To be filled

Part A
A1 Self Declaration
A2 Self Declaration
Available in Policy Copy/ Employee details policy and
A3 To track the insured
Available in Policy Copy By insured/insured the
A4 other details of
A5 Available in Discharge Summary relatives
A6 Self Declaration
A7 Self Declaration
A8 Available in Hospital Bills/ Self Declaration
A9
Available in Hospital Bills
A10 Checklist
A11, Page end Self declaration
To track the hospital
Part B
Hospital/ treatment
B1 Hospital Details To be filled by details and the
Doctor Details Treating doctor details related to the
B2
Patient details patient admission
B3
Treatment/ Procedure Details
B4 customers
B5 Required only for Retail/ Individual
Page end Hospital declaration
Part C
Patient's Name For Electronic fund
C1
Policy Number transfer to the bank
C2
Card No./UHID No. To be filed by Insured account
C3 Group/ Company name
C4
C5 Claim number (if allotted)
Mobile/ Contact no.
C6 proposer
C7 Provide any 1 document of
As per bank pass book
C8
Account holder's signature >1 lakh)
Page end
(0nly for Retail/ Individual customers if claiming As per IRDA, C-KYC is mandate
Part D available: for claims greater than
C-KYC No. KYC (C-KYC) no. To be filled by Insured
Yes
Please provide, if Central 1lakh

form
Piease fill the C-KYC
No
Documents Submitted
Yes No Type of document
Document
Original
S.No. filled Original
Claim form duly
1 Daycare Summary Original
Discharge Summary/
Final Hospital Bill Original
3
Payment Receipts Original
4
Investigation Reports Original
5
6
Pharmacy Bills Orniginal
Implant Sticker/ Invoice Photocopy
Doctor Prescriptions Photocopy
8
Consultation Paper
9 Photocopy
Age Proof
10.
Indoor Case Paper copy
Photocopy
11. self attested ID poof/ Bank attested
12. EFT (Copy of cancelled cheque/ Photocopy
IFSC code
of passbook with claiming > llakh) Original
Form (0nly for Retail/ Ind1vidual customers if
Copy of the Proposer/ Employee
Part D -C-KYC
13.
Mask first 8 digits of your Aadhaar
Card ^
(Mandatory)
Photocopy
14.
15. PAN Card Copy of the Proposer/
Employee
clan documents submitted.
Photocopy
digts of your aadhaar number in cla1n form and
Mask first 8
ICICILombard
Nibhaye Vaade
Lonmbard Healthcare, ICICI Bank Tower, Plot No. 12,
Financial District. Nanakram Guda, Gachibowli,
Hyderabad,
d0fice Address: 1CICI Lonbard House, 414, Veer Savarkar Marg, Near Sidahi Vinayak Temple, Prabhadevi. MumhaiTelangana-500032
MailingAddress: IClCI 40n nr
ihealthcare@icicilombard.com," Toll Free Number: 1800 2666. Toll
vww.icicilombard.com. " E-Mail us at: Free Fax Number: 1800 209 8880
Visit us at: IRDA Registration No. 115
 ICICI Lombard
aicICiCtombard ICICI Health Care
Nebhaye Vaade Lombard Health Care Claim Form - Hospitalisation
(Issuanco
ALL CLAIM SETTLEMENTS SHOULD 8E MADE THROUGH of thisPER
NEFT (AS fommis
IRDAnot CIRCULAR),
to be taken as PLEASE
an admission of liability)
PROVIDE YOUR BANK ACCOUNT DETAILS. REFER TO PARTC
mandatory documents
* Non-submission ot original bills and Please provide the originals &
Ireceipts is the main reason for delay in claim settlements.
Do You Know * To receive update on your claim status, provide your mobile no. &
E-mail ID
NYOu Can track your claim statuS at: www.icicilombard.com ->Claims->Health Claims-> Services-> Track your Clas
TO BE FILLED IN CAPITAL LETTERS ONLY Part- A(To be filled by Insured) Cashless Obtained: Yes No
A1. Typeof Claim: Main Hospitalisation Expenses Pre &Post Hospitalisation Expenses
A2. Details of the Insured person in respect of whom claim is made: (patient details)
Name of the Patient: A MSWAROOf ARNAL
Card No/ UHID of the Patient: IL2 | 44542 37 0 Y Completed age: Years 63 Months 0S
Gender: Male Female Transgender Date of Buth: 7O 6 /| 9s9
Occupation: Service Self Employed Homemaker Student RetiredOther (Please specify)
Are you previously covered by any other Mediclain/ Health Insurance: es No If yes, Company name:
6I SRI RAM NAGAR
Current residential address: R AMShARO0P JANGID
AC HRAAN NADI BENAR RoAD NAA DI KA PHAT AK
3 HOTWARA JAIPVR City: JAIPUR
Pincode:
State:R AJAST HAN
Mobile no. 6 8077 73 l Landline o.
E-mail:
Covaxin Sputnik Others
Covid Vaccination Status: Yes V No Name of the Vaccination Covishield
Dosage of Vaccination: 1st Dose 2nd Dose
("Mandatory)
For Individual/ Retail Policy
A3. For Group/Corporate Policy
Member ID No, Employee lD (Client |D):
*Claim Intimation Service Request no.:
Is this arenewal policy: Yes No
If Yes, kindly mention your previous policy no.:
Group Company name:

