSPITALISED","fields":[{"help":"Enter the full name of the patient (Surname, First Name, Middle Name)","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 of the patient 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":"Tick the right option, if others, please specify","type":"choice","label":"Relation with Primary Insured","options":["Self","Spouse","Child","Father","Mother","Other (Please Specify)"],"required":null,"pdf_field":""},{"help":"Tick the right option, if others, please specify","type":"choice","label":"Occupation","options":["Self","Spouse","Child","Father","Mother","Other (Please Specify)"],"required":null,"pdf_field":""},{"help":"Enter the full postal address including Street, 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":"text","label":"Pin Code","options":[],"required":null,"pdf_field":""},{"help":"Enter complete e-mail address","type":"email","label":"Email ID","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"DETAILS OF HOSPITALISATION","fields":[{"help":"Enter the name of Hospital in full","type":"text","label":"Name of Hospital where admitted","options":[],"required":null,"pdf_field":""},{"help":"Tick the right 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 right 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 right option","type":"choice","label":"If injury, give cause","options":["Self-Inflicted","Road Traffic Accident","Substance Abuse/Alcohol Consumption"],"required":false,"pdf_field":""},{"help":"Tick Yes or No","type":"choice","label":"If medico legal","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Tick Yes or No","type":"choice","label":"Reported to Police","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Tick Yes or No","type":"choice","label":"MLC Report & Police FIR attached","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Enter the system of medicine followed in treating the patient","type":"text","label":"System of Medicine","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"DETAILS OF CLAIM","fields":[{"help":"Enter amounts in rupees (do not enter paise values)","type":"amount","label":"Details of Treatment expenses claimed (in Rupees)","options":[],"required":null,"pdf_field":""},{"help":"","type":"amount","label":"Pre-hospitalisation Expenses","options":[],"required":false,"pdf_field":""},{"help":"","type":"amount","label":"Hospitalisation Expenses","options":[],"required":false,"pdf_field":""},{"help":"","type":"amount","label":"Post-hospitalisation Expenses","options":[],"required":false,"pdf_field":""},{"help":"","type":"amount","label":"Health-Check up cost","options":[],"required":false,"pdf_field":""},{"help":"","type":"amount","label":"Ambulance Charges","options":[],"required":false,"pdf_field":""},{"help":"Specify code for other expenses","type":"text","label":"Others (code)","options":[],"required":false,"pdf_field":""},{"help":"Total amount claimed","type":"amount","label":"Total","options":[],"required":false,"pdf_field":""},{"help":"Enter number of days","type":"number","label":"Pre-hospitalisation Period: days","options":[],"required":false,"pdf_field":""},{"help":"Enter number of days","type":"number","label":"Post-hospitalisation Period: days","options":[],"required":false,"pdf_field":""},{"help":"Tick Yes or No. If yes, provide details in annexure","type":"choice","label":"Claim for domiciliary hospitalisation","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter amounts in rupees (do not enter paise values)","type":"amount","label":"Details of Lump sum / cash benefit claimed (in Rupees)","options":[],"required":false,"pdf_field":""},{"help":"","type":"amount","label":"Hospital Daily Cash","options":[],"required":false,"pdf_field":""},{"help":"","type":"amount","label":"Surgical Cash","options":[],"required":false,"pdf_field":""},{"help":"","type":"amount","label":"Critical Illness Benefit","options":[],"required":false,"pdf_field":""},{"help":"","type":"amount","label":"Convalescence","options":[],"required":false,"pdf_field":""},{"help":"","type":"amount","label":"Pre/Post hospitalisation Lump sum benefit","options":[],"required":false,"pdf_field":""},{"help":"Specify other lump sum/cash benefits","type":"amount","label":"Others","options":[],"required":false,"pdf_field":""},{"help":"Total lump sum/cash benefit claimed","type":"amount","label":"Total","options":[],"required":false,"pdf_field":""},{"help":"Tick the documents submitted","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 BILLS ENCLOSED","fields":[{"help":"Fill Sl. No., Bill No., Date (dd-mm-yy), Issued by, Towards, Amount (₹) for each bill","type":"table","label":"Bills Enclosed","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"DETAILS OF PRIMARY INSURED’S BANK ACCOUNT","fields":[{"help":"Enter the Permanent Account Number as allocated by the income tax department","type":"text","label":"PAN","options":[],"required":null,"pdf_field":""},{"help":"Enter the Bank Account Number as allotted by the Bank","type":"text","label":"Account Number","options":[],"required":null,"pdf_field":""},{"help":"Enter the Bank name along with the Branch in full","type":"text","label":"Bank Name and Branch","options":[],"required":null,"pdf_field":""},{"help":"Enter the name of the beneficiary the cheque/DD should be made out to","type":"text","label":"Cheque/DD Payable details","options":[],"required":null,"pdf_field":""},{"help":"Enter the IFSC Code of the Bank Branch in full","type":"text","label":"IFSC Code","options":[],"required":null,"pdf_field":""}],"filled_by":"insured"},{"title":"DECLARATION BY THE INSURED","fields":[{"help":"Enter date in dd-mm-yy format","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Enter place","type":"text","label":"Place","options":[],"required":true,"pdf_field":""},{"help":"Sign the form","type":"signature","label":"Signature of Insured","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"},{"title":"DETAILS OF HOSPITAL (PART B)","fields":[{"help":"Enter the name of hospital in full","type":"text","label":"Name of the Hospital","options":[],"required":null,"pdf_field":""},{"help":"Enter