{"id":933,"title":"REQUEST FOR CASHLESS HOSPITALISATION FOR HEALTH INSURANCE POLICY","purpose":"claim","insurer":{"slug":"navi-general-insurance","name":"Navi General Insurance Limited"},"source_pdf":"https://public-navi-docs.s3.ap-south-1.amazonaws.com/Navi%20Surrogacy%20Care%20-%20Cashless%20Request%20Form.pdf","sha256":"c20a347ecdc172f45e22d2b05bdc092910e45189a2f92b2b3fbdf3095acd42e9","pages":3,"collected":"2026-10-17","instructions":{"about":"This form is used to request cashless hospitalisation under a health insurance policy. It is filled by the patient, treating doctor, and hospital.","notes":["Fill the form in block letters","Attach all original documents as listed","Patient or insured must sign the declaration","Hospital seal must include hospital ID","Use original bills only","Submit documents within 7 days of discharge"],"title":"REQUEST FOR CASHLESS HOSPITALISATION FOR HEALTH INSURANCE POLICY","submit":{"to":"","how":"","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":"Patient Details","fields":[{"help":"Enter full name of the patient","type":"text","label":"Name of the Patient","options":[],"required":null,"pdf_field":""},{"help":"Select the patient's gender","type":"choice","label":"Gender","options":["Male","Female"],"required":null,"pdf_field":""},{"help":"Enter date of birth in DD/MM/YY format","type":"date","label":"Date of Birth","options":[],"required":null,"pdf_field":""},{"help":"Patient's phone number","type":"phone","label":"Contact Number","options":[],"required":null,"pdf_field":""},{"help":"Phone number of a relative attending the patient","type":"phone","label":"Contact number of attending relative","options":[],"required":null,"pdf_field":""},{"help":"Insurance card identification number","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":null,"pdf_field":""},{"help":"Employee identification number if applicable","type":"text","label":"Employee ID","options":[],"required":null,"pdf_field":""},{"help":"Select yes or no","type":"yes-no","label":"Currently Do you have any other Mediclaim/Health Insurance","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"If yes, provide other insurance company name","type":"text","label":"Company Name","options":[],"required":false,"pdf_field":""},{"help":"Details of other insurance","type":"text","label":"Give Details","options":[],"required":false,"pdf_field":""},{"help":"Select yes or no","type":"yes-no","label":"Do you have family physician","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Name if you have a family physician","type":"text","label":"Name of the family physician","options":[],"required":false,"pdf_field":""},{"help":"Contact number of family physician if any","type":"phone","label":"Contact Number, if any","options":[],"required":false,"pdf_field":""}],"filled_by":""},{"title":"To be filled by the Treating Doctor / Hospital","fields":[{"help":"Full name of the treating doctor","type":"text","label":"Name of the treating doctor","options":[],"required":null,"pdf_field":""},{"help":"Doctor's contact number","type":"phone","label":"Contact Number","options":[],"required":null,"pdf_field":""},{"help":"Describe illness and symptoms","type":"text","label":"Nature of ILLNESS/ Disease with presenting complaints","options":[],"required":null,"pdf_field":""},{"help":"Provide past history if applicable","type":"text","label":"Past History of present ailment, if any","options":[],"required":false,"pdf_field":""},{"help":"Doctor's provisional diagnosis","type":"text","label":"Provisional Diagnosis","options":[],"required":null,"pdf_field":""},{"help":"ICD 10 diagnosis code if known","type":"text","label":"ICD 10 Code","options":[],"required":false,"pdf_field":""},{"help":"Select all applicable treatment types","type":"checkbox","label":"Proposed Line of treatment","options":["Medical Management","Surgical Management","Intensive Care","Investigation","Non-ALLopathic Treatment"],"required":null,"pdf_field":""},{"help":"Details of investigations or medical management","type":"text","label":"If investigation &/or Medical Management provide details","options":[],"required":false,"pdf_field":""},{"help":"Route by which drugs will be administered","type":"text","label":"Route of drug administration","options":[],"required":false,"pdf_field":""},{"help":"Name of surgery if applicable","type":"text","label":"If Surgical, Name of Surgery","options":[],"required":false,"pdf_field":""},{"help":"ICD 10 procedure code if