ICICI Lombard Health Care Claim Form - Hospitalisation
(The issue of this form is not to be taken as an Admission of Liability)
ICICI Lombard Health Care
1. Type of Claim : Main Hospitalisation Expenses Pre & Post
2. Name of Policy Holder/Proposer :
Current Policy Number :
Card No. / UHID:
3. For Group/Corporate Policy For Individual/Retail Policy (Information Mandatory)
Member ID No. / Employee ID (Client ID): Information Claim Intimation Service Request No.
Is this a renewal policy : Yes No
Group/Company Name: If Yes, kindly mention your previous policy no.:
Hospitalisation Expenses Cashless Obtained : Yes No
Bill Heads (as Applicable) Bill Number Bill Date Bills attached Amount (In Rs.)
Room Rent
Doctors Consultation/Visit Charges
Investigation Charges (Includes Radiology and Pathology Reports)
Surgeon and Asst. Surgeon Charges
Anesthetist Charges & Operation Theatre Charges
Equipment Charges/Procedure Charges
Cost of Implant (If Any)
Medicine Charges (Includes Ward and OT Medicines and Consumables)
Taxes/Surcharges/Service Charge
Miscellaneous/Other Charges
Pre Hospitalisation Bills (If Any)
Post Hospitalisation Bills (If Any)
Total Claimed Amount (In `) (Total claimed amount should be equal to the amount in attached bill documents)
Part - A (To be filled by Insured)
7. Details of the Amount Claimed
Information Non-submission of Original Bills and Receipts is the largest cause of delay in claim settlements. Please provide the originals
Information You can get your payment 5 days early: Provide Your Bank details for direct fund transfer (refer Part - C)
Information You will receive updates on your Claim status: Provide your Mobile no. & E-mail address
Information You can check your claim status at: www.icicilombard.com/track-your-claim-status.html
Do You Know
TO BE FILLED IN CAPITAL LETTERS ONLY
4. Details of the Insured Person in respect of whom claim is made:
Name of Insured:
Gender: M F Date of Birth: Present completed age (In Years):
Relationship with the Policy Holder: Current Residential address:
City:
State: Pin Code:
Mobile No. Landline No.
E-mail :
5. Nature of disease / illness contracted or injury suffered ______________________________________________________________
for which insured was hospitalized (Diagnosis): _____________________________________________________________
Date of Admission : Date of Discharge :
Date of injury sustained or disease / illness first detected :
6. Have you lodged any claim against this particular admission date /attached bills with any other Insurance company:
If yes, provide Name of Insurance Company & TPA:
Settled Amount (`):
D D M M Y Y Y Y
IMPORTANT NOTE: Please fill Part C (EFT form) for Online Transfer. If Part C is not filled, the payment will be processed in Cheque mode.
{OE : www.icicilombard.com
Claim documents to be dispatched to: ICICI Lombard Healthcare, ICICI Bank Tower, Plot No. 12, Financial District, Nanakram Guda, Gachibowli, Hyderabad-500032
8. In support of the above claim, I enclose following documents in ORIGINAL (Please indicate by ticking in the Yes/No column below)
Details of the Hospital / Nursing Home in which treatment was taken.
Name of the Hospital/Nursing Home :
Address :
City : State :
Pincode: Telephone No./Mobile No. :
Details of the attending Medical Practitioner / Doctor / Treating Physician or Surgeon
Name:
Qualification & Registration No. : Telephone No. / Mobile No.
Registration No. of Hospital
(Rubber stamp of the hospital) Date : Doctor’s Seal and Signature
As per the policy terms and conditions, the Company reserves its right to have the Insured examined by a doctor appointed by it for verification of diagnosis.
Part - B
DECLARATION
I hereby agree, affirm and declare that
a) The statements/information given/stated by me/us in this claim form is true, correct and complete.
b) No material information which is relevant to the processing of the claim or which in any manner has a bearing on the claim has been withheld or not disclosed.
c) If I have given/made any false or fraudulent statement/information, or suppressed or concealed or in any manner failed to disclose material information, the policy shall be void & that I shall not be entitled to all / any rights to recover there under in respect of any or all claims, past, present or future.
d) The receipt of this claim form/other supporting/related documents does not constitute or be deemed to constitute an agreement by the Company of the claim and the Company reserves the right to process or reject or require further/additional information in respect of the claim.
I/We hereby declare that the particulars made by the insured person in the claim form are true to the best of our knowledge and belief.
Place : Date : Signature of Claimant
e) I hereby provide my consent and authorize ICICI Lombard Health Care to seek any medical information from any hospital/Medical Practitioner who has at any time attended on the insured person.
(To be filled by Treating Doctor/Hospital only)
This section is Mandatory only if your health policy was not provided by your employer
A) Diagnosis
B) Date of First Consultation (Prior to Hospitalization)
C) With what complaints was the patient admitted for
D) Past medical history of the patient with duration of illness
E) Was the patient under influence of alcohol during admission
F) Whether the present treatment ailment is a complication of Pre-Existing disease ?
(i) If yes, please specify the disease (or) complication of any previous surgery done ?
