@iciciElombard |CICI Lombard Health Care Claim Form - Hospitalisation ‘cit tomisra\ ‘Mibhaye Vaade sane this eo Beale as an ain fbi) HealthCare Part A Tobe filed Required to A Sal Delain Ae Saf Declaration a Ave aly Copy gayae aT Ae Avelbein Pay Copy AS Aveilbein Discharge Summary By insured insured Totrack he potey and AB Saf Delran relatives other dts ofthe insured Ar Sal Desiaraon a Availabe in Hospital Bi] Se Decoration a9 ‘Aveabein Hospital Bis 0 Checks Fags end | Saf deleraton Fan a Tospial baie Bz Doctor Oats Tob fille by Hospital To rac he hospitel 83 alent datas ating doctor als andthe wsatment Ba Tietment/ Procedure Daa deta lates tora 5 quted onl for Real nivel estomers patient admission Fogo ond__| Hospital delaatan Pant a Patents Name cz Paley Numbor cs Card No /UKIO No For Electronic fund cs Group! Comoany name Tobe filles by Insured ‘ansort th bank os Claim nunberaloted sccount ob Mobile Contact no cr Provide sy 1 document of proposer, oe Asa bank ass book age ond | Accourt hola’ signature ar (Only Retail Inividual customers f aiming > ak rupees) 1 avant Name m2 Palcy Number 0s Card No UO Na m7 Gro! Comsany name Tobe fil by Insured As par ROA mandste 5 Chae umber (aloe) for claims > 1 ae 06 Mobie/ Contacto Br AYE cosumerts Page ond | Claman signature So, Document Yes | No Type of document 1._| Gia form dy filed Orga 7 Discharge Summary! Dayeare Summary ‘Orignal S| Final Hopital ill Orginal | Payment Recsips Orginal 5. [Investigation Repos Orginal | Pharmacy Bll Orginal 7 |"Iplant Sticker veiw Orginal | Doctor Prescriptions Phoocopy S| onsaation Paper Photocopy To_[Age roof Praiocopy Ti door Case Paper Photocopy TZ | EFF (Copy ofcancaled cheque) sa attested TD pool Bank aionted copy af passbook wih IFSC code Photocopy TE [-KVC [Copy of [0 prookRasidonce proof, 62 Passport size patos) a TT @icict€Lombard Nibhaye Vaade alig Ades: Lb esta, IE ark Toe lat orn Dstt Nae Gd, Gail dab S002 sited Office Aver: II oro es 416, Vu Sart Ma NaS Vrya apl Pratt, Mb 4002, Visiter ac wncclintedcon. «EMail a hte ilorordcom Tl ie Naber 096° Fes Fx Nan 90.2085950 TROA egsrton No. 115AGELEtombard crc) Lombard Health Ca « Hospitelisati maui) Tene ta eres ore ay ‘ALL CLAIM SETTLEMENTS SHOULD BE MADE THROUGH NEFT (AS PER IRDA CIRCULAR), PLEASE PROVIDE YOUR BANK ACCOUNT DETAILS, REFER TO PART C. > Nor-subisson of oii ils and rect th main reson fr delay ince setdements, Pease provide the originals mandatory documents DERE CHRD * To receiv update on your claim status, provide your mobil no, Ena + You can ack your cam status at: wwrwieellombard.com->Chins & Welless-)Health Claims & Wellness Track your ins Prec TOBE FLED CAPITAL LETTERS ONLY [A1.TypeofClaim: MainHosptaisation Expenses | Pro€sPostHospitaistionExpenses_) Cashless Obtained: Yes _J No _| ‘2, Details ofthe Insured personin respect of whom claims made: patient details) Name ofthe Patient: J J JoJo) J) J J Joey J) J assjy Card No/UHID of the Patient J J J J J J) J J) J Gender: Male | Female_) Date of Birth: 8) O)/ Jt) J Completed age: Years __ Months Occupation: Service Self Employed _ Homemaker _) Student) Retired J Other _) (Please specify) ‘Are you previously covered by any other Mediclaimy Health Insurance: Yes No... If yes, Company name: Current residential address: _)_)_ i) Jo JJ JJ JJ 0 J |) _J_) ) JJ | 4 25343 Jo StateJ__J JJ JJ. J) Pin code: 5 Mobile no Soo00055 )_Jtandine no, JJ JJ) J JJ emt J III I A3. For Group/ Corporate Policy For Individual/ Retail Policy a ‘MemberID