{"id":894,"title":"REQUEST FOR CASHLESS HOSPITALISATION FOR MEDICLAIM INSURANCE POLICY","purpose":"claim","insurer":{"slug":"national-insurance","name":"National Insurance Company Limited"},"source_pdf":"https://nationalinsurance.nic.co.in/sites/default/files/2026-04/NYIMPP%20Claim%20Form_0.pdf","sha256":"6c9d9377a1cadf6fbc636fc4d6e4d2af00628646e7805ba973c6d4bccb1d8a30","pages":6,"collected":"2026-10-17","instructions":{"about":"This form is used by the insured/patient to request cashless hospitalisation under the National Young India Mediclaim Plus Policy and by the hospital to provide details and declarations related to the claim.","notes":["Fill the form in block letters","Use dd-mm-yyyy format for dates and hh:mm format for times","Submit all original documents and/or certified copies related to hospitalization","Page 1 only to be faxed/scanned for cashless request; other pages for hospital and insured records","Use the checklist provided to ensure all required documents are submitted","Original bills only; photocopies must be certified","Patient/insured must sign declarations in presence of hospital authority","Hospital must seal and sign the form","Use the guidance notes on page 4 and 6 for correct data entry"],"title":"REQUEST FOR CASHLESS HOSPITALISATION FOR MEDICLAIM INSURANCE POLICY","submit":{"to":"TPA / Insurance Company as per policy terms","how":"Fax / Scan page 1 only; submit original documents after discharge","address":""},"purpose":"claim","sections":[{"title":"Details of the Third Party Administrator","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":""}],"filled_by":""},{"title":"Details of the Patient Admitted","fields":[{"help":"Enter full name of the patient","type":"text","label":"Name of the patient","options":[],"required":true,"pdf_field":""},{"help":"Tick M for Male, F for Female or TG for Transgender","type":"choice","label":"Gender","options":["M","F","TG"],"required":true,"pdf_field":""},{"help":"Use dd-mm-yyyy format","type":"date","label":"Date of Birth","options":[],"required":true,"pdf_field":""},{"help":"Enter phone number of patient or relative","type":"phone","label":"Contact number","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Insured card ID number","options":[],"required":null,"pdf_field":""},{"help":"Enter policy number or corporate name","type":"text","label":"Policy number / Name of corporate","options":[],"required":true,"pdf_field":""},{"help":"Enter full postal address","type":"text","label":"Current address of insured person","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Occupation of insured person","options":[],"required":null,"pdf_field":""}],"filled_by":"insured / patient"},{"title":"Hospitalization Details","fields":[{"help":"Enter full name of hospital","type":"text","label":"Name of Hospital","options":[],"required":true,"pdf_field":""},{"help":"Enter full address of hospital","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"ROHINI ID","options":[],"required":null,"pdf_field":""},{"help":"","type":"email","label":"E-mail ID","options":[],"required":null,"pdf_field":""},{"help":"Use dd-mm-yyyy format","type":"date","label":"Date of admission","options":[],"required":true,"pdf_field":""},{"help":"Use hh:mm format","type":"text","label":"Time of admission","options":[],"required":null,"pdf_field":""},{"help":"Tick the appropriate option","type":"choice","label":"Is this an emergency / a planned hospitalization event?","options":["Emergency","Planned"],"required":true,"pdf_field":""},{"help":"Enter expected duration in days","type":"number","label":"Expected no. of days in hospital","options":[],"required":null,"pdf_field":""},{"help":"Enter number of days in ICU if applicable","type":"number","label":"Days in ICU","options":[],"required":null,"pdf_field":""},{"help":"Enter provisional diagnosis","type":"text","label":"Provisional diagnosis","options":[],"required":null,"pdf_field":""},{"help":"Enter expected cost in INR","type":"amount","label":"Expected cost of investigation + diagnostics (INR)","options":[],"required":null,"pdf_field":""},{"help":"Enter ICU charges in INR","type":"amount","label":"ICU Charges (INR)","options":[],"required":null,"pdf_field":""},{"help":"Enter OT charges in INR","type":"amount","label":"OT Charges (INR)","options":[],"required":null,"pdf_field":""},{"help":"Enter professional fees in INR","type":"amount","label":"Professional fees Surgeon + Anesthetist Fees + consultation charges (INR)","options":[],"required":null,"pdf_field":""},{"help":"Enter cost in INR","type":"amount","label":"Medicines + Consumables + Cost of implants (if applicable, please specify) (INR)","options":[],"required":null,"pdf_field":""},{"help":"Enter package charges if applicable","type":"amount","label":"All inclusive package charges, if any applicable (INR)","options":[],"required":false,"pdf_field":""},{"help":"Use dd-mm-yyyy format","type":"date","label":"In case of maternity: Expected date of Delivery","options":[],"required":false,"pdf_field":""}],"filled_by":"insured / patient"},{"title":"Patient / Insured Declaration","fields":[{"help":"Sign to confirm reading and agreeing to the declaration","type":"signature","label":"Patient / Insured Name & Signature","options":[],"required":true,"pdf_field":""}],"filled_by":"patient / insured"},{"title":"Declaration by the Patient / Representative","fields":[{"help":"Enter full name","type":"text","label":"Patient/ Insured's Name","options":[],"required":true,"pdf_field":""},{"help":"Enter phone number","type":"phone","label":"Contact number","options":[],"required":false,"pdf_field":""},{"help":"Enter email address","type":"email","label":"E-mail ID","options":[],"required":false,"pdf_field":""},{"help":"Sign to agree to declarations","type":"signature","label":"Patient/ Insured's Signature","options":[],"required":true,"pdf_field":""}],"filled_by":"patient / insured or representative"},{"title":"Details of Claim - Part A (To be filled by the insured)","fields":[{"help":"Enter policy