(ii) If yes, please specify the details
G) Whether the disease / disorder is congenital in nature ?
H) Nature of surgery / treatment given for present ailment
I) Number of in-patient beds in the hospital (including ICU)
Claim documents to be dispatched to: ICICI Lombard Healthcare, ICICI Bank Tower, Plot No. 12, Financial District, Nanakram Guda, Gachibowli, Hyderabad-500032

Type of Document(s) - Information Mandatory Yes No Type of Document(s) - As Applicable Yes No
1. Claim form Duly Filled Information
2. Discharge Summary Information
3. Hospital Bills, Final hospital bill and other bills (if any)Information
4. Hospital Payment Receipt & other receipts supporting Bills Information Information
5. Investigation Reports Information (films not required)
6. Medicine/Pharmacy Bills with Doctors Prescription Information
7. Age proof (Driver Licence/ photocopy of PAN card / Passport copy / School Leaving cert. of the proposer)Information
8. ICICI Lombard GIC Authorisation Letter
9. Implant Name and Invoice (If any) with Implant Sticker
Information Please attach all the documents as per above serial number. Films mean x-ray film, CT Scan film, MRI Scan film, etc.
10. Indoor Case Papers/Prescription Papers/Consultation Papers
11. Part - C (If payment is through RTGS / NEFT)
12. Other _______________________________________
13. Part - D (KYC document required if Total Claimed Amount is greater than 1 lakh)
Kindly provide the below mentioned details :
• Proposer Name Information(as per bank records):
• Proposer Account No.:
• Name of the Bank :
• Branch Name :
• Address of the Bank :
• IFSC code no. of the Bank:
• Permanent Account Number (PAN) of Proposer :
Proposer is the person who has paid premium for the policy. Information Please note all the details and the above documents (1 & 2)should be of the proposer only.
Please attach an Original Blank Cancelled Cheque signed by the proposer. Mandatory
Mailing Address : ICICI Lombard Healthcare, ICICI Bank Tower, Plot No. 12, Financial District, Nanakram Guda, Gachibowli, Hyderabad-500032
Toll Free Number: 1800 2666 • Toll Free Fax Number: 1800-209-8880
Corporate Office : ICICI Lombard House, 414, Veer Savarkar Marg, Near Siddhi Vinayak Temple, Prabhadevi, Mumbai 400 025.
Visit us at : www.icicilombard.com • E-Mail us at : ihealthcare [at] icicilombard [dot] com
Terms and Conditions for Payments through RTGS / NEFT
1. The details provided by the Customers in the Mandate Form shall be considered as final and ICICI Lombard General Insurance Company Ltd. shall not be responsible for cross verification of any of the details provided therein.
2. The RTGS / NEFT facility shall be effective for the respective Customer(s) within 15 days of the receipt of the Mandate Form by ICICI Lombard General Insurance Company Ltd. and / or within such period as may be reasonably required by ICICI Lombard General Insurance Company Ltd. to activate the RTGS/ NEFT facility.
3. The Customer agrees that under the RTGS/ NEFT facility, there may be a risk of non-payment in the Account of Customer on the day of the credit of Payments due to change in the applicable regulations pertaining to RTGS/ NEFT facility or due to any other reasons without any fault/inaction/failure on part of ICICI Lombard General Insurance Company or any factor beyond the control of ICICI Lombard General Insurance Company Limited.
4. The Customer agrees to indemnify, without delay or demur, ICICI Lombard General Insurance Company Ltd. and its agents and keep ICICI Lombard General Insurance Company Ltd. and its agent indemnified harmless at all times from and against any and all claims, damages, losses, costs, and expenses (including attorney's fees) which ICICI Lombard General Insurance Company Ltd. may suffer or incur, directly or indirectly, arising from or in connection with, amongst other things, either of the aforesaid reasons stated in above clauses.
5. ICICI Lombard General Insurance Company Ltd. may sub-contract and employ agents to carry out any of its obligations under the RTGS/ NEFT facility The Customer may discontinue or terminate the use of RTGS / NEFT facility by giving a minimum of 15 days prior written notice to ICICI Lombard General Insurance Company Ltd.The date of notice for ICICI Lombard will be the date of receipt of such notice by ICICI Lombard. The notice of, such termination should be given to ICICI Lombard only at its corporate address and be addressed at ICICI Lombard GIC Ltd, ICICI Lombard House (Old Tata Press Building), 414, Veer Savarkar Marg, Near Siddhi Vinayak Temple, Prabhadevi, Mumbai - 400025
6. A confirmation of the receipt of termination notice given by the Customer will be acknowledged through a confirmation letter by ICICI Lombard General Insurance Company Ltd. In no case can the Customer construe his termination notice as effective unless a confirmation has been provided by ICICI Lombard to the Customer stating the date of receipt of such communication by the Customer.
7. The Customer agrees that transaction(s) through RTGS/ NEFT facility may attract inward RTGS/ NEFT charges, which if levied by the Customer's bank, shall be borne by the Customer
8. ICICI Lombard has the absolute discretion to amend or supplement any Terms and Condition stated herein at any time and will endeavor to give prior notice of Ten days for such changes wherever feasible for the terms and conditions to be applicable. By using the new services, or at the completion of such period, whichever is earlier, the Customer shall be deemed to have accepted the changed terms and conditions.
