{"id":642,"title":"IndusInd Nippon Life Wealth + Health Plan Claim Form Hospital Cash Benefit","purpose":"claim","insurer":{"slug":"indusind-nippon-life-insurance","name":"IndusInd Nippon Life Insurance Company Limited"},"source_pdf":"https://www.indusindnipponlife.com/documents/34625/224928/hospitalcashbenefit-wealthhealthclaimform+%281%29.pdf","sha256":"dd60b7e1242a4e84f388a9e9d7d0e150bd7b33ef89355c95e48e072d67c9921b","pages":3,"collected":"2026-10-17","instructions":{"about":"This form is used by the claimant or principal insured to claim hospital cash benefit under the Wealth + Health insurance plan.","notes":["Fill the form in BLOCK LETTERS.","Attach copy of the health card along with identity proof.","Attach original bills and reports as required.","Payments will be made only through direct bank transfer; attach cancelled cheque.","For accident cases, attach copy of FIR.","The list of documents is not exhaustive; TPA/Insurer may request additional documents.","Beware of spurious phone calls and fraudulent offers; IRDAI does not involve in such activities."],"title":"IndusInd Nippon Life Wealth + Health Plan Claim Form Hospital Cash Benefit","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Claimant / Principal Insured Details","fields":[{"help":"Enter the date of filling the form in DD/MM/YYYY format","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Enter full name in block letters","type":"text","label":"Name of the Principal Insured","options":[],"required":true,"pdf_field":""},{"help":"Enter your policy number exactly as on your policy schedule","type":"text","label":"Policy number (as on your policy schedule)","options":[],"required":true,"pdf_field":""},{"help":"Enter date of birth in DD/MM/YYYY format","type":"date","label":"Date of Birth","options":[],"required":true,"pdf_field":""},{"help":"Enter age in years","type":"number","label":"Age","options":[],"required":true,"pdf_field":""},{"help":"Select gender","type":"choice","label":"Gender","options":["Male","Female"],"required":true,"pdf_field":""},{"help":"Indicate if riders are applicable","type":"choice","label":"Riders","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Enter sum assured amount","type":"amount","label":"Sum Assured","options":[],"required":true,"pdf_field":""},{"help":"Enter full address including building, landmark, district, city/village, state, pin code, phone, mobile, email","type":"text","label":"Correspondence Address/ Usual place of residence","options":[],"required":true,"pdf_field":""}],"filled_by":"Claimant / Principal Insured"},{"title":"Insured Person Details and Medical Information","fields":[{"help":"Enter full name of the insured person","type":"text","label":"Name of the Insured person (in respect of whom the claim is made)","options":[],"required":true,"pdf_field":""},{"help":"Specify relationship to principal insured","type":"text","label":"Relationship with Principal Insured","options":[],"required":true,"pdf_field":""},{"help":"Enter date of birth in DD/MM/YYYY format","type":"date","label":"Date of Birth","options":[],"required":true,"pdf_field":""},{"help":"Provide brief description including cause","type":"text","label":"Please describe the injury sustained or disease/illness contracted (including cause)","options":[],"required":true,"pdf_field":""},{"help":"Enter full name","type":"text","label":"Name of the attending medical practitioner","options":[],"required":true,"pdf_field":""},{"help":"Enter full address including building, landmark, district, city/village, state, pin code, phone, mobile, email","type":"text","label":"Address of the attending medical practitioner","options":[],"required":true,"pdf_field":""},{"help":"Enter fax number if available","type":"text","label":"Fax","options":[],"required":false,"pdf_field":""},{"help":"Enter medical registration number","type":"text","label":"Registration No.","options":[],"required":false,"pdf_field":""}],"filled_by":"Claimant / Principal Insured"},{"title":"Hospital Details and Admission Information","fields":[{"help":"Enter full name of hospital or nursing home","type":"text","label":"Name of Hospital/Nursing Home","options":[],"required":true,"pdf_field":""},{"help":"Enter full address including building, landmark, district, city/village, state, pin code, phone, mobile, email","type":"text","label":"Address of Hospital/Nursing Home/Clinic","options":[],"required":true,"pdf_field":""},{"help":"Enter room number if applicable","type":"text","label":"Room No.","options":[],"required":false,"pdf_field":""},{"help":"Enter fax number if available","type":"text","label":"Fax","options":[],"required":false,"pdf_field":""},{"help":"Enter date and time of admission in DD/MM/YYYY and HH:MM