{"id":2217,"title":"ICICI Lombard Health Care Claim Form - Hospitalisation","purpose":"claim","insurer":{"slug":"icici-lombard-general-insurance","name":"ICICI LOMBARD General Insurance Company Limited"},"source_pdf":"https://www.icicilombard.com/docs/default-source/default-document-library/claim-form-less-then-1-lac-1-(1).pdf","sha256":"9b9cb632af309d6448fef36f1f1ddc23a52b756f7176c4e766b889275d3c243a","pages":6,"collected":"2026-10-20","instructions":{"about":"This form is used by insured persons to claim reimbursement for hospitalization and related health expenses under their health insurance policy with ICICI Lombard.","notes":["Fill the form in CAPITAL LETTERS only.","Attach original documents as specified; photocopies only where indicated.","Do not submit films like X-ray, CT Scan, MRI; provide reports only.","Do not furnish Aadhaar card as ID proof; provide other ID proof documents.","All claim settlements should be made through NEFT as per regulatory norms.","Provide mobile number (WhatsApp enabled) and email to receive claim updates.","You can track your claim via ILTake Care/WhatsApp App or website.","For Retail/Individual customers, C-KYC form is mandatory for all claims.","PAN card copy is mandatory if claim amount is greater than 1 lakh.","If policy is serviced by external TPA, dispatch claim documents to respective TPA.","Hospital declaration and doctor’s seal and signature are mandatory.","Provide reason for delay if claim documents are submitted after 30 days from discharge."],"title":"ICICI Lombard Health Care Claim Form - Hospitalisation","submit":{"to":"ICICI Lombard Healthcare, Varun Tower II, 1st, 4th, 5th & 6th Floor, Begumpet, Hyderabad, Telangana, Pincode – 500016","how":"post","address":"ICICI Lombard Healthcare, Varun Tower II, 1st, 4th, 5th & 6th Floor, Begumpet, Hyderabad, Telangana, Pincode – 500016"},"purpose":"claim","sections":[{"title":"Part A - To be filled by Insured","fields":[{"help":"Select the type of claim and indicate if cashless was obtained","type":"choice","label":"A1. Type of Claim","options":["Main Hospitalisation Expenses","Pre & Post Hospitalisation Expenses","Cashless Obtained: Yes","Cashless Obtained: No"],"required":true,"pdf_field":""},{"help":"Enter the full name of the patient","type":"text","label":"A2. Details of the Insured person in respect of whom claim is made: (patient details) Name of the Patient","options":[],"required":true,"pdf_field":""},{"help":"Enter the card or UHID number if available","type":"text","label":"Card No./ UHID of the Patient","options":[],"required":false,"pdf_field":""},{"help":"Enter date of birth of the patient","type":"date","label":"Date of Birth","options":[],"required":true,"pdf_field":""},{"help":"Select the occupation of the patient","type":"choice","label":"Occupation","options":["Service","Self Employed","Homemaker","Student","Retired"],"required":false,"pdf_field":""},{"help":"Indicate if previously covered by any other health insurance","type":"yes-no","label":"Are you previously covered by any other Mediclaim/ Health Insurance","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Enter full current residential address","type":"text","label":"Current residential address","options":[],"required":true,"pdf_field":""},{"help":"Enter city name","type":"text","label":"City","options":[],"required":true,"pdf_field":""},{"help":"Enter state name","type":"text","label":"State","options":[],"required":true,"pdf_field":""},{"help":"Enter postal pin code","type":"number","label":"Pin code","options":[],"required":true,"pdf_field":""},{"help":"Enter mobile phone number","type":"phone","label":"Mobile no.","options":[],"required":false,"pdf_field":""},{"help":"Enter landline number if any","type":"phone","label":"Landline no.","options":[],"required":false,"pdf_field":""},{"help":"Enter email address","type":"email","label":"E-mail","options":[],"required":false,"pdf_field":""},{"help":"Enter 14 digit ABHA number if available","type":"text","label":"ABHA Number","options":[],"required":false,"pdf_field":""},{"help":"Enter member or employee ID","type":"text","label":"A3. For Group/ Corporate Policy For Individual/ Retail Policy Member ID No./ Employee ID (Client ID)","options":[],"required":true,"pdf_field":""},{"help":"Enter claim intimation service request number","type":"text","label":"*Claim Intimation Service Request no.","options":[],"required":true,"pdf_field":""},{"help":"Indicate if policy is renewal","type":"yes-no","label":"Is this a renewal policy","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Enter group or company name if applicable","type":"text","label":"Group/ Company name","options":[],"required":false,"pdf_field":""},{"help":"Enter previous policy number if renewal","type":"text","label":"If Yes, kindly mention your previous policy no.","options":[],"required":false,"pdf_field":""},{"help":"Enter proposer