National Insurance Company Limited

Regd. Office 3, Middleton Street, Post Box 9229, Kolkata 700 071

National Mediclaim Policy

PLEASE FAX / SCAN PAGE 1 ONLY
REQUEST FOR CASHLESS HOSPITALISATION FOR MEDICLAIM INSURANCE POLICY
(To be filled in block letters)
DETAILS OF THE THIRD PARTY ADMINISTRATOR

a) Name of TPA / Insurance Company:

b) Toll free phone number:
c) Toll free Fax:
d) Name of Hospital:
i. Address:
ii. ROHINI ID: iii. E-mail ID:

TO BE FILLED BY THE INSURED / PATIENT

a) Name of the patient:

b) Gender : Male Female c) Age: years months d) Date of Birth:
e) Contact number: f) Contact number of attending relative
g) Insured card ID number:
h) Policy number / Name of corporate: i) Employee ID:
j) Currently do you have any other Mediclaim / Helath Insurance: Yes No Company Name:
Give details:
k) Do you have a family physician? Yes No l) Name of the family physician:
m) Contact number, if any:
n) Current address of insured person
o) Occupation of insured person: (PLEASE COMPLETE DECLARATION ON THE REVERSE SIDE OF THIS FORM)

TO BE FILLED BY THE TREATING DOCTOR / HOSPITAL

a) Name of the treating doctor: b) Contact number:

c) Nature of illness/ disease d) Relevant clinical findins:
with presenting complaints

e) Duration of the present ailment: Days i. Date of first consultation: D D M M Y Y Y Y ii. Past history of
present ailment,
f) Provisional diagnosis: if any
i. ICD 10 Code
g) Proposed line of treatment: Medical Management Surgical Management Intensive Care Investigation Non allopathis Treatment
h) If investigation & / or Medical i. Route of drug administration:
Management, provide details
i) If Surgical, name of surgery: i. ICD 10 PCS Code

j) If other treatments, provide k) How did the injury occur?

details
l) In case of accident: i. Is it RTA? Yes No ii. Date of injury: iii. Reported to Police: Yes No iv. FIR No.:
v. Injury / Disease caused due to substance abuse / alcohol consumption: Yes No vi. Test conducted to extablish this? Yes No (If yes attach reports)
m) In case of maternity: G P L A Expected date of Delivery:
Details of the patient admitted d) Mandatory : Past history of any chronic illness If Yes, since (month / year)
a) Date of admission: b) Time: : Diabetes /
c) Is this an emergency / a planned hospitalization event? Emergency Planned Heart Disease /
e) Expected no. of days in hospital: Days f) Days in ICU: Days Hypertension /
g) Room Type: Hyperlipidemia /
h) Per Day Room Rent + Nursing & Service Charges + Patient's Diet: INR Osteoarthritis /
i) Expected cost of investigation + diagnostics: INR Asthma / COPD / Bronchitis /
j) ICU Charges: INR Cancer /
k) OT Charges: INR Alcohol or drug abuse /
l) Professional fees Surgeon + Anesthetist Fees + consultation charges: INR Any HIV or STD / Related ailments /
m) Medicines + Consumables + Cost of implants (if applicable, please INR Any other Ailment, give details:
n) Other hospital expenses, if any: INR
o) All inclusive package charges, if any applicable: INR
Sum Total INR
(PLEASE READ VERY CAREFULLY)
DECLARATION

We confirm having read, understood and agreed to the Declaration on the reverse of this form
a) Name of the treating doctor:
b) Qualification: c) Registration No. with state code:

Hospital Seal (must contain hospital ID) Patient / Insured Name & Signature
(IMPORTANT: PLEASE TURN OVER)
PAGE 2: NOT TO BE FAXED/SCANNED

National Insurance Co. Ltd. National Mediclaim Policy

Regd. Office 3, Middleton Street, Post Box 9229, Kolkata 700 071 UIN: NICHLIP21166V042021
 National Insurance Company Limited
Regd. Office 3, Middleton Street, Post Box 9229, Kolkata 700 071

DECLARATION BY THE PATIENT / REPRESENTATIVE

a. I agree to allow the hospital to submit all original documents pertaining to hospitalization to the Insurer/T.P.A after the discharge. I agree to sign on the Final Bill & the Discharge Summary, before my discharge.

