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HEALTH BOOSTER POLICY WORDINGS
a. POLICY SCHEDULE
Policy No.
Issued at
Stamp Duty
Policy details
Name of the Policyholder
Contact No.
Mailing address of the Policyholder
Policy Start Date
DD/ MM/ YY & HH:MM
Policy End Date
DD/ MM/ YY & HH:MM
Previous Policy details
Policy number
Policy Period
Claims
Details of the Insured under the Policy
Insured’s name
Address for
correspondence
Relationship with the
Policy holder
Date of Birth
MM/ DD/ YY
MM/ DD/ YY
MM/ DD/ YY
MM/ DD/ YY
MM/ DD/ YY
MM/ DD/ YY
Sex
M/ F
M/ F
M/ F
M/ F
M/ F
M/ F
Nominee’s name
Nominee’s relationship
with the Insured
Pre-Existing Diseases
Special condition: Any
physical, medical
condition or treatment
or service which is
permanently excluded
under the Policy
Annual Sum Insured (`)
Additional Sum Insured
(Cumulative Bonus) (`)
Deductible amount (`)
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Optional covers
applicable*
*As per below table
Optional covers/Extensions under the Policy
S.No
Extensions
Premium (`)
Annual Sum Insured (`)
1.
Hospital Daily Cash
2.
Convalescence Benefit
3.
Personal Accident cover
4.
Temporary Total Disablement (TTD)
Rehabilitation Cover (resulting from
Accident Extension)
5.
Repatriation of Remains
6.
Critical Illness Cover
Plan
Top Up/ Super Top Up
Geographical Scope
India
Premium
Amount (in INR)
Basic Premium
Optional covers premium
Loading (if any)
Discount (if any)
Premium Installment Option (if opted)
GST
TOTAL PREMIUM
In House Claim Processing Details
Name
Complete Address
Contact no.
Signed For and on behalf of ICICI Lombard General Insurance Company Limited, at
--------------------------On this Date --------------
Authorized Signatory
Health Booster
UIN: ICIHLIP22100V032122
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COMPANY CONTACT DETAILS:
a) Toll-free number: 1800 2666
b) Registered Office Address:
ICICI Lombard General Insurance Company Ltd.
ICICI Lombard House,
414, Veer Savarkar Marg,
Near Siddhi Vinayak Temple,
Prabhadevi, Mumbai 400025
CIN:U67200MH2000PLC129408
c) E-mail: customers[email protected]
Agency Details:
Agency name
Agency code
Mobile no.
Landline no.
Health Booster
UIN: ICIHLIP22100V032122
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TAX CERTIFICATE
To,
Name of the Proposer
Address of the Proposer
Subject: Premium certificate for the purpose of deduction under section 80D of Income Tax
Act, 1961 and any amendments made thereafter.
Dear (Name of the Proposer),
This is to certify that the Company has received the premium dated dd/mm/yyyy for Health insurance
coverage under "Health Booster" with the following details.
Proposer’s Name
Policy Number
Policy Start Date
Policy End Date
Plan Name
Total Premium Paid
(₹)
GSTIN Number
(Customer)
GSTIN Reg.No (ICICI
Lombard)
Servicing Branch
Name
Servicing Branch
Address
Premium Details (₹)
Basic Premium
CGST
SGST
Total Tax Payable
Total Premium
%
₹
%
₹
Financial Year
Amount
(₹)
2019-2020
2020-2021
2021-2022
The product is eligible for deduction u/s 80D of the Income Tax, 1961 and any amendments
made there to.
Sincerely,
For ICICI Lombard General Insurance Company Ltd.
Authorised Signatory
Note:
Details of the Policy are as per the Part c,d,e and f of this Policy.
This certificate must be surrendered to the Insurance Company in case of Cancellation of the Policy.
In the event of incorrect representation of this declaration, the liability shall be upon the proposer.
In case You find any variations against Your proposal or any discrepancy in the Policy, please contact Us immediately
on the numbers available on our website www.icicilombard.com Or call on our toll free no. 1800 2666
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b. PREAMBLE
You, the Insured/ Policy Holder, have applied to Us, for insurance and this document is the Policy setting
out the details of the insurance which You have requested. When drawing up this Policy, We have relied
on the information and statements which You have provided in the proposal form. In consideration of
the payment of the premium shown in the Schedule, We agree to insure You on happening of covered
event during the Policy Period as stated in Schedule, upon which one or more benefits become payable
under the Policy, subject to the terms and conditions contained herein or endorsed on this Policy.
c. DEFINITIONS
For the purposes of this Policy, the terms specified below shall have the meaning set forth wherever
appearing/ specified in this Policy or related Extensions/ Endorsements:
Where the context so requires, references to the singular shall also include references to the plural and
references to any gender shall include references to all genders. Further any references to statutory
enactment include subsequent changes to the same.
i. Standard Definitions (Definitions whose wordings are specified by IRDAI)
Accident means a sudden, unforeseen and involuntary event caused by external and visible and
violent means.
Any one Illness means continuous Period of illness and it includes relapse within 45 days from the
date of last consultation with the Hospital/Nursing Home where treatment may have been taken.
Ayush Hospital is a healthcare facility wherein medical/surgical/para-surgical treatment
procedures and interventions are carried out by AYUSH Medical practitioner(s) comprising of any
of the following:
Central or State government AYUSH hospital; or
Teaching hospital attached to AYUSH college recognized by the central government/Central
council of Indian medicine/ Central council for Homeopathy; or
AYUSH Hospital, standalone or co-located with in-patient healthcare facility of any recognized
system of medicine, registered with the local authorities, wherever applicable, and is under the
supervision of a qualified registered AYUSH medical practitioner and must comply with the
following criterion:
i. Having at least 5 in-patient beds
ii. Having qualified AYUSH medical practitioner in charge round the clock
iii. Having dedicated AYUSH therapy sections as required and/or has equipped operation
theatre where surgical procedures are to be carried out;
iv. Maintaining daily records of the patients and making them accessible to the insurance
company’s authorized representative
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AYUSH Day Care Centre means and includes Community Health Centre (CHC), Primary Health
Centre (PHC), Dispensary, Clinic, Polyclinic or any such health centre which is registered with the
local authorities, wherever applicable and having facilities for carrying out treatment procedures
and medical or surgical/para-surgical interventions or both under the supervision of registered
AYUSH Medical Practitioner (s) on day care basis without in- patient services and must comply
with all the following criterion:
Having qualified registered AYUSH Medical Practitioner(s) in charge;
Having dedicated AYUSH therapy sections as required and/or has equipped operation theatre
where surgical procedures are to be carried out;
Maintaining daily records of the patients and making them accessible to the insurance company’s
authorized representative.
(Explanation: Medical practitioner referred in the definition of “AYUSH Hospital” and “AYUSH day
care center” shall carry the same meaning as defined in the definition of “Medical practitioner”
under chapter I of Guidelines)
Cashless facility means a facility extended by the insurer to the insured where the payments, of
the costs of treatment undergone by the insured in accordance with the Policy terms and
conditions, are directly made to the network provider by the insurer to the extent pre-
authorization is approved.
Condition Precedent shall mean a Policy term or condition upon which the Insurer's liability under
the Policy is conditional upon.
Congenital Anomaly refers to a condition(s) which is present since birth, and which is abnormal
with reference to form, structure or position.
Internal Congenital Anomaly -Congenital anomaly which is not in the visible and
accessible parts of the body
External Congenital Anomaly- Congenital anomaly which is in the visible and accessible
parts of the body
Co-Payment is a cost-sharing requirement under a health insurance Policy that provides that the
policyholder/ insured will bear a specified percentage of the admissible claim amount. A co-
payment does not reduce the Sum Insured.
Cumulative Bonus shall mean any increase in the Sum Insured granted by the insurer without an
associated increase in premium.
Day care centre means any institution established for day care treatment of illness and/or injuries
or a medical setup within a hospital and which has been registered with the local authorities,
wherever applicable, and is under the supervision of a registered and qualified medical
practitioner AND must comply with all minimum criteria as under—
--has qualified nursing staff under its employment;
--has qualified medical practitioner/s in charge;
--has a fully equipped operation theatre of its own where surgical procedures are carried out;
--maintains daily records of patients and will make these accessible to the insurance company’s
authorized personnel
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Day Care Treatment refers to medical treatment, and/ or surgical procedure which is:
Undertaken under General or Local Anesthesia in a hospital/ day care centre in less than 24 hrs
because of technological advancement, and
Which would have otherwise required a hospitalization of more than 24 hours
Treatment normally taken on an out-patient basis is not included in the scope of this definition.
Deductible is a cost-sharing requirement under a health insurance Policy that provides that the
insurer will not be liable for a specified rupee amount in case of indemnity policies and for a
specified number of days/ hours in case of hospital cash policies which will apply before any
benefits are payable by the insurer. A deductible does not reduce the Sum Insured.
Dental treatment is treatment carried out by a dental practitioner including examinations, fillings
(where appropriate), crowns, extractions and surgery excluding any form of cosmetic surgery/
implants.
Disclosure to information norm means the policy shall be void and all premium paid thereon shall
be forfeited to the Company in the event of misrepresentation, mis-description or non-disclosure
of any material fact
Domiciliary Hospitalisation means medical treatment for an illness/ disease/ injury which in the
normal course would require care and treatment at a hospital but is actually taken while confined
at home under any of the following circumstances:
the condition of the patient is such that he/ she is not in a condition to be moved to a hospital, or
The patient takes treatment at home on account of non availability of room in a hospital.
Emergency Care means management for a severe illness or injury which results in symptoms
which occur suddenly and unexpectedly, and requires immediate care by a medical practitioner
to prevent death or serious long term impairment of the insured person’s health.
Grace Period means the specified period of time immediately following the premium due date
during which a payment can be made to renew or continue a Policy in force without loss of
continuity benefits such as waiting periods and coverage of Pre-existing Condition/ Disease.
Coverage is not available for the period for which no premium is received.
Hospital means any institution established for in-patient care and day care treatment of illness
and/ or injuries and which has been registered as a hospital with the local authorities under the
Clinical Establishments (Registration and Regulation) Act, 2010 or under the enactments specified
under the Schedule of Section 56(1) of the said Act OR complies with all minimum criteria as
under:
has qualified nursing staff under its employment round the clock;
has at least 10 in-patient beds in towns having a population of less than 10,00,000 and at least 15
in-patient beds in all other places;
has qualified medical practitioner(s) in charge round the clock;
has a fully equipped operation theatre of its own where surgical procedures are carried out;
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maintains daily records of patients and makes these accessible to the insurance company’s
authorized personnel
Hospitalization means admission in a Hospital for a minimum period of 24 Inpatient Care
consecutive hours except for specified procedures/ treatments, where such admission could be
for a period of less than 24 consecutive hours.
Illness means a sickness or a disease or pathological condition leading to the impairment of
normal physiological function which manifests itself during the Policy Period and requires medical
treatment.
Acute condition is a disease, illness or injury that is likely to respond quickly to treatment which
aims to return the person to his or her state of health immediately before suffering the disease/
illness/ injury which leads to full recovery.
Chronic condition is defined as a disease, illness, or injury that has one or more of the following
characteristics
it needs ongoing or long-term monitoring through consultations, examinations, check-ups, and /
or tests
it needs ongoing or long-term control or relief of symptoms
it requires your rehabilitation or for you to be specially trained to cope with it
it continues indefinitely
it recurs or is likely to recur
Injury means any accidental physical bodily harm excluding illness or disease solely and directly
caused by external, violent, visible and evident means which is verified and certified by a Medical
Practitioner.
Inpatient care means treatment for which the insured person has to stay in a Hospital for more
than 24 hours for a covered event.
Intensive care unit means an identified section, ward or wing of a hospital which is under the
constant supervision of a dedicated Medical Practitioner(s), and which is specially equipped for
the continuous monitoring and treatment of patients who are in a critical condition, or require life
support facilities and where the level of care and supervision is considerably more sophisticated
and intensive than in the ordinary and other wards.
ICU (Intensive Care Unit) Charges means the amount charged by a Hospital towards ICU expenses
which shall include the expenses for ICU bed, general medical support services provided to any
ICU patient including monitoring devices, critical care nursing and intensivist charges.
Maternity expenses shall include—
medical treatment expenses traceable to childbirth ( including complicated deliveries and
caesarean sections incurred during hospitalization)
expenses towards lawful medical termination of pregnancy during the policy period.
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Medical Advice is any consultation or advice from a Medical Practitioner including the issue of
any prescription or repeat prescription.
Medical Expenses means those expenses that an Insured Person has necessarily and actually
incurred for medical treatment on account of Illness or Accident on the advice of a Medical
Practitioner, as long as these are no more than would have been payable if the Insured Person
had not been insured and no more than other hospitals or doctors in the same locality would
have charged for the same medical treatment.
