{"id":728,"title":"REQUEST FOR CASHLESS HOSPITALISATION FOR HEALTH INSURANCE POLICY PART - C (Revised)","purpose":"claim","insurer":{"slug":"magma-general-insurance","name":"Magma General Insurance Limited"},"source_pdf":"https://www.magmainsurance.com/documents/5553002/0/Claim+Form+%28Part+C%29+%E2%80%93+OneHealth+Senior.pdf/28714c7a-32e6-b545-d4a2-b0fa8c01d504?t=1765018656356","sha256":"8f997a8055df1eec85362ca6a5189ba2b98fb8e061fd90ad3eff4cce6797d2a4","pages":4,"collected":"2026-10-17","instructions":{"about":"This form is for requesting cashless hospitalisation under a health insurance policy. It is filled by the insured/patient, treating doctor, and hospital.","notes":["Fill form in block letters","Attach test report if injury/disease due to substance abuse/alcohol","Original documents must be submitted after discharge","Patient must sign final bill and discharge summary before discharge"],"title":"REQUEST FOR CASHLESS HOSPITALISATION FOR HEALTH INSURANCE POLICY PART - C (Revised)","submit":{"to":"TPA / Insurance Company","how":"sent within 7 days of discharge","address":""},"purpose":"claim","sections":[{"title":"Details of the Third Party Administrator/Insurer/Hospital","fields":[{"help":"","type":"text","label":"Name of TPA/Insurance Company:","options":[],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"Toll free phone number:","options":[],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"Toll free fax:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Name of Hospital:","options":[],"required":null,"pdf_field":""},{"help":"Full hospital address","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"Hospital Rohini ID if applicable","type":"text","label":"Rohini ID","options":[],"required":null,"pdf_field":""},{"help":"Hospital email address","type":"email","label":"e-mail ID","options":[],"required":null,"pdf_field":""}],"filled_by":""},{"title":"Details to be filled by Insured/Patient","fields":[{"help":"First, Middle, Last names in block letters","type":"text","label":"Name of the Patient:","options":[],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Gender:","options":["Male","Female","Third Gender"],"required":true,"pdf_field":""},{"help":"Enter age in years and months","type":"number","label":"Age:","options":[],"required":true,"pdf_field":""},{"help":"DD MM YYYY format","type":"date","label":"Date of Birth:","options":[],"required":true,"pdf_field":""},{"help":"Include STD code for landline, mobile number mandatory","type":"phone","label":"Contact Number:","options":[],"required":true,"pdf_field":""},{"help":"Mobile number","type":"phone","label":"Contact Number of attending Relative:","options":[],"required":null,"pdf_field":""},{"help":"As per insurance card","type":"text","label":"Insured Card ID number:","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Policy Number/Name of Corporate","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Employee ID:","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Currently do you have any other mediclaim /health insurance:","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"If other insurance exists","type":"text","label":"Company Name:","options":[],"required":null,"pdf_field":""},{"help":"Details of other insurance","type":"text","label":"Give Details:","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Do you have a family Physician:","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Name of the Family Physician:","options":[],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"Contact number, if any:","options":[],"required":null,"pdf_field":""},{"help":"Full current address","type":"text","label":"Current Address of Insured Patient:","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Occupation of Insured Patient:","options":[],"required":null,"pdf_field":""}],"filled_by":"insured/patient"},{"title":"Details to be filled by Treating Doctor/Hospital","fields":[{"help":"","type":"text","label":"Name of the treating Doctor:","options":[],"required":true,"pdf_field":""},{"help":"","type":"phone","label":"Contact Number:","options":[],"required":null,"pdf_field":""},{"help":"Describe illness and symptoms","type":"text","label":"Nature of Illness/Disease with presenting complaint:","options":[],"required":true,"pdf_field":""},{"help":"Important clinical findings","type":"text","label":"Relevant Critical Findings:","options":[],"required":null,"pdf_field":""},{"help":"Number of days","type":"number","label":"Duration of the present ailment","options":[],"required":null,"pdf_field":""},{"help":"DD MM YYYY format","type":"date","label":"Date of First consultation:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Past history of present ailment, if any","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Provisional diagnosis:","options":[],"required":true,"pdf_field":""},{"help":"International