{"id":943,"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/Health-%20Claim%20Form%20-%20Cashless","sha256":"61c7dcd4c35c93a07c1692a253deddf1f013ab22b6d6eb7ed99ee7aa4a9bcd8b","pages":2,"collected":"2026-10-17","instructions":{"about":"This form is for requesting cashless hospitalisation under a health insurance policy. It is filled by the insured/patient, treating doctor, and hospital.","notes":["Fill form in block letters","Page 1 (Part C) only to be faxed or scanned for cashless request","Page 2 is not to be faxed/scanned","Use original bills and documents for claim support","Attach test reports if substance abuse is indicated","Hospital seal must include hospital ID"],"title":"REQUEST FOR CASHLESS HOSPITALISATION FOR HEALTH INSURANCE POLICY","submit":{"to":"","how":"fax or scan page 1 only (Part C)","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":"","type":"text","label":"Name of the Patient","options":[],"required":null,"pdf_field":""},{"help":"","type":"choice","label":"Gender","options":["Male","Female"],"required":null,"pdf_field":""},{"help":"Enter years and months","type":"number","label":"Age","options":[],"required":null,"pdf_field":""},{"help":"DD MM YY format","type":"date","label":"Date of Birth","options":[],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"Contact Number","options":[],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"Contact number of attending relative","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Insured card ID number","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Policy Number/Name of Corporate","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Employee ID","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Currently Do you have any other Mediclaim/Health Insurance","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"If yes to previous question, provide company name","type":"text","label":"Company Name","options":[],"required":false,"pdf_field":""},{"help":"If yes to previous question, provide details","type":"text","label":"Give Details","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Do you have family physician","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"If yes to previous question","type":"text","label":"Name of the family physician","options":[],"required":false,"pdf_field":""},{"help":"If yes to family physician","type":"phone","label":"Contact Number, if any","options":[],"required":false,"pdf_field":""}],"filled_by":"insured / patient"},{"title":"To be filled by the Treating Doctor / Hospital","fields":[{"help":"","type":"text","label":"Name of the treating doctor","options":[],"required":null,"pdf_field":""},{"help":"","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":"Clinical examination findings","type":"text","label":"Relevant clinical findings","options":[],"required":null,"pdf_field":""},{"help":"Number of days","type":"number","label":"Duration of the present ailment","options":[],"required":null,"pdf_field":""},{"help":"DD MM YY format","type":"date","label":"Date of first consultation","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Past History of present ailment, if any","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Provisional Diagnosis","options":[],"required":null,"pdf_field":""},{"help":"International Classification of Diseases code","type":"text","label":"ICD 10 Code","options":[],"required":false,"pdf_field":""},{"help":"Select all applicable","type":"checkbox","label":"Proposed line of treatment","options":["Medical Management","Surgical Management","Intensive Care","Investigation","Non-Allopathic Treatment"],"required":null,"pdf_field":""},{"help":"","type":"text","label":"If investigation &/or Medical Management provide details","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Route of drug administration","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"If Surgical, Name of Surgery","options":[],"required":false,"pdf_field":""},{"help":"Procedure coding","type":"text","label":"ICD 10 PS Code","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"If other treatments, provide details","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"How did injury occur","options":[],"required":false,"pdf_field":""},{"help":"DD MM YY 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":"Police First Information Report number","type":"text","label":"FIR No.","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Injury/Disease caused due to substance abuse","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"If yes, attach reports","type":"yes-no","label":"Test Conducted to establish this","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Gravida, Para, Living children, Abortions","type":"choice","label":"In case of Maternity","options":["G","P","L","A"],"required":false,"pdf_field":""},{"help":"DD MM YY format","type":"date","label":"Date of Delivery","options":[],"required":false,"pdf_field":""},{"help":"DD MM YY format","type":"date","label":"Date of