format","type":"date","label":"Date & Time of Admission","options":[],"required":true,"pdf_field":""},{"help":"Enter number of days spent in hospital ward excluding ICU","type":"number","label":"No. of Days in Hospital (in a ward other than ICU)","options":[],"required":true,"pdf_field":""},{"help":"Enter number of days spent in ICU","type":"number","label":"No. of Days in ICU","options":[],"required":true,"pdf_field":""},{"help":"Enter date and time of ICU admission if applicable","type":"date","label":"Date & Time of Admission in the ICU","options":[],"required":false,"pdf_field":""},{"help":"Enter date and time of discharge from hospital","type":"date","label":"Date & Time of Discharge","options":[],"required":true,"pdf_field":""},{"help":"Enter date and time of discharge from ICU if applicable","type":"date","label":"Date & Time of Discharge from ICU","options":[],"required":false,"pdf_field":""},{"help":"Enter date and mode (phone, email, etc.) of intimation to TPA","type":"text","label":"Date & Mode of Intimation given to the TPA","options":[],"required":false,"pdf_field":""},{"help":"Indicate if pre-authorization approval was taken and attach proof","type":"choice","label":"Pre-authorization approval taken (Attach proof)","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Provide reason if pre-authorization was not taken","type":"text","label":"If No, please provide reason for the same","options":[],"required":false,"pdf_field":""},{"help":"Indicate if police were informed in case of accident","type":"choice","label":"Have the police authorities been informed? (For accident case only)","options":["Yes","No"],"required":false,"pdf_field":""}],"filled_by":"Claimant / Principal Insured"},{"title":"Previous Claims Information","fields":[{"help":"Provide details of previous claims: Name of Insurance Company, Diagnosis, Whether settled/repudiated, Amount, Mode","type":"table","label":"Have you lodged any claim under this policy or any other health insurance policy including mediclaim, hospital case benefit etc. If yes, please provide the following details","options":[],"required":false,"pdf_field":""}],"filled_by":"Claimant / Principal Insured"},{"title":"Schedule of Expenses Incurred","fields":[{"help":"List expenses with original supporting documents as per policy coverage","type":"table","label":"Schedule of expenses incurred under the following benefits (to be supported by original bills/receipts, memos, discharge summary, hospital report or copies of the original reports attested by TPA authorised official etc.)","options":[],"required":true,"pdf_field":""}],"filled_by":"Claimant / Principal Insured"},{"title":"Declaration and Signature by Claimant","fields":[{"help":"Sign here","type":"signature","label":"Signature of the Claimant","options":[],"required":true,"pdf_field":""},{"help":"Enter date of signature in DD/MM/YYYY format","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Sign here","type":"signature","label":"Signature of the Primary Insured","options":[],"required":true,"pdf_field":""},{"help":"Enter date of signature in DD/MM/YYYY format","type":"date","label":"Date","options":[],"required":true,"pdf_field":""}],"filled_by":"Claimant / Primary Insured"},{"title":"Bank Account Details of Claimant/Appointee","fields":[{"help":"Enter name exactly as per bank records","type":"text","label":"Name as per Bank Records","options":[],"required":true,"pdf_field":""},{"help":"Enter bank name","type":"text","label":"Bank Name","options":[],"required":true,"pdf_field":""},{"help":"Enter IFSC code of the bank branch","type":"text","label":"IFSC Code","options":[],"required":true,"pdf_field":""},{"help":"Enter branch name","type":"text","label":"Branch Name","options":[],"required":true,"pdf_field":""}],"filled_by":"Claimant / Appointee"},{"title":"Attending Medical Practitioners Statement","fields":[{"help":"Enter date of filling in DD/MM/YYYY format","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Enter full name","type":"text","label":"Name of the Insured Person","options":[],"required":true,"pdf_field":""},{"help":"Enter age in years","type":"number","label":"Age of the Insured","options":[],"required":true,"pdf_field":""},{"help":"Enter full address including building, landmark, district, city/village, state, pin code, phone, mobile, email","type":"text","label":"Address of the Medical Practitioner/Hospital/Clinic","options":[],"required":true,"pdf_field":""},{"help":"Describe the disease","type":"text","label":"Nature of disease suffered by insured","options":[],"required":true,"pdf_field":""},{"help":"Describe treatment or operation","type":"text","label":"What treatment was given/operation performed, if any?","options":[],"required":true,"pdf_field":""},{"help":"Indicate yes or no","type":"yes-no","label":"Is the present ailment a complication of a pre-existing disease?