A/�/C/�Lombard ICICI Lombard Health Care Claim Form - Hosnitalisation

.,Nibhaye Vaade --- "'

!Issuance of this form is not to be taken as an admission of liabilityl
ALL CLAIM SETTLEMENTS SHOULD BE MADE THROUGH NEFT (AS PER IRDA CIRCULAR).

*
* Non-submission of original bills and receipts is the main reason for delay in claim settlements. Please provide the originals & mandatory documents
- To receive update on your claim status, provide your mobile no. & E-mail ID
* You can track your claim status at: www.icicilombard.com ➔Claims ➔ Health Claims ➔ Services ➔ Track your claims
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Part - A (To be filled by Insured)
TO BE FILLED IN CAPITAL LETTERS ONLY
A 1. Type of Claim : Main Hospitalisation Expenses_J
✔ Pre&Post Hospitalisation Expenses _J Cashless Obtained: Yes _J No _J
A2. Details of the Insured person in respect of whom claim is made: (patient details)
K _J
Name of the Patient: _J E _J_J_J
E R T _J
H _J
I _J_J_J
S I _J_J_J_J_J
D D E S H _J_J_J_J_J
W A R _J_J_J_J_J_J_J_J _J _J _J_J_J_J_J_J
Card No./ UHID of the Patient: I L 1 2
_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J
Gender: Male _J
✔ Female _J Date of Birth: _J_J 0�
2 7 I _J 1 9 �2.J
7 I _J2.) 9 7 Completed age: Years _J_J Months _J_J
Occupation: Service_j Self Employed _J Homemaker _J Student _J Retired_J Other _J (Please specify)--------
Are you previously covered by any other Mediclaim/ Health lnsurance:Yes _JNo _J_ If yes, Company name: ---------
T E S T T E S T
Current residential address: _J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J
_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J
T E S T
_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_Jc�_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J
State· T _J
E _J
S _J 5 _J
T _J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J Pin code: _J 6 _J
4 _J
3 _J
2 _J
1
9 8 4 5 3 5 2 8 7 1
Mobile no. _J_J_J_J_J_J_J_J_J_Jlandline no. _J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J
T E S T I N G + P G O P D @ P L U M H Q . C O M
E-mail: _J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J
A3. For Group/Corporate Policy For Individual/ Retail Policy (*Mandatory)
D _J
Member ID No./ Employee ID (Client ID): _J 1 _J_J
2 _J_J_J_J *Claim Intimation Service Request no.: _J_J_J_J_J_J_J_J_J_J_J
_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J Is this a renewal policy: Yes _J No _J
P _J
Group/ Company name:_J A _J
Y _J
- _J
P _J
E _J
R _J_J
- U _J
S _J
E _J
- _J
T If Yes,kindly mention your previous policy no.:_J_J_J_J_J_J_J_J_J
E S T I N G - 2 T 0 C R V O
_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J _J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J
A4. Name of the Proposer/Employee: K E _J_J_J
_J_J E R T _J
H _J_J_J_J_J
I S I D _J_J_J_J_J
D E S H W _J_J_J_J
A R _J_J_J_J_J_J_J_J_J_J_J_J
Relationship with Proposer*: _J
S _J
E _J
L _J
F _J_J_J_J_J_J_J_J (*Policy Holder. For Retail policy, Proposername required. For Corporate policy, provide Employeename)

Current Policy No.: 1 2 3 1 2 3

_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J Card No./ UHID: _J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J
I L 1 2
A5. Nature of disease/illness contracted or injury suffered for which Insured was hospitalized (Diagnosis): _________

