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ICICI Elevate Policy Wording

ICICI Health Insurance Policy

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0% found this document useful (0 votes)

55 views91 pages

ICICI Elevate Policy Wording

ICICI Health Insurance Policy

Uploaded by

kalelosho

We take content rights seriously. If you suspect this is your content, claim it here.

Available Formats

Download as PDF, TXT or read online on Scribd

1

a. POLICY SCHEDULE ......................................................................................................................... 3

b. PREAMBLE ...................................................................................................................................... 10
c. DEFINITIONS: .................................................................................................................................. 10
i. Standard Definitions.................................................................................................................. 10
ii. Specific definitions (Definitions other than those mentioned under c (i) above) ..... 18
d. Benefits covered under the Policy ............................................................................................ 21
i. Basic cover: ................................................................................................................................. 22
1. In-patient Treatment .............................................................................................................. 23
2. Day Care Procedures/Treatment ........................................................................................ 23
3. Technological Advancements and Treatments ............................................................. 24
4. Pre- Hospitalisation Medical Expenses............................................................................ 25
5. Post Hospitalization Medical Expenses ........................................................................... 25
6. In Patient AYUSH Hospitalization ...................................................................................... 26
7. Domestic Road Ambulance ................................................................................................. 26
8. Donor Expenses ..................................................................................................................... 27
9. Domiciliary Hospitalization.................................................................................................. 27
10. Bariatric Surgery Cover .................................................................................................... 29
11. In-patient Hospitalisation for Surrogate mother ........................................................ 29
12. In-patient Hospitalization for Oocyte donor ................................................................ 30
13. Home Care Treatment ......................................................................................................... 31
14. Waiver of Deductible ......................................................................................................... 32
15. Wellness Program .............................................................................................................. 33
ii. Add ons/ Optional Covers........................................................................................................ 45

ICICI Lombard General Insurance Company Limited

IRDA Reg. No. 115 CIN: L67200MH2000PLC129408 UIN: ICIHLIP25046V012425 Activate Booster
Mailing Address: Registered Office Address: Toll free no: 1800 2666
601 & 602, 6th Floor, Interface 16, ICICI Lombard House, 414, P Balu Marg, Alternate no : 86552 22666 (chargeable)

New Linking Road, Malad (West) Off Veer Savarkar Road, Nr Siddhi Vinayak Temple, E-mail: [email protected]
Mumbai - 400 064 Prabhadevi, Mumbai 400 025 Website : www.icicilombard.com
2

1. Jumpstart ................................................................................................................................. 45
2. Chronic Disease Management Program .......................................................................... 47
3. BeFit........................................................................................................................................... 48
4. Claim Protector ....................................................................................................................... 53
5. Inflation Protector .................................................................................................................. 54
6. Domestic Air Ambulance Cover ......................................................................................... 55
7. Nursing at Home..................................................................................................................... 55
8. Compassionate Visit ............................................................................................................. 56
9. Health Check-up ..................................................................................................................... 56
10. Dependent Accommodation Benefit ............................................................................. 57
11. Durable Medical Equipment Cover ................................................................................ 58
12. Tele Consultation(s) .......................................................................................................... 59
13. Waiting Period Reduction Option (Other than those listed under JumpStart.) . 60
14. Specific Illness Waiting Period Reduction Option .................................................... 60
15. Room Modifier..................................................................................................................... 60
16. Network Advantage ........................................................................................................... 61
17. NRI Advantage - Accidental Emergencies Cover for NRI ........................................ 61
18. Guaranteed Deductible Reduction ................................................................................ 62
e. EXCLUSIONS: ................................................................................................................................. 63
i. Standard Exclusions ................................................................................................................. 63
ii. Specific Exclusions (Exclusions other than those specified under e. i. above) ....... 67
f. GENERAL Terms and CONDITIONS: ........................................................................................ 69
i. Standard General Terms and clauses .................................................................................. 69
ii. Specific terms and clauses (terms and other clauses other than those mentioned
under f.i above) ................................................................................................................................... 75

