ICICI Lombard Health Insurance Claim Form

ICICI Lombard Health Insurance Claim Form

ICICI health insurance claim form is provided by ICICI Lombard General Insurance Company Limited. It is an important document through which the insured can raise a request to get a refund of medical expenses incurred by them under ICICI Lombard health insurance plans.

What is the ICICI Lombard Health Insurance Claim Form?

The ICICI Lombard health insurance claim form is an official document that contains all details about the insured, their health insurance plan, hospitalization, medical bills and insurance history. A completely filled and duly signed health insurance claim form is an integral requirement to raise an ICICI Lombard health insurance claim. Failing to submit the claim form in a timely manner can even lead to rejection of the claim by the insurer.

Types of ICICI Lombard Health Insurance Claim Forms

ICICI health insurance claims can be of two types, cashless and reimbursement. For both claims, different claim forms need to be downloaded.

• For a health insurance reimbursement claim, the insured must initially pay the expenses out of their own pockets and later submit the ICICI reimbursement claim form to receive a refund of the medical expenses incurred.
• The insurer settles the medical bill directly with the hospital for a cashless hospitalization, eliminating the need for the insured to pay the medical expenses upfront. For this, they must fill out the 'pre-authorization form'.

How to Download the ICICI Lombard Health Insurance Claim Form?

Here are different ways through which a policyholder can download the ICICI Lombard health insurance claim form:

Website - Downloads Page

• Visit the 'Downloads' section on the official website of the ICICI Lombard General Insurance Company Limited
• Select 'Health Insurance' in the first drop down. Click on 'Go'
• Options to download different claim forms will be displayed. Choose as applicable
• Choose 'Health Hospitalization Claim Form' for a normal hospitalization, daycare procedure, and pre- & post-hospitalization
• The selected claim form will open in a new tab

Website - Claims Page

• Visit the website's homepage and select the 'Health Claims' option in the main horizontal menu bar
• Select the type of hospitalization from the list mentioned on the left margin
• Click on 'download the claim form here' 
• The selected claim form will open in a new tab

Mobile Application

The ICICI Lombard claim forms can also be downloaded through the IL TakeCare app.

Other ways to get the ICICI Lombard health insurance claim form

The policyholder can obtain the ICICI Lombard claim form from the nearest branch office.

How to Fill the ICICI Lombard Health Insurance Claim Form?

Check out what the ICICI Lombard health insurance claim form contains so that you can fill it out easily.

Part A of the ICICI Lombard Health Insurance Claim Form

The ICICI Lombard health insurance claim form Part A has to be filled out by the insured or the proposer.

• Type of claim
• Details of the insured person for whom the claim is made - patient's name, card number/ UHID number, gender, date of birth, age, occupation, if previously covered by any other insurance, current residential address and contact details, ABHA number
• Policy details - claim intimation service request number, if it is a renewal policy, previous policy number for individual policy; employee ID, group or company name for a group/corporate policy
• Proposer or employee name, relationship with the proposer, current policy no., Card no./UHID no.
• Diagnosis details - hospital name, room category occupied, date & time of admission, date & time of discharge, date of injury or illness first detected, reason for injury, if medico legal or reported to police
• If covered by any top-up or additional policy and its policy number
• If currently covered by any other health insurance policy, date of its commencement, insurer name, policy number, sum insured, if hospitalized in the last 4 years, its date and diagnosis, details of any claim raised
• Claim details - treatment expenses, claim for, details of lump sum or cash benefit
• Details of the amount claimed - bill heads, bill number, bill date, if bills are attached, amount
• Checklist for submitted claim documents
• Reason for delay in submitting documents (if submitting after 30 days of discharge)
• Declaration by the insured

Disclaimer: The above-mentioned claim form details are indicative only. The policyholder must fill out all required details in the claim form provided by ICICI Lombard General Health Insurance Company Limited.

Part B of the ICICI Lombard Health Insurance Claim Form

This part of the claim form is required to track the admitted patient's details about the hospital and treatment. The ICICI Lombard health insurance claim form Part B is to be completed by the hospital.

Part C of the ICICI Lombard Health Insurance Claim Form

Part C refers to the NEFT (National Electronic Fund Transfer) Mandate Form, which requires the insured to provide their EFT details like account number, bank name, IFSC code and PAN Card number. ICICI Lombard health insurance claim form Part C is needed for direct transfer of the reimbursement amount to the policyholder's account.

The following details need to be filled in the form by the proposer:

Patient's name, proposer's PAN no., Card no./UHID no., contact details, proposer's bank account no., name of the bank, address of the bank, branch name, IFSC code, PAN no.

Common Mistakes to Avoid when Submitting ICICI Lombard Health Insurance Claim Form

Here are some of the common mistakes that a policyholder must avoid when submitting the ICICI Lombard health insurance claim form:

• Mentioning incorrect details like name, age, policy number, PAN, etc.
• Delay in submitting claim documents
• Raising a claim for non-medical expenses
• Not attaching original medical bills and receipts
• Submitting incomplete or incorrect documents
• Mismatch in signature
• Filing a claim for an amount higher than the sub-limit

Documents Required with the ICICI Lombard Health Insurance Claim Form

Check out the other mandatory documents required with the ICICI Lombard health insurance claim form:

• Discharge summary
• Original hospital bills
• Original payment receipts and pharmacy bills
• Diagnostic reports
• Doctor's consultation and prescriptions
• Identity and address proof
• EFT/Bank details
• FIR or Medico-Legal Certificate (MLC), in case of accidents

FAQs on ICICI Lombard Health Insurance Claim Form