{"id":2310,"title":"Claim Form","purpose":"claim","insurer":{"slug":"lic","name":"Life Insurance Corporation of India"},"source_pdf":"https://licindia.in/documents/d/guest/020816-claimform-1","sha256":"4eb601ac6fda6be0a03776358e286ab053d63d3f3c1a523ca6df534104499aad","pages":1,"collected":"2026-10-20","instructions":{"about":"This form is used by the policyholder or claimant to claim benefits under LIC's Health Insurance Policy for hospitalization and surgery-related expenses.","notes":["Benefits under the policy are fixed as per Daily Benefit opted at proposal stage and are not related to actual expenses.","Issuance of this Claim Form does not tantamount to acceptance of liability by the insurer.","Claim form and other documents must be submitted to LIC Branch/ Divisional Offices only."],"title":"Claim Form","submit":{"to":"LIC Branch/ Divisional Offices only","how":"submit in person or by post","address":""},"purpose":"claim","sections":[{"title":"Policy and Contact Details","fields":[{"help":"","type":"text","label":"Policy Number","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"UHID NO.of  Health Card","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Name of the TPA","options":[],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"Mobile / Phone of Principal Insured","options":[],"required":null,"pdf_field":""},{"help":"","type":"email","label":"E-mail ID of  Principal Insured","options":[],"required":null,"pdf_field":""}],"filled_by":"policyholder/claimant"},{"title":"Quick Cash Facility (Plan 903 only)","fields":[{"help":"Date when the major surgery was performed","type":"date","label":"Date of Major surgery","options":[],"required":null,"pdf_field":""},{"help":"Specify category 1 or 2 of the major surgery","type":"text","label":"Details of Major Surgery (category1 OR 2)","options":[],"required":null,"pdf_field":""},{"help":"Name of the surgeon who performed the surgery","type":"text","label":"Performing Surgeon’s Name","options":[],"required":null,"pdf_field":""},{"help":"Amount of quick cash claimed","type":"amount","label":"Amount of Quick Cash Availed","options":[],"required":null,"pdf_field":""}],"filled_by":"policyholder/claimant"},{"title":"Benefits Claimed","fields":[{"help":"Daily hospital cash benefit amount as per policy","type":"amount","label":"Daily Hospital Cash Benefit of Insured","options":[],"required":null,"pdf_field":""},{"help":"Number of days the insured was hospitalized","type":"number","label":"No. of days Hospitalized","options":[],"required":null,"pdf_field":""},{"help":"Amount claimed for daily hospital cash benefit","type":"amount","label":"Daily Hospital Cash Benefit Claimed","options":[],"required":null,"pdf_field":""},{"help":"Amount claimed for major surgical benefit","type":"amount","label":"Major Surgical Benefit Claimed","options":[],"required":null,"pdf_field":""},{"help":"Total amount claimed combining daily hospital cash and major surgical benefits","type":"amount","label":"Total Benefits Claimed(C+D)","options":[],"required":null,"pdf_field":""}],"filled_by":"policyholder/claimant"},{"title":"Particulars of the Policy Holder","fields":[{"help":"Full name of the principal insured","type":"text","label":"Name of the Policyholder(Principal Insured)","options":[],"required":true,"pdf_field":""},{"help":"Full postal address of the policyholder","type":"text","label":"Communication Address of the Policyholder","options":[],"required":true,"pdf_field":""}],"filled_by":"policyholder/claimant"},{"title":"Details of Insured Member","fields":[{"help":"Name of the insured member for whom claim is made","type":"text","label":"Name of the Insured","options":[],"required":true,"pdf_field":""},{"help":"Occupation of the insured member","type":"text","label":"Occupation of the Insured","options":[],"required":null,"pdf_field":""},{"help":"Address of the insured member","type":"text","label":"Address of the Insured","options":[],"required":null,"pdf_field":""}],"filled_by":"policyholder/claimant"},{"title":"Particulars of Ailment / Disease / Injury","fields":[{"help":"Relationship of insured to principal insured","type":"text","label":"Relationship of the Insured to PI","options":[],"required":null,"pdf_field":""},{"help":"Describe the nature of the ailment or injury","type":"text","label":"Nature of disease/illness/injury","options":[],"required":true,"pdf_field":""},{"help":"Select gender of the insured","type":"choice","label":"SEX  ( M / F)  :","options":["M","F"],"required":true,"pdf_field":""},{"help":"Date of birth of the insured","type":"date","label":"Date of Birth:","options":[],"required":true,"pdf_field":""},{"help":"Provide past medical history and initial diagnosis if any","type":"text","label":"Details of past history of disease with initial diagnosis","options":[],"required":null,"pdf_field":""},{"help":"Date when the disease or injury was first detected","type":"date","label":"Date of disease/ illness/ injury first detected","options":[],"required":null,"pdf_field":""},{"help":"Provide details of any past hospitalizations","type":"text","label":"Has the insured been hospitalized in the past?  