ICICI Lombard General Insurance Company Limited

New Linking Road, Malad (West) Off Veer Savarkar Road, Nr Siddhi Vinayak Temple, E-mail: [email protected]
Mumbai - 400 064 Prabhadevi, Mumbai 400 025 Website : www.icicilombard.com
3

g. Other Terms and Conditions....................................................................................................... 78

Activate Booster

Policy Wordings

a. POLICY SCHEDULE

Policy No. Issued at

1. Name of the Proposer:

2. Mailing address of the Proposer:
3. Contact No. of the Proposer:
4. Policy Period:
 Start Date: Time________ Hour__________
 End Date: Time________ Hour__________
5. Period of Insurance
 Start Date
 End Date
 Territorial Scope:
6. Details of Previous Policy:
 Previous Policy No.
 Previous Policy Period
 Claims (if any)
7. Details of the Insured Person(s) under the Policy:

Name of the
Insured/s
Address for
corresponde
nce

ICICI Lombard General Insurance Company Limited

New Linking Road, Malad (West) Off Veer Savarkar Road, Nr Siddhi Vinayak Temple, E-mail: [email protected]
Mumbai - 400 064 Prabhadevi, Mumbai 400 025 Website : www.icicilombard.com
4

Relationship
with the
Proposer

Date of Birth
MM/DD/YY

Age
Gender M / F M/ F/ M / F M / F M / F
/ T T / T / T / T

CKYC no
ABHA ID
Income per
Annum
Occupation
Name of the
Nominee
Relation of
the Nominee
with the
Insured
Date of Birth DD/MM/YY DD/MM/YY DD/MM/YY DD/MM/YY DD/MM/YY
of Nominee YY YY YY YY YY
Percentage ___% ___% ___% ___% ___%
of
Nomination
Pre-existing
Condition

ICICI Lombard General Insurance Company Limited

New Linking Road, Malad (West) Off Veer Savarkar Road, Nr Siddhi Vinayak Temple, E-mail: [email protected]
Mumbai - 400 064 Prabhadevi, Mumbai 400 025 Website : www.icicilombard.com
5

Special
condition:
Any physical,
medical
condition or
treatment or
service which
is
permanently
excluded
under the
Policy
Zone opted
Annual Sum
Insured (Rs.)
Total Sum
Insured (due
to Inflation
Protector, if
opted) Sum
Insured
(Rs.)*
JumpStart
opted
(Yes/No)
Guaranteed
Deductible
Reduction
Basic
Premium
(Rs.)
Optional
benefits/Add
ons**
*wherever applicable

ICICI Lombard General Insurance Company Limited

New Linking Road, Malad (West) Off Veer Savarkar Road, Nr Siddhi Vinayak Temple, E-mail: [email protected]
Mumbai - 400 064 Prabhadevi, Mumbai 400 025 Website : www.icicilombard.com
6

Guaranteed Deductible Reduction Deductible Applicable (₹)

Plan Name

** Optional benefits availed under the policy. Refer the details of the applicable Optional
benefits mentioned in table provided below (Table will be customized as per the optional
benefits opted by the customer)

8. Optional benefits available under the policy:

ICICI Lombard General Insurance Company Limited

New Linking Road, Malad (West) Off Veer Savarkar Road, Nr Siddhi Vinayak Temple, E-mail: [email protected]
Mumbai - 400 064 Prabhadevi, Mumbai 400 025 Website : www.icicilombard.com
7

S.no Optional benefits/ Add ons Premium (₹) Annual Sum Insured (₹)
1 Jumpstart
2 Chronic Disease Management
Program
3 BeFit
4 Claim Protector
5 Inflation Protector
6 Domestic Air Ambulance Cover

7 Nursing at Home
8 Compassionate Visit
9 Health Check-Up
10 Dependent Accommodation
Benefit
11 Durable Medical Equipment Cover
12 Tele Consultation(s)
13 Waiting Period Reduction Option
14 Specific Illness Waiting Period
Reduction Option
15 Room Modifier
16 Network Advantage
17 NRI Advantage - Accidental
Emergencies Cover for NRI
18 Guaranteed Deductible Reduction

9. PREMIUM DETAILS
Premium Amount (in INR)
Basic Premium
Optional benefits premium
Loading (if any)
Discount (if any)
Premium Installment Option (if opted)