9. Submission of documents or bank details or any other information does not in any way, shape or form, imply or express or suggest admission of liability by the company.
10. Notices under these terms and conditions may be given in writing by delivering them by hand or e-mail or on ICICI Lombard General Insurance Company Ltd. website
www.icicilombard.com or by sending them by post to the last address of the Customer.
11. These terms and conditions will be governed by the laws of India and any legal action or proceedings arising out of these Terms and Conditions shall be initiated in the courts or tribunals at Mumbai in India.
12. I / We further undertake to refund any excess amount whether demanded by ICICI Lombard General Insurance Company Ltd. or not, which has been credited in excess to my account at any time due to any reason within 7 days of such receipt of such communication from ICICI Lombard of such excess credit or such information of excess credit coming to the knowledge of the Customer through any other source.
13. I/ We agree that my/our claim payment will be credited from the date ICICI Lombard General Insurance Company Ltd. gets confirmation from its bankers, This facility will continue unless it is revoked by any party and any issuance of relevant credit instruction from ICICI Lombard General Insurance Company Ltd. to its bankers will be valid till such instruction is complete irrespective of the fact that the notice period has expired provided such a credit request has been made by ICICI Lombard General Insurance Company Ltd. before the expiry of the notice period of the Customer.
Signature of the Account Holder
Part - C (For Direct Fund Transfer/EFT)
© Your Claim details is just an SMS away -
• For Cashless enquiry: SMS "ILHC AL <12-digit-AL-No.>" send to 575758
• For Claim enquiry: SMS "ILHC CL <12-digit-CL-No.>" send to 575758
• For Payment details: SMS "ILHC PAY <12-digit-Claim-No.>" send to 575758
(AL No. & CL No. is the one you have received on your mobile no. after intimating us)
© Please check your Claim status at: www.icicilombard.com/track-your-claim-status.html
013120MI/SC (V-2)
Proof of Identify
(Any one of below mentioned documents required)
Proof of Residence
(Any one of below mentioned documents required)
Passport
PAN Card
Voter’s Identity Card
Driving License
Please note ONLY for Individual / Retail Policy holders: If the Total Claimed Amount exceeds 100,000, the below documents are mandatory as per AML guidelines set by IRDA
1. Two passport size photos of proposer/ insured
2. One Photocopy of Proof of Identity
3. One Photocopy of Proof of Residence (any 1 in the below list)
(any 1 in the below list)
Electricity bill
Ration card
Letter from any recognized public authority
Passport
Written confirmation from the banks where the prospect is a customer, regarding identification and proof of residence.
Part - D (Know Your Customer) KYC
Proofs of (both) Identify and Residence
Current Statement of bank account with details of permanent/ present residence address (as downloaded) Valid lease agreement along with rent receipt, which is not more than three months old as a residence proof.
Telephone bill pertaining to any kind of telephone connection like, mobile, landline, wireless, etc. provided it is not older than six months from the date of insurance contract Employer’s certificate as a proof of residence (Certificates of employers who have in place systematic procedures for recruitment along with maintenance of mandatory records of its employees are generally reliable)
Letter from a recognized Public Authority (as defined under Section 2 (h) of the Right to Information Act, 2005) or Public Servant (as defined in Section 2(c) of the The Prevention of Corruption Act, 1988’) verifying the identity and residence
of the customer Letter issued by Unique Identification Authority of India containing details of name, address and Aadhaar number.
Job card issued by NREGA duly signed by an officer of the State Government
Current Passbook with details of permanent/present residence address (updated upto the previous month)
Personal identification and certification of the employees of the insurer for identity of the prospective policyholder.
© Your Claim details is just an SMS away -
• For Cashless enquiry: SMS "ILHC AL <12-digit-AL-No.>" send to 575758
• For Claim enquiry: SMS "ILHC CL <12-digit-CL-No.>" send to 575758
• For Payment details: SMS "ILHC PAY <12-digit-Claim-No.>" send to 575758
(AL No. & CL No. is the one you have received on your mobile no. after intimating us)
© Please check your Claim status at: www.icicilombard.com/track-your-claim-status.html
INFORMATION
KYC is an acronym for "Know your Customer," a term used for Customer Identification Process as per AML (Anti Money Laundering) guidelines set by IRDA. It involves making reasonable efforts to determine true identity and beneficial ownership of accounts, source of funds, the nature of customer's business, reasonableness of operations in the account in relation to the customer's business, etc., which in turn helps the financial institutions to manage their risks prudently. The objective of the KYC guidelines is to prevent financial institutions being used, intentionally or unintentionally by criminal elements for money laundering.
KYC is applicable to customers of insurance for customer identification, means identifying the customer and verifying his/her identity by using reliable, independent source documents, data or information. KYC has two components - Identity and Address. While identity remains the same, the address may change and hence the financial institutions are required to periodically update their records.