admission","options":[],"required":true,"pdf_field":""},{"help":"HH:MM format","type":"text","label":"Time","options":[],"required":true,"pdf_field":""},{"help":"","type":"choice","label":"Is this an emergency/a planned hospitalisation","options":["Emergency","Planned"],"required":true,"pdf_field":""},{"help":"Number of days","type":"number","label":"Expected no. of days stay in hospital","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Room Type","options":[],"required":null,"pdf_field":""},{"help":"Enter amount in ₹","type":"amount","label":"Per Day Room Rent + Nursing & Service Charges + Patient’s Diet","options":[],"required":null,"pdf_field":""},{"help":"Enter amount in ₹","type":"amount","label":"Expected cost for investigation + diagnostics","options":[],"required":null,"pdf_field":""},{"help":"Enter amount in ₹","type":"amount","label":"ICU Charges","options":[],"required":false,"pdf_field":""},{"help":"Enter amount in ₹","type":"amount","label":"OT Charges","options":[],"required":false,"pdf_field":""},{"help":"Enter amount in ₹","type":"amount","label":"Professional Fees+ Anaesthetist Fees+ Consultation Charges","options":[],"required":false,"pdf_field":""},{"help":"Enter amount in ₹","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 ₹","type":"amount","label":"All-inclusive package charges if any applicable","options":[],"required":false,"pdf_field":""},{"help":"Enter total expected cost in ₹","type":"amount","label":"Sum Total expected cost of hospitalisation","options":[],"required":true,"pdf_field":""},{"help":"If yes, specify since when (MM:YY)","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":null,"pdf_field":""},{"help":"","type":"text","label":"Any Other Ailments, give details","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"Name of the treating Doctor","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Qualification","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Registration No. with State Code","options":[],"required":true,"pdf_field":""},{"help":"Hospital official seal","type":"signature","label":"Hospital Seal (Must include Hospital Id)","options":[],"required":true,"pdf_field":""},{"help":"Signature of patient or insured","type":"signature","label":"Patient / Insured Name & Signature","options":[],"required":true,"pdf_field":""}],"filled_by":"treating doctor / hospital"},{"title":"Declaration by the Patient / Representative","fields":[{"help":"","type":"text","label":"Patient’s / Insured’s Name","options":[],"required":true,"pdf_field":""},{"help":"","type":"phone","label":"Contact Number","options":[],"required":true,"pdf_field":""},{"help":"","type":"signature","label":"Patient’s / Insured’s Signature","options":[],"required":true,"pdf_field":""}],"filled_by":"patient / representative"},{"title":"Hospital Declaration","fields":[{"help":"Hospital official seal","type":"signature","label":"Hospital Seal","options":[],"required":true,"pdf_field":""},{"help":"Signature of treating doctor","type":"signature","label":"Doctor’s Signature","options":[],"required":true,"pdf_field":""}],"filled_by":"hospital"}],"deadlines":["Hospital to send all valid original documents to TPA / Insurance Company within 7 days of patient’s discharge"],"applies_to":"cashless hospitalisation requests under health insurance policies","attachments":["Original documents pertaining to hospitalization","Final Bill & Discharge Summary signed by patient","Detailed Discharge Summary and all Bills from the hospital","Cash Memos from the Hospitals / Chemists supported by proper prescription","Receipts and Pathological Test Reports supported by note from attending Medical Practitioner / Surgeon","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","Reports of tests conducted to establish substance abuse if applicable"],"declarations":["Patient agrees hospital will submit all original hospitalization documents after discharge and will sign final bill and discharge summary","Payment to hospital governed by policy terms; patient liable if insurer/TPA not liable","Patient pays all non-medical or non-relevant expenses and amounts above insurer/TPA limits","Patient agrees to abide by policy terms and indemnify insurer/TPA if false information is given","TPA does not guarantee hospital service quality","False or untrue statements by patient will forfeit claim","Patient indemnifies hospital for expenses not reimbursed by insurer/TPA","Hospital agrees to allow TPA/Insurance officials to verify documents","Hospital will send all valid original documents countersigned by patient within 7 days of discharge","Hospital will collect non-medical or disallowed expenses from patient","TPA/Insurance not liable if discrepancies exist between form and discharge summary","Patient declaration signed in hospital presence","Hospital responsible for timely clarifications and agrees to MOU terms"],"dropped_labels":1},"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/943-request-for-cashless-hospitalisation-for-health-insurance-policy"}