ICICI Lombard General Insurance Company Limited

New Linking Road, Malad (West) Off Veer Savarkar Road, Nr Siddhi Vinayak Temple, E-mail: [email protected]
Mumbai - 400 064 Prabhadevi, Mumbai 400 025 Website : www.icicilombard.com
8

GST
TOTAL PREMIUM

Stamp duty of Rs. ____ paid vide receipt/challan no. ___ dated ______.
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

Company Contact Details:

a) Toll-free number: 1800-2666
b) Registered Office Address:
ICICI Lombard General Insurance Company Limited
ICICI Lombard House
414, P Balu Marg, Off Veer Savarkar Road,
Near Siddhi Vinayak Temple,
Prabhadevi, Mumbai 400025
E-mail: [email protected]

Agent Details: (Shall be mentioned only for the policy sourced through the registered
Agents)

Agent Name Agent code Agent Contact No.

ICICI Lombard General Insurance Company Limited

New Linking Road, Malad (West) Off Veer Savarkar Road, Nr Siddhi Vinayak Temple, E-mail: [email protected]
Mumbai - 400 064 Prabhadevi, Mumbai 400 025 Website : www.icicilombard.com
9

Quick Links:

Website – www.icicilombard.com

Email – [email protected]

Toll Free No. - 18002666

Please find link to refer CIS

ICICI Lombard General Insurance Company Limited

New Linking Road, Malad (West) Off Veer Savarkar Road, Nr Siddhi Vinayak Temple, E-mail: [email protected]
Mumbai - 400 064 Prabhadevi, Mumbai 400 025 Website : www.icicilombard.com
10

b. PREAMBLE
ICICI Lombard General Insurance Company Limited (“We / Us”), having received a Proposal
and the premium from the Proposer named in Part a of the Policy (hereinafter referred to as
the “Policy Schedule”) and the said Proposal and Declaration together with any statement,
report or other document leading to the issue of this Policy and referred to therein having
been accepted and agreed to by Us and the Proposer as the basis of this contract do, by
this Policy agree, in consideration of and subject to the due receipt of the subsequent
premiums, as set out in the Policy Schedule, and further, subject to the terms and conditions
contained in this Policy that on proof to Our satisfaction of the compensation having become
payable as set out in the Policy Schedule to the title of the said person or persons claiming
payment or upon the happening of an event upon which one or more benefits become
payable under this Policy, the sum insured/ Annual Sum Insured / appropriate benefit
amount will be paid by Us.

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 Add-ons/Optional Covers:
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

"Accident" means a sudden, unforeseen and involuntary event caused by external, visible
and violent means.

"Any one Illness" means continuous period of Illness and it includes a relapse within 45
days from the date of last consultation with the Hospital/Nursing Home where treatment may
have been taken.

"Ayush Treatment" refers to the medical and / or hospitalization treatments given under
‘Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homeopathy systems.

“Break in policy” means the period of gap that occurs at the end of the existing policy
term / installment premium due date, when the premium due for renewal on a given policy

ICICI Lombard General Insurance Company Limited

New Linking Road, Malad (West) Off Veer Savarkar Road, Nr Siddhi Vinayak Temple, E-mail: [email protected]
Mumbai - 400 064 Prabhadevi, Mumbai 400 025 Website : www.icicilombard.com
11

or installment premium due is not paid on or before the premium renewal date or grace
period.
"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 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.

a. Internal Congenital Anomaly - Congenital Anomaly which is not in the visible

and accessible parts of the body is called Internal Congenital Anomaly.

b. External Congenital Anomaly - Congenital Anomaly which is in the visible and

accessible parts of the body is called External Congenital Anomaly.

"Co-Payment" shall mean a cost sharing requirement under a health Insurance policy that
provides that the policy holder/insured will bear a specified percentage of the admissible
claims amount. A co-payment does not reduce the Sum Insured

"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:
i. has qualified nursing staff under its employment
ii. has qualified medical practitioner/s in charge;
iii. has a fully equipped operation theatre of its own where surgical procedures are
carried out
iv. maintains daily records of patients and will make these accessible to the Insurance
Company’s authorized personnel.

