{"id":903,"title":"Divyangjan Sanjeevani Policy - National Insurance Company Limited Claim Form","purpose":"claim","insurer":{"slug":"national-insurance","name":"National Insurance Company Limited"},"source_pdf":"https://nationalinsurance.nic.co.in/sites/default/files/2026-04/Divyangjan%20Sanjeevani%20Claim%20Form.pdf","sha256":"1cd93f1dd6d5684aec4c42a17ba38d838d07019197460a3872938449dd9ad02a","pages":6,"collected":"2026-10-17","instructions":{"about":"This form is used by insured patients and hospitals to claim cashless or reimbursement benefits under the Divyangjan Sanjeevani Policy. The insured/patient fills Part A and the hospital/treating doctor fills Part B.","notes":["Use block letters to fill the form","Use dd-mm-yy format for dates and hh:mm format for times","Attach original bills and documents only","Do not fax or scan page 2 of the form","For cashless hospitalization, fax or scan page 1 only","Fill hospital section only if hospital is non-network","Include all bills/receipts for claim; supplementary claims allowed only for pre/post hospitalization","Ensure all declarations are signed and dated"],"title":"Divyangjan Sanjeevani Policy - National Insurance Company Limited Claim Form","submit":{"to":"TPA / Insurance Company as per policy","how":"Fax or scan page 1 only for cashless request; 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":"To be filled by the Insured / Patient","fields":[{"help":"Enter full name of the patient","type":"text","label":"Name of the patient","options":[],"required":true,"pdf_field":""},{"help":"Tick the appropriate gender","type":"choice","label":"Gender","options":["Male","Female"],"required":true,"pdf_field":""},{"help":"Enter age in years and months","type":"number","label":"Age","options":[],"required":true,"pdf_field":""},{"help":"Use dd-mm-yy format","type":"date","label":"Date of Birth","options":[],"required":true,"pdf_field":""},{"help":"","type":"phone","label":"Contact number","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Employee ID","options":[],"required":false,"pdf_field":""},{"help":"","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":"Use dd-mm-yy format","type":"date","label":"Date of admission","options":[],"required":true,"pdf_field":""},{"help":"Use hh:mm format","type":"text","label":"Time","options":[],"required":true,"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":"Use dd-mm-yy format","type":"date","label":"In case of maternity: Date of Delivery","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Do you have a family physician?","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Name of the family physician","options":[],"required":false,"pdf_field":""}],"filled_by":"insured / patient"},{"title":"To be filled by the Treating Doctor / Hospital","fields":[{"help":"Enter full name","type":"text","label":"Name of the treating doctor","options":[],"required":true,"pdf_field":""},{"help":"Enter educational qualifications","type":"text","label":"Qualification","options":[],"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":"Hospital to affix official seal","type":"signature","label":"Hospital Seal (must contain hospital ID)","options":[],"required":true,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"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":"","type":"text","label":"Any other Ailment, give details","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Provisional diagnosis","options":[],"required":true,"pdf_field":""},{"help":"Enter number of days","type":"number","label":"Duration of the present ailment (Days)","options":[],"required":true,"pdf_field":""},{"help":"Use dd-mm-yy format","type":"date","label":"Date of first consultation","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Past history of management, provide details","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Route of drug administration","options":[],"required":false,"pdf_field":""},{"help":"Enter ICD 10 code","type":"text","label":"ICD 10 Code if any","options":[],"required":false,"pdf_field":""},{"help":"Tick appropriate treatment","type":"choice","label":"Proposed line of treatment","options":["Medical Management","Surgical Management","Intensive Care","Investigation"],"required":true,"pdf_field":""},{"help":"Enter number of days","type":"number","label":"Expected no. of days in hospital","options":[],"required":true,"pdf_field":""},{"help":"Specify room type","type":"text","label":"Room Type","options":[],"required":true,"pdf_field":""},{"help":"Enter amount in rupees","type":"amount","label":"Per Day Room Rent + Nursing & Service Charges + Patient's Diet (₹)","options":[],"required":true,"pdf_field":""},{"help":"Enter amount in rupees","type":"amount","label":"Expected cost of investigation + diagnostics (₹)","options":[],"required":true,"pdf_field":""},{"help":"Enter amount in rupees","type":"amount","label":"Medicines + Consumables + Cost of implants (if applicable, please specify), other hospital expenses, if any","options":[],"required":false,"pdf_field":""},{"help":"Enter amount in rupees","type":"amount","label":"All inclusive package charges, if any applicable (₹)","options":[],"required":false,"pdf_field":""},{"help":"Enter total expected cost","type":"amount","label":"Sum Total, expected cost