J ARWAL
A4. Name ofthe Proposer"/Employee: D E EPAK
Aadhaar No. of the Proposer"/Employee: 5 6 7 260| y4 |74 PAN No. of the Proposer/Employee AOWPJ y y 62K
(Polcy Holder. For Retail polcy, Proposer nane required. For Corporate policy, provide Empioyee name
Relationship with Proposer": F AT H¾ R
Wo X/ CardNo/ UHID: I L 2 I 495 9237 O0
Current Policy No.: 228126
of disease/ illness contracted or injury
suffered for 64
which lnsured Rospitalized(Diagnosis):
A5. Nature

AN kARA H OS P TAL
Name of hospital where admitted: S Single occupancy Awinsharing 3or more beds per room Others
Room category occupied: Day care
Date of Admission: 3 /|o
2 0 22 Time: 0Ogn Date of Discharge: I U20 22 Time: 40o Pom
detected:
Date of injury sustained or disease/ liness first
Road traffic accident Substance abuse/ Alcohol consumption Others
Self inflicted
If Injury, grve cause: Reported to police: Yes No MLC Report &Police FIR attached: Yes No (lfyes, attach repot)
No
1 Medico legal: Yes
System of Medicine:
incident? YesIfyes, provide AL/Claim No.
our policies tovwards the above No
Is there any another claim in any of
Topup/Additional policy: Yes No It yes, provide policy no.
A6. Are you covered under any Mediclaim/ Health Insurance: Date of commencerment of first Insurance without break
A7.Currently covered by any other contract: Date:
years since inception of Dignosis
Have you been hospital1zed in the last 4
odnod anv cain against this particular adnission date/ attached bils with any other lnsurance company If yes, attach settement lettor
Company name
Policy No. Sum Insured:
A8. Details of Claim
expenses claimed
a) Details of the treatment IL. Hospital1zation expenses
Pre-hospital1zation expenses:
ii. Post-hospitalization expenses 46 396 IV. Health-check up cost:
Vi. Others
V. Anbulance charges:
Total:
vi. Preospital1zation period Days
182s0
vii. Post-hospitalization period:
Days

Claim documents to be dispatched

to: lCICI Lombard Healthcare, ICICI Bank Tower, Plot No. 12, Financial District, Nanakram Guda, Gachibowli,
Hyderabad, TS-500032
 b) Claim for
i. Domiciliary Hospitalization:
Yes No
i. Day care: (lf yes, provide details in annexure)
Yes No
ii. Extended care/ Inpatient rehabilitation: Yes No
c) Details of lump sum/ cash
benefit claimed:
i. Hospital daily cash:
Maternity:
üi.Critical illness/PA/Donor Expenses:
IV. Convalescence:
V. Pre/ Post hospitalization lump sum
benefit: VI. Others:
A9. Details of the amount claimed
Bill heads (as applicable) Bill number Bill date
Bills attached Amount
Room rent
Doctors consultation/Visit charges
Investigation charges (Includes Radiology and Pathology reports)
Surgeon and Asst. surgeon charges |SEAJAL /CsS<
Anesthetist charges &Operation theatre charges |sEH JAL/i<ss<3 8 o 22 z3 743 o
Equipment charges/ Procedure charges
Cost of implant (If any)
Medicine charges (Includes ward and 0Tmedicines andconsumables)
Pharmacy charges
Taxes/Surcharges/Service charge
Miscellaneous/ Other charges
Pre hospitalization bills (lf any)
Post hospítalization bills (lf any)
Discount provided by hospital (lf any)
Totalclaimed amount (ln)(Total claimed amount should be equal to the amount in attached bill documents)

MANDATORY: COPY OF AADHAAR CARD^ AND PAN CARD ARE REQUIRED FOR ALL CLAIMS
ticking in the Yes/ No column below)
A10. In support of the above claim, Ienclose following documents in original (Please indicate by
Yes No Type of Document(s) - As Applicable Yes No
Type of Document(s) - *Mandatory 9. Age proof (Driving License/ PAN card/ Passport Aadhaar copy^)*
1. Claim formduly filled and signed*
Employee* 10. Part - C (For EFT/RTGS/ NEFT)*
2. Aadhaar Card ^ copy of the Proposer/
Proposer/ Employee* 11. ICICI Lombard GIC Authorisation Letter
3. PAN Card copy of the
4. Discharge summary* 12. Implant name and invoice (if any) with implant sticker
bill and other bills (if any)* 13. Indoor Case Papers
5. Hospital bills, Final/ main hospital 14. Prescription papers/ Consultation papers
receipts supporting bills
6. Hospital payment receipt &other 15. C-KYC FORM (Only for Retail/Individual customers claiming >Lakh)
ECG/ CT/ MRV USG/ HPE)
7. Investigation reports (Including prescription* 16. Others (details)
with doctors
8. Medicine/ Pharmacy bills
documents as per above serial number.
Films like x-ray film, CT Scan film, MRI Scan film, etc. are not required. Provide repots only
Piease attach all the
submitting the documents
A11.Please provide the reason for delay in
Discharge)
(Post 30 days from Date of

Declaration by the lnsured:

information 1furnished best of my knowledge and belief. If I have
in this claim form is true and correct to the
Iherebydeclare that the made any false or
or concealment of any material fact with respect to questions asked in relation to this
untrue statement, suppression claim, my right to claim
consent and authorize TPA insurance company, to seek necessary medical
reimbursement shall be forfeited. Ialso nformation documents from any
enlMedical Practitioner who has attended on the person against wnom tnis caim is made. I hereby declare that I have inchuded ll the k
nrthe nuroose of this claim and that Iwill not be making any supplementary claim except the pre/ post-hospitalization claim if any

