{"id":896,"title":"National Health Make Your Own Policy Claim Form","purpose":"claim","insurer":{"slug":"national-insurance","name":"National Insurance Company Limited"},"source_pdf":"https://nationalinsurance.nic.co.in/sites/default/files/2026-06/National%20Health%20Make%20Your%20Own%20Policy%20Claim%20Form_0.pdf","sha256":"203451d86b8bcac15b4e3fd9bc0f15b52751afe803eb733716bf760c3b992e53","pages":6,"collected":"2026-10-17","instructions":{"about":"This form is used by insured persons to claim health insurance benefits under the National Health Make-Your-Own Policy. It is filled by the insured/patient and the treating hospital/doctor.","notes":["Use block letters to fill the form","Use dd-mm-yyyy format for dates and hh:mm for times","Attach all original bills and documents as per checklist","Hospital seal and doctor's signature required where indicated","The issue of this form is not to be taken as admission of liability","Page 1 to be faxed/scanned for cashless hospitalization request; page 2 not to be faxed/scanned","Fill hospital and doctor details accurately","If injury is medico legal, attach police reports and FIR","If pre-authorization is not obtained, provide reason","Submit all documents within 7 days of discharge"],"title":"National Health Make Your Own Policy Claim Form","submit":{"to":"TPA / Insurance Company as per policy terms","how":"fax / scan / upload / post as per insurer instructions","address":""},"purpose":"claim","sections":[{"title":"Details of the Insured / Patient","fields":[{"help":"","type":"text","label":"a) Name of the patient:","options":[],"required":null,"pdf_field":""},{"help":"Tick the appropriate gender","type":"choice","label":"b) Gender :","options":["M","F","OTH"],"required":null,"pdf_field":""},{"help":"Enter age in years","type":"number","label":"c) Age:  years","options":[],"required":null,"pdf_field":""},{"help":"Enter additional months if applicable","type":"number","label":"months","options":[],"required":null,"pdf_field":""},{"help":"Use dd-mm-yyyy format","type":"date","label":"d) Date of Birth:","options":[],"required":null,"pdf_field":""},{"help":"Include STD code if applicable","type":"phone","label":"e) Contact number:","options":[],"required":null,"pdf_field":""},{"help":"Briefly describe diagnosis","type":"text","label":"f) Provisional diagnosis:","options":[],"required":null,"pdf_field":""},{"help":"Specify room type occupied","type":"text","label":"g) Room Type:","options":[],"required":null,"pdf_field":""},{"help":"Enter amount in INR","type":"amount","label":"h) Per Day Room Rent + Nursing & Service Charges + Patient's Diet:","options":[],"required":null,"pdf_field":""},{"help":"Enter amount in INR","type":"amount","label":"i) Expected cost of investigation + diagnostics:","options":[],"required":null,"pdf_field":""},{"help":"Enter amount in INR","type":"amount","label":"j) ICU Charges:","options":[],"required":null,"pdf_field":""},{"help":"Enter amount in INR","type":"amount","label":"k) OT Charges:","options":[],"required":null,"pdf_field":""},{"help":"Enter amount in INR","type":"amount","label":"l) Professional fees Surgeon + Anesthetist Fees + consultation charges:","options":[],"required":null,"pdf_field":""},{"help":"Enter amount in INR","type":"amount","label":"m) Medicines + Consumables + Cost of implants (if applicable, please specify):","options":[],"required":null,"pdf_field":""},{"help":"Enter amount in INR","type":"amount","label":"n) Other hospital expenses, if any:","options":[],"required":null,"pdf_field":""},{"help":"Enter amount in INR","type":"amount","label":"o) All inclusive package charges, if any applicable:","options":[],"required":null,"pdf_field":""},{"help":"Include STD code if applicable","type":"phone","label":"b) Contact number:","options":[],"required":null,"pdf_field":""},{"help":"If yes, provide company name","type":"text","label":"Company Name:","options":[],"required":false,"pdf_field":""},{"help":"As per insurance card","type":"text","label":"g) Insured card ID number:","options":[],"required":null,"pdf_field":""},{"help":"Enter policy number or corporate name","type":"text","label":"h) Policy number / Name of corporate:","options":[],"required":null,"pdf_field":""}],"filled_by":"insured / patient"},{"title":"Details of Hospitalization","fields":[{"help":"Use dd-mm-yyyy format","type":"date","label":"a) Date of admission:","options":[],"required":null,"pdf_field":""},{"help":"Use hh:mm format","type":"text","label":"b) Time:","options":[],"required":null,"pdf_field":""},{"help":"Tick appropriate option","type":"choice","label":"c) Is this an emergency / a planned hospitalization event?","options":["Emergency","Planned"],"required":null,"pdf_field":""},{"help":"Enter number of days","type":"number","label":"e) Expected no. of days in hospital:","options":[],"required":null,"pdf_field":""},{"help":"Enter number of days","type":"number","label":"f) Days in ICU:","options":[],"required":null,"pdf_field":""},{"help":"Use dd-mm-yyyy format","type":"date","label":"m) In case of maternity: Expected date of Delivery:","options":[],"required":false,"pdf_field":""}],"filled_by":"insured / patient"},{"title":"To be filled by the Treating Doctor / Hospital","fields":[{"help":"Full name of doctor","type":"text","label":"a) Name of the treating doctor:","options":[],"required":true,"pdf_field":""},{"help":"Doctor's