Day Care Centre includes an AYUSH Day Care Centre as defined below

“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

ICICI Lombard General Insurance Company Limited

New Linking Road, Malad (West) Off Veer Savarkar Road, Nr Siddhi Vinayak Temple, E-mail: [email protected]
Mumbai - 400 064 Prabhadevi, Mumbai 400 025 Website : www.icicilombard.com
12

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:
i. Having qualified registered AYUSH Medical Practitioner(s) in charge;
ii. Having dedicated AYUSH therapy sections as required and/or has equipped
operation theatre where surgical procedures are to be carried out;
iii. Maintaining daily records of the patients and making them accessible to the
insurance company's authorized representative.

"Day Care treatment" means medical treatment, and / or surgical procedure which is:

a. undertaken under general or local anesthesia in a hospital/day care centre in less than
24 hours because of technological advancement, and

b. 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" means 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:” Dental treatment means a treatment related to teeth or structures

supporting teeth including examinations, fillings (where appropriate), crowns, extractions and
surgery.

"Disclosure to information norm" means the Policy shall be void and all premium paid
hereon shall be forfeited to the Company, in the event of misrepresentation, mis-description
or non-disclosure of any material fact.

"Domiciliary hospitalization" 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:
i. the condition of the patient is such that he/she is not in a condition to be removed to a
hospital, or

ICICI Lombard General Insurance Company Limited

New Linking Road, Malad (West) Off Veer Savarkar Road, Nr Siddhi Vinayak Temple, E-mail: [email protected]
Mumbai - 400 064 Prabhadevi, Mumbai 400 025 Website : www.icicilombard.com
13

ii. the patient takes treatment at home on account of non-availability of room in a

hospital.

"Emergency care" means management for an 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 premium payment can be made to renew or continue a policy in force
without loss of continuity benefits pertaining to waiting periods and coverage of pre-existing
diseases. Coverage need not be available during the period for which no premium is
received.
The grace period for payment of the premium for all types of insurance policies shall be:
fifteen days where premium payment mode is monthly and thirty days in all other cases.
Provided the insurers shall offer coverage during the grace period, if the premium is paid in
instalments during the policy period.

"Hospital" - A 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:

i. has qualified nursing staff under its employment round the clock;

ii. 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;

iii. has qualified medical practitioner(s) in charge round the clock;

iv. has a fully equipped operation theatre of its own where surgical procedures are
carried out;

v. maintains daily records of patients and makes these accessible to the insurance
company's authorized personnel.

Hospital includes an AYUSH Hospital as defined below:

ICICI Lombard General Insurance Company Limited

New Linking Road, Malad (West) Off Veer Savarkar Road, Nr Siddhi Vinayak Temple, E-mail: [email protected]
Mumbai - 400 064 Prabhadevi, Mumbai 400 025 Website : www.icicilombard.com
14

“AYUSH Hospital” An 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:
a. Central or State Government AYUSH Hospital; or
b. Teaching hospital attached to AYUSH College recognized by the Central
Government/Central Council of Indian Medicine/Central Council for Homeopathy; or
c. 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 all 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.

"Hospitalization" means admission in a hospital for a minimum period of 24 consecutive

“in-patient care” 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 and requires medical treatment.

a. Acute condition - 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.

b. Chronic condition - A chronic condition is defined as a disease, Illness, or Injury that

has one or more of the following characteristics:

1. it needs ongoing or long-term monitoring through consultations, examinations,

check-ups, and / or tests;
2. it needs ongoing or long-term control or relief of symptoms;
3. it requires rehabilitation for the patient or for the patient to be specially trained to
cope with it;
4. it continues indefinitely;
5. it recurs or is likely to recur

ICICI Lombard General Insurance Company Limited

New Linking Road, Malad (West) Off Veer Savarkar Road, Nr Siddhi Vinayak Temple, E-mail: [email protected]
Mumbai - 400 064 Prabhadevi, Mumbai 400 025 Website : www.icicilombard.com
15

"Injury" means 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 expense" means

a. Medical treatment expenses traceable to childbirth (including complicated deliveries and
caesarean sections incurred during hospitalization).
b. Expenses towards lawful medical termination of pregnancy during the Policy period.