Medically necessary treatment is defined as an treatment, tests, medication, or stay in hospital
which
i. Is required for the medical management of the illness or injury suffered by the insured;
ii. Must not exceed the level of care necessary to provide safe, adequate and appropriate
medical care in scope, duration, or intensity;
iii. Must have been prescribed by a medical practitioner;
iv. Must conform to the professional standards widely accepted in international medical
practice or by the medical community in India.
Migration means the right accorded to health insurance policyholders/proposers (including all
members under family cover and members of group Health insurance policy), to transfer the
credit gained for pre-existing conditions and time bound exclusions, with the same insurer.
Network Provider means hospitals or health care providers enlisted by an insurer or by a TPA and
insurer together to provide medical services to an insured on payment by a cashless facility.
New Born Baby means baby born during the Policy Period and is upto 90 days,
Non-Network Provider means any Hospital, day care centre or other provider that is not part of
the Network.
Notification of claim/ Intimation of claims means the process of intimating a claim to the insurer or
TPA through any of the recognized modes of communication.
OPD treatment is one in which the Insured visits a clinic/ hospital or associated facility like a
consultation room for diagnosis and treatment based on the advice of a Medical Practitioner. The
Insured is not admitted as a day care or in-patient.
Pre-existing Disease means any condition, ailment, injury or disease
That is/ are diagnosed by a physician within 48 months prior to the effective date of the policy
issued by the insurer or its reinstatement OR
For which medical advice or treatment was recommended by, or received from, a physician
within 48 months prior to the effective date of the policy issued by the insurer or its reinstatement.
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Pre-Hospitalisation Medical Expenses means medical expenses incurred during predefined
number of days preceding the hospitalization of the insured person, provided that:
Such Medical Expenses are incurred for the same condition for which the Insured Person’s
Hospitalisation was required, and
The In-patient Hospitalisation claim for such Hospitalisation is admissible by the Insurance
Company
Post-Hospitalisation Medical Expenses means medical expenses incurred during predefined
number of days immediately after the Insured Person is discharged from the hospital, provided
that:
Such Medical Expenses are for the same condition for which the Insured Person’s Hospitalisation
was required, and
The In-patient Hospitalisation claim for such Hospitalisation is admissible by the Insurance
Company.
Portability means the right accorded to an individual health insurance policyholder (including all
members under family cover), to transfer the credit gained for pre-existing conditions and time
bound exclusions, from one insurer to another insurer
Qualified Nurse is a person who holds a valid registration from the Nursing Council of India or the
Nursing Council of any state in India.
Reasonable and Customary Charges means the charges for services or supplies, which are the
standard charges for the specific provider and consistent with the prevailing charges in the
geographical area for identical or similar services, taking into account the nature of Illness/injury
involved.
Renewal defines the terms on which the contract of insurance can be renewed on mutual consent
with a provision of grace period for treating the renewal continuous for the purpose of gaining
credit for pre-existing diseases, time-bound exclusions and for all waiting periods.
Room Rent means the amount charged by a hospital towards Room and Boarding expenses and
shall include associated medical expenses.
Subrogation shall mean the right of the insurer to assume the rights of the insured person to
recover expenses paid out under the Policy that may be recovered from any other source.
Surgery or Surgical Procedure means manual and/ or operative procedure(s) required for
treatment of an illness or injury, correction of deformities and defects, diagnosis and cure of
diseases, relief of suffering or prolongation of life, performed in a hospital or day care centre by a
Medical Practitioner.
Unproven/Experimental treatment is the treatment including drug experimental therapy which is
not based on established medical practice in India, is treatment experimental or unproven.
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ii. Specific Definitions(Definitions other than those mentioned under c(i) above)
Admission means Your admission in a Hospital as an in-patient for the purpose of medical
treatment of an Injury and/ or Illness.
AYUSH treatments refers to the medical aid and / or hospitalisation treatments given under
‘Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homeopathy systems
Annual Sum Insured means and denotes the maximum amount of cover available to You during
each Policy Year of the Policy Period, as stated in the Policy Schedule or any revisions thereof
based on Claim settled under the Policy.
Break in Policy occurs at the end of the existing Policy term, when the premium due for renewal
on a given Policy is not paid on or before the premium renewal date or within 30 days thereof.
Contribution is essentially the right of an insurer to call upon other insurers, liable to the same
insured, to share the cost of an indemnity claim on a rateable proportion of Sum Insured. This
clause shall not apply to any Benefit offered on fixed benefit basis.
Claim means a demand by You or on Your behalf, for payment of Medical expenses or any other
benefits as covered under the Policy.
Company means ICICI Lombard General Insurance Company Limited.
Dependent Child refers to refers to a child (natural or legally adopted), who is financially
dependent on the primary insured or proposer and does not have his / her independent sources
of income. For the purpose of this policy, child up to age 20 years is considered as dependent
child.
Family would comprise of Your spouse, dependent children, brother(s), sister(s) and dependent
parent(s), Grandparents, Grandchildren, Mother-in-law, Father-in-law, Son-in-law and Daughter-in-
law, dependent Brother-in-law and dependent Sister-in-law.
Floater Benefit means the amount of Sum Insured mentioned in the Policy Schedule which is
common to the whole family covered under the policy which will be the maximum amount
payable under this policy for all the covered family members put together, during the policy
period if opted to be a Floater policy.
Immediate Family means spouse, dependent children, brother(s), sister(s) and dependent
parent(s) of the insured.
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Insured/Insured person means the Individual(s) whose name(s) are specifically appearing as such
in Part a. of the Schedule to this Policy.
Maximum limit of indemnity means the sum total of annual sum insured, additional sum insured
(if any,) accrued by the insured
Medical Practitioner is a person who holds a valid registration from the Medical Council of any
State or Medical Council of India or Council for Indian Medicine or for Homeopathy set up by the
Government of India or a State Government and is thereby entitled to practice medicine within its
jurisdiction; and is acting within the scope and jurisdiction of licence.
The term Medical Practitioner would include physician, specialist, anaesthetist and surgeon but
would exclude You and Your spouse, Your children, Your brother(s), Your sister(s) and Your
parent(s).
Period of Insurance means the period as specifically appearing in the Policy Schedule and
commencing from the Policy Period Start Date of the first Policy taken by You from Us and then,
running concurrent to Your current Policy subject to the Your continuous renewal of such Policy
with Us.
Policy means means these Policy wordings, the Policy Schedule and any applicable
endorsements or extensions attaching to or forming part thereof. The Policy contains details of
the extent of cover available to You, what is excluded from the cover and the terms & conditions
on which the Policy is issued to You.
Policy Holder means the person(s) or the entity named in the Policy Schedule who executed the
Policy Schedule and is (are) responsible for payment of premium(s).
Policy Period means the period commencing from the Policy Period Start Date, Time of the Policy
and ending at the Policy Period End Date, Time of the Policy and as specifically appearing in the
Policy Schedule.
Policy Year means a period of twelve months beginning from the Policy Period Start Date, as
specified in Policy Schedule, and ending on the last day of such twelve month period. For the
purpose of subsequent years, the period following the first year of the Period of Insurance, “Policy
Year” shall mean a period of twelve months beginning from the end of the previous Policy Year
and lapsing on the last day of such twelve month period, till the Period of Insurance End Date as
specified in the Policy Schedule.
Senior citizen means any person who has completed sixty or more years of age as on the date of
commencement or renewal of a health insurance Policy.
Service provider means any person, organization, institution, or company that has been
empanelled with Us to provide services specified under the Benefits (including add-ons) to The
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Insured person. These shall also include all healthcare providers empanelled to form a part of
network other than hospitals.
The list of the Service Providers is available at our website
(https://www.icicilombard.com/content/ilom-en/serviceprovider/search.asp) and is subject to
amendment from time to time.
You/Your/Yours/Yourself means the person(s) that We insure and is/ are specifically named as
Insured/ Insured Person(s) in the Policy Schedule.
We/Our/Ours/Us mean the ICICI Lombard General Insurance Company Limited
d. Benefits Covered Under the Policy
At any point of time, our liability for all claims admitted in respect of any/all insured person/s during the
period of insurance shall not exceed the Annual Sum Insured (including Additional Sum Insured) stated
in the schedule.
A. Basic Cover:
If any insured person suffers an illness or Accident during Policy Period, the Policy provides
indemnification of the Medical Expenses incurred by You which is in excess of the Deductible amount.
Below mentioned base covers are Indemnity based covers and would be payable for actuals (post
deductible and/or Co-Payment as applicable) or up to Annual Sum Insured whichever is lower.
Notwithstanding anything contained herein below, this Benefit shall not apply to any Medical Charges
incurred by the Insured in any place or geographical area other than in India.
1. In-patient Treatment
We hereby agree subject to terms, conditions and exclusions herein contained or otherwise
expressed here on that, if during the Policy Period, You require Hospitalization for any Illness or
Injury on the written advice of a Medical Practitioner, then We will reimburse the Medical Expenses
so incurred by You.
We will cover medical expenses for:
Hospital room rent
Intensive Care Unit charges
Medical Practitioners fees
Nursing Charges
Diagnostics procedures
Anesthesia, blood, oxygen, surgical appliances, medicines, drugs and consumables
Intravenous fluids, blood transfusion, injection administration charges
Operation theatre charges
The cost of prosthetics and other devices or equipment if implanted internally during a
Surgical Procedure.
2. Day Care Treatments
We hereby agree subject to terms, conditions and exclusions contained herein or otherwise
expressed here on that, if during the Policy Period, You require Hospitalization as an inpatient for
less than 24 hours in a Hospital (but not in the outpatient department of a Hospital)on the written
advice of a Medical Practitioner, then We will pay You for the Medical Expenses incurred for
undergoing such Day Care Procedure/ Treatment or surgery. The indicative list of day care
treatments is annexed to this policy.
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We will also cover medical expenses for intravenous chemotherapy, radiotherapy, hemodialysis or
any other procedure which require a period of specialized observation or care after completion of
the procedure where such procedure is undertaken by an Insured person as an In-patient
Hospitalization for a continuous period of less than 24 hours.
3. In patient AYUSH Hospitalization
We will reimburse expenses for in patient AYUSH treatment only when the treatment has been
undergone in a AYUSH Hospital or AYUSH day care centre..
We will not cover expenses for hospitalization done for evaluation or investigation only. Treatment
taken at a healthcare facility which is not a Hospital are also excluded.
4. Domiciliary Hospitalization
We will reimburse You for Medical Expenses incurred by You during “Domiciliary Hospitalization”
upto an amount as mentioned in the Policy Schedule, subject always to the Maximum Limit of
Indemnity
The term “Domiciliary Hospitalisation” for the purpose of this Extension means medical treatment
for an Illness/disease/Injury upon the written advice of a Medical Practitioner, for a period exceeding
three consecutive days for such Illness or Injury which otherwise is covered under the Policy and
in the normal course would require Hospitalisation but is actually undertaken by the patient whilst
confined at home (in India) under any of the following circumstances, namely:
The condition of the patient is such that he/ she cannot be moved to the Hospital; or
The patient cannot be moved to Hospital for lack of accommodation therein.
And provided that the condition for which the medical treatment is required continues for at least
three days, in which case We will pay the Reasonable and Customary charges of any necessary
medical treatment for the entire period.
Subject however that Domiciliary Hospitalisation benefits under any circumstances shall not cover:
a) Medical Expenses incurred by You for treatment of any of the following diseases:
Asthma
Bronchitis
Chronic Nephritis and Chronic Nephritic/Nephrotic Syndrome
Diarrhoea and all types of Dysenteries including Gastro-enteritis
Diabetes Mellitus and Insipidus
Epilepsy
Hypertension
Influenza, Cough and Cold
Pyrexia of unknown origin for less than 10 days
Tonsillitis and Upper Respiratory Tract Infection including Laryngitis and
Pharyngitis
Arthritis, Gout and Rheumatism
5. Donor expenses:
We will reimburse You up to an amount not exceeding Annual Sum Insured for the Hospitalization
Expenses incurred in respect of the donor for the organ transplant surgery, provided:
The organ donated is for Your use and We have admitted Your Hospitalisation Claim under
the Policy
The donation conforms to the “Transplantation of Human Organ Act 1994 (amended)
You have been Medically Advised to undergo an organ transplant
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We will not pay the donor’s pre & post medical expenses or any other medical treatment
for the donor consequent on the harvesting
6. Pre-Hospitalization and Post-Hospitalization Expenses
We hereby agree subject to the terms, conditions and exclusions contained herein or otherwise
expressed here on that, We will reimburse You for the relevant Medical Expenses incurred by You in
relation to:
a) Pre-hospitalization Medical Expenses incurred by You up to 60-days immediately prior to Your
Hospitalization; and
b) Post-hospitalization Medical Expenses incurred by You up to 90-days immediately post
Hospitalization
Cover Under this extension will be provided only if,
a) The in-patient or day care hospitalization claim is admissible and payable as per terms and
conditions of policy
b) Such medical expenses are incurred for the same condition for which insured person is
hospitalized
Pre and post hospitalization expenses or screening expenses of the donor or any other medical expenses as a result
of harvesting from the organ donor will not be covered.
Expenses under this section will be covered on reimbursement basis only.