If yes give details","options":[],"required":null,"pdf_field":""},{"help":"Duration of the current disease or injury","type":"text","label":"Duration of disease:","options":[],"required":null,"pdf_field":""},{"help":"Indicate if MLC/FIR was lodged in case of RTA and attach reports if yes","type":"yes-no","label":"In case of Road Traffic Accident , whether MLC /  FIR lodged:   YES  / NO","options":["YES","NO"],"required":null,"pdf_field":""}],"filled_by":"policyholder/claimant"},{"title":"Hospital and Treatment Particulars","fields":[{"help":"Name of the hospital where treatment was received","type":"text","label":"Name of the Hospital:","options":[],"required":true,"pdf_field":""},{"help":"Hospital contact phone number","type":"phone","label":"Phone Number of the Hospital","options":[],"required":null,"pdf_field":""},{"help":"Hospital registration number","type":"text","label":"Registration No.","options":[],"required":null,"pdf_field":""},{"help":"Hospital fax number","type":"text","label":"FAX  No of the Hospital:","options":[],"required":null,"pdf_field":""},{"help":"Full address of the hospital","type":"text","label":"Address of the Hospital","options":[],"required":null,"pdf_field":""},{"help":"Inpatient number assigned by hospital","type":"text","label":"In patient No.","options":[],"required":null,"pdf_field":""},{"help":"Date when admitted to hospital","type":"date","label":"Date of Admission:","options":[],"required":true,"pdf_field":""},{"help":"Time of admission","type":"text","label":"Time:","options":[],"required":null,"pdf_field":""},{"help":"Date when discharged from hospital","type":"date","label":"Date of Discharge:","options":[],"required":true,"pdf_field":""},{"help":"Time of discharge","type":"text","label":"Time:","options":[],"required":null,"pdf_field":""},{"help":"Diagnosis made by hospital","type":"text","label":"Diagnosis:","options":[],"required":true,"pdf_field":""},{"help":"Details of any other health insurance coverage","type":"text","label":"Covered by any other Health insurance: Give Name of the Company &  Pol  No:","options":[],"required":null,"pdf_field":""}],"filled_by":"policyholder/claimant"},{"title":"Particulars of Attending Doctor","fields":[{"help":"Name and specialization of the attending doctor","type":"text","label":"Name of Attending Doctor & his specialisation","options":[],"required":true,"pdf_field":""},{"help":"Doctor's registration number","type":"text","label":"Registration No:","options":[],"required":null,"pdf_field":""},{"help":"Select the system of medicine practiced","type":"choice","label":"System of Medicine:  Allopathy  / Non-Allopathy:","options":["Allopathy","Non-Allopathy"],"required":null,"pdf_field":""}],"filled_by":"policyholder/claimant"},{"title":"ICU Treatment Particulars","fields":[{"help":"Indicate if ICU treatment was included","type":"yes-no","label":"Did the hospitalization include ICU treatment YES / NO","options":["YES","NO"],"required":null,"pdf_field":""},{"help":"Start date and time of ICU treatment if applicable","type":"date","label":"If  “YES”, Date of commencement of ICU treatment / Time","options":[],"required":null,"pdf_field":""},{"help":"End date and time of ICU treatment if applicable","type":"date","label":"Date of completion of ICU treatment/Time","options":[],"required":null,"pdf_field":""}],"filled_by":"policyholder/claimant"},{"title":"Surgical Procedure Particulars","fields":[{"help":"Name of the surgery performed","type":"text","label":"Name of surgery","options":[],"required":null,"pdf_field":""},{"help":"Date when surgery was performed","type":"date","label":"Date of Surgery","options":[],"required":null,"pdf_field":""},{"help":"Name of the surgeon who performed the surgery","type":"text","label":"Name of surgeon who has performed the surgery","options":[],"required":null,"pdf_field":""},{"help":"Attach all surgical reports","type":"attachment","label":"Please attach all surgical reports along with this form","options":[],"required":true,"pdf_field":""}],"filled_by":"policyholder/claimant"},{"title":"Claim Discharge Certificate","fields":[{"help":"Name and code number of the bank","type":"text","label":"NAME OF THE BANK/CODE NO","options":[],"required":true,"pdf_field":""},{"help":"Bank branch location","type":"text","label":"Location","options":[],"required":true,"pdf_field":""},{"help":"Bank account number","type":"text","label":"A/C NO","options":[],"required":true,"pdf_field":""},{"help":"Bank IFSC code","type":"text","label":"IFSC NO","options":[],"required":true,"pdf_field":""},{"help":"PAN number of the account holder","type":"text","label":"PAN NO","options":[],"required":true,"pdf_field":""},{"help":"Attach cancelled cheque leaf","type":"attachment","label":"Please attach a cancelled cheque leaf to authenticate the details given above","options":[],"required":true,"pdf_field":""},{"help":"Sign to authorize claim payment to bank account","type":"signature","label":"Signature of the Principal Insured","options":[],"required":true,"pdf_field":""}],"filled_by":"policyholder/claimant"}],"deadlines":[],"applies_to":"Form for claiming HCB/ MSB/ DCPB/ OSB/ Quick Cash under LIC’s Health Insurance Policy","attachments":["All surgical reports","Cancelled cheque leaf","MLC / FIR reports if applicable"],"declarations":["The information provided is true and correct to the best of the claimant's knowledge and belief.","False or fraudulent statements will forfeit the right to claim under the policy.","Authorization to LIC to make claim payment to the specified bank account.","Discharge is given with full satisfaction in full and final settlement of the claim."],"dropped_labels":1},"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/lic/2310-claim-form"}