Date:
Place Insured's Signature
n clan form and cln docu1ents subnutted.
Mask first 8 digits of your aadhaar nuber

ICICI Lorrmbard Healthcare, ICICIBank Tower, Plot No. 12, Financial District,
Dis Nanakram Guda, Gachibowli, Hyderabad,
Claim documents to be dispatched to:
TS-500032
Yoar Clm dotal re jt SMS ws Please SMS <iEYWoRD> to 57 57 50
cloim Statis:<RWORD>5CGYoyment detala ckawoRD> b UNC PAY 2
AL No. &CL No. is the on0 yo have oceived on your mobile n. after intimating us)
i claim statun., plbesa clickc tpswww.iclcdonmbard.com-Meath-Care/ Customer ClainStn
1. Details of the Hospital/ Part B(To be filled by Treating Doctor/ Hospital only)
Nursing home in which tratment was taken
ame of the Hospital/ Nursing home: S NW ARn e M6S P174L
ddress:
PwG VDw JA1roK
ity:
State RA J ASZH AN
Mobile no. 737Y44187
Pincode: 1o 2i 31 Telepthone no.:
ROHINI ID*: provide below details
Type of Hospital. Network Non Network If Non Network,
Registration No. with State Code: PAN:
Number of Inpatient beds:
Facilities available in the hospital: 0T: ICU:
B2. Details of the attending Medical Practitioner/ Doctor/ Treating Physician or Surgeon
Name:
Qualification: Registration no: o
Telephone no. Mobile no. 3514yy987
B3. Details of the patient admitted
Name of the patientR A m SwARooP JA HhD Months Date of Birth:
IP Registration no.: Gender: M Age:G 3 Years
Time:
Date of Admission: Time: Date of Discharge:
Type of Admission: Emergency Plasnee Day Care Maternity
Type of Treatment: Surgical Procedure Multiple Surgical Procedure Medical Treatment
Gravida Status: G A
IiMaternity, Date of Delivery:
Premature Baby: Yes No
Deceased
Status at time of discharge: Discharge to home Discharge to another hospital
Total claimed amount:
B4. Details of the procedure
Pre-authorizationobtained: Yes No lIf yes, Pre-autharization No.:
If authorization by network hospital not obtained, give reason:
Date of injury sustained or disease/ illness first detected:
Road traffic accident Substance abuse/Alcoholconsumption Others
If Injury. give cause: Self inflicted No MLC Report &Police FIR attached: Yes No (If yes, attach report)
If Medico legal: Yes No Reported to police: Yes
If not reported to Police, give reason:
FIR no.
consumption,test conducted to establish this:Yes No (If yes, attach report)
If injury due to substance abuse/alcohol
provided by your employer
B5.This section is mandatory only if your health policy is not
additional dignosis)
A) Diagnosis (1CD 10Code primary &
10 code )
iiPrimary diagnosis (with ICD
10 code)
i)Additional diagnosis (with ICD
CD10 PCS code)
i)Procedure diagnosis (with
given for present ailment
B) Nature of surgery/ treatment
(Prior to hospitalization)
C) Date of first consultation
patient during admission
D) Presenting complaints of the
the patient along with duration of illness
E) Past medical history ofconsultation paper)
(f yes, attach frst b all past
influence of alcohol during admission
F) Was the patient under ?
ailment is a complication of pre-existing disease
G) Whether the present treatment previous sur gery done?
complication of any
)tf yes. please specty the disease for)
detals
)f yes, please specty the
is congenital in nature ?
H) Whether the dsease/disorder
hosp1tal (including ICU)
) Number of in-patsent beds in the
Declaration by the hospital
ntormation furnished n thhs Claum form is vue &correct to the best of our knowledge and
We hereby declare that the beliet. If we have made any
i e runtrue statement, suppression or concealment of any inaterial tact, our right to claim under this clam shall be forte ited