7. Domestic Road Emergency Ambulance Cover
We will reimburse You up to 1% of Your Sum Insured, maximum upto 5,000 Rs. per Hospitalization, for
the reasonable expenses incurred by You on availing ambulance services offered by a Hospital or by
an ambulance service provider for Your necessary transportation to the nearest Hospital in case of a
life threatening emergency condition, provided however that, a Claim under this extension shall be
payable by Us only when:
a) Such life threatening emergency condition is certified by the Medical Practitioner
b) We have accepted Your Claim under “In-patient Treatment” or “Day Care Procedures” section
of the Policy; and
c) The ambulance service is provided by a healthcare or ambulance service provider
8. Reset Benefit
For plans with Deductible ₹ 3lacs and above, We will reset up to 100% of the Sum insured once in a
policy year in case the Sum insured including accrued Additional Sum Insured (if any) is insufficient as
a result of previous claims in that policy year, provided that:
The total amount of reset will not exceed the Sum Insured for that policy year
The reset amount can only be used for all future claims within the same policy year, not related
to the illness/disease/injury for which a claim has been paid in that policy year for the same person
The claim will be admissible under the reset only if the claim is admissible under “Section A- Basic
cover”
Reset will not trigger for the first claim
For individual policies, reset Sum Insured will be available on individual basis whereas for floater
policies, it will be available on floater basis
Any unutilized reset Sum Insured will not be carried forward to subsequent policy year
Such reset will be available only once during a Policy year to each insured in case of individual
policy and can be utilized by insured persons who stand covered under the Policy before the Sum
Insured was exhausted.
For any single claim during a policy year, the maximum claim amount payable shall not exceed
the sum of
o The Sum Insured, and
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o Additional Sum Insured
During a Policy Year, the aggregate claim amount payable, shall not exceed the sum of:
o The Sum Insured
o Additional Sum Insured
o Reset Sum Insured
9. Additional Sum Insured (Cumulative Bonus)
You will be entitled for Additional Sum Insured (cumulative bonus) as under, for every claim-free
Policy Year under the Policy on its renewal Policy.
Tenure
Additional Sum Insured (Cumulative Bonus)
as a percentage of Sum insured
For each completed and continuous Policy
Year subject to a maximum of 50%
10%
However, in the event of a Claim under the Policy during any subsequent Policy Year, the accrued
Additional Sum Insured (cumulative bonus) will be reduced by 10% of the Sum Insured at the time
of renewal of this Policy.
10. Complimentary Health Check Up
We will provide Complimentary health check-up coupons to the insured for every Policy Year, on
issuance or upon renewal of the Policy, subject to a maximum of 2 coupons per year for floater policies.
11. Wellness Program
Wellness program intends to promote, incentivize and reward You for Your healthy behavior through
various wellness services. All the wellness activities as mentioned below make You earn wellness
points which will be tracked by Us. You can inform us of the various wellness activities undertaken by
You via email or calling our toll free number. You can redeem these wellness points as per Our
redemption terms and conditions.
The wellness services and activities are categorized as below:
A. Manage and track Your health
o Online Health Risk Assessment (HRA)
o Medical Risk Assessment
o Preventive Risk Assessment
B. Disease Management Services
C. Medical Concierge Services
D. Affinity to Wellness
A. Manage & Track Your Health:
Online Health Risk Assessment (HRA)
The Health Risk Assessment (HRA) questionnaire is a tool for evaluation of health and quality of life. It helps
You review Your personal lifestyle practices which may impact your health status. You can log into Your
account on Our website www.icicilombard.com and take HRA. This can be undertaken once per policy year
per insured person.
On taking online HRA test, You can earn 250 wellness points per insured, maximum up to 500 points per
floater policy.
Medical Risk Assessment
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We will reward You with wellness points on undergoing medical checkup, using complimentary checkup
coupons provided with policy, anytime during the policy period. We will help You in getting the appointment
fixed at Our empanelled centers or We will arrange home visit wherever necessary. You will be awarded 1,000
wellness points per insured, maximum up to 2,000 points per floater policy on undergoing these tests.
Second year onwards, if Your medical test results are in normal limits, additional 1,000 wellness points per
insured, maximum up to 2,000 points per floater policy will be awarded for maintenance of health. We will
communicate the findings of this assessment to You and advice You appropriately.
Preventive Risk Assessment
You can also earn wellness points by undergoing certain other diagnostic and preventive health check up
(Specified in list given below or as suggested by Our empanelled medical experts) at any diagnostic centre at
Your own expenses. You shall have to submit medical reports of these tests to Us.
List of Additional tests and corresponding wellness points per Policy Year:
Test
For whom
Wellness Points
Heart related screening tests
(2D echo/ TMT)
Above 45 years
500
HbA1c / Complete lipid profile
Any age
500
PAP Smear
Females above age 45
500
Mammogram
Females above age 45
500
Prostate Specific Antigen (PSA)
Males above age 45
500
Any other test as suggested by
Our empanelled Medical expert
As suggested
500
B. Disease Management Services
In case Your medical tests indicate any health irregularities, We will help You track Your health through Our
empanelled medical experts who will guide You in maintaining/ improving Your health condition. We may also
provide Dietician and nutritional counseling as per Your health condition.
C. Medical Concierge Services
You can also contact Us to avail the following services:
Emergency assistance information such as nearest ambulance / hospital / blood bank etc.
Second opinion provided through electronic mode: E-opinion (Second opinion) of an empanelled
medical expert and/or agency.
Referral for medical service provider, evacuation/ repatriation services, home nursing care etc
D. Affinity to wellness
We will provide You information on health and wellness training, online fitness portals, sporting events, various
sports and health related applications, latest fitness accessories through periodic communications like e-
mailers, blogs, forums etc. and will reward You for undertaking any of the fitness & health related activities as
given below.
List of Fitness initiatives and wellness points
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Initiatives
Wellness
Points
Gym/ Yoga membership for 1 year
2,500
Participation in Professional sporting events like Marathon/Cyclothon/Swimathon etc.
2,500
Participation in any other health & fitness activity/ event organized by Us
2,500
You have to provide Us relevant receipts/ bills and /or certificates indicating participation and completion of
these activities. These fitness centers, gym, yoga centers etc and the companies organizing these fitness
initiatives should be legally registered entities as per rules, regulations as applicable by governing law.
As per the above mentioned activities, You can earn maximum 5,000 wellness points per insured, and
maximum 10,000 wellness points per floater policy.
You can also earn 100 wellness points for each of the following activities:
Quit smoking- based on Self declaration
Share Your fitness success story
On winning any Health quiz organized by Us
Redemption of Wellness Points
Each wellness point will be equivalent to ₹ 0.25. Wellness points not redeemed in the given policy year
can be carry forwarded maximum up to 3 years from the date of awarding of these points, provided the
policy is renewed continuously for subsequent 3 years. You can redeem these wellness points against
outpatient medical expenses like consultation charges, medicine & drugs, diagnostic expenses, dental
expenses, wellness & preventive care and other miscellaneous charges not covered under any medical
insurance, through our Network providers or service providers, the list of which will be updated on our
website www.icicilombard.com from time to time. In case cashless facility is not available for wellness
points’ redemption at these network centres, You can avail reimbursement by submitting relevant
documents with Us.
Terms and conditions under wellness services
Any information provided by You in this regard shall be kept confidential.
You should notify and submit relevant documents, reports, receipts etc for various wellness activities within
60 days of undertaking such activity.
For services that are provided through empanelled service provider, We are only acting as a facilitator; hence
would not be liable for any incremental costs or the services.
All medical services are being provided by empanelled health care service provider. We ensure full due
diligence before empanelment. However You should consult Your doctor before availing/taking the medical
advices/services. The decision to utilize these advices/services is solely at Your discretion.
There will not be any cash redemption against the wellness points.
ICICI Lombard, its group entities, or affiliates, their respective directors, officers, employees, agents,
vendors, is not responsible for or liable for, any actions, claims, demands, losses, damages, costs, charges
and expenses which a Member claims to have suffered, sustained or incurred, by way of and / or on account
of the Program.
Services offered are subject to guidelines issued by IRDA from time to time.
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12. Claim Service Guarantee-
We provide You Claim Service Guarantee as follows:
a) For Reimbursement Claims: We shall make the payment of admissible claim (as per terms &
conditions of Policy) OR communicate non admissibility of claim within 14 days after You submit
complete set of documents & information in respect of the claim. In case We fail to make the
payment of admissible claim or to communicate non admissibility of claim within this time within
this time period, We shall pay 2% interest over and above the rate defined as per IRDAI
(Protection of Policyholder’s Interest) Regulations 2017.
b) For Cashless Claims: If You notify pre authorization request for cashless facility through any of
Our empanelled network hospitals along with complete set of documents & information, We will
respond within 4 hours of the actual receipt of such pre authorization request with:
a) Approval, or
b) Rejection, or
c) Query seeking further information
In case the request is for enhancement, i.e. Request for increase in the amount already
authorized, We will respond to it within 3 hours.
In case of delay in response by Us beyond the time period as stated above for cashless claims,
We shall be liable to pay ₹1,000 to You. Our maximum liability in respect of a single
hospitalization shall, at no time exceed ₹1,000.
We will not be liable to make any payments under this Claim Service Guarantee in case of any force
majeure, natural event or manmade disturbance which impedes Our ability to make a decision or to
communicate such decision to You.
This Claim Service Guarantee shall not be applicable for any cases delayed on account of reasonable
apprehension of fraud or fraudulent claims or cases referred to/by any adjudicative forum for necessary
disposal.
You may lodge claim separately for the hospitalization claim, Pre-Post hospitalization, optional covers,
OPD etc. In such scenarios, if delay happens beyond the time period as specified above, the interest
amount calculated will be on the net sanctioned amount of respective transaction and not the total
amount paid for the entire claim.
If You are not eligible for ‘Claim Service Guarantee’ for the reasons stated in the policy conditions, We
should inform the same to You, within the 14 days for a) and within 4 hours for b) as specified above.
Any amounts paid towards interest under Claim Service Guarantee will not affect the Sum Insured as
specified in the Schedule.
B. Optional Covers
The Benefits listed below shall be available to the Insured Person only if the additional premium has
been received by Us and the Benefit is specified to be in force for that Insured Person in the Policy
Schedule.
Benefits under this Section are subject to the terms, conditions, waiting periods and exclusions of this
Policy and in accordance with the applicable Plan as specified in the Policy.
The Reset Benefit under Section 2.A. 8, will not be applicable for this Section. Claims under this Section
will not impact the Sum insured or Cumulative Bonus
1. Hospital Daily Cash
We will pay You a daily cash amount, as stated against this Extension in the Policy Schedule,
for each and every completed day of Hospitalization up to a maximum of 30 consecutive days,
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if such Hospitalization is at least for a minimum of 3 consecutive days and it falls within the
Policy Period.
2. Convalescence Benefit
We will pay You an amount as stated against this extension in the Policy schedule, if You are
Hospitalized for a minimum period of 10 consecutive days, due to any Injury or Illness as
covered under the Policy. This benefit is payable only once to an Insured Person during each
Policy Year of the Policy Period.
