|
A1. Type of Claim :
|
Main Hospitalisation Expenses
Pre & Post Hospitalisation Expenses
Cashless Obtained:
Yes
No
|
|
A2. Details of the Insured person in respect of whom claim is made: (patient details)
|
|
Name of Patient:
|
|
|
Card No./UHID of the Patient:
|
|
|
Gender : Male
Female
Third Gender
|
Date of Birth:
|
Completed age: Years:
Months:
|
|
|
Occupation: Service
Self Employed
Homemaker
Student
Retired
Other
(Please specify)
|
|
Are you previously covered by any other Mediclaim/ Health Insurance:
Yes
No
If yes, Company name:
|
Current residential address:
|
|
City:
|
Pin code:
|
|
|
|
State:
|
Landline no.
|
|
|
|
Mobile no.
|
|
|
|
|
E-mail:
|
|
ABHA Number:
|
|
ABHA is a 14 digit number that will uniquely identify you as a participant in India's digital healthcare ecosystem.
|
|
Covid Vaccination Status : -
Yes
No
|
Name of the Vaccination :-
Covishield
Covaxin
Sputnik
Other
|
|
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.:
|
|
Group/Company name:
|
Is this a renewal policy: Yes
No
|
|
|
If Yes, kindly mention your previous policy no.:
|
|
|
|
|
A4. Name of the Proposer*:
|
|
|
Relationship with the Proposer*:
|
|
|
Current Policy No.:
|
Card No./ UHID:
|
|
(* Policy Holder. For Retail Policy, Proposer name required. For Corporate policy, provide Employee name)
|
A5. Nature of disease/ illness contracted or injury suffered for which Insured was
hospitalized (Diagnosis):
|
|
|
|
Name of hospital where admitted:
|
|
|
|
Room category occupied: Day care
Single occupancy
Twin sharing
3 or more beds per room
Others:
|
|
Date of Admission:
Time:
Date of Discharge:
Time:
|
|
Date of injury sustained or disease/ Illness first detected:
|
|
If Injury, give cause: Self inflicted
Road traffic accident
Substance abuse/ Alcohol consumption
Others:
|
|
If Medico legal: Yes
No
Reported to police: Yes
No
MLC Report & Police FIR attached:
Yes
(If yes, attach report)
|
|
System of Medicine:
|
|
A6. Are you covered under any Topup/Additional policy : Yes
No
|
If yes, provide policy no.
|
|
A7. Currently covered by any other Mediclaim/ Health Insurance:
Yes
No
Date of commencement of first Insurance without break:
|
|
Have you been hospitalized in the last 4 years since inception of contract:Yes
No
|
Date:
Dignosis:
|
|
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 Insured:
|
|
A8. Details of Claim
|
|
a) Details of the treatment expenses claimed
|
|
i. Pre-hospitalization expenses:
|
|
ii. Hospitalization expenses:
|
|
|
iii. Post-hospitalization expenses:
|
|
iv. Health-check up cost:
|
|
|
v. Ambulance charges:
|
|
vi. Others:
|
|
|
|
|
Total:
|
|
|
vii. Pre-hospitalization period
|
Days
|
viii. Post-hospitalization period:
|
Days
|
|
|
|
b) Claim for
|
|
|
|
|
i. Domiciliary Hospitalization:
|
Yes No
|
(If yes, provide details in annexure)
|
|
|
ii. Day care:
|
Yes No
|
|
|
|
iii. Extended care/ Inpatient rehabilitation:
|
Yes No
|
|
|
|
c) Details of lump sum/ cash benefit claimed:
|
|
|
|
i. Hospital daily cash:
|
|
ii. Surgical cash:
|
|
|
iii. Critical illness:
|
|
iv. Convalescence:
|
|
|
v. Pre/ Post hospitalizationlump sum benefit:
|
|
vi. Others:
|
|
|
A9. Details of the amount claimed
|
|
Bill heads (as applicable)
|
Bill number
|
Bill date
|
Bills attached
|
Amount
|
|
Room rent:
|
|
|
Yes
No
|
|
|
Doctors consultation/ Visit charges:
|
|
|
Yes
No
|
|
|
Investigation charges (Includes Radiology and Pathology reports):
|
|
|
Yes
No
|
|
|
Surgeon and Asst. surgeon charges:
|
|
|
Yes
No
|
|
|
Anesthetist charges & Operation theatre charges:
|
|
|
Yes
No
|
|
|
Equipment charges/ Procedure charges:
|
|
|
Yes
No
|
|
|
Cost of implant (If any):
|
|
|
Yes
No
|
|
|
Medicine charges (Includes ward and OT medicines and consumables):
|
|
|
Yes
No
|
|
|
Pharmacy charges:
|
|
|
Yes
No
|
|
|
Taxes/ Surcharges/ Service charge:
|
|
|
Yes
No
|
|
|
Miscellaneous/ Other charges:
|
|
|
Yes
No
|
|
|
Pre hospitalization bills (If any):
|
|
|
Yes
No
|
|
|
Post hospitalization bills (If any):
|
|
|
Yes