Classification of Diseases code","type":"text","label":"ICD 10 code:","options":[],"required":null,"pdf_field":""},{"help":"Select all applicable","type":"choice","label":"Proposed line of treatment:","options":["Medical Management","Surgical Management","Intensive care","Investigation","Non-allopathic treatment"],"required":true,"pdf_field":""},{"help":"","type":"text","label":"If investigation and/or Medical Management provide details:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Route of Drug Administration:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"If surgical, name of surgery:","options":[],"required":null,"pdf_field":""},{"help":"Procedure coding system code","type":"text","label":"ICD 10 PCS code:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"If other treatment, provide details:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"How did injury occur:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"In case of accident:","options":[],"required":null,"pdf_field":""},{"help":"Road Traffic Accident","type":"yes-no","label":"Is it RTA:","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"DD MM YYYY format","type":"date","label":"Date of Injury:","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Report to Police:","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Police First Information Report number","type":"text","label":"FIR NO:","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Injury /Disease caused due to substance abuse/alcohol consumption:","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Attach test report if yes","type":"yes-no","label":"Test conducted to establish this (if yes, attach report):","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"G, P, L, A details","type":"text","label":"In case of Maternity:","options":[],"required":null,"pdf_field":""},{"help":"DD MM YYYY format","type":"date","label":"Expected date of Delivery:","options":[],"required":null,"pdf_field":""}],"filled_by":"treating doctor/hospital"},{"title":"Details of Patient Admitted","fields":[{"help":"DD MM YYYY format","type":"date","label":"Date of admission","options":[],"required":true,"pdf_field":""},{"help":"HH : MM format","type":"text","label":"Time of admission","options":[],"required":null,"pdf_field":""},{"help":"","type":"choice","label":"Is this an emergency/planned hospitalization event","options":["Emergency","Planned"],"required":true,"pdf_field":""},{"help":"Columns: illness name and since when","type":"table","label":"Mandatory Past History of any chronic illness If yes (Since month/year)","options":[],"required":null,"pdf_field":""},{"help":"Number of days","type":"number","label":"Expected number of Days/stay in hospital","options":[],"required":null,"pdf_field":""},{"help":"Number of days","type":"number","label":"Days in ICU","options":[],"required":null,"pdf_field":""},{"help":"Type of room requested","type":"text","label":"Room Type","options":[],"required":null,"pdf_field":""},{"help":"Expected per day charges","type":"amount","label":"Per day room rent + nursing and service charges+ patients diet","options":[],"required":null,"pdf_field":""},{"help":"","type":"amount","label":"Expected cost of investigation + diagnostic","options":[],"required":null,"pdf_field":""},{"help":"","type":"amount","label":"ICU Charges","options":[],"required":null,"pdf_field":""},{"help":"Operation Theatre charges","type":"amount","label":"OT Charges","options":[],"required":null,"pdf_field":""},{"help":"","type":"amount","label":"Professional fees Surgeon + Anesthetist Fees + consultation Charges:","options":[],"required":null,"pdf_field":""},{"help":"Specify implants if any","type":"amount","label":"Medicines + Consumables + Cost of Implants (if applicable please specify)","options":[],"required":null,"pdf_field":""},{"help":"","type":"amount","label":"Other hospital expenses if any","options":[],"required":null,"pdf_field":""},{"help":"","type":"amount","label":"All-inclusive package charges if any applicable","options":[],"required":null,"pdf_field":""},{"help":"Total expected cost","type":"amount","label":"Sum Total expected cost of hospitalization","options":[],"required":true,"pdf_field":""}],"filled_by":"treating doctor/hospital"},{"title":"Declaration by Treating Doctor and Patient/Representative","fields":[{"help":"","type":"text","label":"Name of the treating doctor","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Qualification:","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Registration number with State code","options":[],"required":true,"pdf_field":""},{"help":"Signature of patient or representative","type":"signature","label":"Patient/Insured Name and Sign","options":[],"required":true,"pdf_field":""}],"filled_by":"treating doctor and patient/representative"},{"title":"Declaration