b. Payment to hospital is governed by the terms and conditions of the policy. In case the Insurer / TPA is not liable to settle the hospital bill, I undertake to settle the bill as per the terms and conditions of the policy.

c. All non-medical expenses and expenses not relevant to current hospitalization and the amounts over & above the limit authorized by the Insurer/T.P.A not governed by the terms and conditions of the policy will be paid by me. In case any clarification is needed on admissibility of a particular item I shall contact
T.P.A at the Toll Free Number on the reverse of this form.

d. I hereby declare to abide by the terms and conditions of the policy and if at any time the facts disclosed by me are found to be false or incorrect I forfeit my claim and agree to indemnify the Insurer / T.P.A

e. I agree and understand that T.P.A is in no way warranting the service of the hospital & that the Insurer / TPA is in no way guaranteeing that the services provided by the hospital will be of a particular quality or standard.

f. I hereby warrant the truth of the forgoing particulars in every respect and I agree that if I have made or shall make any false or untrue statement, suppression or concealment, my right to claim reimbursement of the said expenses shall be absolutely forfeited. I further declare that, in respect of the above
treatment, no benefits are admissible under any other Medical Scheme or Insurance

g. I agree to indemnify the hospital against all expenses incurred on my behalf, which are not reimbursed by the Insurer / TPA.

h. I/We authorize Insurance Company/TPA to contact me/us through mobile/email for any update on this claim.

a) Patient/ Insured's Name:

b) Contact number: c) E-mail ID:

d) Patient/ Insured's Signature:

Date: Time:

HOSPITAL DECLARATION

a. We have no objection to any authorized TPA / Insurance Company official verifying documents pertaining to hospitalization.

b. 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.

c. We agree that TPA / Insurance Company will not be Iiable to make the payment in the event of any discrepancy between the facts in this form and discharge summary or other documents.

d. The patient declaration has been signed by the patient or by his representative in our presence.

e. we agree to provide clarifications for the queries raised regarding this hospitalization and we take the sole responsibility for any delay in offering clarifications.

f. We will abide by the terms and conditions agreed in the MOU.

g. We confirm that no additional amount would be collected liom the insured in excess of Agreed Package Rates except costs towards non-admissible amounts (including additional charges due to opting higher room rent than eligibilityi choosing separate line oftreatment which is not envisaged/considered in
package).

h. We confirm that no recoveries would be made from the d€posit amount collected from the lnsured except for costs towards non-admissible amounts (including additional charges due to opting higher room rent than eligibility/ choosing separate line oftreatment which is not envisaged/considered in package).

i. In the event ofunauthorized recovery ofany additional amount from the Insured in excess of Agreed Package Rates, the adhorized TPA / Insurance Company reserves the right to recoverthe same from us (the Network Provider) and,/or take necessary action, as provided under the MoU or applicable laws.

Hospital Seal Doctor's Signature

Date: Time:

DOCUMENTS TO BE PROVIDED BY THE HOSPITAL IN SUPPORT OF THE CLAIM

1. Detailed Discharge Summary and all Bills from the hospital

2. Cash Memos from the Hospitals / Chemists supported by proper prescription.

3. Receipts and Pathological Test Reports from Pathologists, supported by note from the attending Medical Practitioner / Surgeon recommending such pathological Tests.

4. Surgeon's Certificate stating nature of operation performed and Surgeon's Bill and Receipt.

5. Certificates from attending Medical Practitioner / Surgeon that the patient is fully cured.

National Insurance Co. Ltd. National Mediclaim Policy

Regd. Office 3, Middleton Street, Post Box 9229, Kolkata 700 071 UIN: NICHLIP21166V042021
 National Insurance Company Limited
Regd. Office 3, Middleton Street, Post Box 9229, Kolkata 700 071

National Mediclaim Policy

CLAIM FORM - PART A
TO BE FILLED IN BY THE INSURED
The issue of theis form is not to be taken as admission of liability
Please submit all original documents and/ or certified copies of documents related to the hospitalisation to enable the Company to determine admissibility and payment of claims.
(To be filled in block letters)
DETAILS OF PRIMARY INSURED

a) Policy no: b) Company/ TPA ID No:

c) Name:

SECTION A
d) Address:

City: State:
Pin Code: Phone No: Email ID:
DETAILS OF INSURANCE HISTORY

a) Currently covered by any other Mediclaim/ Health Insurance: Yes No b) Date of commencement of first insurance without break:
c) If yes, company name: Policy No:

SECTION B
Sum Insured (`): d) Have you been hospitalized in the last four years since inception of the contract? Yes No Date:
Diagnosis: e) Previously covered by any other Mediclaim/ Health Insurance : Yes No
f) If yes, Company Name :
DETAILS OF INSURED PERSON HOSPITALIZED

a) Name :
b) Gender : Male Female d) Date of Birth: d d m m y y e) Basic Sum insured: i) CB (if any)
f) Relatuionship to Primary Insured: Self Spouse Child Father Mother Other (Please specify)
g) Occupation: Service Self Employed Homemaker Student Retired Other (Please specify)

SECTION C
h) Address (if different from above):

City: State:
Pin Code: Phone No: Email ID:
DETAILS OF HOSPITALIZATION

a) Name of Hospital where Admitted:

b) Room category occupied: Suite Deluxe room Single occupancy Twin occupancy 3 or more occupancy
c) Hospitalization due to: Injury Illness Accident d) Date of injury/ Date Disease first detected:

SECTION D
e) Date of Admission: f) Time: : g) Date of Discharge: h) Time: :
i) If injury, give cause: Self inflicted Road Traffic Accident Substance abuse / Alcohol Consumption i. If Medico Legal: Yes No
ii. Reported to police: Yes No iii. MLC Report & Police FIR attached: Yes No j) System of medicine: Modern medicine Ayurveda Homeopathy
DETAILS OF CLAIM

a) Details of expenses Claim Documents Submitted- Check List:

i. Pre Hospitalization Expenses ₹ ii. Room/ ICU Charges ₹ Claim FormDuly signed
iii. Medical Practitioner's Fees ₹ iv. Others Expenses: ₹ Copy of the claim intimation, if any
v. Post Hospitalization Expenses: ₹ vi. Health Check Up Expenses ₹ Hospital Main bill
vii. Pre hospitalization period: days viii. Post hospitalization period: days Hospital Break-up bill
ix. Ambulance Charges: ₹ Total ₹ Hospital Discharge Summary

SECTION E
b) Details of Treatment Pharmacy Bill
i. Claim for Day Care Procedure Yes No ii Claim for Organ Donor’s Medical Expenses Yes No Operation Theatre Notes
ii Claim for HIV/ AIDS Treatment Yes No iv Claim for Mental Illness Treatment Yes No ECG
v Claim under reinstated SI Yes No vi Claim for cataract Treatment Yes No Doctor's request for investigation
vii Claim for Hemodialysis Yes No viii Claim for Chemotherapy Yes No Investigation Reports (including CT /
ix Claim for Radiotherapy Yes No x Claim for Morbid Obesity Yes No MRI / USG / HPE)
xi Claim for Refractive Error Yes No xii Claim for Hazardous Sport Yes No Doctor's Prescription
xiii Claim for Modern Treatment Yes No If Yes, name of treatment: Others
DETAILS OF BILLS ENCLOSED

Sl. No. Bill No. Date Issued By Bill Towards No. of bills Amount (₹)
1 Hospital Main Bill
2 Pre hospitalisation Bills: ___ Nos
3 Post hospitalisation Bills: ___ Nos
4 Pharmacy Bills:
SECTION F

5 Others:
6
7
8
9
10
DETAILS OF PRIMARY INSURED'S BANK ACCOUNT

a) PAN: b) Account Number:

SECTION G

c) Bank Name
d) Bank Branch
e) Cheque/ DD Payable details: f) IFSC Code:
DECLARATION BY THE INSURED

I hereby declare that the information furnished in this claim form is true & correct to the best of my knowledge and belief. If I have made any false or untrue statement, suppression or concealment of any material fact with respect to questions asked in relation to this
claim, my right to claim reimbursement shall be forfeited. I also consent & authorize TPA / insurance company, to seek necessary medical information / documents from any hospital / Medical Practitioner who has attended on the person against whom this claim is
made. I hereby declare that I have included all the bills / receipts for the purpose of this claim & that I will not be making any supplementary claim except the pre/post-hospitalization claim, if any.
SECTION H