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Provide details if applicable","type":"text","label":"If yes, please give details","options":[],"required":false,"pdf_field":""},{"help":"Indicate yes or no","type":"yes-no","label":"Does the treatment given necessitate admission?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Indicate yes or no","type":"yes-no","label":"Is the disease/disorder congenital in nature?","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Provide history as reported","type":"text","label":"What was the history reported to you at the time of consultation?","options":[],"required":false,"pdf_field":""},{"help":"Indicate yes or no","type":"yes-no","label":"For accident case: Are the injuries traceable to any pre-existing ailment/infirmities?","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Provide details if applicable","type":"text","label":"Have you provided medical treatment to the insured previous to this treatment? If yes, specify the details","options":[],"required":false,"pdf_field":""},{"help":"Sign here","type":"signature","label":"Signature of the Medical Practitioner","options":[],"required":true,"pdf_field":""},{"help":"Enter full name","type":"text","label":"Name of attending Medical Practitioner","options":[],"required":true,"pdf_field":""},{"help":"Enter registration number","type":"text","label":"Registration No.","options":[],"required":false,"pdf_field":""}],"filled_by":"Attending Medical Practitioner"}],"deadlines":[],"applies_to":"Hospital Cash Benefit claims under the Wealth + Health insurance plan","attachments":["Copy of the health card","Identity proof","Proof of pre-authorization approval (if taken)","Original bills/receipts, memos, discharge summary, hospital report or copies of original reports attested by TPA authorised official","Bill, Receipt and Discharge Certificate/Card from the hospital","Pathological test report from a Pathologist","Attending Doctor's/Surgeon's certificate supporting hospitalisation (including ICU admission if any), diagnosis and treatment","Cancelled cheque for bank account verification","Copy of FIR (in case of accident)","Short case history of the patient"],"declarations":["I warrant the truth of the particulars in every respect of the claim.","I confirm that the amount payable under the coverage terms will constitute full and final discharge towards this claim.","I have undergone treatment as per the details given and warrant the truth of the particulars.","I confirm there is no other information relevant to my claim that would affect consideration.","I give consent and authority to seek medical information from any hospital or doctor regarding my treatment."],"dropped_labels":10},"pdf_fields":null,"fillable_pdf":false,"send_to":[{"purpose":"claim","channel":"address","value":"Claims Department, Office no. 701 & 702, 7th floor, Silver Metropolis, Off Western Express Highway, Goregaon East, Mumbai – 400063","label":"Claims Department postal address","level":null,"hours":null,"applies_to":"all","source_url":"https://www.indusindnipponlife.com/claims","quote":"nearest\nINLIC branch\nfor in-person assistance.\nEmail scanned documents at\nclaims@indusindnipponlife.com\n.\nCourier to\n: Claims Department, Office no. 701 & 702, 7th floor, Silver Metropolis, Off Western Express Highway, Goregaon East, Mumbai – 400063.\nIn case of assistance, contact us on\n1800 102 3330\nor email us on\ncustomerservice@indusindnipponlife.com\nTrack A Claim","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"email","value":"claims@indusindnipponlife.com","label":"Claims Department email","level":null,"hours":null,"applies_to":"all","source_url":"https://www.indusindnipponlife.com/claims","quote":"ou Can Register your claim easily:\nVisit your nearest\nINLIC branch\nfor in-person assistance.\nEmail scanned documents at\nclaims@indusindnipponlife.com\n.\nCourier to\n: Claims Department, Office no. 701 & 702, 7th floor, Silver Metropolis, Off Western Express Highway, Gore","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"1800 102 3330","label":"Claims Helpline","level":null,"hours":null,"applies_to":"all","source_url":"https://www.indusindnipponlife.com/claims","quote":"r, Silver Metropolis, Off Western Express Highway, Goregaon East, Mumbai – 400063.\nIn case of assistance, contact us on\n1800 102 3330\nor email us on\ncustomerservice@indusindnipponlife.com\nTrack A Claim\nFile a Claim\nLiving Benefits / Rider Claims\nGet the","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/indusind-nippon-life-insurance/642-indusind-nippon-life-wealth-health-plan-claim-form-hospital-cash-benefit"}