ICICI Lombard General Insurance Company Limited

(Submission of this form is not to be taken as an admission of liability)

Please give the following information correctly and completely
Policy No: 4016/81958467/00/000. OPD Claim IPD Claim
Indian Institute of Technology Kharagpur
Name of the Insured*
UHID No./Card No.* Student Roll No*
Gender of the patient* Male Female Age of the patient*
Current residential address & contact details including Mobile/Telephone No.*
Email ID :
Nature of disease/illness*
Date of admission* Date of discharge
Name of the hospital/ Nursing home*
Name of the doctor
Address of Hospital/ Nursing Home * (with contact Details)
Doctors registration No.(Signature & Seal of Doctor)
D D M M Y Y Y Y D D M M Y Y Y Y
Claim details Amount Whether original bills attached
Doctors charges Yes No
Medicine charges Yes No
Room rent & Nursing charges( in case of IPD) Yes No
Hospitalization charges(in case of IPD) Yes No
Other charges Yes No
Total claimed amount
*Mandatory fields to be filled compulsory
I, hereby declare that the particulars provided above are true to the best of my knowledge and belief
Place Date Signature of Claimant
D D M M Y Y Y Y
Documents to be Furnished with Medical Reimbursement Claim
In support of the above claim, Please enclose the following documents in Original or Xerox wherever mentioned.
1. Original Discharge Summary
2. Original Detailed Itemized Bill
3. Original Payment Receipts
4. Original Investigation Reports
5. Original Medicine and Pharmacy Bills
6. Original Supporting Prescriptions
7. Original Implant Invoice
8. Photocopy of Institute's ID Card
Note
As per policy terms & conditions, the insurance company reserves it's right to have the claimant examined by a doctor appointed by it for
verification of diagnosis.
1. The statements/information given/stated in this claim form should be true, correct and complete.
2. No material information which is relevant to the processing of the claim or which in any manner has a bearing on the claim should not be
withheld or not disclosed.
3. There should not be 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.
4. The receipt of this claim form/other supporting/related documents does not constitute or be deemed to constitute an agreement by the
Company of paying the claim and the Company reserves the right to process or reject or demand additional information in respect of the claim.
Mailing Address
ICICI Lombard General Insurance Company Limited, ICICI Bank Tower, 9th Floor, Plot No. 12,
Financial District, Nanakram Guda, Gachibowli, Hyderabad - 500032, Andhra Pradesh
Email: ihealthcare@icicilombard.com Toll free No. 1800 2 666