3. Personal Accident Cover
We will pay You or Your Nominee/ legal heir, as the case may be, the sum insured as specified
against this Extension in the Policy Schedule, on occurrence of any Insured Event, as
specifically described hereunder, arising due to an Injury sustained by You during the Policy
Period. This cover is available only for adult members aged maximum up to 60 years. This is a
worldwide cover.
a. Insured Event - Accidental Death
We will pay Your Nominee/legal heir, as the case may be, the sum insured as specified
against this Extension in the Policy Schedule, on the unfortunate event of Your death, provided
such death results solely and directly from an Injury sustained within a period of twelve months
from the date of Accident provided that the date of occurrence of the Accident falls within the
Policy Period.
b. Insured Event - Permanent Total Disablement (PTD) resulting from Accident
We will pay You the sum insured as specified against this Extension in the Policy Schedule on
the occurrence of any of the following losses, provide such losses are total, permanent and
irrecoverable resulting solely and directly from an Injury sustained within a period of twelve
months from the date of Accident resulting in such Injury:
a) Loss of use of both eyes, or physical separation/ loss of use of two entire hands or two
entire feet, or one entire hand and one entire foot, or of such loss of use of one eye and
such physical separation/ loss of use of one entire hand or one entire foot
b) Physical separation/ loss of use of two hands or two feet, or one hand and one foot, or
of Loss of Use of one eye and loss of use of one hand or one foot
If such Injury is permanently and totally, disabling the Insured Person from engaging in any
employment or occupation of any description whatsoever. Provided that the date of occurrence
of the Accident falls within the Policy Period
Notwithstanding anything, We shall not be liable to pay You under this Extension for:
Compensation under more than one of the categories as specified in the Insured Event,
during the Policy Period
Payment of compensation in respect of Death or Permanent Total Disablement arising
from or resulting directly or indirectly from any Illness unless such Illness arose directly
as a consequence of an Accident
Compensation in respect of a death or disablement resulting from, whilst:
i. engaging in aviation or ballooning, or whilst mounting into, or dismounting
from or traveling in any balloon or aircraft other than as a passenger (fare-
paying or otherwise) in any scheduled airlines in the world, or engaging in
any kind of adventure sports for personal gratification
ii. participating in winter sports, skydiving/ parachuting, hang gliding, bungee
jumping, scuba diving, mountain climbing, riding or driving in races or
rallies using a motorized vehicle or bicycle, caving or pot-holing, hunting
or equestrian activities, skin diving or other underwater activity, rafting or
canoeing involving white water rapids, yachting or boating outside coastal
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waters (2 miles), participation in any professional sports, any bodily
contact sport or any other hazardous or potentially dangerous sport
iii. working in underground mines or explosives magazines, or involving
electrical installation with high tension supply, or as jockeys or circus
personnel, or engaged in activities like racing on wheels or horseback, big
game hunting, mountaineering, winter sports, rock climbing, pot holing,
bungee jumping, skiing, ice hockey, ballooning, hang gliding, river rafting,
polo and persons whilst engaged in occupation/ activities of similar hazard
iv. serving in any branch of the military or armed forces of any country during
war or warlike operations
Compensation in respect of death or disablement
i. arising or resulting from You committing any breach of law with a malafide
or criminal intent
ii. directly or indirectly caused by venereal disease
iii. resulting directly from, or indirectly caused by, or contributed to or
aggravated or prolonged by childbirth or pregnancy or in consequence
thereof
Claim Documents for optional cover 3:
You or Your Nominee/ legal heir, as the case may be, shall be required to furnish the following for or in
support of a claim:
a. In case of Death
Policy Copy
Claim form duly filled & signed by Nominee
Post Mortem Report (certified copies) - as applicable and wherever conducted
F.I.R. or Death report or Inquest Panchnama (in original or certified copies)
Spot Panchnama (certified copies)- if applicable
Death certificate (in original or certified copy)
b. In case of PTD
Policy Copy
Claim form duly filled & signed by You
Disability certificate -by an authorized Medical Practitioner of the district/ units concerned,
stating percentage of disablement
F.I.R. and Panchnama wherever applicable (original or certified copies)
Medical report
Original bills, receipts and discharge certificate/card from the Hospital/Medical Practitioner
Original bills from chemists supported by proper prescription
Investigation reports like laboratory test, X-rays and reports essential of confirmation of the
type and percentage of disability and payment receipts
Photo of Insured Person showing the disability
In addition to above, we may also ask for certain relevant documents as required from case to case
basis. If You are covered under any health and accident insurance policy of other insurance company
and become entitled to Claim under such policy, then You can submit to Us the copies of the claim
documents/ medical records, provided they are duly certified by such insurance company or any
hospital where You are getting treated, as applicable.
4. Temporary Total Disablement (TTD ) Rehabilitation Cover (resulting from
Accident Extension)
We, hereby agree to pay a sum as stated in the Policy Schedule against this extension, per
week, on the occurrence of Temporary Total Disablement, which means such loss caused to
the Insured Person provided:
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a. The temporary total disablement results solely and directly from an Injury sustained within
the Policy Period/ Policy Year
b. Such a disablement arises out of an Injury within 7 days from the date of Accident resulting
in such Injury.
c. Completely incapacitates the Insured Person from engaging in any employment or
occupation of any description whatsoever which he/ she was capable of performing at the
time of Accident resulting in such Injury
d. This weekly compensation shall be paid for such time period for which the Insured Person
is totally disabled from engaging in any employment or occupation of any description
whatsoever.
e. The compensation payable under this Benefit shall not be payable for more than 10 weeks
in respect of an Injury, calculated from the date of commencement of disablement
f. Subject to the terms, conditions and exclusions applicable to Extension 03 and the terms,
conditions, general exclusions stated in the Policy
This cover is available only for adult members aged maximum up to 60 years.
Rehabilitation is a treatment or treatments designed to facilitate the process of recovery from injury,
illness, or disease to as normal a condition as possible. Only the rehabilitation services provided by a
certified practitioner will be considered.
5. Repatriation of Remains
In the unfortunate event of death of the Insured Person whilst travelling within the geographical
boundaries of India, during the Policy Period, We will reimburse the legal heir/ Nominee the
costs of transporting the remains of such Insured Person back to his/ her place of residence or,
up to an equivalent amount, for burial or cremation in the city where the death has occurred.
However, Our maximum liability under this cover will not exceed the Annual Sum Insured as
specified against this Extension in the Policy Schedule.
6. Critical Illness Cover
We will pay You/ the Nominee, the sum insured as stated against this Extension in the Policy
Schedule, in case You are diagnosed as suffering from one or more of the Critical Illnesses for
the first time in your life, during the Policy Period.
This cover is available only for adult members aged maximum up to 60 years.
However, We will not make any payment if You are first diagnosed as suffering from a Critical
Illness within 90 days of the Period of Insurance Start Date. This benefit can be availed by You
only once during Your lifetime. No Claim under this Extension shall be admissible in case any
of the Critical Illnesses is a consequence of or arises out of any Pre-Existing Condition(s)/
Disease.
“Critical Illness” for the purpose of this Policy includes the following:
1. Cancer of Specified Severity
I. A malignant tumour characterised by the uncontrolled growth & spread of malignant
cells with invasion & destruction of normal tissues. This diagnosis must be supported
by histological evidence of malignancy & confirmed by a pathologist. The term cancer
includes leukemia, lymphoma and sarcoma.
II. The following are excluded -
i. All tumours which are histologically described as carcinoma in situ, benign, pre-
malignant, borderline malignant, low malignant potential, neoplasm of unknown
behavior, or non-invasive, including but not limited to: Carcinoma in situ of breasts,
Cervical dysplasia CIN-1, CIN -2 and CIN-3.
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ii. Any non-melanoma skin carcinoma unless there is evidence of metastases to
lymph nodes or beyond
iii. Malignant melanoma that has not caused invasion beyond the epidermis;
iv. All tumours of the prostate unless histologically classified as having a Gleason
score greater than 6 or having progressed to at least clinical TNM classification
T2N0M0
v. All Thyroid cancers histologically classified as T1N0M0 (TNM Classification) or
below
vi. Chronic lymphocyctic leukaemia less than RAI stage 3
vii. Non-invasive papillary cancer of the bladder histologically described as TaN0M0
or of a lesser classification;
viii. All Gastro-Intestinal Stromal Tumors histologically classified as T1N0M0 (TNM
Classification) or below and with mitotic count of less than or equal to 5/50 HPFs;
ix. All tumours in the presence of HIV infection.
2. Coronary Artery Bypass Graft Open Chest CABG
I. The actual undergoing of heart surgery to correct blockage or narrowing in one or more
coronary artery(s), by coronary artery bypass grafting done via a sternotomy (cutting
through the breast bone) or minimally invasive keyhole coronary artery bypass procedures.
The diagnosis must be supported by a coronary angiography and the realization of surgery
has to be confirmed by a cardiologist. II. The following are excluded: i. Angioplasty and/or
any other intra-arterial procedures
II. The following are excluded
i. Angioplasty and/or any other intra-arterial procedures
3. First Heart Attack – of Specified Severity (Myocardial infarction)
I. The first occurrence of heart attack or myocardial infarction which means the death of a
portion of the heart muscle as a result of inadequate blood supply to the relevant area. The
diagnosis for Myocardial infarction should be evidenced by all of the following criteria:
i. A history of typical clinical symptoms consistent with the diagnosis of Acute
Myocardial Infarction (for e.g. typical chest pain)
ii. New characteristic electrocardiogram changes
iii. Elevation of infarction specific enzymes, Troponins or other specific
biochemical markers.
II. The following are excluded:
i. Other acute Coronary Syndromes
ii. Any type of angina pectoris.
iii. A rise in cardiac biomarkers or Troponin T or I in absence of overt ischemic
heart disease OR following an intra-arterial cardiac procedure.
4. Open Heart Replacement or Repair of Heart valves
I. The actual undergoing of open-heart valve surgery is to replace or repair one or more heart
valves, as a consequence of defects in, abnormalities of, or disease-affected cardiac
valve(s). The diagnosis of the valve abnormality must be supported by an
echocardiography and the realization of surgery has to be confirmed by a specialist medical
practitioner. Catheter based techniques including but not limited to, balloon
valvotomy/valvuloplasty are excluded.
5. Kidney Failure Requiring Regular Dialysis
I. End stage renal disease presenting as chronic irreversible failure of both kidneys to
function, as a result of which either regular renal dialysis (hemodialysis or peritoneal
dialysis) is instituted or renal transplantation is carried out. Diagnosis has to be confirmed
by a specialist medical practitioner.
6. Major Organ/ Bone marrow Transplant
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I. The actual undergoing of a transplant of:
i. One of the following human organs: heart, lung, liver, kidney, pancreas, that
Resulted from irreversible end-stage failure of the relevant organ, or
ii. Human bone marrow using haematopoietic stem cells. The undergoing of a
transplant has to be confirmed by a specialist medical practitioner.
II. The following are excluded:
i. Other stem-cell transplants
ii. Where only islets of langerhans are transplanted
7. Stroke Resulting in Permanent Symptoms
I. Any cerebrovascular incident producing permanent neurological sequelae. This includes
infarction of brain tissue, thrombosis in an intracranial vessel, haemorrhage and
embolisation from an extracranial source. Diagnosis has to be confirmed by a specialist
medical practitioner and evidenced by typical clinical symptoms as well as typical findings
in CT Scan or MRI of the brain. Evidence of permanent neurological deficit lasting for at
least 3 months has to be produced.
II. The following are excluded:
i. Transient ischemic attacks (TIA)
ii. Traumatic injury of the brain
iii. Vascular disease affecting only the eye or optic nerve or vestibular functions.
8. Permanent Paralysis of Limbs
I. Total and irreversible loss of use of two or more limbs as a result of injury or disease of the
brain or spinal cord. A specialist medical practitioner must be of the opinion that the
paralysis will be permanent with no hope of recovery and must be present for more than 3
months.
9. Multiple Sclerosis with persisting symptoms
I. The unequivocal diagnosis of definite multiple sclerosis confirmed and evidence by all of
the following:
i. investigations including typical MRI which unequivocally confirm the diagnosis to
be multiple sclerosis;
ii. there must be current clinical impairment of motor or sensory function, which must
have persisted for a continuous period of at least 6 months,.
II. Other causes of neurological damage such as SLE and HIV are excluded.
10. Parkinson’s Disease
Unequivocal diagnosis of idiopathic or primary Parkinson’s disease (all other forms of
Parkinson’s are excluded) before age 65 that has to be confirmed by a specialist Medical
Practitioner. There is an associated Neurological Deficit that results in Permanent Inability to
perform independently at least three of the activities of daily living as defined below
Transfer: Getting in and out of bed without requiring external physical assistance
Mobility: The ability to move from one room to another without requiring any
external physical assistance
Dressing: Putting on and taking of all necessary items of clothing without requiring
any external physical assistance
Bathing/Washing: The ability to wash in the bath or shower (including getting in
and out of the bath or shower) or wash by other means
Eating: All tasks of getting food into the body once it has been prepared
OR
must result in a permanent bedridden situation and the inability to get up without
outside assistance. These conditions have to be medically documented for at least
a continuous period of 90 days.
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11. Motor Neuron Disease with permanent symptoms
I. Motor neurone disease diagnosed by a specialist medical practitioner as spinal muscular
atrophy, progressive bulbar palsy, amyotrophic lateral sclerosis or primary lateral sclerosis.
There must be progressive degeneration of corticospinal tracts and anterior horn cells or
bulbar efferent neurons. There must be current significant and permanent functional
neurological impairment with objective evidence of motor dysfunction that has persisted for
a continuous period of at least 3 months.
12. Benign Brain Tumour (resulting in permanent neurological symptoms)
I. Benign brain tumor is defined as a life threatening, non-cancerous tumor in the brain,
cranial nerves or meninges within the skull. The presence of the underlying tumor must be
confirmed by imaging studies such as CT scan or MRI.
II. This brain tumor must result in at least one of the following and must be confirmed by the
relevant medical specialist.
i. Permanent Neurological deficit with persisting clinical symptoms for a continuous
period of at least 90 consecutive days or
ii. Undergone surgical resection or radiation therapy to treat the brain tumor.
III. The following conditions are excluded:
Cysts, Granulomas, malformations in the arteries or veins of the brain, hematomas,
abscesses, pituitary tumors, tumors of skull bones and tumors of the spinal cord.
13. Blindness
I. Total, permanent and irreversible loss of all vision in both eyes as a result of illness or
accident.
II. The Blindness is evidenced by:
i. corrected visual acuity being 3/60 or less in both eyes or ;
ii. the field of vision being less than 10 degrees in both eyes.
III. The diagnosis of blindness must be confirmed and must not be correctable by aids or
surgical procedure.