Registration No. of Hespita

(Rubber stamp of th hospital) Date |2 202 Dr. PgeSealand Signatyre
sandCundtions, the Conkny reserves its ight to have the insured exanined by adoctot
As per the policy Terms appoinjed by it for verification of diagnosis.
Dr. Cn3arwar
RMC Na.8012
 ICICIdLombard
Nibhaye Vaade
Part -C - NEFT
ALL CLAIM For Direct Electronic FundForm
C1. Patient's Name:SETTLEMENTS SHOULD MADETHROUGH NEFT (AS PER IRDA
BE Transfer)
(in respect of whom
RAMShAROOP
claim is made):
CIRCULAR), PLEASE PROVIDE YOUR BANK ACCOUNT DETAILS.
c2. Policy Number: s 0
C3. Card No/ UHID ]6/X /22 8 |266 8
C4. Group/Company Name No.IL2| u954 23 u u/o| /00O
(for Group Corporate polcy holders): P H
C5. Claim Number allotted):
(if NDIT DE E NDH&L
C7. Email: C6. Mobile/ Contact No: 9 68077730|
t0.AS per ihDA UirCular No.:
claim through EFT. IRDA/F&A/CIR/GLD/056/02/2014 Pronnsersl noliey haldors bank account details are mandatory to prouss
Please provide ANY ONE of the below
documents of proposer/ policy
Piease provide a self-attested copy of a valid ldentity proof of the holder
Pronnser/Palicv holderinrovide any of the mentioned in documents Proot ot loenty uo re
Cancelled cheque copy
Bank attested copy of Passbook with IFSC code
C9. Please provide the below
details (all fields are compulsory)
" Proposer (policy holder)/ Employee name*(as per bank records):
" Proposer/ policy holder Bank account no.:
202 y 87059 8 6
" Name of the bank:
SBI
Branch name: Benad Roa d Ja ip uR
Address of the bank:
8enad Road ai puR
" |FSC code no. of the bank: SBI NO O yu 5 (should be same as per the provided cheque leaflet)
" PAN No. of the Proposer: AO Wp J su 6 2K
*Proposer/ Policy holder is the person who has paid premium for the policy.
For Retail policy, Name &Account details of Proposer required. For Corporate policy, Emplayee Name &Account details required.
Terms andConditions for Payments through RTGS/NEFT
1. The detais ormvided by the Proposers/ policy holder in the Mandate Form shall be considered as final and ICici Lombard Generallnsurance Company Ltd. shall not be responsible for cross verification of any of the dptailk
provided therein.
The RTCSNEET facidity shall be effective forthe respective Proposerís)/ policy holder within 15 days of thereceipt ofthe Mandate Form by lCiCI Lombard General Insurance Comoany Ltd and' or within suuch nenedae m
be reasonably required by ICICI Lombard General insurance Company Ltd. to activate the RTGS/ NEFTfacilty.
The Proposerpertain1ng
polcy holder agres that under the RTGS/ NEFT facity, there may be arisk of non payment in the Proposer' polcy holder Accounts No. on the day of the credit of pavments due tn channe in hs sente
to RTGS/NEFT facility or due to any other reasons without any faut/inaction/ falure on part of IClCI Lombard General
requlat1ons Insurance Company or any factor beyond the control of ICICI
insurance Company Limited.
Lombard General
agrees to indemnify. without delay or demur, ICICI Lombard dGeneral Insurance Company Ltd. and its agents and keep ICICILombard General Insurance
The Proposer/ policy holder Company Ltd. and its
harmless at all times from and against any and all claims, damages, losses, costs, and expenses (including attorney's fees) which ICICI Lombard
clauses.
L General Insurance Company Ltd. may suffer ar incur, agent indemnified
arising from or in connection wrth, amongst other things, either of the aforesaid reasons stated in above directily or indirecty.
employ agents to carry out any of its obligations under the RTGS NEFT facility. The
1CICI Lombard General insurance Company Ltd. May sub-contract and Proposer/ poicy holder may
RTGS/NEFT facitty by giving a min1mum of 15 days prior written notice to
ICICILombardrd General lnsurance Company Ltd. The notice of., such
s
termination should be given to ICICI Lombarddiscontinue or terminate the use of
oniy at its corporate address and
tesddreceedat iCiClL onbard GIC Ltd. ICICI Lombard House (Old Tata Press Building), 414, Veer SavarkarMarg. Near SiddhiVinayak Temple, Prabhadevi, Mumbai -40002s
Proposer/ policy holder will be acknowledged through a confirmation letter by ICICI Lom
confirnation of the receipt of termination notice given by the
A Lombard General Insurance Company Ltd. in no
poicy hcider construe his termination notice as effective undesssaa cconfirmation has been provided by ICICI Lombard to the Proposer policy holder
stating the date of receipt of such case can the Proposer
holder
communication by the Proposer poicy
transaction(s) through RIGS/ /NEFTfacility may attract inward RTGS/ NEFT charges, which iif levied by the
7 The Proposer/ pokcy holder agrees that Proposer's poicy holders bank, shall be borne by the
holder only. Proposer pohcv
supplerment any lerms and Cond1tion stated herein at any time and wil endeavor to give
ICICI Lombard has the absolute discretion to anend or prior notice of ten days for such
8
the Completion of such period whichever is earier, the Proposer/ policy holder shall be changes wherever easible for the Terms and
Conditions to be apphcable. By using the new services, or at deemed to have accepted the
Ghmson of docunents or bank detais or any other ntormation doesdelivering
not many way, shape or forn, imply or express or suggest admission otlability by the company changed lems and Conditions.
9.
in witng by them by hand ore-mal or on ICiClLombard General lnsurancee Company Ltd. webs1te
Notices under these Terrns and Conditions may be given
10
the last address of the Proposer/ pocy
holder.
laws ot lnda i and any legal action 0r proceed1ngs arisng out of these Terms and Condi
wwwICIcilombard.com
nditions shall be instated in the courts or
or by sendìng them by
post to
These Terns and Conditions wil be governed by the tribunals at
excess amount whether demanded by ICiCi Lombard General lnsurance Company Ltd. or n0t, which has been creditedin Munbai a lhcha
12 IWe funher undertake to fefund any excess to my accvunt at any time
frorn IC1C)Lombardof such excess cred1t or such intormation of eXcess credt coming tu the knowledye of the
days of such recept of such communcation Proposec/ pobcy holder through any other
due to any reason within 7
Credited from the date ICICI lombard General lnsurance Company Ltd. gets confirmation from its bankers source
|We agree that rny/ our clain payment val be This facilkty will
13
issuance of relevant credit instructuon from
iCiCI Lombard dGeneral lnsurance Company l td. to its bankers wil be vabd tll such instruction iSi coInplete continue unless it is revoked by
any party and any
acedit eQuesthas been made by ICICI Lombard General insurance Company lid belore the enpiry ot the notice pernod of the Proposer' pohcy holder
irespectve ot the fact that the notice period has
expired provided such

