ICICI Lombard Health Insurance Claim Procedure

ICICI Lombard General Insurance Company is the largest private non-life insurance company in India with a wide variety of insurance products in its offering. The company was established in the year 2001 by coming together of two well-established market players – ICICI Bank Ltd, India’s second-largest private bank and Fairfax Financial Holdings Limited, a Toronto based financial company. In the health insurance segment, ICICI Lombard offers a variety of health insurance plans to cater to every unique need of people. With the bouquet of health services offered by the company, it also has a robust in-house health claim processing centre. Let’s take a look at the health claim processes of the company.

Types of Health Insurance Claims

Health insurance claim types vary depending on the type of treatment and hospital at which you have availed medical treatments. Basically, there are two types of health insurance claims – cashless claims and reimbursement claims. Usually, cashless claims are the most preferred types of claims by customers. Let’s take a look at what these claim types mean.

• Cashless health claims: In cashless health claims, hospital bills are directly settled by the insurance company to the hospital without you having to incur out of pocket medical expenses. ICICI Lombard General Insurance Company is empanelled with 5025+ hospitals across the country which is also referred to as network hospitals. List of these hospitals will be available on the company’s website. When you opt to avail treatment in these network hospitals, you can avail the cashless facility by producing your health ID card issued by ICICI Lombard and also by following certain specified processes. 

• Reimbursement health claims: In reimbursement health claims, expenses incurred by you for medical treatments will be later reimbursed to you by the insurance company on producing the relevant claim documents. In case you choose to avail treatment in the hospital that is not a part of ICICI Lombard’s network hospitals, then you can avail treatment at your own cost and later initiate claims with the original bills and get the reimbursement from the insurance company.

Health Insurance Claim Processes for ICICI Lombard Health Insurance Plans

Claim process varies depending on the type of health insurance claim initiated by you. Let’s take a look at the claim process for each type of claim.

Cashless health claims can be planned or emergency ones. Depending on the nature of the cashless claim, the process also slightly varies. Let’s take a look at the step by step process for both emergency and planned cashless health claims.

