{"id":861,"title":"REQUEST FOR CASHLESS HOSPITALISATION FOR HEALTH INSURANCE POLICY","purpose":"claim","insurer":{"slug":"narayana-health-insurance","name":"Narayana Health Insurance Ltd."},"source_pdf":"https://stgaccinwbsprdlrs01.blob.core.windows.net/nhilprd/Cashless_Claim_form_32a464cf63.pdf?sv=2025-05-05&spr=https&st=2025-09-15T10%3A31%3A32Z&se=2035-09-13T10%3A31%3A32Z&sr=b&sp=r&sig=XnE7Imjief2cSyE%2Fv0o%2B3TVc0%2BvO%2BCw4FdtJA5xTBZU%3D","sha256":"15c3c20e6150d0b1301c571c3f03025787caf7d63b5141b3044904e51a82e139","pages":4,"collected":"2026-10-17","instructions":{"about":"This form is used to request cashless hospitalisation under a health insurance policy. It is filled by the insured/patient, treating doctor, and hospital.","notes":["Fill all fields in BLOCK LETTERS","Use original bills only","Patient declaration must be signed in presence of hospital representative","Hospital will send all documents to insurer within 7 days of discharge","Payment depends on policy terms and insurer approval","Use the insurer's contact details for queries: support@narayanahealth.insurance, +91 9821034071"],"title":"REQUEST FOR CASHLESS HOSPITALISATION FOR HEALTH INSURANCE POLICY","submit":{"to":"Narayana Health Insurance Limited","how":"","address":"Registered address: No. 258/A, Bommasandra Industrial Area, Anekal Taluk, Bangalore - 560099, Karnataka, India"},"purpose":"claim","sections":[{"title":"Hospital and Insurer Details","fields":[{"help":"","type":"text","label":"Hospital ID","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"ROHINI ID","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Name of the hospital","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Hospital location","options":[],"required":null,"pdf_field":""},{"help":"","type":"email","label":"Hospital email ID","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Name of Insurer","options":[],"required":null,"pdf_field":""},{"help":"Use the insurer's contact number +91 9821034071","type":"phone","label":"Phone no.","options":[],"required":null,"pdf_field":""}],"filled_by":"hospital"},{"title":"Details to be filled by Insured/Patient","fields":[{"help":"Fill in block letters","type":"text","label":"a) Name of the patient","options":[],"required":true,"pdf_field":""},{"help":"","type":"phone","label":"k.1) Contact no.","options":[],"required":true,"pdf_field":""},{"help":"","type":"phone","label":"d) Alternate contact no.","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"i) Employee ID","options":[],"required":false,"pdf_field":""},{"help":"","type":"choice","label":"b) Gender","options":["Male","Female","Third Gender"],"required":true,"pdf_field":""},{"help":"Enter years and months","type":"number","label":"e) Age","options":[],"required":true,"pdf_field":""},{"help":"DD/MM/YYYY format","type":"date","label":"f) Date of birth","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"g) Insurer ID card no.","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"h) Policy number/Name of Corporate","options":[],"required":true,"pdf_field":""},{"help":"","type":"yes-no","label":"j) Currently do you have any other medical claim/health Insurance","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"If yes to above","type":"text","label":"j.1) Insurer Name","options":[],"required":false,"pdf_field":""},{"help":"If yes to above","type":"text","label":"j.2) Give details","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"k) Do you have a family physician, if yes: Name","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"l) Occupation of insured patient","options":[],"required":false,"pdf_field":""},{"help":"Full postal address","type":"text","label":"m) Address of insured patient","options":[],"required":true,"pdf_field":""}],"filled_by":"insured/patient"},{"title":"Details to be filled by Treating Doctor/Hospital","fields":[{"help":"Fill in block letters","type":"text","label":"a) Name of the treating Doctor","options":[],"required":true,"pdf_field":""},{"help":"","type":"phone","label":"b) Contact no.","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"c) Name of Illness/disease with presenting complaints","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"d) Relevant clinical findings","options":[],"required":false,"pdf_field":""},{"help":"Number of days","type":"number","label":"e) Duration of the present ailment","options":[],"required":false,"pdf_field":""},{"help":"DD/MM/YYYY format","type":"date","label":"e.1) Date of first consultation","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"e.2) Past history of present ailment if any","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"f) Provisional diagnosis","options":[],"required":true,"pdf_field":""},{"help":"If available","type":"text","label":"f.1) ICD 10 code","options":[],"required":false,"pdf_field":""},{"help":"If available","type":"text","label":"i.1) ICD 10 PCS code","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"ABHA ID (If available)","options":[],"required":false,"pdf_field":""},{"help":"Use