“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
license. The term Medical Practitioner includes a physician, specialist and surgeon,
provided that this person is not a member of the Insured/ Insured Person's family who
includes Father, Mother, Father-in-law, Mother-in-law, Son, Daughter, Son-in-law,
Daughter-in-law, Brother or Sister.
"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.

ICICI Lombard General Insurance Company Limited

New Linking Road, Malad (West) Off Veer Savarkar Road, Nr Siddhi Vinayak Temple, E-mail: [email protected]
Mumbai - 400 064 Prabhadevi, Mumbai 400 025 Website : www.icicilombard.com
16

"Medically Necessary treatment" means any treatment, tests, medication, or stay in

hospital or part of a 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.

“Medical Advise” means any consultation or advice from a Medical Practitioner including
the issue of any prescription or follow up prescription.
“Migration” means a facility provided to policyholders (including all members under family
cover and group policies), to transfer the credits gained for pre-existing diseases and
specific waiting periods from one health insurance policy to another with the same insurer.
"Network Provider" means hospitals or health care providers enlisted by an Insurer, TPA
or jointly by an insurer and TPA to provide medical services to an Insured by a cashless
facility.

“Newborn Baby” means baby born during the Policy Period and is aged 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" means the process of intimating a claim to the Insurer or TPA
through any of the recognized modes of communication.

“OPD treatment” means the 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.
“Portability” means a facility provided to the health insurance policyholders (including all
members under family cover), to transfer the credits gained for, pre-existing diseases and
specific waiting periods from one insurer to another insurer.

ICICI Lombard General Insurance Company Limited

New Linking Road, Malad (West) Off Veer Savarkar Road, Nr Siddhi Vinayak Temple, E-mail: [email protected]
Mumbai - 400 064 Prabhadevi, Mumbai 400 025 Website : www.icicilombard.com
17

"Post-hospitalization Medical Expenses" means Medical Expenses incurred during

predefined number of days immediately after the Insured Person is discharged from the
hospital provided that:

i. Such Medical Expenses are for the same condition for which the Insured Person's
Hospitalization was required, and

ii. The In-patient Hospitalization claim for such Hospitalization is admissible by the
Insurance Company.
“Pre-existing Disease” means any condition, ailment, injury or disease:
a) that is/are diagnosed by a physician not more than 36 months prior to the date
of commencement of the policy issued by the insurer; or
b) for which medical advice or treatment was recommended by, or received from,
a physician, not more than 36 months prior to the date of commencement of the
policy.
"Pre-hospitalization Medical Expenses" means medical expenses incurred during
predefined number of days preceding the hospitalization of the Insured Person provided that:

a. Such Medical Expenses are incurred for the same condition for which the Insured
Person's Hospitalization was required, and

b. The In-patient Hospitalization claim for such Hospitalization is admissible by the

Insurance Company.

“Qualified Nurse” means a person who holds a valid registration from the Nursing Council
of India or the Nursing Council of any state in India.

"Renewal" means the terms on which the contract of insurance can be renewed as per
applicable regulatory prescription 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.

"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 the
Illness / Injury involved.

ICICI Lombard General Insurance Company Limited

New Linking Road, Malad (West) Off Veer Savarkar Road, Nr Siddhi Vinayak Temple, E-mail: [email protected]
Mumbai - 400 064 Prabhadevi, Mumbai 400 025 Website : www.icicilombard.com
18

"Room rent" means the amount charged by a hospital towards room and boarding expenses
and shall include associated medical expenses.
“Specific waiting period ” means a period up to 24 months from the commencement of
a health insurance policy during which period specified diseases/treatments (except due
to an accident) are not covered. On completion of the period, diseases/treatments shall
be covered provided the policy has been continuously renewed without any break

"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" means the treatment, including drug Experimental

therapy, which is not based on established medical practice in India, is treatment
experimental or unproven.

ii. Specific definitions (Definitions other than those mentioned under c (i) above)

“Accidental Emergency” means a traumatic bodily injury which, if not immediately

diagnosed and treated, could reasonably be expected to seriously jeopardize a person’s
health or result in loss of life.

