{"id":237,"title":"ICICI Pru Health Saver Health Savings Benefit Claim Form","purpose":"claim","insurer":{"slug":"prudential-hcl-health-insurance","name":"Prudential HCL Health Insurance Limited"},"source_pdf":"https://www.icicilife.com/content/dam/icicipru/download-centre/regionalforms/malayalam/Malayalam_Health_Saver_Health_Savings_Benefit_Claim_Form.pdf","sha256":"92d22c45d089ee4cea2685ee5b2ea91bcdda4b0689e0e90836f383d11a62f600","pages":2,"collected":"2026-10-20","instructions":{"about":"This form is used by the policyholder to claim health savings benefits under the ICICI Pru Health Saver policy.","notes":["Attach original bills only.","Fill the form in block letters.","Contact 1860-266-7766 for assistance.","Office hours are 9:00 AM to 6:00 PM on working days."],"title":"ICICI Pru Health Saver Health Savings Benefit Claim Form","submit":{"to":"RIy]RIy]RI NkPc¢x|¤ RRslV C¢xOr¢yV WÒj] s]o]ãcV., v]SjLhV y]¤¨V o]¤yV SWLÒTºV, \\NWv¡¾] ASwLWV jY¡, WLÍ]vVs] (CTyVãV), oOUmpV 400 101.","how":"post","address":"RIy]RIy]RI NkPc¢x|¤ RRslV C¢xOr¢yV WÒj] s]o]ãcV., v]SjLhV y]¤¨V o]¤yV SWLÒTºV, \\NWv¡¾] ASwLWV jY¡, WLÍ]vVs] (CTyVãV), oOUmpV 400 101."},"purpose":"claim","sections":[{"title":"Claim Details","fields":[{"help":"","type":"text","label":"f}pf]","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"m]¤/ C¢SvLpVyV","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"jÒ¡","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"fOW (qPk)","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Rft]vLpOç","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"C¢SvLp]yOWtORa","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Aô¤ yo¡Õ]\\ÿfV","options":[],"required":null,"pdf_field":""},{"help":"Details of the hospital or clinic where treatment was taken","type":"text","label":"C¢xP¡ R\\pVfpLtORa SkqV mÌU (SkLt]y] DaopOoLp])","options":[],"required":null,"pdf_field":""},{"help":"Details of the treating doctor","type":"text","label":"vÐ R\\svOWtORa v]whLUw°¥ RWæp]U R\\pVf RoL¾U fOW","options":[],"required":null,"pdf_field":""},{"help":"Doctor's signature or stamp","type":"text","label":"f}pf]","options":[],"required":null,"pdf_field":""},{"help":"Date of treatment","type":"text","label":"SkLt]y] DaopORa KÕV","options":[],"required":null,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Hospitalization Details","fields":[{"help":"Details of hospitalization including admission and discharge dates","type":"text","label":"yLƒ]pORa AjOof]","options":[],"required":null,"pdf_field":""},{"help":"Details of illness or injury for which hospitalization was required","type":"text","label":"SlLo]Rs Dça¨U ISÐLaV/`°StLaV v|©oLp] v]wh}Wq]\\ÿO fÐORvÐOU `L¢/`°¥ AfV kP¡¹oLp]","options":[],"required":null,"pdf_field":""},{"help":"Details of treatment and procedures done during hospitalization","type":"text","label":"SlLo]Rs Nkf]Wqe°¥ Ij]¨V/`°¥¨V j¤W]p v]vq°¥ NkWLqU SqXRÕaO¾]pfLReÐV WPa] `L¢ yLƒ|RÕaO¾OÐO","options":[],"required":null,"pdf_field":""},{"help":"Name of the hospital","type":"text","label":"y~Shw]pLp","options":[],"required":null,"pdf_field":""},{"help":"Address of the hospital","type":"text","label":"Rs fLoy¨LqjLp","options":[],"required":null,"pdf_field":""},{"help":"Phone number of the hospital","type":"text","label":"R£ oW¢/oW¥ Bp","options":[],"required":null,"pdf_field":""},{"help":"Hospital registration number and other details","type":"text","label":"Bp (RNkLSÕLyrOoLpOç  mÌU) `L¢ (yLƒ]pORa SkqV)  CT SlLo]Rs Dça¨U","options":[],"required":null,"pdf_field":""},{"help":"Select the appropriate option","type":"choice","label":"o]yVã¡/o]y]yV/o]yV","options":["o]yVã¡","o]y]yV","o]yV"],"required":null,"pdf_field":""},{"help":"Details of the treatment and expenses