1. Cashless emergency claim process: In case of a medical emergency, when the insured gets admitted at the network hospital, following are the process to be followed for cashless claims –
1. Claim intimation:
   After admission to the hospital, the cashless request needs to be submitted to the ICICI Lombard Health Care (Third Party Administrator) within 24 hours. Claim intimation can be done through email or by calling on claim helpline or by visiting the nearest ICICI Lombard branch. The branch can be located using an online branch locator available on their website. While making claim intimation, you need to provide the following information:
1. Health insurance policy number
2. Your name and relationship with the policyholder
3. Nature of illness or injury
4. Details of the hospital and attending medical practitioner
5. Any other information related to the injury/illness
2. Claim forms: You need to submit the relevant claim documents to the TPA (third party administrator) of ICICI Lombard. The company will review the documents and cashless request submitted
3. Claim investigation: After reviewing of cashless request and thorough scrutiny of your documents, ICICI Lombard Health Care (TPA) will inform the hospital with the authorisation status
4. Claim status: Claim status can be:
1. Accepted – if the claim is accepted, you will receive intimation of your ICICI Lombard health insurance claim status through SMS and settlement letter containing the disbursed amount will be sent. Youneed to sign all the relevant documents before discharge and the amount will be disbursed to the hospital by the insurance company
2. Queried – ICICI Lombard will intimate you through SMS and send you a query letter asking for additional documents. You need to produce the required documents within the stipulated time period to get the claim processed. If you fail to produce the documents within the time, the claim will be closed. However, the claim can be re-opened later for processing on submission of necessary documents
3. Rejected – If yourICICI Lombard health insurance claim status is rejected, the same will be intimated through SMS and by sending rejection letter containing the reason for rejection as per the terms and conditions of the policy. However, the rejected claim can be disputed
2. Cashless planned claim process: In case insured visits a doctor at the network hospital and doctor advice of some medical treatments/procedures that require hospital admission in next few days, then it’s referred to as planned claim. Following is the process to follow for cashless planned health claims –
1. Claim intimation: Insured needs to submit cashless request 48 hours or 2 days before the admission at network hospital by producing health ID card, photo ID card, previous consultation papers and other documents if any to ICICI Lombard Health Care (Third party administrator)
2. Claim forms: Once the claim authorisation request is submitted, the company will review the documents, cashless request submitted and also check if the particular illness or medical procedure is covered in the policy benefits
3. Claim investigation: After reviewing of cashless request and thorough scrutiny of your documents, ICICI Lombard Health Care (TPA) will inform the hospital with the authorisation status
4. Claim status: Claim status can be:
1. Accepted – if the claim is accepted, you will receive intimation of your ICICI Lombard health insurance claim status through SMS and settlement letter containing the disbursed amount will be sent. Youneed to sign all the relevant documents before discharge and the amount will be disbursed to the hospital by the insurance company. Insured will be required to take care of only non-medical expenses.
2. Queried – ICICI Lombard will intimate you through SMS and send you a query letter asking for additional documents. You need to produce the required documents within the stipulated time period to get the claim processed. If you fail to produce the documents within the time, the claim will be closed. However, the claim can be re-opened later for processing on submission of necessary documents.
3. Rejected – If yourICICI Lombard health insurance claim status is rejected, the same will be intimated through SMS and by sending rejection letter containing the reason for rejection as per the terms and conditions of the policy. However, the rejected claim can be disputed.
3. Reimbursement health claims: When insured gets admitted at the non-network hospital, he/she will not be able to avail cashless healthcare facilities. In that case, the following is the claim process to follow –
1. Hospitalisation: Insured takes the treatment and pays the bill out of his/her pocket
2. Collection of documents: Insured will have to collect all the relevant documents from the hospital
3. Claim intimation: Insured needs to initiate the reimbursement claim by submitting duly filled and signed claim form along with all the other relevant documents to ICICI Lombard Health Care (TPA) or to ICICI Lombard General Insurance Company by emailing the documents to the address of TPA mentioned below –

   ICICI Lombard Health Care, ICICI Bank Tower, Plot no. 12, Financial District, Nanakram Guda, Gachibowli, Hyderabad – 500032

4. Documents review and claim investigation: All the documents, original bills and the claim form submitted will be thoroughly scrutinised and reviewed by the insurance company. Based on the claim investigation, the decision will be taken and communicated
5. Claim status: Claim status can be –
1. Accepted – if the claim is accepted, you will receive intimation of your ICICI Lombard health insurance claim status through SMS and settlement letter containing the disbursed amount will be sent. If the NEFT and KYC details are updated with the insurance company, payment will be made directly into your account. In case the details are not updated and the proof of bank account is not provided, a cheque for the disbursed amount will be sent to your registered mailing address along with the settlement letter.
2. Queried – ICICI Lombard will intimate you through SMS and send you a query letter asking for additional documents. You need to produce the required documents within the stipulated time period to get the claim processed. If you fail to produce the documents within the time, the claim will be closed. However, the claim can be re-opened later for processing on submission of necessary documents.
3. Rejected – If yourICICI Lombard health insurance claim status is rejected, the same will be intimated through SMS and by sending rejection letter containing the reason for rejection as per the terms and conditions of the policy. However, the rejected claim can be disputed.

Documents Required for ICICI Lombard Health Insurance Claims

Following are the documents required for each type of ICICI Lombard Health Insurance Claims

1. Documents for cashless health claims:

Cashless health claim facilities can be availed only at the network hospitals. It’s important to follow the timeline for availing initial approval in which the insurance company approves part of expected expenses. Later, on submission of final hospital bills, the insurance company provides final approval with the exact amount. Following are the documents to be submitted for cashless health claims-

• Duly filled and signed pre-authorisation form
• Copy of ICICI Lombard health card or health insurance policy
• The photo ID card of the insured
• First consultation letter
• Investigation reports, if any
• Once the initial approval is given, the TPA (Third Party Administrator) desk at the hospital submits the final hospital bills with reports to the insurance company.