or employee name as per policy","type":"text","label":"A4. Name of the Proposer/Employee","options":[],"required":true,"pdf_field":""},{"help":"Specify relationship with proposer","type":"text","label":"Relationship with Proposer","options":[],"required":false,"pdf_field":""},{"help":"Enter current policy number","type":"text","label":"Current Policy No.","options":[],"required":true,"pdf_field":""},{"help":"Enter card or UHID number","type":"text","label":"Card No./ UHID","options":[],"required":false,"pdf_field":""},{"help":"Enter diagnosis details from discharge summary","type":"text","label":"A5. Diagnosis as per discharge summary","options":[],"required":true,"pdf_field":""},{"help":"Enter hospital name","type":"text","label":"Name of hospital where admitted","options":[],"required":true,"pdf_field":""},{"help":"Select room category occupied","type":"choice","label":"Room category occupied","options":["Day care","Single occupancy","Twin sharing","3 or more beds per room","Others"],"required":true,"pdf_field":""},{"help":"Enter admission date","type":"date","label":"Date of Admission","options":[],"required":true,"pdf_field":""},{"help":"Enter discharge date","type":"date","label":"Date of Discharge","options":[],"required":true,"pdf_field":""},{"help":"Enter time of discharge","type":"text","label":"Time of Discharge","options":[],"required":false,"pdf_field":""},{"help":"Enter date of injury or illness detection","type":"date","label":"Date of injury sustained or disease/ Illness first detected","options":[],"required":false,"pdf_field":""},{"help":"Select cause of injury if applicable","type":"choice","label":"If Injury, give cause","options":["Self inflicted","Road traffic accident","Substance abuse/ Alcohol consumption","Others"],"required":false,"pdf_field":""},{"help":"Indicate if case is medico legal","type":"yes-no","label":"If Medico legal","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Indicate if reported to police","type":"yes-no","label":"Reported to police","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Indicate if medico legal case report and FIR are attached","type":"yes-no","label":"MLC Report & Police FIR attached","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Specify system of medicine (e.g. Allopathy, AYUSH)","type":"text","label":"System of Medicine","options":[],"required":false,"pdf_field":""},{"help":"Indicate if another claim exists for this incident","type":"yes-no","label":"Is there any another claim in any of our policies towards the above incident","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Enter claim number if applicable","type":"text","label":"If yes, provide AL/Claim No.","options":[],"required":false,"pdf_field":""},{"help":"Indicate if covered under any top-up or additional policy","type":"yes-no","label":"A6. Are you covered under any Topup/Additional policy","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Enter top-up/additional policy number","type":"text","label":"If yes, provide policy no.","options":[],"required":false,"pdf_field":""},{"help":"Indicate if currently covered by other health insurance","type":"yes-no","label":"A7. Currently covered by any other Mediclaim/ Health Insurance","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Enter start date of first insurance","type":"date","label":"Date of commencement of first Insurance without break","options":[],"required":false,"pdf_field":""},{"help":"Indicate if hospitalized in last 4 years","type":"yes-no","label":"Have you been hospitalized in the last 4 years since inception of contract","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Enter date of previous hospitalization","type":"date","label":"Date","options":[],"required":false,"pdf_field":""},{"help":"Enter diagnosis of previous hospitalization","type":"text","label":"Diagnosis","options":[],"required":false,"pdf_field":""},{"help":"Indicate if claim lodged with other insurer","type":"yes-no","label":"Have you lodged any claim against this particular admission date/ attached bills with any other Insurance company","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Attach settlement letter from other insurer","type":"attachment","label":"If yes, attach settlement letter","options":[],"required":false,"pdf_field":""},{"help":"Enter other insurance company name","type":"text","label":"Company name","options":[],"required":false,"pdf_field":""},{"help":"Enter other insurance policy number","type":"text","label":"Policy No.","options":[],"required":false,"pdf_field":""},{"help":"Enter sum insured under other policy","type":"amount","label":"Sum Insured","options":[],"required":false,"pdf_field":""},{"help":"Enter amount claimed for pre-hospitalization expenses","type":"amount","label":"A8. Details of Claim - a) Details of the treatment expenses claimed i. Pre-hospitalization expenses","options":[],"required":false,"pdf_field":""},{"help":"Enter