Account Holder's Signature

ICICICLombard
Nibhaye Vaade
Mailing Address: ICICI Lombardd Healthcare, ICICIBank Tower, Plot No. 12,Financ1al D1strict, Nanakram Guda,
Hyderabad, Gachibowli,
RegisteredVisitOffice Address: ICICI Lombard House, 414, Veer Savarkar Marg. Near Siddhi Vinayak Tenple, Prabhadev
us at: www.icicilombard.coin, " E-Mail us at: ihealthcare@icicilombard.com. Toll Free
Telangana-500032
Miangana
" Toll Free Fax Number: 1800 209 8880 " IRDA Registration No, 115 Number: 1800 2666.
 lCiCILombard
Nibhaye Vaade
lCICI Lombard Health Care Claim Form - ICICI Lombard
of (lssuance this form is not to be taken as an Hospitalisation
admission of
liability)
Health Care

Part A
Overview Health Claim Form - Hospitalization
A Self Declaration To be filled Requirement
A2 Self Declaration
A3
Available in Policy Copy/ Employee details
A4
Available in Policy Copy
A5 Available in Discharge Summary
A6 By insured/ insured To track the policy and
Self Declaration
relatives other details of the insured
A Self Declaration
AS
Available in Hospital Bills/ Self Declaration
A9 Available in Hospital Bills
A10 Checklist
A11, Page end Self declaration
Part B
B1 Hospital Details
B2 Doctor Details
To be filled by HospitalV To track the hospital
B3 Patient details Treating doctor details and the treatment
B4 Treatment / Procedure Details details related to the
B Required only for Retail/ Individual customers patient admission
Page end Hospital declaration
Part C
Patient's Name
C2 Policy Number
C3 Card No/UHID No. For Electronic fund
C4 Group/ Company name To be filled by Insured transfer to the bank
C5 Claim number (if allotted) account
C6 Mobile/ Contact no.
C7 Provide any 1document of proposer
C8 As per bank pass book
Page end Account holder's signature
C-KYC No. Part D(0nly for Retail/ Individual customers if claiming >1lakh)
Yes Please provide, if Central KYC (C-KYC)no. available: As per IRDA, C-KYC is mandate
To be filled by Insured for claims greater than
71 lakh
No Please fill the C-KYC form

Documents Submitted
Document Yes
S.No. N
1 Claim form duly filled Type of document
2
Discharge Summary/ Daycare Summary Original
3 Final Hospital Bill Original
4 Payment Receipts Original
5 Investigation Reports Original
6 Pharmacy Bills Original
Implant Sticker/ Invoice Original
8 Doctor Prescriptions Original
9 Consultation Paper Photocopy
10 Age Proof Photocopy
11 Indoor Case Paper
EFT(Copy of cancelled cheque/ self attested lD poot/ Bank attested copy Photocopy
12
of passtook vwth IFSC code
Photocopy
13 Part D- C-KYC Forn (0nly tor Retal ndivIdual customers if claimng >Tlakh) Photocopy
14. Mask first 8digits of your Aadhaar Card^ Copy of the Proposer/ Employee
PAN Card Copy of the Proposer/ Employee (Mandatory)
Original
15.
^ Mask frst &digits of your sadhaar umtber un claur fonand claun documents subaNtted
Photocopy
Photocopy
aICICiClombard
Nibhaye Vaade
Mailing Address: ICICI Lombard Healthcae, ICICI Bank Tower, Plot No. 12, Fnancial Distrct, Nanakram Guda
Registered Office Address: ICICI ILombard House, 414, Veer Savarkar Marg Near Siddhi Vnayak Temple. Gachibowi, Hyderabad,
Visit us at: www.icicilombad.com. " E-Mail us at: ihealthcare(@icicilombard. com," Toll Free Number: 1800 2666.Prabhadevi, Telangana-500032
Toll Free Mumbai 400 025.
Fax
IRDA Registration No. 115 Number: 1800 209 8880
 ICICICLombard
Nibhaye Vaade ICICI Lombard Health Care Claim ICICI Lombard
Form -
SHOULD BE MADE THROUGH NEFT (AS PERform is not to be taken as an admissionHospitalisation
Health Care
ALL CLAIM SETTLEMENTS S (Issuance of this
of liabilty!
IRDA YOUR BANKACCOUNT DETAILS. REFER TO PART C.
Do You Know
*
Non-submission of original bills and receipts is the mainCIRCULAR), PLEASE
* To receive update on
PROVIDE
originals &mandatory documents
reason for delay in claim settlements. Please provide the
your claim status, provide your mobile no. &E-mail ID
* You can track your claim
status at:
TO BE FILLED IN CAPITAL LETTERS ONLY www.icicilombard.com->Claims->Health
Part - A(To be filled by Insured)
Claims >Services> Track your Ciaia
A1. Typeof Claim: Main
A2. Details of the Insured Hospitalisation Expenses
person in respect of whom claim is made:
Pre &Post Hospitalisation Expenses Cashless Obtained: Yes No