“Admission” means Your admission in a Hospital as an inpatient for the purpose of medical
treatment of an Injury and/or Illness.

"Company" means ICICI Lombard General Insurance Company Limited.

"Commissioning couple" means an infertile married couple who approach an assisted

reproductive technology clinic or assisted reproductive technology bank for obtaining the
services authorized of the said clinic or bank;
“Couple” means the legally married Indian man and woman above the age of 21 years
and 18 years respectively;
“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.

ICICI Lombard General Insurance Company Limited

New Linking Road, Malad (West) Off Veer Savarkar Road, Nr Siddhi Vinayak Temple, E-mail: [email protected]
Mumbai - 400 064 Prabhadevi, Mumbai 400 025 Website : www.icicilombard.com
19

“Claim” means a demand made by Insured/Policyholders or on Insured/Policyholders

behalf for payment of Medical Expenses or any other expenses or benefits, as covered
under the Policy.
"Dependent Child" means a child (natural or legally adopted), who is unmarried, aged
between 91 days and 30 years, financially dependent on the Insured and does not have his
/ her independent sources of income.

"Disease" means an alteration in the state of the body or of some of its organs, interrupting
or disturbing the performance of the functions, and causing or threatening pain and weakness
or physical or mental disorder and certified by a Medical Practitioner.

"Diagnostic Tests" Investigations, such as X-Ray or blood tests, to find the cause of your
symptoms and medical condition.

"Family Floater Policy" means a Policy in terms of which, two or more persons of a Family
are named in the Schedule as Insured Persons.

Immediate Family means spouse, dependent children, brother(s), sister(s) and

dependent parent(s) of the Insured.
"Insured" / “Insured Person” means the individual(s) whose name(s) is/are specifically
appearing as such in the Policy Schedule and is/are hereinafter referred as “You”/“Your”/
“Yours”/ “Yourself”
“Intending couple” means a couple who have a medical indication necessitating
gestational surrogacy and who intend to become parents through surrogacy;
“Intending woman” means an Indian woman who is a widow or divorcee between the
age of 35 to 45 years and who intends to avail the surrogacy;
“Maximum Limit of Indemnity” means the sum total of Annual Sum Insured, and
Inflation Protector (if opted and accrued)
“Oocyte” means a developing egg in the ovary
“Oocyte donor” means a person who provides oocyte with the objective of enabling an
infertile intending couple or intending woman to have a child
“Oocyte retrieval” means a procedure of removing oocytes from the ovaries of a woman

ICICI Lombard General Insurance Company Limited

New Linking Road, Malad (West) Off Veer Savarkar Road, Nr Siddhi Vinayak Temple, E-mail: [email protected]
Mumbai - 400 064 Prabhadevi, Mumbai 400 025 Website : www.icicilombard.com
20

“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 Your continuous renewal
of such Policy with Us.
“Policy” 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 period" means the period commencing from the Policy Period Start Date, Time 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
and ending on the last day of such twelve-month period. For the purpose of subsequent
years, “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 Policy
Period End Date, as specified in the Policy Schedule

“Single Private Room” means an air conditioned room in a Hospital where a single
patient is accommodated and which has an attached toilet (lavatory and bath). Such room
type shall be the most basic and the most economical of all accommodations available as
a Single room in that Hospital.
“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 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.

"Sum Insured" or “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.

ICICI Lombard General Insurance Company Limited

New Linking Road, Malad (West) Off Veer Savarkar Road, Nr Siddhi Vinayak Temple, E-mail: [email protected]
Mumbai - 400 064 Prabhadevi, Mumbai 400 025 Website : www.icicilombard.com
21

