ICIC' onmbar.

1 ICICILombard Health Care Clain Form- Hospitalisation

Nihyr Vaode ICICILombard
(ssuanc.e of thus form is not to be taken 8s an adhnussion of hability Health Care
Dvardaw OVervewHholalnFormHoitalizaton
Part A To be filled Required to
Seli Declaratnn
Sell Decleation
A3 Avnilabhle in Poliu y Copy Eployee details
A4 Available in Policy Copy
Ab Available in Discharge Summaiy By insured/ insured To track the policy and
A6 Sell Declaration relatives other details of the insured
A7 Sell Declaration
A8 Avalable in Hosptal Bills/ Self Declaration
A9 Available in Hospital Blls
A10 Checklist
Pageend Self declaration
Part B
Hospal Details
B2 joctm Details To be filled by Hospiial To track the hospital
63 Fatient details Treating doctor details and the treatment
B4 ireatment / Procediure Details details related to the
B5
ñequired onlyfor Retai'Individual customers patient admission
Pageend Hospitaldeclaration
Part C
Paient'sName
Policy Nuiiber
C3 Card No./UHID No._ For Electronic fund
4 Group/ Company
name To be filled by Insured transfer to the bank
Cleim number (ifaliotted) account
Mobile/ Contact no.
Provide any 1 document of preposer
C8 As per bank pass book
Page
en Account holders signature
PartD(0nly fot Reta/ tndividual custemers if claimin >1 lakh rupecs
D1 Patient's Name
D2 Policy
Number
D3 Card No./UHID No._
D4 Group/ Company name To be frilled by Insured As per IRDA mandate
D5 Claim number(if allotted) forclaims> 1 lac
D6 Mobile/ Contact no.
D7 KYC documents
Pageend Claimant's signature

Documents Submitted
S.No. Docunment Yes No Type of document
1. Claimform duly filled Original
Discharge Summary/ Daycare Summary Original
3 Final Hospital Bill Original
PaymentReceipts Original
5.
Investigation Reports Original
Pharmacy Bills Original
7. Implant Sticker/ Invoice Original
8. Doctor Prescriptions Photocopy
9. Consultation Paper Photocopy
10. Age Proof
11. Indoor Case Paper
Photocopy
12. EFT (Copy of cancelled cheque/ self attested ID poof/ Bank attested copy
Photocopy
ofpassbook with IFSCcode Photocopy
13. KYC (Copy of 1D proof,Residence proof,b2 Passportsize photos) Photocopy

ICICIClombard
Nibhaye Vaade
Mailing Adress CICl LombardHelthcar, ICiCI Bank Tower, Plat No. 12, Financial Distict, Nanakram Guda, Gachibowi, Hyderabad500032
Registered Ofice Address:1CIClLombard House, 414, Ver Savarkar Marg, Near Siddhi Vinayak Temple, Prabhadevi, Murmbai 400 025.
Visit us at: wwwiciclombard.com . EMail us at: heathcare@iciciombard.com. Toll Free Number: 1800 2666. Toll Free Fax Number 1800-209-980
RDA Registraion No. 115
 ICICiClombard
Nibhaye Veade ICICI Lombard Health Care Claim Form-Hospitalisation ICICILombard
Health Care/
(ssuance of this fom isnotto betaken osanadmissionofliobility)

ALL CLAMSETLEMENTSSHOUDBEMADETHROUGHNERTIASPERIROADIRCULAR),PLEASEPROVIDEYOUR BANKACOUNTDETAILS AEFERTOPART

Non-submission of original bils and receipts is tho main roason for dolay in claim settlements, Please provide the originals b mandatory documets

Da You Know To receive update on your claim status, provide your mobilo no. &E-mail I0
You can tract your claim status at: www.icicilombard.comClaims &Wellness->Health Claims &WellnssTrackyour claims

TO BE FILLED IN CAPITAL LETTERS ONLY Part-ATo bo llad by Insurad)