Name of the Patient: (patient details)

Card No./ UHID of the Patient:
Gender: Male Female Transgender Completed age: Years Months
Date of Birth:
Occupation: Service Self Employed Homemaker (Please specify)
Student Retired Other
Are you previously covered by any other Mediclaim/
Health Insurance: Yes No .If yes, Company name:
Current residential address:

City:
State: Pin code:
Mobile no. Landline no.
E-mail:
Covid Vaccination Status: Yes No Name of the Vaccination Covishield Covaxin Sputnik Others
Dosage of Vaccination: 1st Dose 2nd Dose
A3. For Group/Corporate Policy For Individual/ Retail Policy ('Mandatory)
Member ID No./Employee ID (Client ID): *Claim Intimation Service Request no.:
Is this a renewal policy: Yes No

Group/Company name: If Yes,kindly mention your previous policy no.:

A4. Name of the Proposer*/Employee:

Aadhaar No. of the Proposer"/Employee: PAN No. of the Proposer*/Employee:
Relationship with Proposer*: ('Policy Holder. For Retail policy, Proposer name required. For Corporate policy. provide Employee name

Current Policy No.: Card No./UHID:

A5. Nature of disease/illness contracted or injury suffered for which Insured was hospitalized (Diagnosis):

Name of hospital where admitted:

Single occupancy Twin sharing 3or more beds per room
Room category occupied: Day care Others
Date of Admission: Time: Date of Discharge:
Time:
lness first detected:
Date of injury sustained or disease/
inflicted Road traffic accident Substance abuse/ Alcohol consumption
If injury, give cause: Self Others
If Medico legal: Yes No Reported to police: Yes No MLC Report &Police FIR attached: Yes No (lfyes, attach report)
Systen of Medicine:
towards the above incident? Yes No
Is there any another claim in any of our policies If yes,provide AL/Claim No.
policy : Yes Ifyes, proide policy no.
Are you covered under any Topup/Additional
No
A6.
Insurance: Date of commencement of first
AZ.Currently covered by any other Mediclaim/ Health Insurance without break:
been hospital1zed in the last 4 years since inception of contract: Date:
Have you Dignosis:
admission date/ attached bills with any other
Have you lodged any claimagainstthis particular lnsurance company: t yes, attach settlement letter,
Company name: Policy No.
Sum nsured:
A8. Details of Claim
clairmed
a) Details of the treatment expenses
I. Pre-hospitalization expenses: i. Hospital1zation expenses:
ii. Post-hospitalization expernses: IV. Health- check up cost:
Ambulance charges: VI. Others
Total:
v, Pre-hospitalization period Days Vii. Post-hospital1zation period:
Lombard Healthcare, ICICI Bank Tower, Plot No. 12.
Days
Claim documents to be dispatched to: ICICI Financial District,
 b) Claim for
i. Domiciliary Hospitalization: Yes No (If yes, provide details in annexure)
il. Day care:
Yes No
ii, Extended care/ Inpatient
rehabilitation: Yes No
c) Details of lump sum/ cash benefit
claimed:
i. Hospital daily cash:
. Maternity:
ii. Critical illness/PADonor Expenses: Convalescence:
V. Pre/ Post hospitalization lump sum benefit: vi. Others:
A9. Details of the amount claimed
Bills attached Amount
Bill heads (as applicable) Bill number Bill date
Room rent
Doctors consultation/Visit charges TALSO2e47 T o 2 2TYES 350/
Investigation charges (Includes Radiology and Pathology reports) JAlSOp/2/3023 3 |T0 2 2 y£S
Surgeon and Asst. surgeon charges 750o/
Anesthetist charges &Operation theatre charges YCS 737 430 -
JALSIP/22.)2934 & I o22
Equipment charges/ Procedure charges
Cost of implant (If any)
Medicine charges (lncludes ward and 0T medicines and consumables)
Pharmacy charges JAL sOP/9eTo 22 VES
Taxes/Surcharges/Service charge
Miscellaneous/Other charges
Pre hospitalization bills (lf any)
Post hospitalization bills (If any)
Discount provided by hospital (lIf any)
Total claimed amount (ln )(Total claimed amount should be equal to the amount in attached billdocuments) 4225o
MANDATORY:COPY OF AADHAAR CARD AND PAN CARDARE REQUIRED FOR ALL CLAIMS
ticking in the Yes/ No column below)
A10. In support of the above claim, Ienclose following documents in original (Please indicate by
Type of Document(s) - *Mandatory Yes No Type of Document(s) - As Applicable Yes No
9. Age proof (Driving License/ PAN card/ Passport/ Aadhaar copy ^)
1. Claim form duly filled and signed*
Proposer/ Employee* 10. Part - C(For EFT/RTGS/NEFT)*
2. Aadhaar Card ^ copy of the 11. ICICI Lombard GIC Authorisation Letter
the Proposer/ Employee*
3. PAN Card copy of 12. Implant name and invoice (if any) with implant sticker
4. Discharge summary*
13. Indoor Case Papers
hospital bill and other bills (if any)*
5. Hospital bills, Final/ main 14. Prescription papers/ Consultation papers
6. Hospital payment receipt &
other receipts supporting bills*
15. C-KYC FORM (Only for
(Including ECG/ CT/ MRV USG/ HPE) Retai/Individual customers, claiming > lLakh)
7. Investigation reports* 16. Others (details)
with doctors prescription*
8. Medicine/ Pharmacy bills number. Films like x-ray film, CT Scan film, MRI :|Scan film, etc. are not required. Provide reports only
as per above serial
attach all the documents
Please
documents
delay in submitting the
A11.Please provide the reason for
Discharge)
(Post 30 days from Date of

Declaration by the Insured:

information furnished in this claim form is true and correct to the best of my knowledge
and belief. If Ihave made any false or
lhereby declare that the of any material fact with respect to questions asked in relation to this
suppression or concealment
untrue statement, claim, my right to claim
reimbursement shall be forfeited. I also
consent.and authorize TPA/insurance company, to seek
medical necessary 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/
ite for the purpose of this claim and that Iwill not be making any supplermentary clam except the pre/ post-hospitalization caim fen.