amount claimed for hospitalization expenses","type":"amount","label":"ii. Hospitalization expenses","options":[],"required":false,"pdf_field":""},{"help":"Enter amount claimed for post-hospitalization expenses","type":"amount","label":"iii. Post-hospitalization expenses","options":[],"required":false,"pdf_field":""},{"help":"Enter amount claimed for health check-up","type":"amount","label":"iv. Health-check up cost","options":[],"required":false,"pdf_field":""},{"help":"Enter ambulance charges claimed","type":"amount","label":"v. Ambulance charges","options":[],"required":false,"pdf_field":""},{"help":"Enter other expenses claimed and specify","type":"amount","label":"vi. Others","options":[],"required":false,"pdf_field":""},{"help":"Enter total amount claimed","type":"amount","label":"Total","options":[],"required":false,"pdf_field":""},{"help":"Enter number of days for pre-hospitalization period","type":"number","label":"vii. Pre-hospitalization period (Days)","options":[],"required":false,"pdf_field":""},{"help":"Enter number of days for post-hospitalization period","type":"number","label":"viii. Post-hospitalization period (Days)","options":[],"required":false,"pdf_field":""},{"help":"Indicate if claim is for domiciliary hospitalization","type":"yes-no","label":"b) Claim for i. Domiciliary Hospitalization","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Indicate if claim is for day care","type":"yes-no","label":"ii. Day care","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Indicate if claim is for extended care or inpatient rehabilitation","type":"yes-no","label":"iii. Extended care/ Inpatient rehabilitation","options":["Yes","No"],"required":false,"pdf_field":""}],"filled_by":"insured person"},{"title":"Part B - To be filled by Treating Doctor/ Hospital only","fields":[{"help":"Enter hospital or nursing home name","type":"text","label":"B1. Details of the Hospital/ Nursing home in which treatment was taken Name of the Hospital/ Nursing home","options":[],"required":true,"pdf_field":""},{"help":"Enter hospital address","type":"text","label":"Address","options":[],"required":true,"pdf_field":""},{"help":"Enter city","type":"text","label":"City","options":[],"required":true,"pdf_field":""},{"help":"Enter state","type":"text","label":"State","options":[],"required":true,"pdf_field":""},{"help":"Enter postal code","type":"number","label":"Pincode","options":[],"required":true,"pdf_field":""},{"help":"Enter hospital telephone number","type":"phone","label":"Telephone no.","options":[],"required":false,"pdf_field":""},{"help":"Enter hospital mobile number","type":"phone","label":"Mobile no.","options":[],"required":false,"pdf_field":""},{"help":"Enter ROHINI ID if applicable","type":"text","label":"ROHINI ID*","options":[],"required":false,"pdf_field":""},{"help":"Select hospital type","type":"choice","label":"Type of Hospital","options":["Network","Non Network"],"required":true,"pdf_field":""},{"help":"Enter registration number with state code","type":"text","label":"If Non Network, provide below details Registration No. with State Code","options":[],"required":false,"pdf_field":""},{"help":"Enter PAN number","type":"text","label":"PAN","options":[],"required":false,"pdf_field":""},{"help":"Enter number of inpatient beds including ICU","type":"number","label":"Number of Inpatient beds","options":[],"required":false,"pdf_field":""},{"help":"Tick available facilities","type":"checkbox","label":"Facilities available in the hospital OT","options":["OT","ICU"],"required":false,"pdf_field":""},{"help":"Enter doctor's full name","type":"text","label":"B2. Details of the attending Medical Practitioner/ Doctor/ Treating Physician or Surgeon Name","options":[],"required":true,"pdf_field":""},{"help":"Enter doctor's qualification","type":"text","label":"Qualification","options":[],"required":true,"pdf_field":""},{"help":"Enter doctor's registration number","type":"text","label":"Registration no","options":[],"required":true,"pdf_field":""},{"help":"Enter doctor's telephone number","type":"phone","label":"Telephone no.","options":[],"required":false,"pdf_field":""},{"help":"Enter doctor's mobile number","type":"phone","label":"Mobile no.","options":[],"required":false,"pdf_field":""},{"help":"Enter patient name","type":"text","label":"B3. Details of the patient admitted Name of the patient","options":[],"required":true,"pdf_field":""},{"help":"Enter inpatient registration number","type":"text","label":"IP Registration no.","options":[],"required":false,"pdf_field":""},{"help":"Select gender","type":"choice","label":"Gender","options":["Male","Female","Transgender"],"required":true,"pdf_field":""},{"help":"Enter date of birth","type":"date","label":"Date of Birth","options":[],"required":false,"pdf_field":""},{"help":"Enter admission date","type":"date","label":"Date of