14. End Stage Lung Failure
I. End stage lung disease, causing chronic respiratory failure, as confirmed and evidenced
by all of the following:
i. FEV1 test results consistently less than 1 litre measured on 3 occasions 3 months
apart; and
ii. Requiring continuous permanent supplementary oxygen therapy for hypoxemia;
and
iii. Arterial blood gas analysis with partial oxygen pressure of 55mmHg or less (PaO2
< 55mmHg); and
iv. Dyspnea at rest.
15. Alzheimer’s Disease
Unequivocal diagnosis of Alzheihmer’s Disease (presenile dementia) before age 65 that has to
be confirmed by a specialist Medical Practitioner and evidenced by typical findings in cognitive
and neuroradiological tests (e.g. CT Scan, MRI, PET of the brain). The disease must result in
a permanent inability to perform independently three or more Activities of Daily Living- bathing
(ability to wash in the bath or shower), dressing (ability to put on, take off, secure and unfasten
garments), personal hygiene (ability to use the lavatory and to maintain a reasonable level of
hygiene), mobility (ability to move indoors on a level surface), continence (ability to manage
bowel and bladder functions), eating/ drinking (ability to feed oneself but not to prepare the
food) or must result in need of supervision and the permanent presence of care staff due to
the disease. These conditions have to be medically documented for at least a continuous period
of 90 days
16. Primary (Idiopathic) Pulmonary Hypertension
I. An unequivocal diagnosis of Primary (Idiopathic) Pulmonary Hypertension by a
Cardiologist or specialist in respiratory medicine with evidence of right ventricular
enlargement and the pulmonary artery pressure above 30 mm of Hg on Cardiac
Cauterization. There must be permanent irreversible physical impairment to the degree
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of at least Class IV of the New York Heart Association Classification of cardiac
impairment.
II. The NYHA Classification of Cardiac Impairment are as follows:
i. Class III: Marked limitation of physical activity. Comfortable at rest, but less
than ordinary activity causes symptoms.
ii. Class IV: Unable to engage in any physical activity without discomfort.
Symptoms may be present even at rest.
III. Pulmonary hypertension associated with lung disease, chronic hypoventilation,
pulmonary thromboembolic disease, drugs and toxins, diseases of the left side of the
heart, congenital heart disease and any secondary cause are specifically excluded.
17. Surgery to Aorta
The actual undergoing of surgery for a chronic disease of the aorta needing excision and
surgical replacement of the diseased aorta with a graft. For the purpose of this definition aorta
shall mean the thoracic and abdominal aorta but not its branches.
Traumatic injury of the aorta is excluded.
Realisation of the aortic surgery has to be confirmed by a specialist Medical Practitioner.
18. Aplastic Anaemia
Aplastic Anaemia involving Chronic persistent bone marrow failure which results in anaemia,
leucoopenia and thrombocytopenia requiring treatment. The diagnosis has to be confirmed by
a specialist medical practitioner and supported by characteristic findings on peripheral blood
smear and bone marrow biopsy.
19. Bacterial Meningitis
Bacterial Meningitis involving bacterial infection causing in severe inflammation of the
membranes of the brain or spinal chord resulting in significant, irreversible and permanent
neurological deficit. The neurological deficit must persist for at least 6 weeks.
The diagnosis of bacterial meningitis must be supported by analysis of cerebrospinal fluid,
including culture, showing characteristic bacterial growth. Meningitis due to any other cause
will not be covered.
Meningitis occurring in a person with HIV/ AIDS will not be covered.
20. Fulminant Viral Hepatitis
Fulminant Hepatitis involving sub-massive to massive necrosis of the liver by the Hepatitis virus,
leading precipitously to liver failure characterized by
Permanent jaundice (bilirubin > 2 micromol/ l)
Moderate ascites
Albumin <3.5g/ dl
Prothrombin time <70% of the normal for the age & gender
Hepatic encephalopathy
The etiology of hepatitis must be viral in origin – limited to Hepatitis A, or B, or C, or D or E or
G; it must be evidenced by significant rise in titers of viral DNA/ RNA
The following are excluded:
i. Child-Pugh-Stage A
ii. Liver Disease Secondary to alcohol or drug misuse
iii. Fulminant Viral Hepatitis occurring in a person with HIV/ AIDS will not be covered
21. End Stage Liver Disease
I. Permanent and irreversible failure of liver function that has resulted in all three of the
following:
i. Permanent jaundice and;
ii. Ascites; and
iii. Hepatic encephalopathy.
II. Liver failure secondary to drug or alcohol abuse is excluded.
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How Deductible works:
Top Up Plan:
Deductible will apply for each and every hospitalisation except for claims made for Any one illness.
(Any one illness means continuous Period of illness and it includes relapse within 45 days from the date
of last consultation with the Hospital/Nursing Home where treatment may have been taken.)
In case of an accident where more than one member of a family is hospitalized, Deductible will apply
on the aggregate claim amount.
Claim amount under optional covers will not be considered for deductible.
Super Top Up Plan:
Deductible will apply on aggregate basis for all hospitalisation expenses during the policy year.
The deductible will apply on individual basis in case of individual policy and on floater basis in case of
floater policy.
Claim amount under optional covers will not be considered for deductible.
e. Exclusions
i. Standard Exclusions(Exclusions for which standard wordings are specified by
IRDAI)
1. Code- Excl01: Pre-Existing Diseases
a) Expenses related to the treatment of a pre-existing Disease (PED) and its direct
complications shall be excluded until the expiry of 24 months of continuous coverage
after the date of inception of the first policy with insurer.
b) In case of enhancement of sum insured the exclusion shall apply afresh to the extent of
sum insured increase.
c) If the Insured Person is continuously covered without any break as defined under the
portability norms of the extant IRDAI (Health Insurance) Regulations, then waiting
period for the same would be reduced to the extent of prior coverage
d) Coverage under the policy after the expiry of 24 months for any pre-existing disease is
subject to the same being declared at the time of application and accepted by Insurer.
2. Code- Excl02: Specified disease/procedure waiting period
a) Expenses related to the treatment of the listed Conditions, surgeries/treatments shall
be excluded until the expiry of 24 months of continuous coverage after the date of
inception of the first policy with us. This exclusion shall not be applicable for claims
arising due to an accident.
b) In case of enhancement of sum insured the exclusion shall apply afresh to the extent of
sum insured increase.
c) If any of the specified disease/procedure falls under the waiting period specified for pre-
Existing diseases, then the longer of the two waiting periods shall apply.
d) The waiting period for listed conditions shall apply even if contracted after the policy or
declared and accepted without a specific exclusion.
e) If the Insured Person is continuously covered without any break as defined under the
applicable norms on portability stipulated by IRDAI, then waiting period for the same
would be reduced to the extent of prior coverage.
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S.No.
Organ /Organ
System
Illness
Treatment/ Procedure
A
ENT
Sinusitis
Deviated Nasal Septum
Treatment for conditions
related to Tonsils, adenoids,
sinuses
Mastoidectomy
B
Gynaecological
Fibroids (fibromyoma)
Endometriosis
Prolapsed uterus
Polycystic ovarian disorder
(PCOD)
Dilatation and curettage (D&C)
Myomectomy
Hysterectomy
C
Orthopaedic
Arthritis
Gout and Rheumatism
Osteoarthritis and
Osteoporosis
Spinal or Vertebral Disorders
Surgery for inter vertebral disc
Joint replacement surgeries
D
Gastrointestinal
Calculus diseases of gall
bladder including Cholecystitis
Esophageal Varices
Pancreatitis
Fissure/fistula in anus,
hemorrhoids, pilonidal sinus,
piles
Ulcer and erosion
Gastro Esophageal Reflux
Disorder (GERD)
Perineal Abscesses
Perianal Abscesses
Cholecystectomy
Procedures for Biliary stones
E
Uro-genital
Calculus diseases of Urogenital
system Example: Kidney stone,
Urinary bladder stone etc.
Benign enlargement of
Prostate
Chronic Kidney Disease
Surgery on prostate
Surgery for Hydrocele/
Rectocele
Dialysis
F
Eye
Cataract
PHACO emulcification
Any other cataract surgery
G
Other General
conditions( Appli
cable to all organ
systems/ organs/
disciplines
whether or not
described above)
Internal tumors, cysts, nodules,
polyps, skin tumors, Lumps, All
types of Internal congenital
anomalies/illnesses/defects
Surgery of varicose veins and
varicose ulcers
Varicocele
Surgery for any Hernia
3. Code- Excl03: 30-day waiting period
a) Expenses related to the treatment of any illness within 30 days from the first policy
commencement date shall be excluded except claims arising due to an accident,
provided the same are covered.
b) This exclusion shall not, however, apply if the Insured Person has Continuous
Coverage for more than twelve months.
c) The within referred waiting period is made applicable to the enhanced sum insured in
the event of granting higher sum insured subsequently.
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4.
a. Expenses related to the treatment of the below mentioned illness within 90 days from
the first policy commencement date shall be excluded unless they are pre-existing and
disclosed at the time of underwriting
i. Hypertension
ii. Diabetes
iii. Cardiac Conditions
b. This exclusion shall not, however, apply if the Insured Person has continuous coverage
for more than twelve months.
c. The within referred waiting period is made applicable to the enhanced sum insured in
the event of granting higher sum insured subsequently.
5. Code- Excl04: Investigation & Evaluation
a) Expenses related to any admission primarily for diagnostics and evaluation
purposes only are excluded.
b) Any diagnostic expenses which are not related or not incidental to the current
diagnosis and treatment are excluded.
6. Excl05: Rest Cure, rehabilitation and respite care
a) Expenses related to any admission primarily for enforced bed rest and not for
receiving treatment. This also includes:
I. Custodial care either at home or in a nursing facility for personal care
such as help with activities of daily living such as bathing, dressing,
moving around either by skilled nurses or assistant or non-skilled
persons.
II. Any services for people who are terminally ill to address physical,
social, emotional and spiritual needs.
7. Code-Excl06: Obesity/ Weight Control
Expenses related to the surgical treatment of obesity that does not fulfil all the below
conditions:
1) Surgery to be conducted is upon the advice of the Doctor
2) The surgery/Procedure conducted should be supported by clinical protocols
3) The member has to be 18 years of age or older and
4) Body Mass Index (BMI);
5) greater than or equal to 40 or
6) greater than or equal to 35 in conjunction with any of the following severe co-
morbidities following failure of less invasive methods of weight loss:
o Obesity-related cardiomyopathy
o Coronary heart disease
o Severe Sleep Apnea
o Uncontrolled Type2 Diabetes
8. Code- Excl07: Change of Gender treatments
Expenses related to any treatment, including surgical management, to change characteristics
of the body to those of the opposite sex.
9. Code- Excl08: Cosmetic or plastic Surgery
Expenses for cosmetic or plastic surgery or any treatment to change appearance unless for
reconstruction following an Accident, Burn(s) or Cancer or as part of medically necessary
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treatment to remove a direct and immediate health risk to the insured. For this to be considered
a medical necessity, it must be certified by the attending Medical Practitioner.
10. Code-Excl09: Hazardous or Adventure sports
Expenses related to any treatment necessitated due to participation as a professional in
hazardous or adventure sports, including but not limited to, para-jumping, rock climbing,
mountaineering, rafting, motor racing, horse racing or scuba diving, hand gliding, sky diving,
deep-sea diving
11. Excl10: Breach of law
Expenses for treatment directly arising from or consequent upon any Insured Person
committing or attempting to commit a breach of law with criminal intent.
12. Code- Excl11: Excluded Providers
Expenses incurred towards treatment in any hospital or by any Medical Practitioner or any other
provider specifically excluded by the Insurer and disclosed in its website / notified to the
policyholders/proposers are not admissible. However, in case of life threatening situations or
following an accident, expenses up to the stage of stabilization are payable but not the complete
claim.
13. Code- Excl12: Treatment for, Alcoholism, drug or substance abuse or any addictive condition
and consequences thereof.
14. Code- Excl13: Treatments received in heath hydros, nature cure clinics, spas or
similar establishments or private beds registered as a nursing home attached to such
establishments or where admission is arranged wholly or partly for domestic reasons.
15. Code- Excl14: Dietary supplements and substances that can be purchased without
prescription, including but not limited to Vitamins, minerals and organic substances unless
prescribed by a medical practitioner as part of hospitalisation claim or day care procedure.
16. Code- Excl15: Refractive Error: Expenses related to the treatment for correction of eye sight
due to refractive error less than 7.5 dioptres
17. Code-Excl16: Unproven Treatments: Expenses related to any unproven treatment, services
and supplies for or in connection with any treatment. Unproven treatments are treatments,
procedures or supplies that lack significant medical documentation to support their
effectiveness.
18. Code- Excl17: Sterility and Infertility: Expenses related to, sterility and infertility. This
includes:
a) Any type of contraception, sterilization
b) Assisted Reproduction services including artificial insemination and advanced
reproductive technologies such as IVF, ZIFT, GIFT, ICSI
c) Gestational Surrogacy
d) Reversal of sterilization
19. Code-Excl18: Maternity: Medical treatment expenses traceable to childbirth (including
complicated deliveries and caesarean sections incurred during hospitalisation) except ectopic
pregnancy. Expenses towards miscarriage (unless due to an accident) and lawful medical
termination of pregnancy during the policy period
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ii. Specific Exclusions (Exclusions other than those mentioned under e(i) above)
1 Deductible: We shall not be liable for the Deductible amount as specifically defined in Part c.i
(Definitions) of the Schedule.