Date: Place: Signature of the insured:

National Insurance Co. Ltd. National Mediclaim Policy

Regd. Office 3, Middleton Street, Post Box 9229, Kolkata 700 071 UIN: NICHLIP21166V042021
 National Insurance Company Limited
Regd. Office 3, Middleton Street, Post Box 9229, Kolkata 700 071

GUIDANCE FOR FILLING CLAIM FORM – PART A (To be filled in by the insured)
DATA ELEMENT DESCRIPTION FORMAT
SECTION A - DETAILS OF PRIMARY INSURED
a) Policy No. Enter the policy number As allotted by the insurance company
License number as allotted by IRDA and printed in TPA
b) Company TPA ID No. Enter the TPA ID No
documents.
c) Name Enter the full name of the policyholder Surname, First name, Middle name
d) Address Enter the full postal address Include Street, City and Pin Code
SECTION B - DETAILS OF INSURANCE HISTORY
a) Currently covered by any other Mediclaim / Health Insurance? Indicate whether currently covered by another Mediclaim / Health Insurance Tick Yes or No
b) Date of Commencement of first Insurance without break Enter the date of commencement of first insurance Use dd-mm-yy format
c) Company Name Enter the full name of the insurance company Name of the organization in full
Policy No. Enter the policy number As allotted by the insurance company
Sum Insured Enter the total sum insured as per the policy In rupees
d) Have you been Hospitalized in the last 4 years since inception of the contract? Indicate whether hospitalized in the last 4 years Tick Yes or No
Date Enter the date of hospitalization Use mm-yy format
Diagnosis Enter the diagnosis details Open Text

e) Previously Covered by any other Mediclaim/ Health Insurance? Indicate whether previously covered by another Mediclaim / Health Insurance Tick Yes or No

f) Company Name Enter the full name of the insurance company Name of the organization in full
SECTION C - DETAILS OF INSURED PERSON HOSPITALIZED
a) Name Enter the full name of the patient Surname, First name, Middle name
b) Gender Indicate Gender of the patient Tick Male or Female
c) Age Enter age of the patient Number of years and months
d) Date of Birth Enter Date of Birth of patient Use dd-mm-yy format
e) Relationship to primary Insured Indicate relationship of patient with policyholder Tick the right option. If others, please specify.
f) Occupation Indicate occupation of patient Tick the right option. If others, please specify.
g) Address Enter the full postal address Include Street, City and Pin Code
h) Phone No Enter the phone number of patient Include STD code with telephone number
i) E-mail ID Enter e-mail address of patient Complete e-mail address
SECTION D - DETAILS OF HOSPITALIZATION
a) Name of Hospital where admitted Enter the name of hospital Name of hospital in full
b) Room category occupied Indicate the room category occupied Tick the right option
c) Hospitalization due to Indicate reason of hospitalization Tick the right option
d) Date of Injury/Date Disease first detected Enter the relevant date Use dd-mm-yy format
e) Date of admission Enter date of admission Use dd-mm-yy format
f) Time Enter time of admission Use hh:mm format
g) Date of discharge Enter date of discharge Use dd-mm-yy format
h) Time Enter time of discharge Use hh:mm format
i) If Injury give cause Indicate cause of injury Tick the right option
If Medico legal Indicate whether injury is medico legal Tick Yes or No
Reported to Police Indicate whether police report was filed Tick Yes or No
MLC Report & Police FIR attached Indicate whether MLC report and Police FIR attached Tick Yes or No
j) System of Medicine Enter the system of medicine followed in treating the patient Open Text
SECTION E - DETAILS OF CLAIM
a) Details of Treatment Expenses Enter the amount claimed as treatment expenses In rupees (Do not enter paise values)
b) Claim Documents Submitted-Check List Indicate which supporting documents are submitted Tick the right option
SECTION F - DETAILS OF BILLS ENCLOSED
Indicate which bills are enclosed with the amounts in rupees
SECTION G - DETAILS OF PRIMARY INSURED’S BANK ACCOUNT
a) PAN Enter the permanent account number As allotted by the Income Tax department
b) Account Number Enter the bank account number As allotted by the bank
c) Bank Name Enter the bank name Name of the Bank in full
d) Bank Branch Enter the bank branch name Name of the Bank Branch in full
e) Cheque/ DD payable details Enter the name of the beneficiary the cheque/ DD should be made out to Name of the individual/ organization in full
f) IFSC Code Enter the IFSC code of the bank branch IFSC code of the bank branch in full
SECTION H - DECLARATION BY THE INSURED
Read declaration carefully and mention date (in dd:mm:yy format), place (open text) and sign.