Admission","options":[],"required":true,"pdf_field":""},{"help":"Enter discharge date","type":"date","label":"Date of Discharge","options":[],"required":true,"pdf_field":""},{"help":"Enter discharge time","type":"text","label":"Time of Discharge","options":[],"required":false,"pdf_field":""},{"help":"Select type of admission","type":"choice","label":"Type of Admission","options":["Emergency","Planned","Day Care","Maternity"],"required":true,"pdf_field":""},{"help":"Select type of treatment","type":"choice","label":"Type of Treatment","options":["Surgical Procedure","Multiple Surgical Procedure","Medical Treatment"],"required":true,"pdf_field":""},{"help":"Enter date of delivery if maternity case","type":"date","label":"If Maternity, Date of Delivery","options":[],"required":false,"pdf_field":""},{"help":"Enter gravida status (G, P, A, L)","type":"text","label":"Gravida Status","options":[],"required":false,"pdf_field":""},{"help":"Indicate if baby was premature","type":"yes-no","label":"Premature Baby","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Select discharge status","type":"choice","label":"Status at time of discharge","options":["Discharge to home","Discharge to another hospital","Deceased"],"required":true,"pdf_field":""},{"help":"Enter total claimed amount","type":"amount","label":"Total claimed amount","options":[],"required":false,"pdf_field":""},{"help":"Indicate if pre-authorization was obtained","type":"yes-no","label":"B4. Details of the procedure Pre-authorization obtained","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Enter pre-authorization number","type":"text","label":"If yes, Pre-authorization No.","options":[],"required":false,"pdf_field":""},{"help":"Provide reason if authorization not obtained","type":"text","label":"If authorization by network hospital not obtained, give reason","options":[],"required":false,"pdf_field":""},{"help":"Enter date of injury or illness detection","type":"date","label":"Date of injury sustained or disease/ illness first detected","options":[],"required":false,"pdf_field":""},{"help":"Select cause of injury","type":"choice","label":"If Injury, give cause","options":["Self inflicted","Road traffic accident","Substance abuse/Alcohol consumption","Others"],"required":false,"pdf_field":""},{"help":"Indicate if medico legal case","type":"yes-no","label":"If Medico legal","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Indicate if reported to police","type":"yes-no","label":"Reported to police","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Indicate if medico legal case report and FIR attached","type":"yes-no","label":"MLC Report & Police FIR attached","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Enter FIR number if applicable","type":"text","label":"FIR no.","options":[],"required":false,"pdf_field":""},{"help":"Provide reason if not reported to police","type":"text","label":"If not reported to Police, give reason","options":[],"required":false,"pdf_field":""},{"help":"Indicate if test conducted and attach report","type":"yes-no","label":"If injury due to substance abuse/alcohol consumption, test conducted to establish this","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Hospital rubber stamp and doctor’s seal and signature required","type":"signature","label":"Hospital declaration","options":[],"required":true,"pdf_field":""}],"filled_by":"hospital / treating doctor"},{"title":"Part C - NEFT Form (To be filled by Insured)","fields":[{"help":"Enter patient name","type":"text","label":"C1. Patient's Name (in respect of whom claim is made)","options":[],"required":true,"pdf_field":""},{"help":"Enter PAN number of proposer","type":"text","label":"C2. PAN No. of the Proposer (Mandatory if claim amount is greater than 1 lakh)","options":[],"required":false,"pdf_field":""},{"help":"Enter card or UHID number","type":"text","label":"C3. Card No./ UHID No.","options":[],"required":false,"pdf_field":""},{"help":"Enter claim number if available","type":"text","label":"C4. Claim Number (if allotted)","options":[],"required":false,"pdf_field":""},{"help":"Enter mobile or contact number","type":"phone","label":"C5. Mobile/ Contact No.","options":[],"required":false,"pdf_field":""},{"help":"Enter email address","type":"email","label":"C6. Email","options":[],"required":false,"pdf_field":""},{"help":"Attach cancelled cheque or bank passbook copy with IFSC","type":"attachment","label":"Cancelled cheque copy/ Bank attested copy of Passbook with IFSC code","options":[],"required":true,"pdf_field":""},{"help":"Enter name as per bank records","type":"text","label":"Proposer (Policy holder)/ Employee name (as per bank records)","options":[],"required":true,"pdf_field":""},{"help":"Enter bank account number","type":"text","label":"Proposer/ Policy holder Bank account no.","options":[],"required":true,"pdf_field":""},{"help":"Enter bank name","type":"text","label":"Name