No
|
|
|
Discount provided by hospital (If any):
|
|
|
Yes
No
|
|
|
Total claimed amount (In INR) (Total claimed amount should be equal
to the amount in attached bill documents)
|
|
|
|
Type of Document(s) - *Mandatory
|
Yes
|
No
|
Type of Document(s) - As Applicable
|
Yes No
|
|
1. Claim form duly filled and signed*
|
|
|
9. ICICI Lombard GIC Authorisation Letter
|
|
|
2. Discharge summary*
|
|
|
10. Implant name and invoice (if any) with implant sticker
|
|
|
3. Hospital bills, Final/ main hospital bill and other bills (if any)*
|
|
|
11. Indoor Case Papers
|
|
|
4. Hospital payment receipt & other receipts supporting bills*
|
|
|
12. Prescription papers/ Consultation papers
|
|
|
5. Investigation reports* (Including ECG/ CT/ MRI/ USG/ HPE)
|
|
|
13. Others (details):
|
|
|
6. Medicine/ Pharmacy bills with doctors prescription**
|
|
|
|
|
|
|
7. Age proof (Driving License/ PAN card/ Passport/ Aadhar copy)*
|
|
|
|
|
|
|
8. Part - C (For EFT/RTGS/ NEFT)*
|
|
|
14. Part - D (KYC documents required if total claimed amt. is > 1 lakh)
|
|
|
*Mandatory.
|
|
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
|
|
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
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 and that I will not be making any supplementary claim except the pre/ post-hospitalization claim, if any.
|
|
|
|
|
|
Date:
|
Place:
|
Insured's Signature:_________________________
|
|
|
|
B1. 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.:
|
|
Hospital ID:
|
|
Type of Hospital:
Network
Non Network
If Non Network, provide below details
|
|
Registration No. with State Code:
|
|
PAN:
|
|
Number of Inpatient beds:
|
|
Facilities available in the hospital: OT: Yes:
No: ICU: Yes:
No:
|
|
B2. Details of the attending Medical Practitioner/ Doctor/ Treating Physician
or Surgeon
|
|
Name:
|
|
|
Qualification:
|
|
Registration no:
|
|
|
Telephone no.:
|
|
Mobile no.:
|
|
|
B3. Details of the patient admitted
|
|
Name of the patient:
|
|
|
IP Registration no.:
|
|
Gender : Male
Female
Age:
Years
Months
Date of Birth:
|
|
Date of Admission:
|
Time:
|
Date of Discharge:
Time:
|
|
Type of Admission: Emergency
|
Planned
|
Day Care
|
Maternity
|
|
Type of Treatment: Surgical Procedure
|
Multiple Surgical Procedure
|
Medical Treatment
|
|
|
If Maternity, Date of Delivery:
|
Gravida Status: G
P
A
L
|
|
|
Premature Baby: Yes:
No:
|
|
|
|
|
Status at time of discharge: Discharge to home
|
Discharge to another hospital
|
Deceased
|
|
Total claimed amount:
|
|
|
|
|
B4. Details of the procedure
|
|
Pre-authorization obtained: Yes:
No:
|
If yes, Pre-authorization No.:
|
|
|
If authorization by network hospital not obtained, give reason:
|
|
Date of injury sustained or disease/ illness first detected:
|
|
|
|
If Injury, give cause: Self inflicted
Road traffic accident
Substance abuse/Alcohol consumption
Others:
|
|
If Medico legal: Yes
No
Reported to police: Yes
No
MLC Report & Police FIR attached: Yes
No
(If yes, attach report)
|
|
FIR no.:
|
If not reported to Police, give reason:
|
|
If injury due to substance abuse/alcohol consumption, test conducted to establish
this: Yes No (If yes, attach report)
|
|
B5. This section is mandatory only if your health policy is
not provided by your employer
|
|
A) Diagnosis (ICD 10 Code primary & additional dignosis)
|
|
|
i) Primary diagnosis (with ICD 10 code )
|
|
|
ii) Additional diagnosis (with ICD 10 code)
|
|
|
iii) Procedure diagnosis (with ICD 10 PCS code)
|
|
|
B) Nature of surgery/ treatment given for present ailment
|
|
|
C) Date of first consultation (Prior to hospitalization)
|
|
|
D) Presenting complaints of the patient during admission
|
|
|
E) Past medical history of the patient along with duration of illness (If yes, attach
first & all past consultation paper)
|
|
|
F) Was the patient under influence of alcohol during admission
|
|
|
G) 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
|
|
|
H) Whether the disease/ disorder is congenital in nature ?