National Insurance Co. Ltd. National Mediclaim Policy

Regd. Office 3, Middleton Street, Post Box 9229, Kolkata 700 071 UIN: NICHLIP21166V042021
 National Insurance Company Limited
Regd. Office 3, Middleton Street, Post Box 9229, Kolkata 700 071

National Mediclaim Policy

CLAIM FORM - PART B
TO BE FILLED IN BY THE HOSPITAL
The issue of theis form is not to be taken as admission of liability
Please include the original preauthorization request form in lieu of PART A

(To be filled in block letters)

DETAILS OF HOSPITAL

a) Name of the Hospital:

b) Hospital ID: c) Type of Hospital: Network Non Network (if non network, fill Section E)

SECTION A
d) Name of the treating doctor:
e) Qualification: f) Registration No. with state code: g) Phone No.
DETAILS OF PATIENT ADMITTED

a) Name of Patient:
b) IP Registration No.: c) Gender : Male Female d) Age: years months e) Date of Birth:

SECTION B
f) Date of Admission: g) Time: : h) Date of Discharge: i) Time: :
j) Type of Admission: Emergency Planned Day Care Maternity k) If Maternity: i. Date of Delivery: ii. Gravida Status:
l) Status at time of discharge: Discharged to home Discharged to another hospital Deceased m) Total claimed amount
DETAILS OF AILMENT DIAGNOSED (PRIMARY)

a) ICD 10 Codes Description b) ICD 10 PCS Description

i. Primary Diagnosis : i. Procedure 1 :

ii. Additional Diagnosis : ii. Procedure 2 :

iii. Co-morbidities : iii. Procedure 3 :

SECTION C
iv. Co-morbidities : iv. Details of Procedure :

c) Pre authorization obtained: Yes No d) Pre-authorization number:

e) If authorization by network hospital not obtained, give reason:
f) Hospitalization due to injury: Yes No i. If yes, give cause Self inflicted Road Traffic Accident Substance abuse / alcohol consumption
ii. If injurydue to Substance abuse / alcohol consumption, Test Conducted to establish this: Yes No (if yes, attach reports) iii. If Medico Legal: Yes No iv. Reported to Police: Yes No
v. FIR No. vi. If not reported to police, give reason:
CLAIM DOCUMENTS SUBMITTED - CHECKLIST

Claim Form duly signed Investigation reports

Original Pre-authorization request CT/ MRI/ USG/ HPE/ Investigation reports
Copy of the Pre-authorization approval letter Doctor's referance slip

SECTION D
Copy of photo ID card of patient verified by hospital ECG
Hospital discharge summary Pharmacy bills
Oparation Theatre Notes MLC report & Police FIR
Hospital main bill Original death summary from hospital, where applicable
Hospital break-up bill Any other, please specify

ADDITIONAL DETAILS IN CASE OF NON NETWORK HOSPITAL (ONLY FILL IN CASE OF NON NETWORK HOSPITAL)

a) Address of the hospital:

SECTION E
City: State:
Pin Code: b) Phone No: c) Registration No. with State Code:

d) Hospital PAN e) Number of inpatient beds f) Facilities available in the hospital: i. OT: Yes No ii. ICU: Yes No
iii. Others:
DECLARATION BY THE HOSPITAL (Please read very carefully)

We hereby declare that the information furnished in this Claim Form is true & correct to the best of our knowledge and belief. If we have made any false or untrue statement, suppress or concealment of anu material fact, our right to claim under this claim shall be
forfeited.
SECTION F

Date:

Place: Signature and seal of the hospital authority:

National Insurance Co. Ltd. National Mediclaim Policy

Regd. Office 3, Middleton Street, Post Box 9229, Kolkata 700 071 UIN: NICHLIP21166V042021
 National Insurance Company Limited
Regd. Office 3, Middleton Street, Post Box 9229, Kolkata 700 071