It’s important to note that non-medical expenses are to be borne by the insured at the time of bill settlement.

2. Documents for reimbursement health claims

Submitting the correct and relevant document plays a crucial role in claim processing. The process of claim will start only when all the relevant documents are submitted. In reimbursement claims, it’s important to submit the NEFT and KYC details to get the claim settlement faster. Following are the documents required for reimbursement of health claims –

• Duly filled and signed claim form (both insured and the treating medical practitioner needs to sign)
• Doctors’ prescription and consultation paper
• Diagnosis reports (ECG/Scan/X-ray, Lab test reports etc.)
• Discharge summary with details of illness/injury and the treatment availed
• Final hospital bills (with break-up) along with receipts given by hospitals, diagnostic centres, doctors and pharmacies
• Implant sticker or invoice, if any (for example stent used in angioplasty, details of lens used in cataract)
• Detailed bills supported by prescription from treating medical practitioner for miscellaneous expenses
• PAN copy of insured
• Copy of ICICI Lombard health card
• Police FIR (First Information Report) copy or Medico-legal certificate (MLC) for accident cases
• NEFT bank details along with cheque copy containing all the details (account number, IFSC code and name etc.)
• Additional documents, if any required by ICICI Lombard General Insurance Company

For any other queries, you can contact Turtlemint support team on 1800-266-0101 or ICICI Lombard General Insurance Company.

Company Address and Contact Information –ICICI Lombard General Insurance Company

Company Address: ICICI Lombard General Insurance Limited, ICICI Lombard House, 414, Veer Savarkar Marg, Near Siddhi Vinayak Temple, Prabhadevi, Mumbai – 400 025

E-mail: customersupport@icicilombard.com

Toll-free number: 1800-2666

Tips for Easy Online Claim Process for ICICI Lombard Health Insurance

ICICI Lombard health insurance process is user-friendly, simple and transparent. Following are some of the essential tips for online claim processes.

1. Check the network hospital list: ICICI Lombard is tied up with more than 5000 hospitals across India to provide cashless health insurance facilities. You can check the list of hospitals to know the nearest best hospital listed for you to avail the services. The information is available on ICICI Lombard’s website and also on their mobile application.
2. Know your policy in detail: Knowing what is covered and the limit of the policy is not enough. You need to know about the services excluded by the policy, terms and conditions applicable to your policy and other benefits that you have such as free health check-ups, no claim bonus and wellness programmes etc.
3. Be well-timed: Availing certain facilities and benefits require you to be prompt and well-timed. To avail the cashless claim facility, you need to seek pre-authorisation before 48 hours of admission at the network hospital if it is a planned hospitalisation. You need to give a cashless request to the company within 24 hours of admission at the hospital in case of emergency hospitalisation. Road accidents would require you to report the incident to police and file FIR immediately. Non-adherence to the timeline can lead to delay in claim settlement.
4. Keep documents handy for faster claims: Documents play a pivotal role in the claim process. For faster and smooth claim settlement, it’s important to keep the necessary documents handy. More importantly, the documentation required varies based on claim nature. A clear understanding of the documentation can help in quick claim initiations. Ensure to fill in all the relevant information in the claim form along with all the relevant documents enclosed. Keep every communication between you and the insurance company safely stored.
5. Make use of the technology: ICICI Lombard offers effective and efficient services on its digital platform. This includes a mobile application, SMS and email communications, e-payment of claims through NEFT etc. Make use of this technology to get the claim processed faster and without any hassles.

Incurred Claims Ratio for ICICI Lombard Health Insurance

Parameters	FY 2017-18	FY 2018-19
Net Earned Premium (in Cr)	1349.32	1826.99
Net Claims Incurred (in Cr)	921	1396.80
Incurred Claims Ratio (in %)	68%	76%