No/Employeet0 (CentiDy. —]_)_ TJ *ctaiminimatonseniceRequestna: JJ JJ JJ) JJ Je so Isthisarenewalpolicy:Yes No | Group/Companyname: |_| _J_J_)_J_J__J_._)_)_) |tt¥es, kindly mention your proviouspolicyno.: JJ J) J) J J JIL JI Io 5} Jo JI MNameotthePopeses J J RelationshipwiththeProposer"s |) J J) |) | J J Jd CunrentPolicyNo: =|) | J) J J) |) Card Noy uso: {Policy Hole. Forfetalloey, Proposer name require Fr Coperat poly, provide Egloysenams) AS, Nature of disease/ilness contracted or injury suffered for which Insured was hospitalized (Diagnosis) Nameothospitalwnoreadmites JJ J.J) JJJIIIJJ.J....,JJ)3)))0)04 Roomeategeryaccupiod: Daycare) Singleaccupancy . Twinsharing | Sormorebeds porroom Others Dateot Admission: J LY) Time: $) J Dateot Discharge: 2) 0) / vs 4 9) 1 TS) Ta Detour sustainadordisease/lossfretdetectae: 9) J 0) 1) injury, givecause: Salfinicted_) Road affic accidant __ Substance abuse/Aeohalconsumption —_JOthes, U1Medicoegak Yes.) No Reporedtopolie: Yes_JNo_) MLCReport&PolceFRattached: Yes _| No llyes,attachepor) System of Medicine {AS Are you coverod undo any Topup/Additonal pol J No) tives, provide patiey no. AAT. Currently covered by any other Medictaim/ Health Insurance: | | DateofcommencementoffrstInsurance withoutbreak: ) J) ) Haveyoubeenhasptalzedinthelast4yearssince inception ofcontract: |_| Date: ©) 9) Jv) | °) 1) v) Dignosis: ave you lodged any claim agains this particular admission data stachedils with anyother Insurance company: yes, altach settementte, Company name: Picy No Suminsued® |) J) AB. Details of Claim a} Detals ofthe treatment expenses claimed i, Pre-hospitalizationexpenses: % J | | | J J ii, Hospitalization expenses: ii, Post-hospitalzation expenses: = © J _)_)_|_J_J iv Health-checkup cost: v. Ambulance charges: ze JJ J Iw. Others Total: vit Pre-hospitaization period Jays Vii. Posthosptazation period: —__)_ Days sro ft fg pre rd trae eee Sr wovisclombard com ‘Chaim document to be dispatched t: ICICI Lomas Heakteae, CII Sank Tove Pot No, 12, Finacial svt, Nanakram Gude, Gchibowi, Hyderabod- 500082b) Chim for i, Domiciiary Hospitalization: Yes__| No _|{If yes, provide details in annexure) ii, Day care: Yes_| No} ii, Extended care/Inpatient rehabilitation: Yes_) No_} }_ Details of ump sum cash benefit claimed i. Hospital dally cas TJS SJ J) te Surgicalcash: TJ it. Ctl ites: TJS JJ J ie Comlescence: TI \ Pre/Posthosptalzatoniumpsumbenefi: € | J | J J) J wi Others: es AS, Details of the amount claimed Bil heads (as sppicable) Bill number Room re Doctors consultaton/Visiteharges Trvestigation charges lncludos Radiology and Pathology reports) ‘Surgeon and Asst, surgeon charges ‘Anesthetist charges & Operation theatre charges Eauipment charges/ Procedure charges Cost ofimplant any) [Wasiine charges (neler ward and medicines and consiabla] Pharmacy charges Taxes) Surcharges Service charge Tiscellaneous/ Other charges Pre hospitalization bls fany) Posthasptalzation bil (any) Discount provided hosptal any) J Total claimed amount (in eelinedameunshala be eqaliote wnauntnatachsblldocamaris) Jo JIS MANDATORY: ALL CLAIM SETTLEMENTS SHOULD BE MADE THROUGH NEFT (AS PER IRDA CIRCULAR), PLEASE PROVIDE YOUR BANK ACCOUNT DETAILS REFER TO PART C. ‘A10. In support of the above claim | enclose fllowing documents in orignal (lease indicate by ticking in the Yes/ No column below) ‘Type of Document(s) - “Mandatory Yes | No | Type of Document(s) - As Applicable Yes [No 1. Chaim Ferm duly ied and sgned™ T [1]. iol ontard GC Authorisation eter Ta 2. Discharge summany™ T [710% pan name andinvoie if any] wit plan ker Ta 3. Hospital bil, Final’ main haepal band ater Bile any™ |_| 1 [11 Indoor Case Papers a 4. Hospital payment reset & other ecents supporting bis" |__| || 12 Prescription papes/ Consutaien papers Ja . Investigation epets* (nolucing EOG/ C17 MAU USG/HPe) | | |13. Others (details). 