number","type":"text","label":"Policy No","options":[],"required":true,"pdf_field":""},{"help":"Includes name, gender, age, date of birth, address, phone, email, relationship to primary insured, occupation","type":"table","label":"Details of Primary Insured","options":[],"required":true,"pdf_field":""},{"help":"Includes current coverage, date of commencement, previous hospitalizations","type":"table","label":"Details of Insurance History","options":[],"required":true,"pdf_field":""},{"help":"Includes name, gender, date of birth, occupation, address, phone, email","type":"table","label":"Details of Insured Person Hospitalized","options":[],"required":true,"pdf_field":""},{"help":"Includes hospital name, address, dates and times of admission and discharge, room category, cause of hospitalization, injury details","type":"table","label":"Details of Hospitalization","options":[],"required":true,"pdf_field":""},{"help":"Includes treatment expenses, claim types (day care, critical illness, maternity, etc.)","type":"table","label":"Details of Claim","options":[],"required":true,"pdf_field":""},{"help":"List number and type of bills enclosed","type":"table","label":"Details of Bills Enclosed","options":[],"required":true,"pdf_field":""},{"help":"Includes PAN, account number, bank name, branch, IFSC code, cheque/DD payable details","type":"table","label":"Details of Primary Insured's Bank Account","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"},{"title":"Declaration by the Insured","fields":[{"help":"Sign to declare correctness of information","type":"signature","label":"Signature of the insured","options":[],"required":true,"pdf_field":""},{"help":"Use dd-mm-yyyy format","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Enter place of signing","type":"text","label":"Place","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"},{"title":"Details of Ailment Diagnosed and Hospital Details - Part B (To be filled by the hospital)","fields":[{"help":"Enter full hospital name","type":"text","label":"Name of Hospital","options":[],"required":true,"pdf_field":""},{"help":"Enter hospital ID as allocated by TPA","type":"text","label":"Hospital ID","options":[],"required":true,"pdf_field":""},{"help":"Tick appropriate option","type":"choice","label":"Type of Hospital","options":["Network","Non Network"],"required":true,"pdf_field":""},{"help":"Enter registration number with state code","type":"text","label":"Registration No. with state code","options":[],"required":true,"pdf_field":""},{"help":"Enter hospital phone number with STD code","type":"phone","label":"Phone No","options":[],"required":true,"pdf_field":""},{"help":"Enter full postal address","type":"text","label":"Address","options":[],"required":true,"pdf_field":""},{"help":"Enter permanent account number","type":"text","label":"Hospital PAN","options":[],"required":false,"pdf_field":""},{"help":"Enter number of inpatient beds","type":"number","label":"Number of inpatient beds","options":[],"required":false,"pdf_field":""},{"help":"Tick available facilities","type":"checkbox","label":"Facilities available in the hospital","options":["OT","ICU","Others"],"required":false,"pdf_field":""},{"help":"Includes patient name, IP registration number, dates and times of admission and discharge, type of admission, maternity details, status at discharge, total claimed amount","type":"table","label":"Details of Patient Admitted","options":[],"required":true,"pdf_field":""},{"help":"Includes ICD 10 codes and descriptions for primary diagnosis, procedures, co-morbidities, additional diagnosis","type":"table","label":"Details of Ailment Diagnosed (Primary)","options":[],"required":true,"pdf_field":""}],"filled_by":"hospital"},{"title":"Declaration by the Hospital","fields":[{"help":"Sign and seal to declare correctness of information","type":"signature","label":"Signature and seal of the hospital authority","options":[],"required":true,"pdf_field":""},{"help":"Use dd-mm-yyyy format","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Enter place of signing","type":"text","label":"Place","options":[],"required":true,"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 TPA / Insurance Company within 7 days of the patient's discharge"],"applies_to":"National Young India Mediclaim Plus Policy","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","Copy of photo ID card of patient verified by hospital","MLC Report & Police FIR (if applicable)","Investigation reports (including CT / MRI / USG / HPE)","Original Pre-authorization request","Copy of the Pre-authorization approval letter","Doctor's reference slip","Hospital main bill","Hospital break-up bill","Pharmacy bills","Operation Theatre Notes"],"declarations":["The patient/insured agrees to allow the hospital to submit all original documents pertaining to hospitalization to the Insurer/TPA after discharge","Payment to hospital is governed by the terms and conditions of the policy; if insurer/TPA is not liable, patient undertakes to settle the bill","All non-medical expenses and expenses not relevant to current hospitalization and amounts over authorized limits will be paid by the patient","The patient declares to abide by the terms and conditions of the policy and understands that false information will forfeit the claim","The hospital declares that the information furnished is true and correct and agrees to abide by terms of the MoU","The insured declares that the information furnished is true and authorizes TPA/insurance company to seek medical information","The hospital confirms no additional amount will be collected from the insured beyond agreed package rates except non-admissible amounts","In case of unauthorized recovery of additional amount, TPA/Insurance Company reserves the right to recover the same from the hospital"],"dropped_labels":5},"pdf_fields":null,"fillable_pdf":false,"send_to":[],"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/national-insurance/894-request-for-cashless-hospitalisation-for-mediclaim-insurance-policy"}