of the bank","options":[],"required":true,"pdf_field":""},{"help":"Enter branch name","type":"text","label":"Branch name","options":[],"required":true,"pdf_field":""},{"help":"Enter bank branch address","type":"text","label":"Address of the bank","options":[],"required":true,"pdf_field":""},{"help":"Enter IFSC code","type":"text","label":"IFSC code no. of the bank","options":[],"required":true,"pdf_field":""}],"filled_by":"insured person"},{"title":"Part D - KYC Details (To be filled by Proposer)","fields":[{"help":"Enter KYC number if available","type":"text","label":"KYC Number","options":[],"required":false,"pdf_field":""},{"help":"Enter maiden name if applicable","type":"text","label":"Maiden Name (If any)","options":[],"required":false,"pdf_field":""},{"help":"Enter father or spouse name","type":"text","label":"Father / Spouse Name","options":[],"required":true,"pdf_field":""},{"help":"Enter mother name","type":"text","label":"Mother Name","options":[],"required":true,"pdf_field":""},{"help":"Enter date of birth","type":"date","label":"Date of Birth","options":[],"required":true,"pdf_field":""},{"help":"Select gender","type":"choice","label":"Gender","options":["Male","Female","Transgender"],"required":true,"pdf_field":""},{"help":"Provide signature or thumb impression","type":"signature","label":"Signature / Thumb Impression","options":[],"required":true,"pdf_field":""},{"help":"Attach recent photograph","type":"photo","label":"PHOTO","options":[],"required":true,"pdf_field":""},{"help":"Enter full address details","type":"text","label":"Current / Permanent / Overseas Address Details","options":[],"required":true,"pdf_field":""},{"help":"Signature of account holder","type":"signature","label":"Account Holder's Signature","options":[],"required":true,"pdf_field":""}],"filled_by":"insured person / proposer"},{"title":"Self Declaration by Insured","fields":[{"help":"Sign and date the declaration","type":"signature","label":"Declaration by the Insured","options":[],"required":true,"pdf_field":""},{"help":"Enter date of signing","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Enter place of signing","type":"text","label":"Place","options":[],"required":true,"pdf_field":""}],"filled_by":"insured person"}],"deadlines":["Submit claim documents within 30 days from date of discharge","Reason for delay to be provided if documents submitted after 30 days from date of discharge"],"applies_to":"Hospitalisation claims including main hospitalization expenses, pre and post hospitalization expenses, cashless claims, domiciliary hospitalization, day care, extended care/inpatient rehabilitation, maternity, and other health-related claims under ICICI Lombard health insurance policies.","attachments":["Claim form duly filled","Discharge Summary/ Daycare Summary (Original)","ICICI Lombard Health card (Original)","Final Hospital Bill (Original)","Payment Receipts (Original)","Investigation Reports (Original)","Pharmacy Bills (Original)","Implant Sticker/ Invoice (Original)","Doctor Prescriptions (Photocopy)","Consultation Paper (Photocopy)","Age Proof (Photocopy)","Indoor Case Paper (Photocopy)","C-KYC Form (Only for Retail/ Individual customers for all claims) (Original)","PAN Card Copy of the Proposer/ Employee (Mandatory if claim amount is greater than 1 lakh) (Photocopy)","Copy of cancelled cheque/Copy of passbook or bank statement with Payee/account holders name and IFSC code","Proof of Identity (Certified copy)","Proof of Address (Certified copy)"],"declarations":["The information furnished in this claim form is true and correct to the best of my knowledge and belief.","False or untrue statements or concealment of material facts will forfeit the right to claim reimbursement.","Consent is given to TPA/insurance company to seek necessary medical information from hospitals or doctors.","All bills and receipts for the claim are included and no supplementary claim will be made except pre/post hospitalization claims.","Consent is given to verify identity through Central KYC Registry or UIDAI or other modes for KYC purposes.","Hospital declares that information furnished is true and correct and false statements will forfeit claim rights.","Claim settlements will be made through NEFT and bank details provided are correct and consent is given for validation.","Submission of documents or bank details does not imply admission of liability by the company."],"dropped_labels":10},"pdf_fields":null,"fillable_pdf":false,"send_to":[],"how_to_use":"Ask the user for each field in order, in plain words; never invent an answer. Labels are as printed. If fillable_pdf is true, pdf_fields gives the PDF's own field names so the file can be filled directly. The printed form decides if anything differs.","url":"https://indiainsurances.com/forms/icici-lombard-general-insurance/2217-icici-lombard-health-care-claim-form-hospitalisation"}