We are not liable for any payment unless the medical expenses exceed the deductible.
Deductible shall not be applicable for optional covers, if any.
2 Co-Payment: We are not liable to pay twenty percent (20%) of admissible claim amount above
the Deductible applicable under the Policy, for insured(s) above 60 years of age. This does not
apply if insured is 60 years of age or below.
However, this condition will not be applicable if You were aged 45 years or below at the time of
buying this policy first time with Us and have renewed it continuously after that.
3 Co payment will not be applicable for optional covers, if any.
4 Permanent exclusions
Unless covered by way of an appropriate Extension/optional covers, We shall not be liable to make
any payment under this Policy in connection with or in respect of
i. Any physical, medical or mental condition or treatment or service that is specifically
excluded in the Policy Schedule under Special Conditions.
ii. Cost of routine medical, eye and ear examinations, preventive health check-up, cost of
spectacles , contact lenses or hearing aids, dentures and artificial teeth.
iii. Any expenses incurred on prosthesis, corrective devices, external durable medical
equipment of any kind( like wheelchairs, crutches), instruments used in treatment of sleep
apnoea syndrome or continuous ambulatory peritoneal dialysis (C.A.P.D.), oxygen
concentrator for bronchial asthmatic condition, cost of cochlear implant(s) unless
necessitated by an Accident or required intra-operatively.
iv. Expenses incurred on all dental treatment unless necessitated due to Accident.
v. Personal comfort, cosmetics convenience and hygiene related items and services.
vi. Circumcision unless necessary for treatment of a disease or necessitated due to an
Accident.
vii. Vaccination and inoculation of any kind unless it is post animal bite.
viii. Intentional self-injury (whether arising from an attempt to commit suicide or otherwise)
ix. Treatment relating to birth defects and external congenital Illnesses or defects or
anomalies.
x. Cost incurred for any health check-up or for the purpose of issuance of medical certificates
and examinations required for employment or travel or any other such purpose
xi. Treatment received outside the country.
xii. Treatment by a family member and self-medication or any treatment that is not scientifically
recognized. Treatment taken from anyone not falling within the scope of definition of
Medical Practitioner. Any treatment charges or fees charged by any Medical Practitioner
acting outside the scope of licence or registration granted to him by any medical Council
xiii. Any travel or transportation expenses excluding ambulance charges, unless specifically
covered.
xiv. Any Injury or Illness directly or indirectly caused by or arising from or attributable to war,
invasion, act of foreign enemies, hostilities (whether declared or not), civil war, commotion,
confiscation or nationalisation or requisition of or damage by or under the order of any
government or public local authority.
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xv. Any Injury or Illness directly or indirectly caused by or contributed to by nuclear weapons/
materials or contributed to by or arising from ionizing radiation or contamination by
radioactivity from any nuclear fuel or from any nuclear waste from the combustion of nuclear
fuel..
xvi. Any Injury or Illness sustained or contracted due to flying other than as a passenger on a
scheduled regular carrier.
xvii. Any losses directly or indirectly due to contamination caused by any act of terrorism,
regardless of any contributory causes
xviii. Any consequential or indirect loss or expenses arising out of or related to the
Hospitalization.
xix. If Policy is issued to You as per condition based exclusion clause, that particular condition
and its related complications will be permanent exclusion for that insured.
Condition based specific exclusion clause:
Subject to our underwriting guidelines, for specific conditions and illnesses, we may provide Policy
but with terms that any expenses directly or indirectly related to this condition / illness, including its
complications will be considered permanent exclusion for that insured under this Policy.
We will give You an intimation by post/ phone call/ e-mail regarding this term & condition. We will
issue You a Policy only if You accept this condition based exclusion. You have to revert Us in 15
days for the same. If You do not, it would be considered as non acceptance and Policy will not be
issued.
f. General Terms and clauses
i. Standard General Terms and Clauses (General terms and clauses whose
wordings are specified by IRDAI)
1. Disclosure of lnformation
The policy shall be void and all premium paid thereon shall be forfeited to the Company in the event of
misrepresentation, mis description or non-disclosure of any material fact by the policyholder.
(Explanation: "Material facts" for the purpose of this policy shall mean all relevant information sought
by the company in the proposal form and other connected documents to enable it to take informed
decision in the context of underwriting the risk
2. Condition Precedent to Admission of Liability
The terms and conditions of the policy must be fulfilled by the insured person for the Company to make
any payment for claim(s) arising under the policy.
3. Claim Settlement (provision for Penal lnterest)
i. The Company shall settle or reject a claim, as the case may be, within 30 days from
the date of receipt of last necessary document.
ii. ln the case of delay in the payment of a claim, the Company shall be liable to pay
interest to the policyholder from the date of receipt of last necessary document to the
date of payment of claim at a rate 2% above the bank rate.
iii. However, where the circumstances of a claim warrant an investigation in the opinion of
the Company, it shall initiate and complete such investigation at the earliest, in any
case not later than 30 days from the date of receipt of last necessary document- ln
such cases, the Company shall settle or reject the claim within 45 days from the date
of receipt of last necessary document
iv. ln case of delay beyond stipulated 45 days, the Company shall be liable to pay interest
to the policyholder at a rate 2% above the bank rate from the date of receipt of last
necessary document to the date of payment of claim.
(Explanation: "Bank rate" shall mean the rate fixed by the Reserve Bank of lndia (RBl) at the
beginning of the financial year in which claim has fallen due)
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4. Complete Discharge
Any payment to the policyholder, insured person or his/ her nominees or his/ her legal
representative or assignee or to the Hospital, as the case may be, for any benefit under the policy
shall be a valid discharge towards payment of claim by the Company to the extent of that amount
for the particular claim.
5. Multiple Policies
i. ln case of multiple policies taken by an insured person during a period from one or
more insurers to indemnify treatment costs, the insured person shall have the right to
require a settlement of his/her claim in terms of any of his/her policies. ln all such cases
the insurer chosen by the insured person shall be obliged to settle the claim as long as
the claim is within the limits of and according to the terms of the chosen policy.
ii. lnsured person having multiple policies shall also have the right to prefer claims under
this policy for the amounts disallowed under any other policy / policies even if the sum
insured is not exhausted. Then the insurer shall independently settle the claim subject
to the terms and conditions of this policy.
iii. lf the amount to be claimed exceeds the sum insured under a single policy, the insured
person shall have the right to choose insurer from whom he/she wants to claim the
balance amount.
iv. Where an insured person has policies from more than one insurer to cover the same
risk on indemnity basis, the insured person shall only be indemnified the treatment
costs in accordance with the terms and conditions of the chosen policy.
6. Fraud
lf any claim made by the insured person, is in any respect fraudulent, or if any false
statement, or declaration is made or used in support thereof, or if any fraudulent means or
devices are used by the insured person or anyone acting on his/her behalf to obtain any benefit
under this policy, all benefits under this policy and the premium paid shall be forfeited.
Any amount already paid against claims made under this policy but which are found fraudulent
later shall be repaid by all recipient(s)/policyholder(s), who has made that particular claim, who
shall be jointly and severally liable for such repayment to the insurer.
For the purpose of this clause, the expression "fraud" means any of the following acts
committed by the insured person or by his agent or the hospital/doctor/any other party acting
on behalf of the insured person, with intent to deceive the insurer or to induce the insurer to
issue an insurance policy:
a. the suggestion, as a fact of that which is not true and which the insured person does
not believe to be true;
b. the active concealment of a fact by the insured person having knowledge or belief of
the fact;
c. any other act fitted to deceive; and d) any such act or omission as the law specially
declares to be fraudulent
The Company shall not repudiate the claim and / or forfeit the policy benefits on the ground of
Fraud, if the insured person / beneficiary can prove that the misstatement was true to the best
of his knowledge and there was no deliberate intention to suppress the fact or that such
misstatement of or suppression of material fact are within the knowledge of the insurer.
7. Cancellation
i. The policyholder may cancel this policy by giving 15 days' written notice and in such
an event, the Company shall refund premium for the unexpired policy period as detailed
below.
Cancellation Period
Refund %
for 1 year
tenure
policy
Refund % for
2 years
tenure policy
Refund % for
3 years tenure
policy
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Within 1 month
80%
80%
80%
From 1 month to 3 months
60%
70%
70%
From 3 months to 6 months
40%
60%
65%
From 6 months to 9 months
20%
50%
60%
From 9 months to 12 months
0%
40%
55%
From 12 months to 15 months
NA
30%
45%
From 15 months to 18 months
NA
20%
40%
From 18 months to 21 months
NA
10%
35%
From 21 months to 24 months
NA
0%
25%
From 24 months to 27 months
NA
NA
20%
From 27 months to 30 months
NA
NA
10%
From 30 months to 33 months
NA
NA
5%
From 33 months to 36 months
NA
NA
0%
Notwithstanding anything contained herein or otherwise, no refunds of premium shall be made
in respect of Cancellation where, any claim has been admitted or has been lodged or any
benefit has been availed by the insured person under the policy.
ii. The Company may cancel the policy at any time on grounds of misrepresentation non-
disclosure of material facts, fraud by the insured person by giving 15 days' written
notice. There would be no refund of premium on cancellation on grounds of
misrepresentation, non-disclosure of material facts or fraud
8. Portability
The insured person will have the option to port the policy to other insurers by applying to such
insurer to port the entire policy along with all the members of the family, if any, at least 45 days
before, but not earlier than 60 days from the policy renewal date as per IRDAI guidelines related
to portability. lf such person is presently covered and has been continuously covered without
any lapses under any health insurance policy with an lndian General/Health insurer, the
proposed insured person will get the accrued continuity benefits in waiting periods as per IRDAI
guidelines on portability.
For Detailed Guidelines on portability, kindly refer the link
https://www.irdai.gov.in/ADMINCMS/cms/frmGuidelines_Layout.aspx?page=PageNo3987
9. Migration
The insured person will have the option to migrate the policy to other health insurance
products/plans offered by the company by applying for migration of the policy at least 30 days
before the policy renewal date as per IRDAI guidelines on Migration. lf such person is presently
covered and has been continuously covered without any lapses under any health insurance
product plan offered by the company, the insured person will get the accrued continuity benefits
in waiting periods as per IRDAI guidelines on migration.
For Detailed Guidelines on migration, kindly refer the link
https://www.irdai.gov.in/ADMINCMS/cms/frmGuidelines_Layout.aspx?page=PageNo3987
10. Renewal of Policy
The policy shall ordinarily be renewable except on misrepresentation by the insured person.
grounds of fraud,
i. The Company shall endeavour to give notice for renewal. However, the Company is
not under obligation to give any notice for renewal.
ii. Renewal shall not be denied on the ground that the insured person had made a claim
or claims in the preceding policy years.
iii. Request for renewal along with requisite premium shall be received by the Company
before the end of the policy period.
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iv. At the end of the policy period, the policy shall terminate and can be renewed within
the Grace Period of 30 days to maintain continuity of benefits without break in policy.
Coverage is not available during the grace period.
v. No loading shall apply on renewals based on individual claims experience.
11. Withdrawal of Policy
i. ln the likelihood of this product being withdrawn in future, the Company will intimate the
insured person about the same 90 days prior to expiry of the policy.
ii. lnsured Person will have the option to migrate to similar health insurance product
available with the Company at the time of renewal with all the accrued continuity
benefits such as cumulative bonus, waiver of waiting period. as per IRDAI guidelines,
provided the policy has been maintained without a break.
12. Moratorium Period
After completion of eight continuous years under the policy no look back to be applied. This period
of eight years is called as moratorium period. The moratorium would be applicable for the sums
insured of the first policy and subsequently completion of 8 continuous years would be
applicable from date of enhancement of sums insured only on the enhanced limits. After the
expiry of Moratorium Period no health insurance claim shall be contestable except for proven
fraud and permanent exclusions specified in the policy contract. The policies would however
be subject to all limits, sub limits, co-payments, deductibles as per the policy contract.
13. Premium Payment in instalments
lf the insured person has opted for Payment of Premium on an instalment basis i.e. Half Yearly,
Quarterly or Monthly, as mentioned in the policy Schedule/Certificate of insurance, the following
Conditions shall apply (notwithstanding any terms contrary elsewhere in the policy)
i. Grace Period of 15 days would be given to pay the instalment premium due for the
policy.
ii. During such grace period, coverage will not be available from the due date of instalment
premium till the date of receipt of premium by Company.
iii. The insured person will get the accrued continuity benefit in respect of the "Waiting
Periods", "Specific Waiting Periods" in the event of payment of premium within the
stipulated grace Period.
iv. No interest will be charged lf the instalment premium is not paid on due date
v. ln case of instalment premium due not received within the grace period, the policy will
get cancelled.
vi. ln the event of a claim, all subsequent premium instalments shall immediately become
due and payable.
vii. The company has the right to recover and deduct all the pending installments from the
claim amount due under the policy.