preauth@narayanahealth.insurance if applicable","type":"email","label":"c) Email ID","options":[],"required":false,"pdf_field":""},{"help":"Select all that apply","type":"choice","label":"g) Proposed line of treatment","options":["Medical management","Surgical management","Intensive care","Non-Allopathic treatment","Investigation"],"required":true,"pdf_field":""},{"help":"","type":"text","label":"h) If investigation and/or medical management, provide details","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"j) If other treatments provide details","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"k) How did injury occur","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"L) In case of accident: I. Is it RTA","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"DD/MM/YYYY format","type":"date","label":"ii. Date of injury","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"iii. Reported to Police","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"If reported to police","type":"text","label":"iv. FIR no","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"v) Injury/Disease caused due to substance abuse/alcohol consumption","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Gravida, Para, Living, Abortions","type":"text","label":"m) In case of maternity: G P L A","options":[],"required":false,"pdf_field":""},{"help":"DD/MM/YYYY format","type":"date","label":"n) Expected date of delivery","options":[],"required":false,"pdf_field":""},{"help":"DD/MM/YYYY format","type":"date","label":"a) Date of admission","options":[],"required":true,"pdf_field":""},{"help":"HH:MM format","type":"text","label":"b) Time of admission","options":[],"required":false,"pdf_field":""},{"help":"","type":"choice","label":"c) This is an emergency/a planned hospitalization event","options":["emergency","planned hospitalization event"],"required":true,"pdf_field":""},{"help":"Number of days","type":"number","label":"d) Expected no. of days stay in hospital","options":[],"required":false,"pdf_field":""},{"help":"Number of days","type":"number","label":"e) Days in ICU","options":[],"required":false,"pdf_field":""},{"help":"Type of room","type":"text","label":"f) Room Stay","options":[],"required":false,"pdf_field":""},{"help":"Expected per day cost","type":"amount","label":"g) Per Day Room Rent + Nursing & Service charges + Patient’s Diet","options":[],"required":false,"pdf_field":""},{"help":"","type":"amount","label":"h) Expected cost for investigation + diagnostics","options":[],"required":false,"pdf_field":""},{"help":"","type":"amount","label":"i) ICU Charges","options":[],"required":false,"pdf_field":""},{"help":"","type":"amount","label":"j) OT Charges","options":[],"required":false,"pdf_field":""},{"help":"","type":"amount","label":"k) Professional fees Surgeon + Anesthetist fees + Consultation charges","options":[],"required":false,"pdf_field":""},{"help":"Specify if implants used","type":"amount","label":"L) Medicines + Consumables cost of Implants (specify if applicable)","options":[],"required":false,"pdf_field":""},{"help":"","type":"amount","label":"m) Other hospital expenses if any","options":[],"required":false,"pdf_field":""},{"help":"","type":"amount","label":"n) All-inclusive package charges if any applicable","options":[],"required":false,"pdf_field":""},{"help":"Total expected cost in Rs.","type":"amount","label":"o) Sum Total expected cost of hospitalization","options":[],"required":true,"pdf_field":""},{"help":"List illnesses and since when","type":"text","label":"p. Mandatory past history of any chronic illness. If yes (since month/year)","options":[],"required":false,"pdf_field":""},{"help":"Check if applicable","type":"checkbox","label":"1. Diabetes","options":["Yes"],"required":false,"pdf_field":""},{"help":"Check if applicable","type":"checkbox","label":"2. Heart Disease","options":["Yes"],"required":false,"pdf_field":""},{"help":"Check if applicable","type":"checkbox","label":"3. Hypertension","options":["Yes"],"required":false,"pdf_field":""},{"help":"Check if applicable","type":"checkbox","label":"4. Hyperlipidemias","options":["Yes"],"required":false,"pdf_field":""},{"help":"Check if applicable","type":"checkbox","label":"5. Osteoarthritis","options":["Yes"],"required":false,"pdf_field":""},{"help":"Check if applicable","type":"checkbox","label":"6. Asthma/ COPD / Bronchitis","options":["Yes"],"required":false,"pdf_field":""},{"help":"Check if applicable","type":"checkbox","label":"7. Cancer","options":["Yes"],"required":false,"pdf_field":""},{"help":"Check if applicable","type":"checkbox","label":"8. Alcohol or drug abuse","options":["Yes"],"required":false,"pdf_field":""},{"help":"Check if applicable","type":"checkbox","label":"9. Any HIV or STD / related ailments","options":["Yes"],"required":false,"pdf_field":""},{"help":"Specify other ailments if any","type":"text","label":"10. Any other ailment give details","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"a) Name of the treating