{"id":653,"title":"Claim form major surgical benefit","purpose":"claim","insurer":{"slug":"indusind-nippon-life-insurance","name":"IndusInd Nippon Life Insurance Company Limited"},"source_pdf":"https://www.indusindnipponlife.com/documents/34625/224924/Wealth+%2B+Health+Claim+Form_Major+Surgical+Benefit+Rider_20may.pdf","sha256":"850728a825f91fb2d045855aa76f6a004debe58bc910075690aa28b3c56763ec","pages":3,"collected":"2026-10-17","instructions":{"about":"This form is used by the life assured to claim the major surgical benefit under their insurance policy.","notes":["The form must be completed by the Life Assured or a declarant if the Life Assured cannot read, write or speak English.","Attach original bills and documents as listed.","Payment will be credited to the given bank account except where banks do not participate in Electronic Clearing.","Beware of spurious phone calls and fraudulent offers; IRDAI does not involve in selling policies or announcing bonuses."],"title":"Claim form major surgical benefit","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Policy and Insured Details","fields":[{"help":"Enter the date of filling the form in DD/MM/YYYY format","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Enter your insurance policy number","type":"text","label":"POLICY No.","options":[],"required":null,"pdf_field":""},{"help":"Enter the full name of the policyholder","type":"text","label":"Name of the Policy holder","options":[],"required":null,"pdf_field":""},{"help":"Enter the start date of the base insurance plan","type":"date","label":"Date of commencement of base plan","options":[],"required":null,"pdf_field":""},{"help":"Provide details of the insured person for whom the claim is made","type":"text","label":"Details of the insured person: (in respect of whom claim is made)","options":[],"required":null,"pdf_field":""},{"help":"Specify your relationship with the insured person","type":"text","label":"Relationship with the insured","options":[],"required":null,"pdf_field":""},{"help":"Enter the current age of the insured person","type":"number","label":"Present completed age","options":[],"required":null,"pdf_field":""},{"help":"Select the gender of the insured person","type":"choice","label":"Gender","options":["Male","Female","Other"],"required":null,"pdf_field":""},{"help":"Enter the occupation of the insured person","type":"text","label":"Occupation","options":[],"required":null,"pdf_field":""},{"help":"Enter the sum assured under the policy","type":"amount","label":"Sum Assured","options":[],"required":null,"pdf_field":""},{"help":"Enter the date when injury was sustained or illness first detected","type":"date","label":"Date of Injury sustained or Disease/Illness First detected","options":[],"required":null,"pdf_field":""},{"help":"Describe the disease, illness or injury","type":"text","label":"Nature of Disease/illness contracted or injury suffered","options":[],"required":null,"pdf_field":""},{"help":"Enter the name of the surgery performed","type":"text","label":"Name of the surgical procedure performed","options":[],"required":null,"pdf_field":""},{"help":"Enter the full name of the doctor who attended the patient","type":"text","label":"Name of the attending Medical Practitioner","options":[],"required":null,"pdf_field":""},{"help":"Provide the address of the attending doctor","type":"text","label":"Address of the attending Medical Practitioner","options":[],"required":null,"pdf_field":""},{"help":"Enter the phone number of the attending doctor","type":"phone","label":"Telephone No.","options":[],"required":null,"pdf_field":""},{"help":"Enter the registration number of the attending doctor","type":"text","label":"Registration No.","options":[],"required":null,"pdf_field":""},{"help":"Provide the name and address of the hospital or clinic","type":"text","label":"Name & Address of the hospital/nursing home/clinic","options":[],"required":null,"pdf_field":""},{"help":"Enter the hospital's registration number","type":"text","label":"Registration Number","options":[],"required":null,"pdf_field":""},{"help":"Enter the number of beds in the hospital","type":"number","label":"No. of beds in the Hospital","options":[],"required":null,"pdf_field":""},{"help":"Enter the hospital admission date","type":"date","label":"Date of Admission","options":[],"required":null,"pdf_field":""},{"help":"Enter the hospital discharge date","type":"date","label":"Date of Discharge","options":[],"required":null,"pdf_field":""},{"help":"Enter the date when surgery was performed","type":"date","label":"Date of Surgery","options":[],"required":null,"pdf_field":""},{"help":"Indicate if you have made any previous claims under this or other policies","type":"yes-no","label":"Have you lodged any claim under this policy or any