known","type":"text","label":"ICD 10 PS Code","options":[],"required":false,"pdf_field":""},{"help":"Details of other treatments if any","type":"text","label":"If other treatments, provide details","options":[],"required":false,"pdf_field":""},{"help":"Explain cause of injury if applicable","type":"text","label":"How did injury occur","options":[],"required":false,"pdf_field":""},{"help":"Date when injury occurred","type":"date","label":"Date of Injury","options":[],"required":false,"pdf_field":""},{"help":"Whether injury was reported to police","type":"yes-no","label":"Reported to Police","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Police FIR number if applicable","type":"text","label":"FIR No.","options":[],"required":false,"pdf_field":""},{"help":"Select yes if injury/disease caused by substance abuse","type":"yes-no","label":"Injury/Disease caused due to substance abuse","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Select yes if tests were done to confirm substance abuse; attach reports if yes","type":"yes-no","label":"Test Conducted to establish this","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Number of pregnancies","type":"number","label":"In case of Maternity: G","options":[],"required":false,"pdf_field":""},{"help":"Number of deliveries","type":"number","label":"P","options":[],"required":false,"pdf_field":""},{"help":"Number of living children","type":"number","label":"L","options":[],"required":false,"pdf_field":""},{"help":"Number of abortions","type":"number","label":"A","options":[],"required":false,"pdf_field":""},{"help":"Date of delivery if maternity case","type":"date","label":"Date of Delivery","options":[],"required":false,"pdf_field":""}],"filled_by":"treating doctor / hospital"},{"title":"Details of the patient admitted","fields":[{"help":"Date patient was admitted to hospital","type":"date","label":"Date of admission","options":[],"required":true,"pdf_field":""},{"help":"Time of admission (HH:MM)","type":"text","label":"Time","options":[],"required":true,"pdf_field":""},{"help":"Expected duration of hospital stay in days","type":"number","label":"Expected no. of days stay in hospital","options":[],"required":true,"pdf_field":""},{"help":"Type of room requested","type":"text","label":"Room Type","options":[],"required":null,"pdf_field":""},{"help":"Enter amount in rupees","type":"amount","label":"Per Day Room Rent + Nursing & Service Charges + Patient’s Diet","options":[],"required":null,"pdf_field":""},{"help":"Enter amount in rupees","type":"amount","label":"Expected cost for investigation + diagnostics","options":[],"required":null,"pdf_field":""},{"help":"Enter ICU charges if applicable","type":"amount","label":"ICU Charges","options":[],"required":false,"pdf_field":""},{"help":"Operation theatre charges if applicable","type":"amount","label":"OT Charges","options":[],"required":false,"pdf_field":""},{"help":"Enter combined fees amount","type":"amount","label":"Professional Fees+ Anaesthetist Fees+ Consultation Charges","options":[],"required":false,"pdf_field":""},{"help":"Enter amount for medicines and other expenses","type":"amount","label":"Medicines+ Consumables+ Cost of implants (if applicable please specify) Other hospital expenses if any","options":[],"required":false,"pdf_field":""},{"help":"Enter package charges if applicable","type":"amount","label":"ALL-inclusive package charges if any applicable","options":[],"required":false,"pdf_field":""},{"help":"Total expected cost in rupees","type":"amount","label":"Sum Total expected cost of hospitalisation","options":[],"required":true,"pdf_field":""},{"help":"Select all applicable chronic illnesses","type":"checkbox","label":"Mandatory: Past history of any chronic illness","options":["Diabetes","Heart Disease","Hypertension","HyperLipidaemia","Osteoarthritis","Asthma / COPD / Bronchitis","Cancer","Alcohol or Drug Abuse","Any HIV or STD / Related Ailments"],"required":false,"pdf_field":""},{"help":"Describe any other ailments","type":"text","label":"Any Other Ailments, give details","options":[],"required":false,"pdf_field":""}],"filled_by":""},{"title":"Declaration by Patient / Insured","fields":[{"help":"Doctor's name","type":"text","label":"Name of the treating Doctor","options":[],"required":null,"pdf_field":""},{"help":"Doctor's qualification","type":"text","label":"Qualification","options":[],"required":null,"pdf_field":""},{"help":"Doctor's registration number","type":"text","label":"Registration