5, Madicina/ Pharmacy bls with doctors prescription” JTS fe 7. Age poof Diving License PAN card Pesspor Aacharcopyl™ |_| |) ec 14, Parc = [6 documents equ tot aimed anf > 21 ak) "Mandatory. Please attach alte documents as pr above srl numbat, Fins hey fn CT Scan Hm, MB Scan fi, at, notoqute, Provo rapes nly Declaration by the Insured: hereby declare that the information furnished in ths claim form is tue and correct tothe best of my knowledge and betaf. have made any false or untrue statoment, suppression or concealment of any material fact with rospoet to questions asked in rlation to this claim, my right to claim ‘eimbursement shall be fateite. | also consent and authorize TPA/ insurance company, to seek necessary medical information! documents from any hospital Medical Practitioner who has attended onthe person against whom this claim is made. I hereby declare that | have inched al the bills! receipts forthe purpose ofthis claim and that willnotbe making any supolementary claim except the pra/posthospitalzation claim, it any, pate Pace Insured Signat sri i Rea frg pe ed TE SE wctombard om {Haim document tobe dispatched t: ICICI Lombard Heatcare, CII Bark Tov, Plat No, 12 Financial istrict, Norakram Gude, Gachibowi, Hyderabad 500032 ee ot eet er eer) co ee eee eee ee en Cee ee ee Ce eet)Part - B (To be filled by B1. Details ofthe Hospital Nursing home in which treatment was taken Name otheHosptalNursing home: _) J Address: J J City J ste) J Preode J iephone no) J Hosp Type of Hospital: Network Registration No with State Code: PAW Facilities availabe in the hospital: OT: JJ CU: 2, Details ofthe attending Medical Practtoner/ Doctor/ Treating Physician or Surgeon Name: Jj Jj JJ Cuolication: | J JJ) Registration ne: JI. Telephone no 5 Mobile no. Jo 3. Details ofthe pationt admitted Nameofthe patient IP Registration. Date of Admission: Date of ischarge: s Time: Type of Admission: Emergency __) Plenned Dey Care_| Maternity | Typeot Treatment: Surgical Procedure) MutipleSurgicalProcedure MediealTreatment | |f Maternity, Date of Delivery: ! GravidaStatus:6_ P_J A_J L_) Premature Baby:Yes_) No_) Status attime of discharge: Discharge tohome Dischargetoanotherhospital_ | Deceased Totalclaimedamount:® J) JJ) 4. Details ofthe procedure Pre-authorizationobtained:Yes_JNo_J Ityes, Pe-authorzationNo. JI authorization by network hospital not obtained, gvereason: Date oinjury sustained o disease ness fist dotted Injury. give cause:Selfinficted | Roadtraficaccdent Substance abuse/Alohol consumption _) Others Medico egal Yes No Reported topolice: Yes) No) MLCReport& PobceF IR attached: Yes | No. (Ifyes, attach report) FR. Iinot reported to Police, givereason Ifinjury duet substance abuse/alcohol consumption, testconducted to establish tis: Yes No_| lfyes,attachreport) BS, This section is mandatory only if your health policy isnot provided by your employer ‘A) Diagnosis ICD 10 Code primary & additional dignosis) i}Primary diagnosis withICD 10 code) TAdaitional diagnosis (withICD 10 code) TilProcedure diagnosis (with ICD 10 PCS code BY Nature ofsurgery/ treatment given for present alent