|
|
|
I) Number of in-patient beds in the hospital (including ICU)
|
|
|
Declaration by the hospital
|
|
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, suppression or concealment of any material fact, our
right to claim under this claim shall be forfeited.
|
|
|
|
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.
|
|
|
C1. Patient's Name:
|
|
|
(in respect of whom claim is made)
|
|
C2. Policy Number:
|
|
|
C3. Card No./ UHID No.:
|
|
|
C4. Group/Company Name (for Group/Corporate policy holders):
|
|
C5. Claim Number (if allotted):
|
C6. Mobile/ Contact No.:
|
|
|
Please provide a self-attested
copy of a valid Identity proof of the Proposer/Policy holder (provide any of the
mentioned documents in Proof of Identity under Part-D)
|
|
Cancelled cheque copy
|
|
Bank attested copy of Passbook
with IFSC code
|
|
|
• Proposer/ policy holder 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)
|
|
Terms and Conditions for Payments through RTGS/ NEFT
1. The details provided by the Proposers/ policy holder 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 Proposer(s)/ policy holder 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 Proposer/ policy holder agrees that under the RTGS/ NEFT facility, there may be a risk of non-payment in the Proposer/ policy holder Accounts No. 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 Proposer/ policy holder 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 Proposer/ policy holder 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 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 Proposer/ policy holder will be acknowledged through a confirmation letter by ICICI Lombard General Insurance Company Ltd. In no case can
the Proposer/ policy holder construe his termination notice as effective unless a confirmation has been provided by ICICI Lombard to the Proposer/ policy holder stating the date of receipt of such
communication by the Proposer/ policy holder.
7. The Proposer/ policy holder agrees that transaction(s) through RTGS/ NEFT facility may attract inward RTGS/ NEFT charges, which if levied by the Proposer's/ policy holder's bank, shall be borne by the
Proposer/ policy holder only.
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 Proposer/ policy holder 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 Proposer/ policy holder.
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 Proposer/ policy holder 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 Proposer/ policy holder.
|
|
|
|
|
|
D1. Patient's Name:
|
|
|
(in respect of whom claim is made)
|
|
D2. Policy Number:
|
|
|
D3. Card No./ UHID No.:
|
|
|
D4. Group/Company Name (for Group/Corporate policy holders):
|
|
D5. Claim Number (if allotted):
|
D6. Mobile/ Contact No.:
|
|
D7. The below KYC documents are mandatory as per AML guidelines by IRDA
|
|
1.
Two passport size photos of Proposer
(stick in the space provided below)
|
|
2.
One photocopy of proof of identity
of Proposer (any 1 in the below list)
|
|
3.
One photocopy of proof of
residence of Proposer (any 1 in the below list)
|
|
|
Passport
|
Electricity bill
|
|
PAN card
|
Ration card
|
|
Voter’s Identity card
|
Letter from any recognized
public authority
|
|
Driving license
|
Current statement of bank
account with details of permanent/ present residence address (as downloaded)
|
|
Personal identification and
certification of the employees of the insurer for identity of the prospective policyholder.
|
Current passbook with details of
permanent/present residence address (updated upto the previous month)
|
|
Letter issued by Unique Identification
Authority of India containing details of name, address and Aadhar number.
|
Valid lease agreement along
with rent receipt, which is not more than three months old as a residence proof.
|
|
Job card issued by NREGA duly signed
by an officer of the State Government
|
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
|
|
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
|
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)
|
|
|
Passport
|
|
Written confirmation from
the banks where the prospect is a customer, regarding identification and proof of
residence.
|
|
Current passbook with details
of present/ permanent residence address (updated to the previous month)
|
|
Current statement of Bank
account with details of present/ permanent residence address (as downloaded)
|
|