No. with State Code","options":[],"required":null,"pdf_field":""},{"help":"Patient or insured must sign here","type":"signature","label":"Patient / Insured: Name & Signature","options":[],"required":true,"pdf_field":""}],"filled_by":"patient / insured"}],"deadlines":["All valid original documents duly countersigned by the insured / patient as per the checklist will be sent to TPA / Insurance Company within 7 days of the patient’s discharge"],"applies_to":"health insurance policies requiring cashless hospitalisation approval","attachments":["Test reports if substance abuse test conducted","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 hospitalisation to the Insurer/TPA after discharge and to sign the final bill and discharge summary before discharge","Payment to hospital is governed by the terms and conditions of the policy; if insurer/TPA does not settle the bill, I will pay as per policy terms","All non-medical expenses and expenses not relevant to current hospitalisation or above authorized limits will be paid by me","I declare to abide by policy terms and if any facts disclosed are false or incorrect, I forfeit my claim and indemnify the insurer/TPA","I understand TPA does not warrant hospital services or guarantee quality or standard of services","I warrant the truth of all particulars and understand that false statements will forfeit my claim","I agree to indemnify the hospital against all expenses not reimbursed by insurer/TPA","Hospital agrees to allow authorized TPA/Insurance officials to verify documents","Hospital will send all valid original documents countersigned by insured/patient within 7 days of discharge","Hospital will collect non-medical or disallowed expenses from patient","Hospital agrees TPA/Insurance will not pay if discrepancies exist between form and discharge summary or other documents","Patient declaration signed in hospital presence","Hospital will provide clarifications for queries and is responsible for delays","Hospital agrees to abide by terms in the MOU"],"dropped_labels":5},"pdf_fields":null,"fillable_pdf":false,"send_to":[{"purpose":"claim","channel":"email","value":"insurance.help@navi.com","label":"Claims intimation","level":1,"hours":null,"applies_to":"all","source_url":"https://public-navi-docs.s3.ap-south-1.amazonaws.com/NaviCommercialVehicleLiabilityOnlyInsurance%20CIS.pdf","quote":"own damage claim\n12 | Policy Servicing Claim Intimation and Processing | 1. Call Us: Toll Free 1800 123 0004 2. Email: insurance.help@navi.com 3. Email for Senior Citizens- seniorcare@navi.com 4. Visit our website: https://www.naviinsurance.com/service/ 5. Walk","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"email","value":"seniorcare@navi.com","label":"Email for Senior Citizens","level":1,"hours":null,"applies_to":"all","source_url":"https://public-navi-docs.s3.ap-south-1.amazonaws.com/NaviCommercialVehicleLiabilityOnlyInsurance%20CIS.pdf","quote":"on and Processing | 1. Call Us: Toll Free 1800 123 0004 2. Email: insurance.help@navi.com 3. Email for Senior Citizens- seniorcare@navi.com 4. Visit our website: https://www.naviinsurance.com/service/ 5. Walk in for assistance 6. Dispatch your letters to us a","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"1800 123 0004","label":"Toll Free","level":1,"hours":null,"applies_to":"all","source_url":"https://public-navi-docs.s3.ap-south-1.amazonaws.com/NaviCommercialVehicleLiabilityOnlyInsurance%20CIS.pdf","quote":"nses - paid amount under own damage claim\n12 | Policy Servicing Claim Intimation and Processing | 1. Call Us: Toll Free 1800 123 0004 2. Email: insurance.help@navi.com 3. Email for Senior Citizens- seniorcare@navi.com 4. Visit our website: https://www.n","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"url","value":"https://www.naviinsurance.com/service/","label":"Customer Portal on website","level":1,"hours":null,"applies_to":"all","source_url":"https://public-navi-docs.s3.ap-south-1.amazonaws.com/NaviCommercialVehicleLiabilityOnlyInsurance%20CIS.pdf","quote":"1800 123 0004 2. Email: insurance.help@navi.com 3. Email for Senior Citizens- seniorcare@navi.com 4. Visit our website: https://www.naviinsurance.com/service/ 5. Walk in for assistance 6. Dispatch your letters to us at – Corporate Office: Navi General Insurance Limited, Vaishna","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/navi-general-insurance/933-request-for-cashless-hospitalisation-for-health-insurance-policy"}