C} Date frst consultation (Prior to hospitalization) 1)_Presenting complains ofthe patient during admission ) Pastmedicalhistory ofthe patient along with duration ofiiness yes ashes ipsa pp FT Was thepatientunder influence of aloha uring admission (G)_ Whether the present teatmentalmentisa complication of pre-existing disease T yes, please spociy the disease (ar complication a any previous curgery dane? Tivos, lease speci To aotals Whether the cisease/ dsorderis congenitalinnature7 T._Numborofin-pation beds in the hospital including ICU) Declaration by the hospital We hereby declare that the information furnished inthis Claim Form is true & correct tothe best of our knowledge and belt I we have made any false or untrue statomont, suppression or concealmont of any material fact, our right to claim under this claim shal be forfeited, Registration No. of Hospital (Rubberstamp ofthe hospital) Date: 2).9)/ si} de Doctors SeatandSigntive As perth policy Terms and Conditions, tha Company reserves its right te havethe Insured examinedby a dactor appointed by tor verification of agnosisAlerelClombard BEARD aA NAN EeT ‘ALL CLAIM SETTLEMENTS SHOULD BE MADE THROUGH NEFT (AS PER IRDA CIRCULAR), PLEASE PROVIDE YOUR BANK ACCOUNT DETAII C1. Patient's Name) J JJ Innspectt tonchm ree I I ¢3.cardNo/uHIDNe J J J C4, Group/Company Name vxcnsronorsrorymites: J J IIIS SIS IIIS oso dd 5. Claim Number ranewsr J) SS 6. obiter Contacto: J J J J J) 7, As per IRDA Circular No IRDA/FEAVCIRIGLO/056/02/2014, Proposer policyholders bank account details are mandatory to process the faim through EF. Please provide ANY ONE ofthe below documents of roposerpolicyholder- _} Please provide a selt-attested copy of a valid Identity proof of the Proposer/Policy holder provide any ofthe mecticned documents inProu of entity under Pat-D) J Canceledcheque copy __| Bankattested copy of Pessbook with IFSC code 8.Pleaseprovdethe below details alfeds are compulsory + Proposer (policy holder Employee namewispertnenente: J JJ Jo J JJ JJ JI + Proposer policy holder Bank account no. JJj5 55554 + Name of the bank JJ + Branch name: SIDS 555 Jo = + Ades ofthe bank JJ JI) J JJ J JJ J + trsc codeno.oftrobanc —_)_J_J_)_J_J_J_J_)_J_Jtatsesre aprenden ah 1) Policy older isthe person who has pal premium for he policy. polly, Name & Account detals of Proposer required. Fr Corporate poly, Employee Name & Account details required Tors Cnn fr Payers tnegS RESIN {1 Teta rnd ly Be seer katate Mader lb crs eae artn Canela Cammy al ater ce vii tay 2, Ta RTGSINEF ty sao eset Pps eyo Sastre ae Fom iy El ambedGewrhsvans Compa ad thinsch ie srmaytrezoay nr llamba Geant ose TEN ly 4. Taapre pkey he spend bo RTES/REF ny he may bak rape te Peat pky ak At ny th ct aly a change ‘economies heey rec apt Caney yn {Ta Pops etek ae oe, win cam Lob Gan res Campy pes ne Hl Laas Gowallnce Cogay Us a ‘oreo a ie oma ps ny ce eamags sn os an gers (esergatoeys to whch lamba Cana se Comp say na, clyde sng arwcorctonuih sneer tire amar elte sonnei eer 5. lcleanbs Gewese Comenius cont erty oes cya i sgn da he TGS NET ly Te Pepa peyote are ‘sos TGS NET avin orimonelStasprerwiton eso LonbeGewntisuetesCompyli he wvadl su urine bx guICEanbedont scopes ‘esanbo essed ert, Eats Bug YS Mr ws ere Pee, Numb =#0025, 1 earring ope Genres Conary Lv cas cane ‘gen pclae erate ci hee cs enna pee ly. 1. Tareas pty ha eee testo regh TEST ety may eri TG/ HEF chs, hcl vey he oss ple ale, shel bye Pease pelyaer 1 [ambassador semen ey Tere nod std