14. Possibility of Revision of Terms of the Policy lncluding the Premium Rates
The Company, with prior approval of lRDAl, may revise or modify the terms of the policy including
the premium rates. The insured person shall be notified three months before the changes are
effected.
15. Free look period
The Free Look Period shall be applicable on new individual health insurance policies and not on
renewals or at the time of porting/migrating the policy.
The insured person shall be allowed free look period of fifteen days from date of receipt of the policy
document to review the terms and conditions of the policy, and to return the same if not
acceptable.
i. lf the insured has not made any claim during the Free Look Period, the insured shall
be entitled to a refund of the premium paid less any expenses incurred by the Company
on medical examination of the insured person and the stamp duty charges or
ii. where the risk has already commenced and the option of return of the policy is
exercised by the insured person, a deduction towards the proportionate risk premium
for period of cover or
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Where only a part of the insurance coverage has commenced, such proportionate premium
commensurate with the insurance coverage during such period;
16. Redressal of Grievance
ln case of any grievance the insured person (including senior citizens) may contact the company
through
Website: www.icicilombard.com
Toll free: 1800 2666
Email: custom[email protected]om
lnsured person may also approach the grievance cell at any of the company's branches with the
details of grievance lf lnsured person is not satisfied with the redressal of grievance through one of
the above methods, insured person may contact the grievance officer at
Manager- Service Quality,
Corporate Manager- Service Quality,
National Manager- Operations & finally
Director-services and Business development at the following address:
ICICI Lombard General Insurance Company Limited,
ICICI Lombard House,
414, Veer Savarkar Marg,
Near Siddhi Vinayak Temple,
Prabhadevi, Mumbai 400025
For updated details of grievance officer, kindly refer the link https://www.icicilombard.com/grievance-
redressal
lf lnsured person is not satisfied with the redressal of grievance through above methods, the insured
person may also approach the office of lnsurance Ombudsman of the respective area/region for
redressal of grievance as per lnsurance Ombudsman Rules 2017. The contact details of the
ombudsman have been provided as an annexure to the policy wordings
Grievance may also be lodged at IRDAI lntegrated Grievance Management System - https:/igms.
irda.qov. in/
Areas of Jurisdiction
Office of the Insurance Ombudsman
Gujarat , UT of Dadra and Nagar Haveli,
Daman and Diu
Office of the Insurance Ombudsman,
JeevanPrakash Building, 6th floor,
TilakMarg, Relief Road,
Ahmedabad – 380 001.
Tel.: 079 - 25501201/02/05/06
Email: bim[email protected]
Karnataka
Office of the Insurance Ombudsman,
JeevanSoudhaBuilding,PID No. 57-27-N-19, Ground
Floor, 19/19, 24th Main Road,JP Nagar, Ist Phase,
Bengaluru – 560 078.
Tel.: 080 - 26652048 / 26652049
Email: bim[email protected].in
Madhya Pradesh and Chhattisgarh
Office of the Insurance Ombudsman,
JanakVihar Complex, 2nd Floor,
6, Malviya Nagar, Opp. Airtel Office,
Near New Market,
Bhopal – 462 003.
Tel.: 0755 - 2769201 / 2769202
Fax: 0755 - 2769203
Email: bim[email protected]
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Odisha
Office of the Insurance Ombudsman,
62, Forest park,
Bhubneshwar – 751 009.
Tel.: 0674 - 2596461 /2596455
Fax: 0674 - 2596429
Email: bimalokpal.bhubaneswar@ecoi.co.in
Punjab , Haryana, Himachal Pradesh,
Jammu and Kashmir, UT of Chandigarh
Office of the Insurance Ombudsman,
S.C.O. No. 101, 102 & 103, 2nd Floor,
Batra Building, Sector 17 – D,
Chandigarh – 160 017.
Tel.: 0172 - 2706196 / 2706468
Fax: 0172 - 2708274
Email: bim[email protected]
Tamil Nadu, UT–Pondicherry Town and
Karaikal (which are part of UT of
Pondicherry)
Office of the Insurance Ombudsman,
Fatima Akhtar Court, 4th Floor, 453,
Anna Salai, Teynampet,
CHENNAI – 600 018.
Tel.: 044 - 24333668 / 24335284
Fax: 044 - 24333664
Email: bim[email protected]
Delhi
Office of the Insurance Ombudsman,
2/2 A, Universal Insurance Building,
Asaf Ali Road,
New Delhi – 110 002.
Tel.: 011 - 23232481/23213504
Email: bim[email protected]
Assam , Meghalaya, Manipur, Mizoram,
Arunachal Pradesh, Nagaland and
Tripura
Office of the Insurance Ombudsman,
JeevanNivesh, 5th Floor,
Nr. Panbazar over bridge, S.S. Road,
Guwahati – 781001(ASSAM).
Tel.: 0361 - 2632204 / 2602205
Email: bim[email protected]
Andhra Pradesh, Telangana and UT of
Yanam – a part of the UT of Pondicherry
Office of the Insurance Ombudsman,
6-2-46, 1st floor, "Moin Court",
Lane Opp. Saleem Function Palace,
A. C. Guards, Lakdi-Ka-Pool,
Hyderabad - 500 004.
Tel.: 040 - 67504123 / 23312122
Fax: 040 - 23376599
Email: bim[email protected]
Rajasthan
Office of the Insurance Ombudsman,
JeevanNidhi – II Bldg., Gr. Floor,
Bhawani Singh Marg,
Jaipur - 302 005.
Tel.: 0141 - 2740363
Email: Bim[email protected]
Kerala , UT of (a) Lakshadweep, (b)
Mahe – a part of UT of Pondicherry
Office of the Insurance Ombudsman,
2nd Floor, Pulinat Bldg.,
Opp. Cochin Shipyard, M. G. Road,
Ernakulam-682015.
Tel.: 0484 - 2358759/2359338
Fax: 0484-2359336
Email: bimalokpal.ernakulam@ecoi.co.in
West Bengal, UT of Andaman and
Nicobar Islands, Sikkim
Office of the Insurance Ombudsman,
Hindustan Bldg. Annexe, 4th Floor,
4, C.R. Avenue,
KOLKATA - 700 072.
Tel.: 033 - 22124339 / 22124340
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Fax : 033 - 22124341
Email: bim[email protected]
Districts of Uttar Pradesh :
Laitpur, Jhansi, Mahoba, Hamirpur,
Banda, Chitrakoot, Allahabad, Mirzapur,
Sonbhabdra, Fatehpur, Pratapgarh,
Jaunpur,Varanasi, Gazipur, Jalaun,
Kanpur, Lucknow, Unnao, Sitapur,
Lakhimpur, Bahraich, Barabanki,
Raebareli, Sravasti, Gonda, Faizabad,
Amethi, Kaushambi, Balrampur, Basti,
Ambedkarnagar, Sultanpur,
Maharajgang, Santkabirnagar,
Azamgarh, Kushinagar, Gorkhpur,
Deoria, Mau, Ghazipur, Chandauli,
Ballia, Sidharathnagar.
Office of the Insurance Ombudsman,
6th Floor, JeevanBhawan, Phase-II,
Nawal Kishore Road, Hazratganj,
Lucknow - 226 001.
Tel.: 0522 - 2231330 / 2231331
Fax: 0522 - 2231310
Email: bim[email protected]
Goa,
Mumbai Metropolitan Region
excluding Navi Mumbai & Thane
Office of the Insurance Ombudsman,
3rd Floor, JeevanSevaAnnexe,
S. V. Road, Santacruz (W),
Mumbai - 400 054.
Tel.: 022 - 26106552 / 26106960
Fax: 022 - 26106052
Email: bim[email protected]
State of Uttaranchal and the following
Districts of Uttar Pradesh:
Agra, Aligarh, Bagpat, Bareilly, Bijnor,
Budaun, Bulandshehar, Etah, Kanooj,
Mainpuri, Mathura, Meerut, Moradabad,
Muzaffarnagar, Oraiyya, Pilibhit, Etawah,
Farrukhabad, Firozbad,
Gautambodhanagar, Ghaziabad, Hardoi,
Shahjahanpur, Hapur, Shamli, Rampur,
Kashganj, Sambhal, Amroha, Hathras,
Kanshiramnagar, Saharanpur.
Office of the Insurance Ombudsman,
BhagwanSahai Palace
4th Floor, Main Road,
Naya Bans, Sector 15,
Distt: GautamBuddh Nagar,
U.P-201301.
Tel.: 0120-2514250 / 2514252 / 2514253
Email: bim[email protected]
Bihar,
Jharkhand.
Office of the Insurance Ombudsman,
1st Floor,Kalpana Arcade Building,,
Bazar Samiti Road,
Bahadurpur,
Patna 800 006.
Tel.: 0612-2680952
Email: bim[email protected]
Maharashtra,
Area of Navi Mumbai and Thane
excluding Mumbai Metropolitan Region
Office of the Insurance Ombudsman,
JeevanDarshan Bldg., 3rd Floor,
C.T.S. No.s. 195 to 198,
N.C. Kelkar Road, Narayan Peth,
Pune – 411 030.
Tel.: 020-41312555
Email: bim[email protected]
The updated details of Insurance Ombudsman are also available on IRDA website: www.irda.gov.in on
the website of General Insurance Council: www.generalinsurancecouncil.org.in, website of the
company www.icicilombard.com or from any of the offices of the Company
17. Nomination:
The policyholder is required at the inception of the policy to make a nomination for the purpose of
payment of claims under the policy in the event of death of the policyholder. Any change of nomination
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shall be communicated to the company in writing and such change shall be effective only when an
endorsement on the policy is made. ln the event of death of the policyholder, the Company will pay the
nominee {as named in the Policy Schedule/Policy Certificate/Endorsement (if any)} and in case there
is no subsisting nominee, to the legal heirs or legal representatives of the policyholder whose discharge
shall be treated as full and final discharge of its liability under the policy
ii. Specific Terms and Clauses(terms and clauses other than those
mentioned under f(i) above)
1. Material Change
The Insured shall notify the Company in writing of any material change in the risk in relation to the
declaration made in the proposal form or medical examination report at each Renewal and the
Company may, adjust the scope of cover and/or premium, if necessary, accordingly
2. Records to be Maintained
The Insured Person shall keep an accurate record containing all relevant medical records and shall
allow the Company or its representatives to inspect such records. The Proposer or Insured Person
shall furnish such information as the Company may require for settlement of any claim under the
Policy, within reasonable time limit and within the time limit specified in the Policy.
3. Arbitration
i. If any dispute or difference shall arise as to the quantum to be paid by the Policy, (liability
being otherwise admitted) such difference shall independently of all other questions, be
referred to the decision of a sole arbitrator to be appointed in writing by the parties here to or
if they cannot agree upon a single arbitrator within thirty days of any party invoking arbitration,
the same shall be referred to a panel of three arbitrators, comprising two arbitrators, one to
be appointed by each of the parties to the dispute/difference and the third arbitrator to be
appointed by such two arbitrators and arbitration shall be conducted under and in accordance
with the provisions of the Arbitration and Conciliation Act 1996, as amended by Arbitration
and Conciliation (Amendment) Act, 2015 (No. 3 of 2016).
ii. It is clearly agreed and understood that no difference or dispute shall be preferable to
arbitration as herein before provided, if the Company has disputed or not accepted liability
under or in respect of the policy, iii. It is hereby expressly stipulated and declared that it shall
be a condition precedent to any right of action or suit upon the policy that award by such
arbitrator/arbitrators of the amount of expenses shall be first obtained.
4. Policy alignment
Policy Alignment option will be available in cases wherein insured(s) with two separate health
indemnity policies with Us, having different policy end dates but want to align the policy start
dates. We can align the policies by extending the coverage of one policy till the end date of the
other policy.
Such policies will be charged with premium on pro rata basis though the sum insured under the
policy shall remain constant.
5. Endorsements (Changes in Policy)
i. This policy constitutes the complete contract of insurance. This Policy cannot be
modified by anyone (including an insurance agent or broker) except the company.
Any change made by the company shall be evidenced by a written endorsement
signed and stamped.
ii. The proposer may be changed only at the time of renewal. The new proposer must
be the legal heir/immediate family member. Such change would be subject to
acceptance by the company and payment of premium (if any). The renewed Policy
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shall be treated as having been renewed without break.
iii. The proposer may be changed during the Policy Period only in case of his/her demise
or him/her moving out of India.
iv. Mid- term endorsement of addition of member in the policy shall only be allowed for
newly wedded spouse by marriage and new born baby with relevant documentation
6. Change of Sum Insured
Sum insured can be changed (increased/ decreased) only at the time of renewal or at any
time, subject to underwriting by the Company. For any increase in SI, the waiting period shall
start afresh only for the enhanced portion of the sum insured.
