Subject: Query Claim Number 220202008443 - JORGE RAFAEL BLANCHART ORTIZ
From: [email-masked]
To: [email-masked]
Date: Thu, 24 Sep 2020 21:56:18 +0530

|

ADDITIONAL INFORMATION REQUEST FORM

Ref : CPU37
Date: 24-SEP-20
To,

ASHISH DABRAL | |

CHERRY E COMMERCE SERVICES P LTD
A-72, SECTOR-2 GAUTAM BUDDHA NAGAR UTTAR PRADESH-201301
GAUTAM BUDH NAGAR,Uttar Pradesh-201301

Dear Sir/Madam,
| Claim Number | 220202008443 |
| Claim of | JORGE RAFAEL BLANCHART ORTIZ |
| UHID | IL17815441000 |
| Policy Number | 4016/X/195525873/00/000 |
| Policy Name | CHERRY E COMMERCE SERVICES P LTD |
| Coverage Period | 22-FEB-20 to 21-FEB-21 |
| Date of Admission | 26-JUN-20 |
| Date of Discharge | 03-JUL-20 |
| Diagnosis | Fracture of ribs sternum and thoratic spine |
| Hospital Name | Tripathi Hospital |
| AL Number | |

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 | Reason | Description

1

Clarification or Confirmation

Kindly furnish a letter from the treating doctor regarding the details of incident leading to injury including time ,date ,place, condition(under influence of any substance) of patient at the time of incident along with a copy of MLC if any for further processing of the claim.

Note: C-KYC form can be download from the following link
http://www.icicilombard.com/downloads -> Health Insurance -> Claims -> Central KYC form

“ALL ABOVE MENTIONED DOCUMENTS TO BE SUBMITTED IN ORIGINAL”

Please submit the documents to us within 7 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.

Associate Vice President- Health Claims

For ICICI Lombard General Insurance Company Ltd

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