other health insurance policy including Mediclaim, critical illness etc? If yes, please provide the following details.","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"If yes, enter the name of the insurance company","type":"text","label":"Name of the company","options":[],"required":false,"pdf_field":""},{"help":"Enter the diagnosis for the previous claim","type":"text","label":"Diagnosis","options":[],"required":false,"pdf_field":""},{"help":"Specify if the previous claim was settled or repudiated","type":"text","label":"Whether settled/repudiated","options":[],"required":false,"pdf_field":""},{"help":"Enter the amount paid or claimed previously","type":"amount","label":"Amount","options":[],"required":false,"pdf_field":""},{"help":"Enter the date of payment for the previous claim","type":"date","label":"Date of Payment","options":[],"required":false,"pdf_field":""},{"help":"Enter the sum assured amount paid previously","type":"amount","label":"Sum Assured Paid","options":[],"required":false,"pdf_field":""},{"help":"Enter the start date of the major surgical rider","type":"date","label":"Date of commencement of major surgical rider","options":[],"required":null,"pdf_field":""}],"filled_by":"life assured"},{"title":"Documents to be enclosed","fields":[{"help":"Tick if attached","type":"checkbox","label":"Pathological test report from a Pathologist","options":["Attached"],"required":null,"pdf_field":""},{"help":"Tick if attached","type":"checkbox","label":"Cancelled cheque leaf & bank passbook/bank statement","options":["Attached"],"required":null,"pdf_field":""}],"filled_by":"life assured"},{"title":"Declaration and Signatures","fields":[{"help":"Signature of a witness","type":"signature","label":"Signature of Witness","options":[],"required":null,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Signature of the insured person","type":"signature","label":"Signature of the Life Assured","options":[],"required":true,"pdf_field":""},{"help":"Full name of the witness","type":"text","label":"Name of Witness","options":[],"required":null,"pdf_field":""},{"help":"If completed by someone other than the Life Assured, declarant must fill name, address, contact details and sign","type":"text","label":"Declaration by the person completing this claim form","options":[],"required":null,"pdf_field":""},{"help":"Full name of the declarant if not the Life Assured","type":"text","label":"Name of Declarant","options":[],"required":null,"pdf_field":""},{"help":"Address of the declarant","type":"text","label":"Address C/o.","options":[],"required":null,"pdf_field":""},{"help":"Postal code of declarant's address","type":"number","label":"Pin Code","options":[],"required":null,"pdf_field":""},{"help":"Mobile number of declarant","type":"phone","label":"Mobile","options":[],"required":null,"pdf_field":""},{"help":"Email address of declarant","type":"email","label":"Email Address","options":[],"required":null,"pdf_field":""},{"help":"Signature of the declarant","type":"signature","label":"Signature of Declarant","options":[],"required":null,"pdf_field":""}],"filled_by":"life assured or declarant"},{"title":"Claimant and Bank Details","fields":[{"help":"Enter the claimant's full name","type":"text","label":"Name of the Claimant","options":[],"required":null,"pdf_field":""},{"help":"Enter the claimant's name exactly as in bank records","type":"text","label":"Claimant Name as per bank records","options":[],"required":null,"pdf_field":""},{"help":"Signature of the claimant","type":"signature","label":"Signature of the Claimant","options":[],"required":true,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Fill bank account details including account number, bank name, IFSC code, MICR code, branch name, address, and contact details","type":"table","label":"Bank Account Details","options":[],"required":null,"pdf_field":""},{"help":"Enter your correspondence address","type":"text","label":"Correspondence Address/ Usual place of residence","options":[],"required":null,"pdf_field":""}],"filled_by":"claimant"}],"deadlines":[],"applies_to":"Major Surgical Benefit Rider claims","attachments":["Bill, Receipt and Discharge certificate/card from the Hospital","Pathological test report from a Pathologist","Attending Doctor?/Surgeons certificate stating nature of operation performed","Cancelled cheque leaf & bank passbook/bank statement"],"declarations":["I hereby declare that the statements made in this claim form by me are true and correct to the best of my knowledge and belief.","If the form is completed by another person, they declare that they have explained the contents to the Life Assured and recorded the responses accurately."],"dropped_labels":4},"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/653-claim-form-major-surgical-benefit"}