Name of hospital where admitted: T E D T

_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J
Room category occupied: Day care _J Single occupancy _J Twin sharing _J 3 or more beds per room _J Others ________
Date ofAdmission:_J_J 0 1 / 2.)2.)�2.J
0 2 I _J_J 2 0 2 4 Time: _J_J_J_J Date of Discharge: _J_J 0 1 / 2.)2.)�2.J
0 4 / _J_J 2 0 2 4 Time: _J_J:_J_J
Date of injury sustained or disease/lllness first detected: _J� I _J� I 2.)2.)�2.J
If Injury,give cause: Self inflicted _J Road traffic accident _J Substance abuse/Alcohol consumption _J Others --------
1 f Medico IegaI: Yes_J No_J Reported to police: Yes _J No_J MLC Report&PoliceFIR attached: Yes _J No _J (lf yes,attach report)
System of Medicine: _________________________________
Is there any another claim in any of our policies towards the above incident? Yes _J No _J . If yes,provideAL/Claim No. -------
A6. Are you covered under any Topup/Additional policy : Yes_J No_J If yes,provide policy no.-------------
A 7. Currently covered by any other Mediclaim/ Health Insurance: _J _J Date of commencement of first Insurance without break: _J_J_J_J_J_J
Have you been hospitalized in the last 4 years since inception of contract: _J _J Date: _J_J I _J _J I _J Dignosis: ----- 2-J 2-J 2-J
Have you lodged any claim against this particular admission date/ attached bills with any other Insurance company: If yes,attach settlement letter,
Company name: ________ Policy No. ____________ Sum lnsured:t _J_J_J_J_J_J_J
AS. Details of Claim
a) Details of the treatment expenses claimed
i. Pre-hospitalization expenses: t _J_J_J_J_J_J_J ii. Hospitalization expenses: t _J_J_J_J_J_J_J
iii. Post-hospitalization expenses: t _J_J_J_J_J_J_J iv. Health-check up cost: t _J_J_J_J_J_J_J
v. Ambulance charges: t _J_J_J_J_J_J_J vi. Others ---- t _J_J_J_J_J_J_J
Total: 1 2 5 0 0 0
t _J_J_J_J_J_J_J
vii. Pre-hospitalization period _J_J_J Days viii. Post-hospitalization period: _J_J_J Days
b) Claim for
i. Domiciliary Hospitalization: Yes _J No _J ii. Day care: Yes _J No _J iii. Extended care/ Inpatient rehabilitation: Yes _J No _J
 c) Details of lump sum/ cash benefit claimed:
i. Hospital daily cash: t _J_J_J_J_J_J_J ii. Maternity: t _J_J_J_J_J_J_J
iii. Critical illness/PA/Donor Expenses: t _J_J_J_J_J_J_J iv. Convalescence: t _J_J_J_J_J_J_J
v. Pre/ Post hospitalization lump sum benefit: t _J_J_J_J_J_J_J vi. Others: t _J_J_J_J_J_J_J
A9. Details of the amount claimed
Bill heads (as applicable) Bill number Bill date Bills attached Amount
Room rent _J _J _J _J _J _J _J _J t _J_J_J_J_J_J_J
Doctors consultation/Visit charges _J _J _J _J _J _J _J _J t _J_J_J_J_J_J_J
Investigation charges (Includes Radiology and Pathology reports) _J _J _J _J _J _J _J _J t _J_J_J_J_J_J_J
Surgeon and Asst. surgeon charges _J _J _J _J _J _J _J _J t _J_J_J_J_J_J_J
Anesthetist charges & Operation theatre charges _J _J _J _J _J _J _J _J t _J_J_J_J_J_J_J
Equipment charges/ Procedure charges _J _J _J _J _J _J _J _J t _J_J_J_J_J_J_J
Cost of implant (If any) _J _J _J _J _J _J _J _J t _J_J_J_J_J_J_J
Medicine charges & Pharmacy charges _J _J _J _J _J _J _J _J t _J_J_J_J_J_J_J
Taxes/Surcharges/ Miscellaneous/Service charge/ Other charges/
Discount provided by hospital (If any) _J _J _J _J _J _J _J _J t _J_J_J_J_J_J_J
Pre hospitalization bills & Post hospitalization bills (If any) _J _J _J _J _J _J _J _J t _J_J_J_J_J_J_J
Total claimed amount (In�) (Total claimed amount should be equal to the amount in attached bill documents) t _J_J_J_J_J_J_J
1 2 5 0 0 0
A10. In support of the above claim, I enclose following documents in original (Please indicate by ticking in the Yes/ No column below)
Tvoe of Documentlsl - *Mandatorv Yes No Tvoe of Documentlsl - As Annlicable Yes No
1. Claim form dulv filled and sianed* _J _J 8. Cancelled cheque (for bank account details) _J _J
2. Discharge summary* _J _J 9. ICICI Lombard GIC Authorisation Letter _J _J
3. Hospital bills, Final/ main hospital bill and other bills (if any)* _J _J 10. Implant name and invoice (if any) with implant sticker _J _J
4. Hospital payment receipt & other receipts supporting bills* _J _J 11. Indoor Case Papers _J _J
5. Investigation reports* (Including ECG/ CT/ MRI/ USG/ HPE) _J _J 12. Prescription papers/ Consultation papers _J _J
6. Medicine/ Pharmacy bills with doctors prescription* _J _J 13. C-KYC FORM (Only for RetaiVlndividual customers, claiming > , 1 Lakh) _J _J
7. Age proof (Driving License/ PAN card/ Passport/ Aadhaar copy)* _J _J 14. Others (details) _J _J
Please attach all the documents as per above serial number. Films like x-ray film, CT Scan film, MRI Scan film, etc. are not required. Provide reports only

A11.Please provide the reason for delay in submitting the documents

(Post 30 days from Date of Discharge) I Prov :l£ Details ( App able)
'------------------------'
A12. Please provide the below details (all fields are compulsory)
• Proposer (policy holder)/ Employee name*(as per bank records): _J
T _J
E _J
S _J
T _J _J _J _J _J _J _J _J_J _J _J _J_J _J
• Proposer/ policy holder Bank account no.: _J
1 _J
2 _J
3 _J
4 _J
5 _J
6 _J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J
• Name of the bank: _J
T _J
E _J
S _J_J_J
T _J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J
• Branch name: _J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J_J
T E S T

_J_J_J_J_J_J_J_J_J_J
• IFSC code no. of the bank: S B I N 0 1 2 3 4 5 6 PAN No. of the Proposer: E E Y H J 4 3 2 1 L _J_J_J_J_J_J_J_J_J_J
*Please provide a Cancelled cheque of account holder.
*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, Employee Name & Account details required.

Declaration by the Insured:

I hereby declare that the information furnished in this claim form is true and 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 and authorize TPA/ insurance company, to seek necessary medical information/ documents from any
hospitaV 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 and that I will not be making any supplementary claim except the pre/ post-hospitalization claim, if any.

Date: _J 5 I _J
0 _J 0 _J
1 I _J
2 _!..!
0 _J 2 _!..!
4 Place: ----------- Keerthi Siddeshwar
lnsured's Signature: ___________ _

'ifflJf 1li1lf �iii���� 1« ;;n.J �: www.icicilombard.com

Claim documents to be dispatched to: ICICI Lombard Healthcare, ICICI Bank Tower, Plot No. 12, Financial District, Nanakram Guda, Gachibowli, Hyderabad, TS-500032

A Your Claim details are just an SMS away, Please SMS <KEYWORD> to 57 57 58
• Cashless Status: <KEYWORD> is "ILHC AL <12-digit-AL-No.>" • Claim Status: <KEYWORD> is "ILHC CL <12-digit-CL-No.>" • Payment details: <KEYWORD> is "ILHC PAY <12-digit-Claim-No.>"
(AL No. & CL No. is the one you have received on your mobile no. after intimating us)