incurred","type":"text","label":"jV vLp]\\ÿO RWLaO¨OWpOU v]wh}Wq]\\ÿO RWLaO¨OWpOU R\\pVf]ŸORºÐOU ASÇzU/Av¥/Av¡ AfV","options":[],"required":null,"pdf_field":""},{"help":"Details of the claim amount requested","type":"text","label":"ojô]sL¨]RpÐOU SkLt]y]pORa IsæL v|vòWtOU vWOÕOWtOU kLs]¨OvL¢ yÚf]R\\ÿÐOU `L¢ Cf]jL¤ yLƒ|RÕaO¾OÐO","options":[],"required":null,"pdf_field":""},{"help":"Details of any other benefits claimed","type":"text","label":"`L¢ oOWt]¤ yLƒ|RÕaO¾]pRfsæLU IR£ kqoLvi] Ar]v]sOU v]w~Ly¾]sOU vLyVfvvOU yf|oLReÐV `L¢ yf|vL‚VoPsU j¤WOÐO","options":[],"required":null,"pdf_field":""},{"help":"Additional remarks or notes","type":"text","label":"¤ v\\ÿV CfV pgLv]i] ò]q}Wq]\\ÿO","options":[],"required":null,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Documents to Attach","fields":[{"help":"Attach original hospital bills","type":"checkbox","label":"1. Roc]¨¤ C¢xOr¢y]R£ kq]i]¨V kOrSopOç BwOkNf]vLy R\\svOW¥","options":[],"required":true,"pdf_field":""},{"help":"Attach original pharmacy bills","type":"checkbox","label":"2. Roc]¨¤ C¢xOr¢yV mLiWoLWL¾ BwOkNf]vLy R\\svOW¥","options":[],"required":true,"pdf_field":""},{"help":"Attach discharge summary and investigation reports","type":"checkbox","label":"3. Roc]¨¤ Wvr]R£ nLYoLpOç SWL&SkpVyV","options":[],"required":true,"pdf_field":""},{"help":"Attach other relevant medical documents","type":"checkbox","label":"4. oqOÐOWtOU KTxi°tOU + RRvSh|LkWqe°¥, SqLYj]¡¹p R\\svOW¥, hÍyLoNY]WtORa R\\svOW¥, ScLWVarORa yΡwj°¥","options":[],"required":true,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Declaration and Signature","fields":[{"help":"Signature of the claimant","type":"signature","label":"f}pf]","options":[],"required":true,"pdf_field":""},{"help":"Name of the claimant","type":"text","label":"SkLt]y] jÒ¡","options":[],"required":true,"pdf_field":""},{"help":"Date of signing","type":"date","label":"SkLt]y] DaopORa SkqV","options":[],"required":true,"pdf_field":""}],"filled_by":"policyholder"}],"deadlines":[],"applies_to":"Health Savings Benefit claims under ICICI Pru Health Saver policy","attachments":["Original hospital bills","Original pharmacy bills","Discharge summary and investigation reports","Other relevant medical documents"],"declarations":["The claimant declares that the information provided is true and correct to the best of their knowledge.","The claimant agrees to provide original documents as proof for the claim.","The claimant consents to the insurer verifying the information provided."],"dropped_labels":1},"pdf_fields":null,"fillable_pdf":false,"send_to":[{"purpose":"claim","channel":"email","value":"customersupport@prudentialhealth.in","label":"Claims Support Email","level":null,"hours":null,"applies_to":"health","source_url":"https://prudentialhealth.in/how-to-claim","quote":"7th Floor, One Unity Center, Senapati Bapat Marg,\nDadar West, Lower Parel, Mumbai – 400013\nGet in Touch\n➔\n1800 268 2000\ncustomersupport@prudentialhealth.in\nInsurance Plans\nHealth Insurance Plans\nPRUHealth Edge\nPRUHealth Signature\nPRUHealth Protect\nPRUHealth Guardian\nTools &","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"1800 268 2000","label":"Claims Support Toll-Free Number","level":null,"hours":null,"applies_to":"health","source_url":"https://prudentialhealth.in/how-to-claim","quote":"704 to 1708, 17th Floor, One Unity Center, Senapati Bapat Marg,\nDadar West, Lower Parel, Mumbai – 400013\nGet in Touch\n➔\n1800 268 2000\ncustomersupport@prudentialhealth.in\nInsurance Plans\nHealth Insurance Plans\nPRUHealth Edge\nPRUHealth Signature\nPRUHealth","fetched_at":"2026-10-20"}],"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/prudential-hcl-health-insurance/237-icici-pru-health-saver-health-savings-benefit-claim-form"}