qualifications","type":"text","label":"b) Qualification:","options":[],"required":true,"pdf_field":""},{"help":"Medical registration number with state code","type":"text","label":"c) Registration No. with state code:","options":[],"required":true,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"d) Mandatory : Past history of any chronic illness","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Specify month and year","type":"text","label":"If Yes, since (month / year)","options":[],"required":false,"pdf_field":""},{"help":"Specify other ailments if any","type":"text","label":"Any other Ailment, give details:","options":[],"required":false,"pdf_field":""},{"help":"Clinical findings related to current ailment","type":"text","label":"Relevant clinical findings:","options":[],"required":null,"pdf_field":""},{"help":"Describe illness and complaints","type":"text","label":"Nature of illness/ disease with presenting complaints","options":[],"required":null,"pdf_field":""},{"help":"Number of days patient has been ill","type":"number","label":"Duration of the present ailment: Days","options":[],"required":null,"pdf_field":""},{"help":"Use dd-mm-yyyy format","type":"date","label":"Date of first consultation:","options":[],"required":null,"pdf_field":""},{"help":"Details of past treatment","type":"text","label":"Past history of Management, provide details","options":[],"required":false,"pdf_field":""},{"help":"Specify route (oral, IV, etc.)","type":"text","label":"Route of drug administration:","options":[],"required":false,"pdf_field":""},{"help":"Enter ICD 10 diagnosis code","type":"text","label":"ICD 10 Code if any","options":[],"required":false,"pdf_field":""},{"help":"Tick applicable treatment type","type":"choice","label":"Proposed line of treatment:","options":["Medical Management","Surgical Management","Intensive Care","Investigation","AYUSH Treatment (Please Specify)"],"required":null,"pdf_field":""},{"help":"Name of surgery if applicable","type":"text","label":"If Surgical, name of surgery:","options":[],"required":false,"pdf_field":""},{"help":"Specify other treatments if any","type":"text","label":"If other treatments, provide details","options":[],"required":false,"pdf_field":""},{"help":"Use dd-mm-yyyy format","type":"date","label":"Date of injury:","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Reported to Police:","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Attach copy if available","type":"text","label":"FIR No.:","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Injury / Disease caused due to substance abuse / alcohol consumption:","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Attach test reports if yes","type":"yes-no","label":"Test conducted to establish this? (If yes attach reports)","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Contact number of family physician if any","type":"phone","label":"Contact number, if any:","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Do you have a family physician?","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"If yes, provide name","type":"text","label":"Name of the family physician:","options":[],"required":false,"pdf_field":""}],"filled_by":"treating doctor / hospital"},{"title":"Details of Hospital","fields":[{"help":"Full name of hospital","type":"text","label":"a) Name of Hospital:","options":[],"required":true,"pdf_field":""},{"help":"As allocated by TPA","type":"text","label":"b) Hospital ID:","options":[],"required":false,"pdf_field":""},{"help":"Hospital registration number with state code","type":"text","label":"c) Registration No. with state code:","options":[],"required":true,"pdf_field":""},{"help":"Include STD code","type":"phone","label":"e) Phone No:","options":[],"required":true,"pdf_field":""},{"help":"Tick applicable facilities","type":"checkbox","label":"f) Facilities available in the hospital:","options":["OT","ICU","Others"],"required":false,"pdf_field":""},{"help":"Permanent Account Number of hospital","type":"text","label":"d) Hospital PAN","options":[],"required":false,"pdf_field":""},{"help":"Enter number of beds","type":"number","label":"e) Number of inpatient beds","options":[],"required":false,"pdf_field":""}],"filled_by":"hospital"},{"title":"Details of Patient Admitted","fields":[{"help":"Full name of patient","type":"text","label":"a) Name of Patient:","options":[],"required":true,"pdf_field":""},{"help":"Inpatient registration number","type":"text","label":"b) IP Registration No.:","options":[],"required":false,"pdf_field":""},{"help":"Use dd-mm-yyyy format","type":"date","label":"f) Date of Admission:","options":[],"required":true,"pdf_field":""},{"help":"Use hh:mm format","type":"text","label":"g) Time:","options":[],"required":true,"pdf_field":""},{"help":"Use dd-mm-yyyy format","type":"date","label":"h) Date of Discharge:","options":[],"required":true,"pdf_field":""},{"help":"Use hh:mm format","type":"text","label":"i) Time:","options":[],"required":true,"pdf_field":""},{"help":"Tick applicable admission type","type":"choice","label":"j) Type of Admission:","options":["Emergency","Planned","Day Care","Maternity"],"required":true,"pdf_field":""},{"help":"Number of months pregnant","type":"number","label":"k) If Maternity: months","options":[],"required":false,"pdf_field":""},{"help":"Use dd-mm-yyyy format","type":"date","label":"i. Date of