ID number of the hospital as allocated by the TPA","type":"text","label":"Hospital ID","options":[],"required":null,"pdf_field":""},{"help":"Tick the right option","type":"choice","label":"Type of Hospital","options":["Network","Non Network"],"required":null,"pdf_field":""},{"help":"Enter the name of the treating doctor in full","type":"text","label":"Name of the treating doctor","options":[],"required":null,"pdf_field":""},{"help":"Enter the qualification of the treating doctor (abbreviations allowed)","type":"text","label":"Qualification","options":[],"required":null,"pdf_field":""},{"help":"Enter the registration number of the doctor along with the state code","type":"text","label":"Registration No. with state code","options":[],"required":null,"pdf_field":""},{"help":"Include STD code with telephone number","type":"phone","label":"Phone No.","options":[],"required":null,"pdf_field":""}],"filled_by":"hospital"},{"title":"DETAILS OF THE PATIENT ADMITTED (PART B)","fields":[{"help":"Enter the name of patient in full","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 right 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":false,"pdf_field":""},{"help":"Enter gravida status if maternity","type":"text","label":"Gravida Status","options":[],"required":false,"pdf_field":""},{"help":"Tick the right option","type":"choice","label":"Status at time of Discharge","options":["Discharge to home","Discharge to another hospital","Deceased"],"required":null,"pdf_field":""},{"help":"Enter total claimed amount in rupees","type":"amount","label":"Total claimed amount","options":[],"required":null,"pdf_field":""}],"filled_by":"hospital"},{"title":"DETAILS OF AILMENT DIAGNOSED (PRIMARY)","fields":[{"help":"Enter details of the procedure","type":"text","label":"Details of Procedure","options":[],"required":false,"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 as allotted by TPA","type":"text","label":"Pre-authorisation number","options":[],"required":false,"pdf_field":""},{"help":"Enter reason for not obtaining pre-authorisation","type":"text","label":"If authorisation by network hospital not obtained, give reason","options":[],"required":false,"pdf_field":""},{"help":"Tick Yes or No","type":"choice","label":"Hospitalisation due to injury","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Tick the right option","type":"choice","label":"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":"choice","label":"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":"choice","label":"If Medico legal","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Tick Yes or No","type":"choice","label":"Reported to Police","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Enter first information report number as issued by police authorities","type":"text","label":"FIR No.","options":[],"required":false,"pdf_field":""},{"help":"Enter reason for not reporting to police","type":"text","label":"If not reported to Police give reason","options":[],"required":false,"pdf_field":""}],"filled_by":"hospital"},{"title":"CLAIM DOCUMENTS SUBMITTED – CHECK LIST (HOSPITAL)","fields":[{"help":"Tick the documents submitted","type":"checkbox","label":"Claim documents submitted","options":["Claim form duly signed","Investigation reports","Original Pre-authorisation request","CT/MRI/USG/HPE investigation reports","Copy of the Pre-authorisation approval letter","Doctor’s reference slip for investigation","Hospital Discharge Summary","ECG","Operation Theatre Notes","Pharmacy Bills","Hospital main bill","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","Any other, please specify"],"required":null,"pdf_field":""}],"filled_by":"hospital"},{"title":"ADDITIONAL DETAILS IN CASE OF NON NETWORK HOSPITAL","fields":[{"help":"Enter full postal address including Street, 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":"text","label":"Pin Code","options":[],"required":null,"pdf_field":""},{"help":"Include STD code with telephone number","type":"phone","label":"Phone No.","options":[],"required":null,"pdf_field":""},{"help":"Enter registration number of the hospital obtained from local body like City Corporation/Municipality","type":"text","label":"Registration No. with state code","options":[],"required":null,"pdf_field":""},{"help":"Enter the Permanent Account Number as allocated by the income tax department","type":"text","label":"Hospital PAN","options":[],"required":null,"pdf_field":""},{"help":"Enter the number of inpatient beds","type":"number","label":"Number of inpatient beds","options":[],"required":null,"pdf_field":""},{"help":"Tick the right option. If others, please specify","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":"Enter date in dd-mm-yy format","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Enter place","type":"text","label":"Place","options":[],"required":true,"pdf_field":""},{"help":"Sign and stamp the form","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":["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","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"],"declarations":["The information furnished in the claim form is true and correct to the best of my knowledge and belief.","If any false or untrue statement, suppression or concealment of any material fact is made, the right to claim reimbursement shall be forfeited.","Consent and authorisation is given to TPA/Insurance Company to seek necessary medical information/documents from any hospital/Medical Practitioner who has attended on the person against whom this claim is made.","All bills/receipts for the purpose of this claim are included and no supplementary claim will be made except the pre/post-hospitalisation claim, if any.","The hospital declares that the information furnished is true and correct to the best of their knowledge and belief.","If any false or untrue statement, suppression or concealment of any material fact is made by the hospital, the right to claim under this claim shall be forfeited."],"dropped_labels":6},"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/2304-claim-form-part-a"}