{"id":244,"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/punjabi/Punjabi_Health_Saver_Health_Savings_Benefit_Claim_Form.pdf","sha256":"2db8221fa739c432fd7a162c3e176d469e4fae49a94600e863e952bb07368fee","pages":2,"collected":"2026-10-20","instructions":{"about":"This form is used by the policyholder or claimant to claim health savings benefits under the ICICI Prudential Health Saver policy.","notes":["Use block letters to fill the form.","Attach original bills and documents only.","Incomplete or incorrect forms may delay claim processing.","For assistance, call 1860 266 7766 between 9 AM to 9 PM on working days."],"title":"ICICI Pru Health Saver Health Savings Benefit Claim Form","submit":{"to":"ApBrgrApBrgrApBr \\cvTzqfAd dpBr³ qB¥qfatczg H¥. qd., cqOgRcT \\Wp: ApBrgrApBrgrApBr \\cvdpBr³ Rpec, 1089, A§\\pgphy^ `cpSy¾ `pcJ, \\o_pYyer, `t¥^Br-400025","how":"post","address":"ApBrgrApBrgrApBr \\cvdpBr³ Rpec, 1089, A§\\pgphy^ `cpSy¾ `pcJ, \\o_pYyer, `t¥^Br-400025"},"purpose":"claim","sections":[{"title":"Claimant Details and Declaration","fields":[{"help":"Enter the name of the hospital or health care provider where treatment was taken","type":"text","label":"dpJv qO§Xy \\ogWpeH A²¾-\\mª h± Op£ A\\¥JWp W~ \\rmW h± qOg Hc Hy qdIVp gr`W h± Op£ qO§Xy \\ogWpeH  ²y¾ Yygr _pfp qe§M YgWIW HrWy h²¾& (²}¾R: hyS¾ qdIW Yr Jephr Eg qeAHWr ed~ h}ey O} H¥\\²¾r Yp gdphHpc / `tdpk` ²¾p h}ey)&","options":[],"required":null,"pdf_field":""},{"help":"Provide details of the treating doctor or consultant","type":"text","label":"`|/Ags qBg Yr \\tgRr HcYy hp£ qH qBg ³pc` Yp qegW pc `±²¥¾v / gp²¥¾v M¥Jr Wcªp£ g`PpqBAp qJAp h± AWy `| / Ags qBg ²¥¾v \\vcr Wcªp£ g`P JBy hp£& `| / Ags qBg Yr er \\tgRr HcYy hp£ qH ³pc` Yy A¥Yc Oep^ `ycy / gpTy ed~ \\oYp²¾ OpVHpcr `tWp^H YcO HrWy JBy h²¾&","options":[],"required":null,"pdf_field":""},{"help":"Enter the date of signature","type":"text","label":"`| (Jeph Yp ²¾p`)","options":[],"required":null,"pdf_field":""},{"help":"Enter the claimant's name and relationship to the insured","type":"text","label":"²¾pJqcH, _______________________ qeIy qchpqBf AWy (\\ogWpeH ²¾pd qcfWp)__________________________________ `| \\tgRr HcYp hp£ qH `| for`p²¾/for`Wr/Ht.","options":[],"required":null,"pdf_field":""},{"help":"Provide details of the treatment and claim","type":"text","label":"²¥¾v qBg ³pc` Yp eycep \\mª Hy g`PpqBAp h± AWy Eg ²y¾ qBg ²¥¾v g`P qdAp h± AWy \\pqdgr Yy gpcy q²¾a` AWy fcWp£ AWy Eg Yy E\\epH Yr \\pd²¾p Hc²¾ dBr gqh`W h±&","options":[],"required":null,"pdf_field":""},{"help":"Enter place","type":"text","label":"q`Wr","options":[],"required":null,"pdf_field":""},{"help":"Enter date","type":"date","label":"²y¾mªy","options":[],"required":null,"pdf_field":""},{"help":"Enter claimant's signature","type":"text","label":"g¥\\cH ²¥¾^c","options":[],"required":null,"pdf_field":""}],"filled_by":"claimant"}],"deadlines":[],"applies_to":"Health Savings Benefit claims under ICICI Prudential Health Saver policy","attachments":["Attach original bills, receipts, discharge summary, investigation reports, and other relevant documents as per the form instructions"],"declarations":["The claimant declares that the information provided is true and correct to the best of their knowledge.","The claimant authorizes the insurer to seek medical information from the hospital or doctor for claim verification.","The claimant agrees to submit original documents and cooperate with the insurer during claim processing."],"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/244-icici-pru-health-saver-health-savings-benefit-claim-form"}