______________________________________ ______________________________________
Signature of Claimant Verified by
(Official of IIT Kharagpur)
I hereby declare that the particulars given above are correct and complete. If the transaction is delayed or not effected
at all reasons of incomplete or incorrect information, I would not hold the user institution responsible.
2. Accounts Details
a) Name of the Bank:
b) Address of the Bank:
c) IFSC Code No. of the Bank:
d) Full Account No.
e) Type of Accounts: Saving account Current Account
NEFT/EFT Mandate form
(Payments through EFT mechanism)
1. Payee Details
Group/ Network Name:
a) Payee Name
b) Address with Pin Code:
c) Contact no.:
d) Contact Person:
Terms and Conditions for Payments through RTGS I NEFT
The details provided by the Customers in the Mandate Form shall be considered as final and shall not be responsible for cross verification of any of the details provided therein.
The RTGS/ NEFTfacility shall be effective for the respective Customer(s) within 15 days of the receipt of the Mandate Form by ICICI Lombard General Insurance Company Ltd. and/
or within such period as may be reasonably required by ICICI Lombard General Insurance Company Ltd. to activate the RTGS/ NEFTfacility
The Customer agrees that under the RTGS/ NEFTfacility, there may be a risk of non-payment in the Account of Customer on the day of the credit of
Payments due to any of the following events :
1. holiday at the concerned bank(s)
2. wrong credit entry which may be due to incorrect information provided by the Customer in the Mandate Form
3. force majeure event, which includes any event beyond the reasonable control of ICICI Lombard General Insurance Company Ltd., including, without limitation, unavailability of any
communication system, system failure, sabotage, fire, flood, explosion, acts of God, civil commotion, strikes or industrial action of any kind, riots, insurrection, war or acts of
government, changes in legislation and other allied acts of regulatory nature
4. Change in the applicable regulations pertaining to RTGS/ NEFTfacility
5. By virtue of any default, error, inaccuracy or mistake caused by the Customer, Customer's bank or its employees and agents.
The Customer agrees to indemnify, without delay or demur, ICICI Lombard General Insurance Company Ltd. and its agents and keep ICICI Lombard General Insurance
Company Ltd. and its agent indemnified harmless at all times from and against any and all claims, damages, losses, costs, and expenses (including attorney's fees)
whichICICI Lombard General Insurance Company Ltd. may suffer or incur, directly or indirectly, arising from or in connection with, amongst other things, either of the
aforesaid reasons stated in clauses 2 and 5.
The Customer acknowledges that transaction through the RTGS/ NEFT facility is irrevocable upon execution and revocation of such transaction may not be possible.
The Customer shall forthwith report to ICICI Lombard General Insurance Company Ltd. any error and/or dispute regarding the correctness in the execution of a RTGS/
NEFTpayment or the amount credited to his Account at the earliest, preferably within 3 days of the RTGS/ NEFTtransaction.
Mailing Address
ICICI Lombard General Insurance Company Limited, ICICI Bank Tower, 9th Floor, Plot No. 12,
Financial District, Nanakram Guda, Gachibowli, Hyderabad - 500032, Andhra Pradesh
Email: ihealthcare@icicilombard.com Toll free No. 1800 2 666
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The Customer agrees that ICICI Lombard General Insurance Company Ltd. may send information including data, statements and reports to the Customer's bank via the
electronic mode through RTGS/ NEFT and the Customer recognizes that such information could be of a confidential nature and the information may be intercepted, read,
modified or altered by any person during such transmission and ICICI Lombard General Insurance Company Ltd. cannot be held liable for any such act by a third party.
The Customer agrees thatICICI Lombard General Insurance Company Ltd. can disclose the data, information of the Customer to RBI, any statutory body, courts etc. so as to
comply with any regulatory or statutory requirements.
ICICI Lombard General Insurance Company Ltd. may sub-contract and employ agents to carry out any of its obligations under the RTGS/ NEFTfacility The Customer may
discontinue or terminate the use of RTGS / NEFT facility by giving a minimum of 15 days prior written notice to ICICI Lombard General Insurance Company Ltd. The date of
notice for ICICI Lombard will be the date of receipt of such notice by ICICI Lombard. The notice of, such termination should be given to ICICILombard only at its corporate
address and be addressed at: ICICI Lombard General Insurance Company Ltd. Zenith House, Keshav Rao Khadye Marg, Mahalaxmi, Mumbai-400034
Such a termination shall not affect the Customer's liability to fulfill and complete its obligations in connection with the RTGS/ NEFTfacility. The termination of the RTGS/
NEFTfacility shall not affect any accrued rights and liabilities of the Customer and/or ICICI Lombard General Insurance Company Ltd. In no case a notice should be given to
any of the Branch offices of ICICILombard or to any of its agents.
A confirmation of the receipt of termination notice given by the Customer will be acknowledged through a confirmation letter by ICICI Lombard General Insurance Company
Ltd. In no case can the Customer construe his termination notice as effective unless a confirmation has been provided by ICICI Lombard to the Customer stating the date of
receipt of such communication by the Customer.
ICICI Lombard General Insurance Company Ltd. may withdraw, terminate or suspend the RTGS/ NEFTfacility anytime at its option either entirely or with reference to a
specific ICICI Lombard General Insurance Company Ltd. RTGS/ NEFTfacility without assigning any reasons whatsoever and without any prior notice.
The Customer agrees that transaction(s) through RTGS/ NEFTfacility may attract inward RTGS/ NEFT charges, which if levied by the Customer's bank, shall be borne by the
Customer.
ICICILombard has the absolute discretion to amend or supplement any Terms and Condition stated herein at any time and will endeavor to giveprior notice of Ten days for
such changes wherever feasible for the terms and conditions to be applicable. By using the new services, or at the completion of such period, whichever is earlier, the
Customer shall be deemed to have accepted the changed terms and conditions.
* NEFT is applicable for only the corporates employees for whom HR has opted for NEFT as a mode of payment. Kindly check with your respective HR department for this
facility.
* In case of any issues, HR decison and approval will be taken into consideration.
Notices under these terms and conditions may be given in writing by delivering them by hand or e-mail or onICICI Lombard General Insurance Company Ltd. website or by
sending them by post to the last address of the Customer
These terms and conditions will be governed by the laws of India and any legal action or proceedings arising out of these Terms and Conditions shall be initiated in the courts
or tribunals at Mumbai in India.
I/ We authorize ICICI Lombard General Insurance Company Ltd. . to revoke the RTGS/NEFTfacility without any prior notice on the completion of 7 days of the termination of
business relationship between us.
I / We further undertake to refund any excess amount whether demanded by ICICI Lombard General Insurance Company Ltd. or not, which has been credited in excess to my
account at any time due to any reason within 7 days of such receipt of such communication from ICICI Lombard of such excess credit or such information of excess credit
coming to the knowledge of the Customer through any other source.
I/ We agree that the payment will be credited starting from the date ICICI Lombard General Insurance Company Ltd. gets confirmation from its bankers, This facility will
continue unless it is revoked by any party and any issuance of relevant credit instruction fromICICI Lombard General Insurance Company Ltd. to its bankers will be valid till
such instruction is complete irrespective of the fact that the notice period has expired provided such a credit request has been made byICICI Lombard General Insurance
Company Ltd. . before the expiry of the notice period of the Customer.
I/ We further confirm that we understand this mode as a method of payment introduced by Reserve Bank of India, which provides us an option to collect our payments, as
and when they become due directly through our bank accounts
I / We further confirm that we understand that, ICICI Lombard General Insurance Company Ltd. , shall accomplish this by issuing the Payment instruction electronically
through its banker to the Clearing Authority/centre and the Clearing Authority/centre would ensure credit to our specified bank account.
I / We further confirm that ICICI Lombard General Insurance Company Ltd. will have the right to return to the option of paying by cheque if there are more than 2 consecutive
failures in remittances for no fault on the side of ICICI Lombard General Insurance Company Ltd. (For our records, please attach a blank cancelled cheque or photo copy of a
cheque for verification of the above particulars)
________________________________________
Signature of the declarant
Date
ICICI Lombard General Insurance Company Ltd.
www.icicilombard.com