1.

Insured Details /
a) Policy Certificate No. /
b) Name of Insured Person(s) / ilc lc(i) +i =i
c) ICICI Lombard Health Care Card No. / =i;=i=i;=i=i; airis ;- + +is =.
d) Age / =
e) Email Address / ; a +ci
f) Correspondence Address / +a ;i +i +ci
(including State, City, Pincode)
g) Mobile No. /
h) Residence No. / +i +i= =.
2. Nature of disease / illness contracted/ailment of
injury suffered / tto,rttr,aor t +r n+|a .
3. Kindly indicate / +vt at .
a) Date of commencement of treatment /
=+i =i ;i= +| lcl
b) Name and contact details of treating doctor /
=+i +=ia sic +i =i =i =r++ l
4. Amount Claimed / tt +r o t+ .
a) Consulting Doctor's Fees / +im +=ia sic +| +|=
b) Pharmacy/Medicine Charges / +i=i{=il m-+
c) Investigation Charges / =i - +la m-+
d) Others (Kindly Specify) / =- (++i =+c +)
Total Claimed Amount / tt +r o +a tt|n
r|a tvfa +t |tn .
+ila=i =lcl++c =.
ii;a =
In support to the above claim, I enclose following documents {Please indicate by (?)} / =+ic i +
== , l=r=laluc +i+=ic =a= + ;i ; (++i (?) +i l=mi= a+i+ mi|)
1. Bills/Receipt/Cash Memos in original for medicines etc. (name of patient along with date should
be mentioned on it.) / =ili + a la{=i{+m i =il (== + i+i + =i +i ciiu + =i =-au ;i=i
il;|)
2. Most Recent Medical prescription in support of the above. / =+ic + == == =i ls+a rl=+m=.
3. Receipts and Investigation test reports in original from a Pathological Lab supported by the note
from the treating doctor/ Surgeon advising such Investigation tests. / l+=i +iail=+a a +| +la
l+ic= ci =ii +| a rlc, l==+ =i =+i +ci sic{=== +i =ic ;i l== |= +la c=c= +| =ai; i +i ;i.
4. Attending doctors/Consultant's/ Specialist's bill and receipt and certificate regarding diagnosis,
whichever is prescribed and thereby expenses incurred along with doctors registration number
(compulsory). / =+i += ia sici{+=-c-c={=+mila=c= + la ci =i =i ==+ ;ii l=ilc l+| + l=i=
+ i =lcl++c | ==+ +a==+ ;| , l==+ =i sici +i l==cm= = (=l=i).
Health Claim Form - Outpatient Department /
rtrv tt t-tn ttor |vto
(The issue of this is not to be taken as an Admission of Liability) /
Please give the following information correctly and completely /
(a ttr +t= +t t|vat rr+tt +t=t = apt t)
+vt |=r=|a|oa t=+ttr +t ar at tr at vt
Please use this claim form for settlement of claims under benefit b of this policy. / ;= +ila=i + =c+c l=l+c (ai) + i (ar=)
+i =cac += ;c ++i ;= a +i +i ri+ +.
ICICI Lombard
Health Care
Buy / Renew / Service / Claim related queries Log on to www.icicilombard.com or call 1800 2666
Declaration /
I hereby agree, affirm and declare that /
a) The statements / information given / stated by me/us in this claim form are true, correct and
complete. /
b) No material information which is relevant to the processing of the claim or which any manner has
a bearing on the claim has been withheld or not disclosed. /
c) If I have given/made any false or fraudulent statement/information or suppressed or concealed
or in any manner failed to disclose material information, the policy shall be void and that I shall
not be entitled to all/any rights to recover there under in respect of any or all claims, past, present
or future. /
d) I have not submitted any other claim under Outpatient Treatment Cover (Benefit 'B') and shall not be
submitting any other Outpatient Treatment Cover claim in future under the above referred Policy
Certificate. / = io i+i =+i =a (ai i') [=i=c+m-c cic-c + (l=l+c i')] + =c+c +i; =i ii
r=cc =;i l+i ; ci l i =+ic =lc +ila=i =lcl++c + =c+c +i; =- io i+i =+i =a ii r=cc
=;i +=+i.
e) The receipt of this claim form/other supporting/related documents, does not constitute an
agreement by the Company of the claim and the company reserve the right to process or reject or
require further/additional information in respect of the claim. /
f) I also consent and authorize ICICI Lombard Health Care to seek medical information from any
hospital/medical practitioner who has any time attended on the insured person. / ; i =;lc ci
; ci =i;=i=i;=i=i; airis ;- + +i l+=i ==+cia{ls+a rlc== = ll+=i =i =i=+ii ric += + la|
=l+c +ci ;, l=== +i ilc lc +i =+i l+i ;i.
g) I confirm that the expenses for which claim is being lodged have been incurred in respect of the
insured. /
Place / ___________________
Date / ____________________ __________________________________
Signature of Claimant /
vtnt .
|c;ii =;c ;, +lc ci ilc +ci ; l+ :
;= ii +i {;i ;ii l| + += { =i=+ii { =-au =;i, = | + ;.
l+=i |=i ;-+ =i=+ii +i lc+ii i
=r+c =;i l+i +i ; =i l+ i +| rl+i = =lc ;i i i + l==+i +i; ri +sci ;i.
=+ = +i; +ac i ++c+ +={=i=i+i i ;i i l+=i ;-+ =i=+ii +i lc+ii i ii ;i i l+=i
r+i = r+c += ==+a ;i ;i= ci ; +ila=i =i- ;i =i|+i ci +ila=i + =r- =cic, ci= i l
l+=i i =i i += + =+= =i{l+=i =l+i ui +i.
;= ii +i{=- =+{=lc +i+=ici
+| rilc ++=i ;ii i +| =;lc =;i ; ci ++=i + +i= i + = rl+i += i ;= ==i+c += =i
+=:{=lclc =i=+ii i+= +i =l+i =lac ;.
+lc +ci ; l+ l== ui + la| ii = l+i +i ; iii+ + = l+| + ;.
=i= :
l=i+ :
ii + ;=cia
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Mailing Address : ICICI Lombard Healthcare, ICICI Bank Tower, Plot No. 12, Financial District, Nanakram Guda, Gachibowli, Hyderabad-500032
Fax No : (040) 6698 9160/6698 9161 Toll Free Fax No: 1800-209-8880
Corporate Office : ICICI Lombard House, 414, Veer Savarkar Marg, Near Siddhi Vinayak Temple, Prabhadevi, Mumbai 400 025.
Visit us at www.icicilombard.com Mail us at customersupport@icicilombard.com
Now One Number for all your Insurance needs 1800 2 666 (Toll Free also accessible from your mobile)
ICICI Lombard General Insurance Company Limited. Insurance is the subject matter of the solicitation. IRDA Reg. No. 115.