A1. Type of Claim: Main Hospitalisation Expenses Pre& Post HospitalisationExpenses Cashless Obtained: Yes No
A2. Details of the Insured person in respect of whom claim is made: (patient details)
Name of the Patient: S A TYABRIAJTAJJJJJJJJJJJJJSAhOD
Card No./UHIDofthePatient IL20 0 81H1550)4
Date of Birth: 02/0/19J6H
JJJJJJJJJJ
Gender: MaleFemale Completed age: Years 2 MonthsJJ
Occupation: Service V Sell EnmployedHomemakerJ SudentRetiredOther(Please specihy)_
Are you previously covered by any other Mediclaim/ Health Insurance: YesJNo V. If yes, Company name:
Curent residential address: S3,JJ1112p113), JAILAJP RT VILHARJJJ.
CuADR ASEKHAJRPJURJJJJIJJJJJJJJJJJJJJJ.
UUJJJJ JJJJJ Cty: B)HIU BANCSl ARJJJJJ
State:D 219 A JJ J J J J J J J J J J J J J J J Pincode 2S 11021
Mobile no. 113130182llandline no. JJJJJUJJJJJJJJ JJ
E-mail: J J JJJJ JJJJJJJJJ. JJJJJ
A3. ForGroup/Corporate Policy For Individual/ Retail Policy ("Mandatory)
Member 1DNo./Employee ID (Client ID): PUIOJJJ|"Claim lntimation ServiceRequest n o . : J U J J J J J
JJJJJJJJJJJJJ|Is thisarenewalpolicy.YesNo
Group/Ccmpanyname: P OEJ NUXJKDBO)T fYes, kindly mention yourprevious policy no. J
1X PRIVATOJJLIM) ITEDJ| JJ JJJJJ
A4. Name of the Proposer*
AJS TSHJJSAUO0IJ. JUJJJJJJJJJJJJJJ
withthe
Relationship EATIHERJJJJJJJJJJ
Proposer":
Curent Poicy No: 0L6/x/1qj015 88 U40ard No./UHID ]L200$115500 JJJ
(Policy Holder. For Retail policy, Proposer name required. For Corporate policy, provide Employee name)
A5. Nature of disease/illness contracted orinjurysuffered for which Insured was hospitalized (Diagnosis):
Chroni Pogd Anal istuhe, 9ferna HaontUThoide
Nameofhaspitalwhereadnite: PAJCHAJMUKHTJH OSIPT1AILJJJJJJJJJ
Room category occupied: DaycareSingle occupancy winsharing3ormore beds perroomOthers
DateofAdmission:29J 0)6)/20)22 Time: A 0O Dateof Discharge: 031/042022 Time:2;0
Date of injury sustained or disease/ liness first detected: 0 0 S / 0j22
IfInjury, give cause: SelfinflictedRoadtraffic accidentSubstance abuse/Alcohol consumption JOthers
IfMedicolegal: Yes No Reported to police: YesJNoMLC Report&Police FIR attached: Yes No (lf yes, attach report)
System of Medicine:
A6. Are you covered under any Topup/Additionalpolicy: Yes No fyes, provide polcy no.
A7. Currentlycovered byany other Mediclaim/Health Insurance: N Date ofcommencementoffirst Insurancewithoutbreak:JJJ
Haveyoubeenhospitalizedinthelast4 yearssinceinceptionof contract: Date: J J J J J Dignosis:
Have you lodged any claim against this particular admission date/ attached bill with any other lnsurance company:. f yes, attach settlement letter,
Company name: Policy No. SumInsured: 3JJJ_JJJ
A8. Details of Claim

a) Details of the treatment expenses claimed

i. Pre-hospitalization expenses: 28 00/ i. Hospitalizationexpenses: 317 D10/
ii. Post-hospitalization expenses: 128 iv. Health-check up cost: J JJ.
V. Ambulance charges: JUJJJ vi. Others 415) 3 $
Total: JJJJJ.
vii. Pre-hospitalization period JDFDays vii. Post-hospitalization period 30Days
Claim documents to be dispatched to: ICICl Lombard Healthcare, ICICI Bank Tower, Plot No. 12, Financial District, Nanakranm Guda, Gachibowli, Hyderabad-500032
 b) Claum for
i. Donmiciliary Ho:pilalization: Yes No (ll yes, provide details in annexure)
l. Day care Yes No
ii. Extcnded care/ Inpatient rehabilitation: Yes No
cl Details of lump sum' cash benefit claimed:
i. Hospital deily cash:
J J i . Surgicalcash
. Criticalilliness:
iv Covalescence
v. Pre'Post hospitalizationlump sum benefit:
JJ Vi. OtherS:

A9.Details of the amount cloimad

Bill heads (as applicabie) Bill number Bill date Bills attached Amount
oom rent
Doctors consultation/Visit charges 1581/13 19 102 R4000
Investigation charges (Includes Radiology and Pathology reports)
Surgeon and Asst. surgeon charges
Anesthetist charges &Operation theatre charges
IIss13 630422
Equipment charges/ Procedure charges
50 00
O2 22
Cost of implat (if any)
Medicine charges (Includes ward and 0T
medicines and consumables) s&i/L3 2 0212 656
Pharmacy charges
Taxes/Surcharges/Service charge
ISSG/13 3 02 22
ISE4/13 36 22 S61 5
Miscellaneous/ Othercharges
Pre hospitalization bills (lf any) eB$126o22 2 25 0
Fosthospitalizationbills(lfany) 100 O 2072
Discount provided by hospital (lf any) JJI
Total claim:d amount (ln 7) (Total claimed amount should be equal to the amount in attached bill docunments)
4153J

A10.Insupport of theabove claim,I enclosefollowing docunmentsinoriginal (Please indicatebytickingintheYes/Nocolumnbelow)

Type of Document/s)- *Mandatory
Yes No Type of Documant(s)-As Applicable Yes No0
1.Claimform dulyfilled andsigned* 91CICI
. Lonberd GIC Authorisation Letter
2.Discharge summary |10. Implant name andinvoice(if any)withimplantsticker
3. Hospital bills,Final/main hospital bill and other bills (if any 11.Indoor Case Papers
4.Hospital paymentreceipt &other receiptssupportingbills" V 12. Prescription papers/Consultation papers
5.Investigation reports (Including ECG/CT/MRV USG/HPE) 13. 0thers (detalls)
6.Medicine/ Pharmacybillswith doctors prescription
7. Age proof (Driving License/ PAN card/ Passport/ Aadhar copy)

PariD18 touiis rueuittualstamed arSah

Mandatory.
Plcase atach all the documents as per above serial number. Films like xray film, CT Scan film, MRI Scan film, eic. 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 l 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 MedicalPractitionerwho hasattended on the personagainstwhom this claim is made.Ihereby declare thatIhave included allthe bills/
receipts for the purpose of this claim and that Iwill not he making any supplenmentary claimexceptthe pre/ post-hospitalization claim,if any.

Date: 6/012D) 212 Place 13anandeh Insured's Signature: hw

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