Date:
Place: Insured's Signature:
first 8 digits of your aadhaar number in claim form and claim docunents subrnitted.
^Mask

to: ICICI Lombard Healthcare, ICICI Bank Tower, Plot No. 12, Financial District, Nanakram Guda, Gachibowli,
Claim documents to be dispatched
Hyderabad, TS-500032
AYour claim detais are just an SMSaway,PleaseSMS <KEYWORD>to575758
NGA2digit-AL-No. Claim Status <KEYWORD Is LHC CL <12-digie-C-No. Payment
AL No. &CtNo. is the one you havereceivod on yourmobile. no, after intimating, us) detal s:<KEYwORDLHGPAY <12-digi-ClaimNo.
wFoal time cioimstatus, please cick: https:/www.icicilombard.convL-Health-Care/Customer/ClaimSe
 Part- B (To be filled by Treating Doctor/ Hospital only
B1. Details ofthe Hospita/ Nursing home in which
treatment was taken
Name of the Hospital/ Nursing home:
Address:
City: State:
Pincode: Telephone no.: Mobile no.:
details
ROHINI ID*: Type of Hospital: Network Non Network . If Non Network, provide below
Number of Inpatient beds:
Registration No. with State Code: PAN:
Facilities available in the hospital: 0T: ICU:
B2. Details of the attending VMedical Practitioner/ Doctor/ Treating Physician or Surgeon
Name:
Qualification: Registration no:
Telephone no.: Mobile no.:

B3. Details of the patient admitted

Name of the patient:
Months Date of Birth:
IP Registration no.: Gender: Age: Years
Time:
Date of Admission: Time: Date of Discharge:
Type of Admission: Emergency Planned Day Care Maternity
Type of Treatment: Surgical Procedure Multiple Surgical Procedure Medical Treatment
Gravida Status: G P A L
If Maternity, Date of Delivery:
Premature Baby: Yes No
Discharge to another hospital Deceased
Status at time of discharge: Discharge to home
Total claimedamount:
B4. Details of the procedure
Pre-authorization obtained: Yes No Ifyes, Pre-authorization No.:
Ifauthorization by network hospital not obtained, give reason:
Date of injury sustained or disease/illness first detected:
Road traffic accident Substance abuse/Alcohol consumption Others
If Injury, give cause: Self inflicted
If Medico legal: Yes N Reported to police: Yes No MLC Report &Police FIR attached: Yes No (lf yes, attach report)
FIR no. Ifnot reported to Police, give reason:
If injury due to substance abuse/alcohol consumption, test conducted to establish this: Yes No (If yes, attach report)
by your employer
B5. This section is mandatory only if your health policy is not provided
dignosis)
A) Diagnosis (ICD 10 Code primary &additional
i)Primary diagnosis (with ICD 10 code )
code)
ii) Additional diagnosis (with lCD 10
(with ICD 10 PCS code)
iii)Procedure diagnosis
for present ailment
B) Nature of surgery/ treatment givenhospitalization)
C) Date of first consultation
(Prior to
D) Presenting complaints of the patient during admission
along with duration of illness
E) Past medical history of the patient
consultation paper)
(lf yes, attach first &all past
alcohol during admission
F) Was the patient under influence of
G) Whether the present treatment ailment is acomplication of pre-existing disease?
i) If ves, please specify the disease (or) complication of any previous surgery done ?
ii) lf yes, please specify the details
in nature ?
H) Whether the disease/ disorder is congenital
(including ICU)
I) Number of in-patient beds in the hospital
Declaration by the hospital
information furnished in this Claim Form is true &correct to the
We hereby declare that the best of our
false or untrue statement, suppression or concealment of any material fact, our right to claim under this knowledge
claim
and belief. If we have
made any
shall be forfeited.
Registration No. of Hospital
(Rubber stamp of the hospital) Date:

As per the policy Terms and tConditions, the Company reserves its right to have the Insuredd exanined byadoctor appointed byDoctor'
it for
s Seal and Signature
verificationof diagnosis.
 LOMbard
Nibhaye Vaade
ALL CLAIM
Part- C NEFT Form
(For Direct Electronic
C1. Patient's Name:
SETTLEMENTS SHOULD BE MADE THROUGH NEFT (AS PER Fund Transfer)
(in
IRDA CIRCULAR), , PLEASE PROVIDE YOUR BANK ACCOUNT DETAILS,
respect of whom claim is made):
c2. Policy Number:
C3. Card No./ UHID No.
C4.
Group/Company Name (tor Group/Corporate policy holders):
C5.Claim Number (if
C1. Email:
allotted): C6. Mobile/ Contact No.:

3. AS per lRUA Circular No.:

claim through EFT.
IRDA/F&A/CIR/GLD/056/02/2014 Pronnser's/ nolicy hoiders bank account details are mandatory to process tie
Please provide ANY ONE of the beiow documents of
proposer/ policy holder
Please provide aselt-attested copy of a valid ldentity proof of the Pronnser/Pnlicy holder (nrovide any of the mentioned documents in Proof of ldentity under Part-U)
Cancelled cheque copy
Bank attested copy of Passbook with IFSC code
C9. Please provide the below details (all fields are
compulsory)
" Proposer (policy holder)/ Employee name*(as per
bank records):
Proposer/ policy holder Bank account no.:
" Name of the bank:
" Branch name:
" Address of the bank:

" IFSC code no. of the bank: (should be same as per the provided cheque leaflet)
" PAN No. of the Proposer:
Proposer/ Policy holder is the person who has paid premium for the policy.
orRetail policy, Name &Account details of Proposer required. For Corporate policy, Employee Name &Account details required.
erms and Conditions for Payments through RTGS/NEFT
The deteis oovided by the Proposers/ policy holder in the Mandate Form shallbe considered as final and ICICI Lombard General Insurance Company Ltd. shal not be responsible for cross verfication of any of the erais
provided therein.
The pTCS:NEET feciitvy shall be effective for the respective Proposer(si policy holder within 15NEFT
days facility.
ofthe receipt of the Mandate Form by ICiCI Lombard General lInsurance Company Lrd. and' or within such perniod as may
Company Ltd. to activate the RTGS/
be reasonabBy required by IClCI Lombard General lnsurance facility.
under the RTGS/ NEFT there may be a risk of non-payment in the Proposer/ policy holder Accounts No..onthe day of the cre dit of payments due to change in the appicable
The Prop0 ser/ policy holder agrees that
e t oRTCS/NEFT facility or due to any other reasons without any fauBt inaction' failure on part ofICICILombard General Insurance Company or any factor beyond the control of ICICI Lombars Ranel
insurance Company L1mited.
indemnify, without delay or demur, ICICI LLombard General Insurance Company Ltd. and its agents and keep ICICI Lombard General Insurance Company Ltd. and its agent indemnfed
The Proposer/policy hoider agrees to all claims, damages, losses, costs, and expenses (including attorney's fees) which ICIC! Lombard General
harmiess at all times from and
against any and Insurance Company Ltd. may suffer ar incur, directy or incirecty.
stated in above clauses
from or in connection with, amongst other things, eitherofthe aforesaid reasons
arising May sub-contract and employ agents to carry out any of its obligations under the RTGS NEFT facility. The Proposer
Company Ltd. poicy holder may discontnue or terminate the use af
ICICI LGmbard General Insurance prior written notice to lCICI Lombard General lnsurance Company Ltd. The notice of, such termination should be given to ICICI Lombard oniy at its
minimum of 15 days
RTGS/NEFT facilety by gving a House (0ld Tata Press Building), 414, Veer Savarkar Marg, Near Siddhii Vinayak Temple, Prabhadevi, Munmbai - cerporate address and
Lombard GIC Ltd., ICICILombard 400025.
be addressed at iCICI the Proposer/ policy holder will be acknowledged through aaconfimation letter by IC1CI
notice given by
confirmation of the receipt of termnation as effective unless a confirmation has been provided by ICICI lLombard to the Proposer/ policy holder
Lombard General Insurance Company Ltd. In no case can
A
termination notice stating the date of receipt of such communication by the the PropOse
pokcy hoider costrue his Proposec pokcy
holder. RTGS/ /NEFT facility may attract inward RTGS/ NEFT charges, which it levied by the
agrees that LransaCtion(s) through Proposers/ policy holders bank, shall be bone by the
The Proposer/ pohcy hoider Propesec pobcy
holder only. supplement any Terms and (Condition stated herein at any time and wil endeayor to give pnor notice of ten days for such
absolute discreton to arnend or changes wherever feasibie for the Terms and
ICICI Lombard has the the new services, orat the completion of such
period, whichever is earlier,.tthe Proposer' policy holder shail be deemed to have
Conditions to be apphcable.By using does not in any way, shape or form, imply or rexpress or accepted the changed Terms and Conditons.
detads or any other information suggest admission of liab1lity the company.
by
Subm1sSI0n of documents orbank vwnting by del1vering thern by hand or e-nad or on ICICI Lombard General lnsurance Company Ltd.
Notices under these Terms and Conditsons may be given n website
10. Proposer/ polcy holder
www..ciciiombard.com or by sending them by post to
the last address of the the lavws of Indúa andany legal action oI proceedings ar1sng out of these Terms and Condtions shall be
These Terrns and Condituons vwll
be yoverned by intated n the courts or tribunas at Mnba hnda.
1.
IWe futher undertake to orefund ariy excess atnount whether denanded by ICICiLombard Generalinsurance Company Ltd. or not, which has been credited in excess to
CICILombarduf such excess credit or such untonmatonunofexcess credit my account at any
12.
days ofsuch receipt uf such
conmuicatiun from coming tu the knowedge of thePropeser polcy holder thrvugh any hte due to any reason within 7
fromn the date ICICI Lombard General lnsurance Company Ltd. gets
confirmation from its bankers, This facity will other source.
my/our claim pa yment wl be credited