doctor","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"b) Qualification","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"c) Registration No. with State code","options":[],"required":true,"pdf_field":""}],"filled_by":"treating doctor/hospital"},{"title":"Declaration by the Patient / Representative","fields":[{"help":"","type":"phone","label":"Contact number","options":[],"required":true,"pdf_field":""},{"help":"","type":"email","label":"Email ID (Optional)","options":[],"required":false,"pdf_field":""},{"help":"","type":"signature","label":"Patient’s / Insured’s signature","options":[],"required":true,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Time of signing","type":"text","label":"Time","options":[],"required":false,"pdf_field":""}],"filled_by":"patient/representative"},{"title":"Hospital Declaration","fields":[{"help":"Official hospital seal","type":"attachment","label":"Hospital seal","options":[],"required":true,"pdf_field":""},{"help":"","type":"signature","label":"Doctor’s signature","options":[],"required":true,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Time of signing","type":"text","label":"Time","options":[],"required":false,"pdf_field":""}],"filled_by":"hospital"}],"deadlines":["All valid original documents duly countersigned by the insured / patient as per the checklist below will be sent to Insurance Company within 7 days of the patient’s discharge"],"applies_to":"health insurance cashless hospitalisation claims","attachments":["Detailed Discharge Summary and all Bills from the hospital","Cash Memos from the Hospitals / Chemists supported by proper prescription","Receipts and Pathological Test Reports from Pathologists, supported by note from the attending Medical Practitioner / Surgeon recommending such pathological Tests","Surgeon’s Certificate stating nature of Operation performed and Surgeon’s Bill and Receipt","Certificates from attending Medical Practitioner / Surgeon that the patient is fully cured"],"declarations":["I agree to allow the hospital to submit all original documents pertaining to hospitalization to the Insurer after the discharge","I agree to sign on the Final Bill & the Discharge Summary, before my discharge","Payment to the hospital is governed by the terms and conditions of the policy","I undertake to settle the bill as per the terms and conditions of the policy if the insurer does not settle","All non-medical expenses and expenses not relevant to current hospitalization and amounts over the insurer's authorized limit will be paid by me","I declare to abide by the terms and conditions of the policy and forfeit claim if facts are false or incorrect","I understand the insurer does not guarantee the quality or standard of hospital services","I warrant the truth of the particulars and agree to forfeit claim if false statements are made","I agree to indemnify the hospital against expenses not reimbursed by the insurer","I authorize the insurance company to contact me via mobile/email for claim updates","Hospital confirms no additional amount will be collected from insured beyond agreed package rates except non-admissible amounts","Hospital agrees to provide clarifications for queries and take responsibility for delays","Hospital agrees that insurance company may take action for unauthorized recovery of amounts from insured"],"dropped_labels":1},"pdf_fields":null,"fillable_pdf":false,"send_to":[{"purpose":"claim","channel":"email","value":"support@narayanahealth.insurance","label":"Customer Support Email","level":1,"hours":null,"applies_to":"all","source_url":"https://www.narayanahealth.insurance/cashless-claim","quote":"yana Aditi\nArya Health Insurance\nContact us\nCall : +91-9821034071\nToll-Free for Senior Citizens : 1800 2030 234\nE-mail: support@narayanahealth.insurance\nLegal\nIRDAI customer education\nInsurance ombudsman\nPrivacy notice and disclaimers\nTerms of use\nUnderwriting policy\nWhis","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"+91-9821034071","label":"Customer Support","level":1,"hours":null,"applies_to":"all","source_url":"https://www.narayanahealth.insurance/cashless-claim","quote":"download the Cashless Claim Form\nView / Download\nRetail Products\nNarayana Aditi\nArya Health Insurance\nContact us\nCall : +91-9821034071\nToll-Free for Senior Citizens : 1800 2030 234\nE-mail: support@narayanahealth.insurance\nLegal\nIRDAI customer education\nI","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"email","value":"claims@narayanahealth.insurance","label":"Claims Email","level":null,"hours":null,"applies_to":"health","source_url":"https://www.narayanahealth.insurance/reimbursement-claim","quote":"y hospital (network or non-network)\n2\nIntimate us within 24 hours of hospitalisation by calling\n+91 9821034071\nor email\nclaims@narayanahealth.insurance\n3\nPay the total bill amount at the time of discharge\n4\nSubmit the original claim documents (see checklist below) to 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/narayana-health-insurance/861-request-for-cashless-hospitalisation-for-health-insurance-policy"}