aan nen land porno oe sah ange warren ‘ms enon nbsp By ung ane cx the conptan th bro wie Pepe ln let shale Somat hat ceed he ge Ta rn teatnenn yo sirtom ndorepessrugpamse gy ep vangogh cecngbenty etre nuded nes pyc ce chon eng ey ole Pean poly 11, Thurston gman ance agosto 12, Witney oes no Seth Elana Gaelcrwen Conny st whi ced ery etn Ure a Nt ‘won acetate Coane aes caren net emi ean ean tbe ole Papa ly foe no oer 1. arnt niece or eas oy. sr ni. eta ‘Svat cast equates CE lonbadewanaresconpey bore arp Pee ha ‘Mailing Address: ICICI Lombard Healthcare, IIE Bank Tower, Plot No. 12, Financial Ostrit, Nanakram Guda, Gachibowl, Hydorabad-500032 Visit us at wivmiciclombard.com * EMail us at ihvatnare@icicmbar.com + Toll Free Number: 18002686. RDA Registration No. 118@gic1 Lombard ‘Nibhaye Vaade [rey Cno ee ood KYC is required only for Individual Retail policy holders i the total claimed amount exceeds & 100,000, Inmectl hon chris J JJ III oJ. b2.PolicyNumber: J J J D3. Card No/ UID No.: J II J J J J J J D4, Group/Company Name forcrpcopeuepterrovent J J J IIS JI JI 1S, Claim Number wears: JJ JJ J) 6, Mobite/ Contacto: J J) J J 17. The below KYC documents are mandatory as per AML guidelines by RDA 1 3, _ One photocopy of proof of residence of Proposer (ary 1 inthe bebw ist) Two passport size photos of Proposer (sick inthe space provides below) — One photocopy of proof of identity of Proposer (any inthe below list) Cr Per (Any one of below mentioned documents required) nee eee J J J J IL} UU Passport PAN card Voter’ Identity ard Diving Heense Personal denation and cerilicaton ofthe employees ofthe insure for idanty othe prospective policyholder Lata issued by Unique Kenieaton Autonty of hi continng deals of name, address and Aadhar numb. Job card issuedby NREGA oul signed by an office ofthe State Government Later om a ecagnzed Pubic Autarty (as defined under Section 2 (hi of ‘he Right to Information Act, 2005) o Public Servant as define in Secon 2oftha"The PravatanofCoruption At, 196) vr ying the idemity and Bee Passport Witton confirmation from the banks where the prospectis a custome CILILIJL Electret bil Raton card Letter from any recagrized pubic authority Curent statement of bank account with detalls of permanent! present residence address as downloaded) Curent passbook with detls of petmanentpresant residence address Vale lease groomer long with et receipt, wich ot more than theo ‘months olds aresdenceproct Talephore bil peraning to any kind of telephone comecton tke, rabie, landline, weless, et. rovdedit sna ole than six months om the date of insurancecontact Apa gtetheprevius mont) J Employer's certificates aproofofresidenceCerifiats of employers who hive in-place systemate procedures for recutnent alongwith ‘maintenance of mandstoy ecards ofits employees re gencay ese) dng idontiication and proof of residence, Current passbook with details of present/ permanent esidence address {updated tothe previous month) ‘Current statement of Bank account with det Stick Proposer's Photographs of present permanent es\dence address (es downloaded) Claimants Signature icict@tombard ‘Nibhaye Vaade Maing Aros: 1 Loris Heathar 111 Bank Tower Pt No 12 Franc sri Nara Ga, Gachoo, Hyer S00082 ogistred Ofico Aer: III Lonoard Hous, 44, Ver Savarar Mar. Near Sih Vrayak Temple, Pabade, Mumba 400025. Visits at: winwicelombedeam. » BlMallus a hedewe@eelonourdcom.+ Tl Free Naber: 180 286 » Tal Foe Fax Number: 160-208-6880 ovsezacrst IRDA Registration No. 115