of hospitalization (₹)","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"If Surgical, name of surgery","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"If other treatments, provide details","options":[],"required":false,"pdf_field":""},{"help":"Use dd-mm-yy format","type":"date","label":"Date of injury","options":[],"required":false,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"Reported to Police","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"","type":"text","label":"FIR No.","options":[],"required":false,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"Injury / Disease caused due to substance abuse / alcohol consumption","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Tick Yes or No and 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":"Enter ICD 10 PCS code","type":"text","label":"ICD 10 PCS Code","options":[],"required":false,"pdf_field":""},{"help":"","type":"phone","label":"Contact number of attending relative","options":[],"required":false,"pdf_field":""}],"filled_by":"treating doctor / hospital"},{"title":"Claim Form - 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, Date of Birth, Sum Insured, Relationship to Primary Insured","type":"table","label":"Details of Primary Insured","options":[],"required":true,"pdf_field":""},{"help":"Includes currently covered by other Mediclaim, date of commencement, company name","type":"table","label":"Details of Insurance History","options":[],"required":true,"pdf_field":""},{"help":"Includes Name, Gender, Age, Date of Birth, Occupation, Address","type":"table","label":"Details of Insured Person Hospitalized","options":[],"required":true,"pdf_field":""},{"help":"Includes Hospital name, Room category, Dates and times of admission and discharge, Cause of hospitalization","type":"table","label":"Details of Hospitalization","options":[],"required":true,"pdf_field":""},{"help":"Includes details of expenses claimed and check list of claim documents submitted","type":"table","label":"Details of Claim","options":[],"required":true,"pdf_field":""},{"help":"Includes number of bills for hospital main bill, pre and post hospitalization, pharmacy bills, others","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":""},{"help":"Sign and date the declaration","type":"signature","label":"Declaration by the Insured","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"},{"title":"Claim Form - Part B (To be filled by the Hospital)","fields":[{"help":"Includes Hospital name, ID, type (Network/Non Network), address, phone, registration number, PAN, number of inpatient beds, facilities available","type":"table","label":"Details of Hospital","options":[],"required":true,"pdf_field":""},{"help":"Includes patient name, IP registration number, gender, age, date of birth, date/time of admission and discharge, type of admission, maternity details, status at discharge","type":"table","label":"Details of Patient Admitted","options":[],"required":true,"pdf_field":""},{"help":"Includes ICD 10 codes and descriptions for primary diagnosis, additional diagnosis, co-morbidities, procedures","type":"table","label":"Details of Ailment Diagnosed (Primary)","options":[],"required":true,"pdf_field":""},{"help":"Tick all documents submitted","type":"checkbox","label":"Claim Documents Submitted - Checklist","options":["Hospital main bill","Hospital break-up bill","Discharge summary","Pharmacy bills","Operation Theatre Notes","MLC report & Police FIR","Investigation reports","Doctor's reference slip","Pre-authorization request and approval letter","Others"],"required":true,"pdf_field":""},{"help":"Fill only if hospital is non-network","type":"text","label":"Additional Details in Case of Non Network Hospital","options":[],"required":false,"pdf_field":""},{"help":"Hospital authority to sign and seal","type":"signature","label":"Declaration by the Hospital","options":[],"required":true,"pdf_field":""}],"filled_by":"hospital"},{"title":"Declarations by Patient / Representative and Hospital","fields":[{"help":"Sign to confirm reading and agreeing to declaration","type":"signature","label":"Patient / Insured Name & Signature","options":[],"required":true,"pdf_field":""}],"filled_by":"patient / representative and 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 Divyangjan Sanjeevani Policy for cashless hospitalisation and reimbursement","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)","Original Pre-authorization request and approval letter"],"declarations":["The patient agrees to allow 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; patient undertakes to settle bill if insurer/TPA is not liable","All non-medical and disallowed expenses will be paid by the patient","Patient declares to abide by policy terms and understands that false information will forfeit claim","TPA/Insurer does not guarantee hospital service quality","Hospital declares information furnished is true and correct to best of knowledge","Hospital agrees to provide clarifications for queries and takes responsibility for delays","Patient agrees to indemnify hospital against expenses not reimbursed by insurer/TPA"],"dropped_labels":3},"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/903-divyangjan-sanjeevani-policy-national-insurance-company-limited-claim-form"}