{"id":430,"title":"Group Hospital Cash","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/group-hospital-cash8c0007ff45fd68ff8a0df0055f5f6903.pdf","sha256":"4f88abe5d6811127b48153b4973072c9d10979fa727e72e2a4d0075e25fd2456","pages":3,"collected":"2026-10-20","instructions":{"about":"This form is for submitting a hospital cash insurance claim under a group policy. The claimant or policyholder fills it.","notes":["All claims shall be settled in electronic mode only, as per IRDA; provide correct bank details.","Policy holder is the person who has paid premium for the policy.","In case of accidental hospitalisation, submit original bills and receipts.","Use self-attested copies for identity proofs.","Submit a self-attested copy of valid government-issued identity proof along with the consent letter.","Original hospitalization or day-care treatment documents collected at discharge but not submitted must be submitted to process the claim."],"title":"Group Hospital Cash","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":"Other Insurance Details","fields":[{"help":"","type":"yes-no","label":"Do You have any other insurance for similar claim (either with Us or with any other insurer)","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"","type":"text","label":"If yes please specify details","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Name of the  insurer","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Policy No.","options":[],"required":null,"pdf_field":""},{"help":"Enter the policy coverage period","type":"text","label":"Policy Period","options":[],"required":null,"pdf_field":""},{"help":"","type":"amount","label":"Sum Insured","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Policy / product  name","options":[],"required":null,"pdf_field":""}],"filled_by":""},{"title":"Part - C - Bank Details","fields":[{"help":"Policy holder is the person who has paid premium for the policy","type":"text","label":"Name of the Policy Holder:","options":[],"required":true,"pdf_field":""},{"help":"Provide correct bank account details for electronic claim settlement","type":"text","label":"Bank account number of Policy Holder:","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Name of the Bank:","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Branch Name:","options":[],"required":true,"pdf_field":""},{"help":"Should be same as per the provided cheque leaflet","type":"text","label":"IFSC of the Bank:","options":[],"required":true,"pdf_field":""},{"help":"Attach either EFT mandate or cancelled cheque copy","type":"attachment","label":"EFT Mandate   Cancelled cheque copy (OR)","options":[],"required":true,"pdf_field":""},{"help":"Attach self-attested valid photo ID proof","type":"attachment","label":"Valid photo identity proof (self attested) (OR)","options":[],"required":true,"pdf_field":""},{"help":"Attach bank attested passbook copy with IFSC","type":"attachment","label":"Bank attested copy of passbook with IFSC","options":[],"required":true,"pdf_field":""}],"filled_by":""},{"title":"Enclosure Check List","fields":[{"help":"","type":"checkbox","label":"Claim form duly filled & signed","options":["Yes"],"required":true,"pdf_field":""},{"help":"","type":"checkbox","label":"Copy of Discharge Summary","options":["Yes"],"required":true,"pdf_field":""},{"help":"","type":"checkbox","label":"EFT Mandate","options":["Yes"],"required":true,"pdf_field":""},{"help":"","type":"checkbox","label":"PAN Card Copy","options":["Yes"],"required":true,"pdf_field":""},{"help":"Specify any other documents submitted","type":"attachment","label":"Any other documents","options":[],"required":false,"pdf_field":""}],"filled_by":""},{"title":"Documents for Accidental Hospitalisation (Originals)","fields":[{"help":"Submit original final bill","type":"attachment","label":"Final bill","options":[],"required":true,"pdf_field":""},{"help":"Submit original medicine bills with prescriptions","type":"attachment","label":"Medicine bills with Prescriptions","options":[],"required":true,"pdf_field":""},{"help":"Submit original investigation bills with prescriptions and reports","type":"attachment","label":"Investigation bills supported by Prescriptions & Reports","options":[],"required":true,"pdf_field":""},{"help":"Submit original payment receipts","type":"attachment","label":"Payment Receipts","options":[],"required":true,"pdf_field":""}],"filled_by":""},{"title":"Declaration","fields":[{"help":"","type":"text","label":"Place","options":[],"required":true,"pdf_field":""},{"help":"","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"","type":"signature","label":"Signature of Claimant/ Policy Holder","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant / policyholder"},{"title":"Mailing Address","fields":[{"help":"Address for sending the claim form","type":"text","label":"Mailing Address","options":[],"required":null,"pdf_field":""}],"filled_by":""},{"title":"Consent Letter","fields":[{"help":"Enter your proposal or policy number","type":"text","label":"Proposal No. / Policy No.","options":[],"required":true,"pdf_field":""},{"help":"","type":"text","label":"Name of the Insured","options":[],"required":true,"pdf_field":""},{"help":"","type":"signature","label":"Claimant / Insured Signature","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant / insured"}],"deadlines":[],"applies_to":"","attachments":["EFT Mandate or Cancelled cheque copy","Valid photo identity proof (self attested)","Bank attested copy of passbook with IFSC","Copy of Discharge Summary","PAN Card Copy","Final bill (original, if accidental hospitalisation)","Medicine bills with Prescriptions (original, if accidental hospitalisation)","Investigation bills supported by Prescriptions & Reports (original, if accidental hospitalisation)","Payment Receipts (original, if accidental hospitalisation)","Self-attested copy of valid government-issued identity proof (with consent letter)"],"declarations":["The information given in this claim form is true, correct and complete to the best of my knowledge.","No material information relevant to the claim has been withheld or not disclosed.","False or fraudulent statements or concealment of material information will void the policy and claims.","Receipt of claim form or documents does not guarantee claim acceptance; company may require more information.","I consent to ICICI Lombard seeking medical information from any hospital or medical practitioner who attended the insured.","I declare that all bills and receipts for this claim are included and no supplementary claim will be made.","I confirm the expenses claimed were incurred for the insured person.","I consent to the company verifying my identity/address proof through Central KYC Registry or other modes."],"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/430-group-hospital-cash"}