{"id":375,"title":"Wellness Reward Points Redemption (OPD) Form","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/wellness-rewards-points-redemption-form.pdf","sha256":"dc6229918e733a6d8be9f957ff280e4152c1c698e8e900433690f3369bd0b29e","pages":1,"collected":"2026-10-20","instructions":{"about":"This form is for policyholders to redeem wellness reward points for OPD expenses by submitting claim details and bank information.","notes":["Please provide original bills only.","Fill the form in CAPITAL letters only.","Separate claim form to be filled for every insured person for redemption.","As per IRDA, all claims shall be settled in electronic mode only; provide correct bank account details."],"title":"Wellness Reward Points Redemption (OPD) Form","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 (Insured Details)","fields":[{"help":"Enter the full name of the policyholder or proposer","type":"text","label":"Name of Policy holder/Proposer*","options":[],"required":true,"pdf_field":""},{"help":"Enter your current policy number","type":"text","label":"Current Policy number","options":[],"required":null,"pdf_field":""},{"help":"Enter your card number or UHID","type":"text","label":"Card No./UHID","options":[],"required":null,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Part - B (Claim Details)","fields":[{"help":"Describe the nature of each expense","type":"text","label":"Nature of expense","options":[],"required":null,"pdf_field":""},{"help":"Enter the bill number for each expense","type":"text","label":"Bill Number","options":[],"required":null,"pdf_field":""},{"help":"Enter the date of the bill","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Enter the amount claimed for each bill","type":"amount","label":"Amount (in `)","options":[],"required":null,"pdf_field":""},{"help":"Enter the total amount claimed","type":"amount","label":"Total Claimed Amount* (In `)","options":[],"required":true,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Claimant Details","fields":[{"help":"Enter the name of the insured person","type":"text","label":"Name of Insured","options":[],"required":null,"pdf_field":""},{"help":"Specify your relationship with the policyholder","type":"text","label":"Relationship with the Policy holder","options":[],"required":null,"pdf_field":""},{"help":"Enter the age in completed years","type":"number","label":"Present completed age (in years)","options":[],"required":null,"pdf_field":""},{"help":"Select the gender","type":"choice","label":"Gender :  M         F","options":["M","F"],"required":null,"pdf_field":""},{"help":"Enter your current residential address","type":"text","label":"Current Residential address","options":[],"required":null,"pdf_field":""},{"help":"Enter your city","type":"text","label":"City","options":[],"required":null,"pdf_field":""},{"help":"Enter your state","type":"text","label":"State","options":[],"required":null,"pdf_field":""},{"help":"Enter your postal pin code","type":"number","label":"Pin Code","options":[],"required":null,"pdf_field":""},{"help":"Enter your mobile phone number","type":"phone","label":"Mobile No.","options":[],"required":null,"pdf_field":""},{"help":"Enter your landline number if any","type":"phone","label":"Landline No.","options":[],"required":false,"pdf_field":""},{"help":"Enter your email address","type":"email","label":"E-mail","options":[],"required":false,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Part - C - (EFT Details)","fields":[{"help":"Enter the name of the policyholder or proposer","type":"text","label":"Name of Policy holder/Proposer*","options":[],"required":true,"pdf_field":""},{"help":"Enter your bank account number","type":"text","label":"Bank account number of Policy holder/Proposer","options":[],"required":true,"pdf_field":""},{"help":"Enter the bank name","type":"text","label":"Name of the Bank","options":[],"required":true,"pdf_field":""},{"help":"Enter the branch name","type":"text","label":"Branch Name","options":[],"required":true,"pdf_field":""},{"help":"Enter the IFSC code as per the cheque leaf","type":"text","label":"IFSC of the Bank","options":[],"required":true,"pdf_field":""},{"help":"Attach one of the specified documents for EFT verification","type":"attachment","label":"EFT DETAILS : Provide any ONE of the below (Mandatory) Cancelled cheque copy/ Valid photo identity proof (self attested)/ Bank attested copy of passbook with IFSC","options":[],"required":true,"pdf_field":""}],"filled_by":"policyholder"},{"title":"Declaration","fields":[{"help":"Enter the place of signing","type":"text","label":"Place","options":[],"required":null,"pdf_field":""},{"help":"Enter the date of signing","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Sign the form","type":"signature","label":"Signature of Claimant/ Proposer","options":[],"required":null,"pdf_field":""}],"filled_by":"claimant/proposer"}],"deadlines":[],"applies_to":"Wellness reward points redemption under OPD","attachments":["Claim form duly filled & signed","Investigation bills","Investigation reports","Hospitalization bills","Medicine bills","Doctor prescription","Any other documents (Please specify) _____________________________","Cancelled cheque copy or Valid photo identity proof (self attested) or Bank attested copy of passbook with IFSC"],"declarations":["The information given in this claim form is true, correct and complete to the best of my knowledge.","No relevant information has been withheld or undisclosed.","False or fraudulent statements or concealment of information will void the policy and claims.","Receipt of this form does not admit claim liability; the company may require further information or reject the claim.","I consent to ICICI Lombard Health Care seeking medical information from any hospital or doctor who attended the insured.","I have included all bills and receipts for this claim and will not make any supplementary claim.","The expenses claimed have been incurred for the insured."],"dropped_labels":0},"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/375-wellness-reward-points-redemption-opd-form"}