GUIDANCE FOR FILLING CLAIM FORM – PART B (To be filled in by the hospital)
DATA ELEMENT DESCRIPTION FORMAT
SECTION A - DETAILS OF HOSPITAL
a) Name of Hospital Enter the name of hospital Name of hospital in full
b) Hospital ID Enter ID number of hospital As allocated by the TPA
c) Type of Hospital Indicate whether In network or non network nospital Tick the right option
d) Name of treating doctor Enter the name of the treating doctor Name of doctor in full
e) Qualification Enter the qualifications of the treating doctor Abbreviations of educational qualifications
f) Registration No. with State Code Enter the registration number of the doctor along with the state code As allocated by the Medical Council of India
g) Phone No. Enter the phone number of doctor Include STD code with telephone number
SECTION B – DETAILS OF THE PATIENT ADMITTED
a) Name of Patient Enter the name of hospital Name of hospital in full
b) IP Registration Number Enter insurance provider registration number As allotted by the insurance provider
c) Gender Indicate Gender of the patient Tick Male or Female
d) Age Enter age of the patient Number of years and months
e) Date of Admission Enter date of admission Use dd-mm-yy format
f) Date of Birth Enter date of birth Use dd-mm-yy format
g) Time Enter time of admission Use hh:mm format
h) Date of Discharge Enter date of discharge Use dd-mm-yy format
i) Time Enter time of discharge Use hh:mm format
j) Type of Admission Indicate type of admission of patient Tick the right option
k) If Maternity
Date of Delivery Enter Date of Delivery if maternity Use dd-mm-yy format
Gravida Status Enter Gravida status if maternity Use standard format
l) Status at time of discharge Indicate status of patient at time of discharge Tick the right option
SECTION C – DETAILS OF AILMENT DIAGNOSED (PRIMARY)
a) ICD 10 Code
Primary Diagnosis Enter the ICD 10 Code and description of the primary diagnosis Standard Format and Open text
Additional Diagnosis Enter the ICD 10 Code and description of the additional diagnosis Standard Format and Open text
Co-morbidities Enter the ICD 10 Code and description of the co-morbidities Standard Format and Open text
b) ICD 10 PCS
Procedure 1 Enter the ICD 10 PCS and description of the first procedure Standard Format and Open text
Procedure 2 Enter the ICD 10 PCS and description of the second procedure Standard Format and Open text
Procedure 3 Enter the ICD 10 PCS and description of the third procedure Standard Format and Open text
Details of Procedure Enter the details of the procedure Open text
c) Pre-authorization obtained Indicate whether pre-authorization obtained Tick Yes or No
d) Pre-authorization Number Enter pre-authorization number As allotted by TPA
e) If authorization by network hospital not obtained, give reason Enter reason for not obtaining pre-authorization number Open text
f) Hospitalization due to injury Indicate if hospitalization is due to injury Tick Yes or No
Cause Indicate cause of injury Tick the right option
If injury due to substance abuse/alcohol consumption, test conducted to establish this Indicate whether test conducted Tick Yes or No
Medico Legal Indicate whether injury is medico legal Tick Yes or No
Reported To Police Indicate whether police report was filed Tick Yes or No
FIR No. Enter first information report number As issued by police authorities
If not reported to police, give reason Enter reason for not reporting to police Open Text
SECTION D – CLAIM DOCUMENTS SUBMITTED-CHECK LIST
Indicate which supporting documents are submitted
SECTION E – ADDITIONAL DETAILS IN CASE OF NON NETWORK HOSPITAL
a) Address Enter the full postal address Include Street, City and Pin Code
b) Phone No. Enter the phone number of hospital Include STD code with telephone number
c) Registration No. with State Code Enter the registration number of the doctor along with the state code As allocated by the Medical Council of India
d) Hospital PAN Enter the permanent account number As allotted by the Income Tax department
e) Number of Inpatient Beds Enter the number of inpatient beds Digits
f) Facilities available in the hospital Indicate facilities available in the hospital Tick the right option. If others, please specify
SECTION F - DECLARATION BY THE INSURED
Read declaration carefully and mention date (in dd:mm:yy format), place (open text) and sign.

National Insurance Co. Ltd. National Mediclaim Policy

Regd. Office 3, Middleton Street, Post Box 9229, Kolkata 700 071 UIN: NICHLIP21166V042021