ADDITIONAL INFORMATION REQUEST FORM

Ref : 571 Date: 03-AUG-11

To, Parshuram Pandurang Pawar POMANAL LTNO 01 BIJAPUR BIJAPUR,Karnataka-586801 Dear Sir/Madam, Claim Number Claim of UHID Policy Number Coverage Period Date of Admission Date of Discharge Diagnosis Hospital Name AL Number

220200401993 Pandurang Pawar ILGIC/RJP/00/000000301/F 4016/0004771/00/000 01-DEC-10 to 31-JUL-11 22-JUN-11 24-JUN-11 Fever of unknown origin SHRI B.M. PATIL MEDICAL COLLEGE HOSPITAL AND RESEARCH CENTRE

On behalf of ICICI Lombard General Insurance Co. Ltd, we thank you for preferring ICICI Lombard as your health insurance partner.With reference to your claim intimated in our office we request you to send the following documents for further processing of your claim.

Sr No 1

Query Discharge Summary Not Received

Investigation Reports Not Received

Remarks KINDLY PROVIDE THE ORIGINAL DETAILED DISCHARGE SUMMARY MENTIONING THE DATE OF ADMISSION, DATE OF DISCHARGE, PRESENTING COMPLAINTS, TREATMENT GIVEN DURING THE PERIOD OF HOSPITALIZATION AND TREATMENT ADVICE ON DISCHARGE FOR FURTHER PROCESSING OF THE CLAIM. KINDLY PROVIDE ALL ORIGINAL PATHOLOGY , X-RAY, GRBS, ECG INVESTIGATION REPORT AS GIVEN IN THE FINAL HOSPITAL BILL FOR FURTHER PROCESSING OF CLAIM.

ALL ABOVE MENTIONED DOCUMENTS TO BE SUBMITTED IN ORIGINAL Please submit the documents to us within 15 days from the date of receipt of this letter at the below mentioned address to ensure speedy service. Please note that the conclusion regarding the eligibility of coverage /admissible amount can only be arrived on submission of the above mentioned documents. In case of any further clarification, please feel free to write to us at the below mentioned address. Please quote our claim number as mentioned above in all your claim correspondences. We look forward to your co-operation in helping us serve you better. P.S.: Effective June 01, 2011 ICICI Lombard Health Care office would be shifted to new location, please find communication address details below.

Head Customer Service For ICICI Lombard General Insurance Company Ltd ICICI LOMBARD HEALTH CARE Address: Old Address: ICICI Lombard GIC, ICICI Lombard Health Care, TGV Mansion, 6th Floor, Plot No. 6-2- 1012 Khairatabad, Hyderabad - 500004, New Address: ICICI Lombard GIC, ICICI Lombard Health Care, ICICI Bank Tower, Plot No 12, Financial District, Nanakram Guda, Gachibowli, Hyderabad 500032, Email: ihealthcare@icicilombard.com Contact Us 1800 209 8888 Toll Free Fax No.: 1800 209 8880 Fax No. Line 1: 040-66989160 Fax No. Line 2: 040-66989161
Toll Free Helpline No.:

Andhra Pradesh

Andhra Pradesh

i Health Care is now ICICI Lombard Health Care"

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