7. No constructive Notice: Any knowledge or information of any circumstances or condition in
Your connection in possession of any of Our officials shall not be the notice to or be held to
bind or prejudicially affect Us notwithstanding subsequent acceptance of any premium.
8. Notice of charge etc.: We shall not be bound to take notice or be affected by any notice of any
trust, charge, lien, assignment or other dealing with or relating to this Policy, but the payment
by Us to You or Your legal representative of any compensation or benefit under the Policy shall
in all cases be an effectual discharge to Us.
9. Overriding effect of Part d of the Policy: The terms and conditions contained herein and in
Part d of the Policy shall be deemed to form part of the Policy and shall be read as if they are
specifically incorporated herein; however in case of any inconsistency of any term and condition
with the scope of cover contained in Part d of the Policy, then the term(s) and condition(s)
contained herein shall be read mutatis mutandis with the scope of cover/ terms and conditions
contained in Part d of the Policy and shall be deemed to be modified accordingly or superseded
in case of inconsistency being irreconcilable.
10. Your duties on occurrence of loss: On the occurrence of any loss, within the scope of cover
under the Policy, You shall:
Forthwith file/ submit a Claim Form in accordance with ‘Claim Procedure’ Clause as provided
in Part g (other terms and clauses) of the Policy.
Assist and not hinder or prevent Us or any of Our representative from taking any reasonable
steps in pursuance of their duties for ascertaining the admissibility of the Claim under the Policy.
If You do not comply with the provisions of this Clause or other obligations cast upon You
under this Policy, in terms of the other clauses referred to herein or in terms of the other clauses
in any of the Policy documents, all benefits under the Policy shall be forfeited, at Our option.
We may condone the delay on merit for delayed claims where the delay is proved to be for
reasons beyond Your control. Subrogation: You and any claimant under this Policy shall at no
cost or expense to Us do whatever is necessary to enable Us to enforce any rights and
remedies or obtain relief or indemnity from other parties to which We would become entitled or
subrogated upon Us paying for or making good any Claim or loss under this Policy whether
such acts and things shall be or become necessary or required by Us or otherwise before or
after Your indemnification by Us. However, this condition shall not be applicable for all the
benefit based covers under the Policy, as applicable.
11. Contribution: Contribution is essentially the right of an insurer to call upon other insurers liable
to the same insured to share the cost of an indemnity claim on a ratable proportion of Sum
Insured.
This clause shall not apply to any Benefit offered on fixed benefit basis.
12. Cause of Action/ Currency for payments: No Claims shall be payable under this Policy
unless the cause of action arises in India, unless otherwise specifically provided in Policy
Schedule. The cause of action can arise anywhere in the world in case of Personal Accident
Cover (Extension HC 05), if available under the Policy. All Claims shall be payable in India and
shall be in Indian Rupees only.
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13. Policy Disputes: Any dispute concerning the interpretation of the terms, conditions, limitations
and/ or exclusions contained herein is understood and agreed by both You and Us to be
adjudicated or interpreted in accordance with the Laws of India and only competent Courts of
India shall have the exclusive jurisdiction to try all or any matters arising hereunder. The matter
shall be determined or adjudicated in accordance with the law and practice of such Court.
14. Non Payables
Below are the non payable items applicable in the policy. The list may be updated as per the
direction of Authority, For updated list please visit Our website: www.iciciclombard.com
List of Non Payable Items as per IRDAI
Sr. No
Items
1
BABY FOOD
2
BABY UTILITIES CHARGES
3
BEAUTY SERVICES
4
BELTS/ BRACES
5
BUDS
6
COLD PACK/HOT PACK
7
CARRY BAGS
8
EMAIL / INTERNET CHARGES
9
FOOD CHARGES (OTHER THAN PATIENT's DIET PROVIDED BY HOSPITAL)
10
LEGGINGS
11
LAUNDRY CHARGES
12
MINERAL WATER
13
SANITARY PAD
14
TELEPHONE CHARGES
15
GUEST SERVICES
16
CREPE BANDAGE
17
DIAPER OF ANY TYPE
18
EYELET COLLAR
19
SLINGS
20
BLOOD GROUPING AND CROSS MATCHING OF DONORS SAMPLES
21
SERVICE CHARGES WHERE NURSING CHARGE ALSO CHARGED
22
Television Charges
23
SURCHARGES
24
ATTENDANT CHARGES
25
EXTRA DIET OF PATIENT (OTHER THAN THAT WHICH FORMS PART OF BED
26
BIRTH CERTIFICATE
27
CERTIFICATE CHARGES
28
COURIER CHARGES
29
CONVEYANCE CHARGES
30
MEDICAL CERTIFICATE
31
MEDICAL RECORDS
32
PHOTOCOPIES CHARGES
33
MORTUARY CHARGES
34
WALKING AIDS CHARGES
35
OXYGEN CYLINDER (FOR USAGE OUTSIDE THE HOSPITAL)
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36
SPACER
37
SPIROMETRE
38
NEBULIZER KIT
39
STEAM INHALER
40
ARMSLING
41
THERMOMETER
42
CERVICAL COLLAR
43
SPLINT
44
DIABETIC FOOT WEAR
45
KNEE BRACES (LONG/ SHORT/ HINGED)
46
KNEE IMMOBILIZER/SHOULDER IMMOBILIZER
47
LUMBO SACRAL BELT
48
NIMBUS BED OR WATER OR AIR BED CHARGES
49
AMBULANCE COLLAR
50
AMBULANCE EQUIPMENT
51
ABDOMINAL BINDER
52
PRIVATE NURSES CHARGES- SPECIAL NURSING CHARGES
53
SUGAR FREE Tablets
54
CREAMS POWDERS LOTIONS (Toiletries are not payable, only prescribed
medical pharmaceuticals payable)
55
ECG ELECTRODES
56
GLOVES
57
NEBULISATION KIT
58
RECOVERY KIT, ETC]ANY KIT WITH NO DETAILS MENTIONED [DELIVERY KIT,
ORTHOKIT,
59
KIDNEY TRAY
60
MASK
61
OUNCE GLASS
62
OXYGEN MASK
63
PELVIC TRACTION BELT
64
PAN CAN
65
TROLLY COVER
66
UROMETER, URINE JUG
67
AMBULANCE
68
VASOFIX SAFETY
g. Other terms and conditions
CLAIM ADMINISTRATION
The fulfillment of the terms and conditions of this Policy (including payment of premium by the due dates
mentioned in the Policy Schedule) insofar as they relate to anything to be done or complied with by
You shall be conditions precedent to admission of Our liability.
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Further, upon the discovery or happening of any Illness or Injury that may give rise to a Claim under
this Policy, then as a condition precedent to the admission of Our liability, You shall undertake the
following:
1. Notification of Claim
For Reimbursement
Treatment/ Procedure
You should inform Us
Any Planned Hospitalization for which claim can
be made
At least 48 hours prior to admission in hospital
Any Emergency Hospitalization for which claim
can be made
Within 24 hours of hospitalization
For all other cases/benefits
Within 7 days of completion of such treatment or
procedure
For Cashless Services
Treatment/ Procedure
Taken at
We must be notified along with
full particulars
Any Planned treatment/
Hospitalization
Network hospital
At least 48 hours before the
treatment/ hospitalization
Any Emergency treatment/
Hospitalization
Network hospital
Within 24 hours of the
treatment/ hospitalization
In case of covered Hospitalization, the cost of which were not initially estimated to exceed the
deductible but were subsequently found likely to exceed the deductible, the intimation should be
submitted along with a copy of intimation made to the other insurer immediately.
2. Claims procedure
i. For Cashless Settlement
Cashless treatment is only available at a Network Provider (List of Network Provider is available at our
website. The list is updated as and when there is any change in the Network Provider). In order to avail
of cashless treatment, the following procedure must be followed by You:
Pre-authorization
Prior to taking treatment and/ or incurring Medical Expenses at a Network Provider, You must contact
Us or Our In house claim processing team accompanied with full particulars namely, Policy Number,
Your name, Your relationship with Policy Holder, nature of Illness or Injury, name and address of the
Medical Practitioner/ Hospital and any other information that may be relevant to the Illness/
Hospitalisation. You must request pre-authorisation at least 48 hours before a planned Hospitalization
and in case of an emergency situation, within 24 hours of Hospitalization.
To avail of Cashless Hospitalization facility, You are required to produce the health card, as provided
to You with this Policy, subject to the terms and conditions for the usage of the said health card or You can seek
pre authorization by providing Your Policy number and ID proof to the hospital who can co-ordinate with
Our claims team to provide cashless facility. We will consider Your request after having obtained accurate and
complete information for the Illness or Injury for which cashless Hospitalization facility is sought by You and
We will confirm Your request in writing.
ii. For Reimbursement Settlement
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a) You shall give notice to Us or Our In house claim processing team by calling the toll free number
1800 2666 or emailing us at customersupport@icicilombard.com as specified in the Policy
provided to You and also in writing at Our address with particulars as below:
Policy number
Your Name
Your relationship with the Policyholder
Nature of Illness
Name and address of the attending Medical Practitioner and the Hospital
Any other information that may be relevant to the Illness/ Hospitalization
The above information needs to be provided to Us or Our In house claim processing team
immediately within 24 hours of Hospitalization in case of an emergency situation or at least 48
hours before a planned hospitalization, failing which We will have the right to treat the Claim as
inadmissible, as We may deem fit at Our sole discretion.
b) You must immediately consult a Medical Practitioner and follow the advice and treatment that
he/she recommends.
c) You or someone claiming on Your behalf must promptly and in any event within 30 days of Your
discharge from a Hospital (for post-hospitalization expenses, within 30 days from the completion
of post-hospitalization period) deliver to Us the documentation (written details of the quantum of
any Claim along with all original supporting documentation) as more particularly listed in CLAIM
DOCUMENTS section
However, in both the above cases i.e. 2 (i) & 2(ii), You must take reasonable steps or measure
to minimise the quantum of any Claim that may be covered under the Policy
If so requested by Us or Our In house claim processing team, You will have to undergo a medical
examination from Our nominated Medical Practitioner, as and when We or Our In house claim
processing team considers reasonable and necessary. The cost of such examination will be
borne by Us.
.
3. Claim documents
You shall be required to furnish the following documents in originals for or in support of a Claim:
a) Duly completed Claim form signed by You and the Medical Practitioner (Claim form can be
downloaded from our website www.icicilombard.com)
b) Original bills, receipts and discharge certificate/ card from the Hospital/ Medical Practitioner
c) Original bills from chemists supported by proper prescription.
d) Original investigation test reports and payment receipts.
e) Indoor case papers
f) Medical Practitioner’s referral letter advising Hospitalization in non-Accident cases.
g) Any other document as required by Us or Our In house claim processing team to investigate the
Claim or Our obligation to make payment for it
In case of multiple health policies, the customer has to provide attested photocopy of the claim
documents duly stamped by the hospital along with the Claim settlement letter from the other insurer
who has paid the claim. In case certain documents which were not considered by the previous insurer
are required, those have to be provided in original to the company for claim processing.
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4. Claim assessment in case of Co payment
If the insured in respect of whom, claim is made, is aged above 60 years, 20% co pay will be
applicable. Claim shall be assessed in following order:
a. Deductible will be applied as per cover on admissible claim amount
b. Co payment will be applied on admissible claim amount over and above deductible
c. Balance amount will be the claim payable
However, this condition will not be applicable if You were aged 45 years or below at the time of buying
this policy first time with us and have renewed it continuously after that.
No co payment is applicable for optional covers, if any.
5. Settlement/ Rejection of Claim
The Settlement of claims including its rejection would be done by Us within 30 days after receipt of last
necessary documents, any rejections if done, would be provided with proper reasons by Us.
Penal interest provision shall be as per Regulation 9(6) of (Protection of Policyholders’ Interests)
Regulations, 2017.
6. Claim falling in two Policy periods
If the claim event falls within two Policy periods, the claims shall be paid taking into consideration the
available Sum Insured in the two Policy Periods, including the Deductibles for each Policy Period. Such
eligible claim amount to be payable to the Insured shall be reduced to the extent of premium to be
received for the Renewal/due date of premium of health insurance Policy, if not received earlier.
SPECIAL CONDITIONS APPLICABLE TO THE POLICY
It is hereby declared and agreed that:
a) Any notice or declaration for Your attention shall be deemed served if sent by Us to the Policy
Holder at his/ her latest known address
b) Any payment due to You (insured) under this Policy shall be paid to the Policy Holder by Us.
We shall not be responsible for any liability arising out of the Policy Holder’s delay or default in
making payment to You (insured). However, We also reserve Our right to pay the Claim directly
to You or to the Hospital or to someone on Your behalf. The receipt by the Policy Holder / You
or Hospital or someone claiming on Your behalf shall be considered as a complete discharge
of Our liability against any Claim under the Policy.
c) We shall have no liability under this Policy, once the Annual Sum Insured (including Additional
Sum Insured) as stated in the Policy Schedule, is exhausted by You.
d) For any payment to be made by Us under any Claim arising under this Policy, We shall make
the payment in India and in Indian rupees only.
