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ICICI Lombard Health Insurance Claim Form Details

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ICICI Lombard Health Insurance Claim Form Details

If you’re an ICICI Lombard Health Insurance Customer and want to know how the claim process works? You’re at the right place! When a claim arises, you need to intimate ICICI Lombard Health Insurance to get the expenses covered. Because if you don’t notify the insurer, it might reject your claim later. To file a claim, you need the ICICI Lombard Health Insurance Claim Form which you can get from the official website of the insurer, network hospital, branch office. Read this page further and see what details you need to fill in the claim form and why they are important for the claim processing.

Part A – ICICI Lombard Health Insurance Claim Form

You need to fill in the following details in the claim form –

A1 Self Declaration

Select the type of claim for which you need the money –

  • Hospitalization – If you’re seeking compensation for the medical expenses incurred during your stay at the hospital for the treatment of the illness/injury, tick on this.
  • Pre and post-hospitalization – Get reimbursement of the expenses incurred before and after the admission to the hospital. To file a claim, you need to provide evidence to the insurer that the expenses are related to the illness/injury for which you’re admitted or going to be admitted. 
  • Cashless or Reimbursement – If you’re applying for a cashless claim, tick on the same. Otherwise, tick the reimbursement option.

A2 Self Declaration

Provide the following details to the insurer –

  • Name of the Patient
  • Card No. or Unique Health Identification (UHID) of the Patient
  • Gender – Male/Female 
  • Date of Birth
  • Completed age
  • Occupation
  • Are you previously covered by any other Mediclaim or Health Insurance if yes, enter the company name
  • Current residential address
  • City
  • State
  • Pin code
  • Mobile no. 
  • Landline no.
  • E-mail ID

A3 Group/Corporate Policy

If you’re covered under a group health insurance policy, you need to enter the following details in the ICICI Lombard Health Insurance Claim Form –

  • Member ID or Employee ID (Client ID)
  • Group or Company name

A4 Individual or Retail Policy

Here, enter the following information –

  • Claim Intimation Service Request no.
  • If there is a renewal, select ‘Yes’
  • Enter your previous & current policy nos.
  • Relationship with the Proposer
  • Card number or UHID

A5 Nature of Illness/Injury

You need to provide the details of the illness/injury contracted during the policy term, such as –

  • Name of hospital 
  • Room category – Daycare, Single occupancy, Twin sharing, Three or more beds per room or Others
  • Date of Admission and Discharge
  • Date of injury sustained or disease or Illness first diagnosed
  • Mention the cause of injury
  • MLC Report & Police FIR 
  • System of Medicine

A6 Top-Up Policy Details

If you have a top-up plan of ICICI Lombard Health Insurance, enter the policy number.

A7 Coverage from Other Health Insurance

If you are covered under any other mediclaim policy, enter the following details –

  • Date of commencement of the first insurance policy without a break
  • Have you been hospitalized in the last four years since the inception of the policy
  • Date of diagnosis
  • Number of claims against this particular illness
  • Admission date or attached bills with any other insurance company
  • Settlement letter
  • Company name
  • Policy No.
  • Sum Insured:

A8 Details of Treatment Expenses

Provide the list of expenses for which you need to file a claim –

  • Pre-hospitalization expenses
  • Hospitalization expenses
  • Post-hospitalization expenses
  • Health-check up costs
  • Ambulance charges
  • Other Costs
  • Pre-hospitalization period
  • Post-hospitalization period

A9 Documents Checklist

Submission of the following documents is critical to successful claim

  • Duly filled and signed ICICI Lombard Health Insurance Claim Form 
  • Discharge summary
  • Hospital bills, final or main hospital bill and other bills (if any)
  • Hospital payment receipt & other receipts 
  • Investigation reports including CT, HPE, ECG,  USG, MRI 
  • Medicine or pharmacy bills with doctors prescription
  • Driving License, PAN Card, Passport or Aadhar copy
  • EFT, RTGS or NEFT
  • ICICI Lombard GIC Authorisation Letter
  • Implant name and invoice (if any) with implant sticker
  • Indoor Case Papers
  • Prescription papers or consultation paper
  • KYC document if the total claim is > INR 1 Lakh

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