by the Patient / Representative","fields":[{"help":"","type":"phone","label":"Contact number","options":[],"required":true,"pdf_field":""},{"help":"","type":"email","label":"e-mail Id (optional)","options":[],"required":false,"pdf_field":""},{"help":"","type":"signature","label":"Patient’s / Insured’s Signature","options":[],"required":true,"pdf_field":""},{"help":"","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"HH MM format","type":"text","label":"Time","options":[],"required":true,"pdf_field":""}],"filled_by":"patient/representative"},{"title":"Hospital Declaration","fields":[{"help":"Official hospital seal","type":"signature","label":"Hospital Seal","options":[],"required":true,"pdf_field":""},{"help":"Signature of treating doctor","type":"signature","label":"Doctor’s Signature","options":[],"required":true,"pdf_field":""},{"help":"","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"HH MM format","type":"text","label":"Time","options":[],"required":true,"pdf_field":""}],"filled_by":"hospital"}],"deadlines":["All valid original documents to be sent to TPA / Insurance Company within 7 days of the patient’s discharge"],"applies_to":"health insurance policy Part - C cashless hospitalisation requests","attachments":["Test report if injury/disease caused due to substance abuse/alcohol consumption","All valid original documents as per checklist to be sent within 7 days of discharge"],"declarations":["Patient agrees hospital will submit all original documents after discharge and will sign final bill and discharge summary","Payment to hospital governed by policy terms; patient liable if insurer/TPA not liable","Non-medical and non-relevant expenses and amounts above authorized limit to be paid by patient","Patient declares all information is true and agrees to indemnify insurer/TPA if false","TPA does not guarantee hospital service quality","False or untrue statements will forfeit claim reimbursement","Patient agrees to indemnify hospital for expenses not reimbursed by insurer/TPA","Patient authorizes insurer/TPA to contact via mobile/email for claim updates","Hospital agrees to allow TPA/Insurance officials to verify documents","Hospital will send all valid original documents countersigned by patient within 7 days of discharge","Hospital agrees TPA/Insurance not liable for discrepancies between form and documents","Patient declaration signed in hospital presence","Hospital will provide clarifications and take responsibility for delays","Hospital will abide by terms in MOU","Hospital confirms no extra amount collected beyond agreed package rates except non-admissible costs","Hospital confirms no recoveries from deposit except for non-admissible costs","Unauthorized recovery of extra amounts may be recovered by TPA/Insurance or action taken"],"dropped_labels":1},"pdf_fields":null,"fillable_pdf":false,"send_to":[{"purpose":"claim","channel":"address","value":"Magma General Insurance Limited (Claims Hub), Srinilaya Cyber Spazio Suite 101, 102, Ground Floor, Road No. 2, Banjara Hills, Hyderabad, Telangana – 500034","label":"Claims Hub Address","level":null,"hours":null,"applies_to":"health","source_url":"https://www.magmainsurance.com/learn-about-claims","quote":"fe takes an unexpected turn. When that moment comes, a clear and dependable claims process makes all the difference. At Magma General Insurance, our aim is to make the process simple to understand, transparent to follow, and supportive at every step. This page explains how claims work across Health, Motor and Non‑Motor policies.\nClaim is easy at Magma General Insurance.\nRegister Claim\nHealth","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"email","value":"customercare@magmainsurance.com","label":"Customer Care Email","level":null,"hours":null,"applies_to":"all","source_url":"https://www.magmainsurance.com/web/magmainsurance/claims","quote":"ma HDI General Insurance Company Limited) | All Rights Reserved\n| IRDAI Reg. No. 149 |\nwww.magmainsurance.com\n| E-mail:\ncustomercare@magmainsurance.com\n| Registered & Corporate Office: Equinox Business Park, Tower 3, Ambedkar Nagar, 2\nnd\nFloor, Unit Number 1B & 2B, LBS M","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"1800 266 3202","label":"Claims Intimation Toll Free Number","level":null,"hours":null,"applies_to":"all","source_url":"https://www.magmainsurance.com/web/magmainsurance/claims","quote":"surance Claims - Motor & Health Insurance Claim Process - Magma Insurance - Magma\nSkip to Content\nOne-Line-Hearder-Test\n1800 266 3202\nNavigation\nCustomer Service\nSenior Citizen Services\nRoad side Assistance\nAnnual Health Check-up\nPolicy Servicing assist","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/magma-general-insurance/728-request-for-cashless-hospitalisation-for-health-insurance-policy-part-c-revised"}