Delivery:","options":[],"required":false,"pdf_field":""},{"help":"Specify gravida status","type":"text","label":"ii. Gravida Status:","options":[],"required":false,"pdf_field":""},{"help":"Tick applicable status","type":"choice","label":"l) Status at time of discharge:","options":["Discharged to home","Discharged to another hospital","Deceased"],"required":true,"pdf_field":""},{"help":"Enter total claim amount in INR","type":"amount","label":"m) Total claimed amount","options":[],"required":true,"pdf_field":""}],"filled_by":"hospital"},{"title":"Details of Ailment Diagnosed (Primary)","fields":[{"help":"Enter ICD 10 diagnosis code","type":"text","label":"a) ICD 10 Code","options":[],"required":true,"pdf_field":""},{"help":"Describe primary diagnosis","type":"text","label":"i. Primary Diagnosis :","options":[],"required":true,"pdf_field":""},{"help":"Describe additional diagnosis if any","type":"text","label":"ii. Additional Diagnosis :","options":[],"required":false,"pdf_field":""},{"help":"List co-morbid conditions","type":"text","label":"iii. Co-morbidities :","options":[],"required":false,"pdf_field":""},{"help":"Enter ICD 10 PCS procedure code","type":"text","label":"i) ICD 10 PCS","options":[],"required":false,"pdf_field":""},{"help":"Describe first procedure","type":"text","label":"i. Procedure 1 :","options":[],"required":false,"pdf_field":""},{"help":"Describe second procedure","type":"text","label":"ii. Procedure 2 :","options":[],"required":false,"pdf_field":""},{"help":"Describe third procedure","type":"text","label":"iii. Procedure 3 :","options":[],"required":false,"pdf_field":""}],"filled_by":"hospital"},{"title":"Details of Insurance History","fields":[{"help":"","type":"yes-no","label":"a) Currently covered by any other Mediclaim/ Health Insurance:","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Use dd-mm-yyyy format","type":"date","label":"b) Date of commencement of first insurance without break:","options":[],"required":false,"pdf_field":""},{"help":"Name of other insurance company","type":"text","label":"c) If yes, company name:","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"d) Have you been hospitalized in the last four years since inception of the contract?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Date of previous hospitalization if yes","type":"date","label":"Date:","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"Details of Claim","fields":[{"help":"List expenses with amounts in INR","type":"table","label":"a) Details of expenses:","options":[],"required":true,"pdf_field":""},{"help":"Tick all documents submitted","type":"checkbox","label":"b) Claim Documents Submitted- Check List:","options":["Copy of the claim intimation, if any","Doctor's Prescription","Doctor's request for investigation","Investigation Reports (including CT / MRI / USG / HPE)","Hospital Discharge Summary","Pharmacy Bill","Operation Theatre Notes","Post hospitalization Bills","Pre hospitalization Bills","Hospital Main Bill","Hospital Break-up bill","MLC report & Police FIR","Original Pre-authorization request","Copy of the Pre-authorization approval letter"],"required":true,"pdf_field":""}],"filled_by":"insured"},{"title":"Details of Primary Insured's Bank Account","fields":[{"help":"Permanent Account Number","type":"text","label":"a) PAN:","options":[],"required":true,"pdf_field":""},{"help":"Bank account number for claim payment","type":"text","label":"b) Account Number:","options":[],"required":true,"pdf_field":""},{"help":"Name of bank","type":"text","label":"c) Bank Name","options":[],"required":true,"pdf_field":""},{"help":"Branch name","type":"text","label":"d) Bank Branch","options":[],"required":true,"pdf_field":""},{"help":"IFSC code of bank branch","type":"text","label":"e) IFSC Code:","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"},{"title":"Declarations","fields":[{"help":"Sign after reading declaration on reverse","type":"signature","label":"Declaration by the Patient / Representative","options":[],"required":true,"pdf_field":""},{"help":"Hospital authority to sign and seal","type":"signature","label":"Declaration by the Hospital","options":[],"required":true,"pdf_field":""}],"filled_by":"insured / 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":"claims under National Health Make-Your-Own 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","MLC report & Police FIR (if applicable)","Original Pre-authorization request","Copy of the Pre-authorization approval letter","Doctor's reference slip","Investigation reports (including CT / MRI / USG / HPE)"],"declarations":["The hospital confirms the truth of the particulars and agrees to provide clarifications if needed","The patient agrees to allow hospital to submit all original documents to insurer/TPA after discharge","Payment to hospital is governed by policy terms; patient undertakes to settle bill if insurer/TPA is not liable","Patient agrees to pay non-medical and non-admissible expenses","Patient declares information is true and agrees to indemnify insurer/TPA if false","TPA/Insurer is not responsible for hospital service quality","Hospital agrees no unauthorized extra charges will be collected beyond agreed package rates","Patient authorizes insurer/TPA to contact for claim updates"],"dropped_labels":4},"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/896-national-health-make-your-own-policy-claim-form"}