“Surrogacy” means a practice whereby one woman bears and gives birth to a child for
an intending couple with the intention of handing over such child to the intending couple
after the birth;
“Surrogacy clinic” means surrogacy clinic, centre or laboratory, conducting assisted
reproductive technology services, invitro fertilisation services, genetic counselling centre,
genetic laboratory, Assisted Reproductive Technology Banks conducting surrogacy
procedure or any clinical establishment, by whatsoever name called, conducting
surrogacy procedures in any form;
“Surrogate mother” means a woman who agrees to bear a child (who is genetically
related to the intending couple or intending woman) through surrogacy from the
implantation of embryo in her womb and fulfils the conditions as specified in the surrogacy
(regulation) act, 2021
“Surrogacy procedures” means all gynaecological, obstetrical or medical procedures,
techniques, tests, practices or services involving handling of human gametes and human
embryo in surrogacy
"Third Party Administrator (TPA)" means any organization or institution that is licensed
by the IRDA as a TPA and is engaged by the Company for a fee or remuneration for providing
Policy and claims facilitation services to the Insured/ Insured Person as well as to the
Company for an insurable event.

“Twin Sharing Room” means an air conditioned Hospital room where at least two
patients are accommodated at the same time. Such room shall be the most basic and the
most economical of all accommodations available as twin sharing rooms in that Hospital
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 means the ICICI Lombard General Insurance Company Limited

d. Benefits covered under the Policy

The coverage mentioned below differs between the various plan offerings and the wordings of only
the relevant covers opted by the Insured Person and as mentioned in the Policy schedule will be
applicable.

ICICI Lombard General Insurance Company Limited

New Linking Road, Malad (West) Off Veer Savarkar Road, Nr Siddhi Vinayak Temple, E-mail: [email protected]
Mumbai - 400 064 Prabhadevi, Mumbai 400 025 Website : www.icicilombard.com
22

The Company hereby agrees subject to the terms, conditions and exclusions herein contained or
otherwise expressed, for the period and to the extent of the Sum Insured as specified in the
Schedule to this Policy. The Policy covers Reasonable and Customary Charges incurred towards
medical treatment taken during the Policy Period for an Illness, Accident or condition described
below if this is contracted or sustained by an Insured Person during the Policy Period and subject
always to the Sum Insured, any subsidiary limit specified in the schedule of Benefits, the terms,
conditions, limitations and exclusions mentioned in the Policy and eligibility as per the insurance
plan opted by Insured and as stated in the Schedule.

i. Basic cover:

This Policy provides coverage(s) subject to the Sum Insured and / or the sub-limit as specified in the
Policy Schedule for the events described below and occurring during the policy period only if the
aggregate of covered medical expenses exceed the deductible.

We will indemnify the Reasonable and Customary Charges incurred towards Medically Necessary
Treatment taken by the Insured Person for an Illness, Injury or conditions described in the coverages
below. Notwithstanding anything contained herein below we shall not pay any Medical Charges
incurred by the Insured Person in any place or area outside the geographical boundaries of India.

Assessment of all the claims including those falling within the deductible shall be as per terms,
conditions & exclusions as stated in this policy.

How Deductible works:

 Deductible will apply on aggregate basis for all hospitalization 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

ICICI Lombard General Insurance Company Limited

New Linking Road, Malad (West) Off Veer Savarkar Road, Nr Siddhi Vinayak Temple, E-mail: [email protected]
Mumbai - 400 064 Prabhadevi, Mumbai 400 025 Website : www.icicilombard.com
23

1. In-patient Treatment
We will cover the following Medical Expenses incurred in respect of Hospitalization of the Insured
Person during the Policy Period, up to the Annual Sum Insured specified in the Policy Schedule
against this In-Patient Care treatment:
i. Room Rent charges up to Single Private AC room;
ii. Intensive Care Unit Charges;
iii. Qualified Nurse charges;
iv. Medical Practitioner’s Fees;
v. Anaesthesia, blood, oxygen, operation theatre charges, medicines, drugs and
consumables (other than those specified in the list of excluded expenses (non-
medical) in Annexure II.
vi. Surgical appliances and prosthetic devices recommended in writing by the attending
Medical Practitioner and that are used intra operatively during a Surgical Procedure.
Cost of investigative tests or prescribed diagnostic procedures directly related to the
Injury/Illness for which the Insured Person is hospitalized

We will consider a claim under this Cover, subject to the following:

i. If the Insured Person is admitted in a room category/limit that is higher than the one
that is specified in the Policy Schedule/ Product benefit table of this policy, then the
Insured Person shall bear a rateable proportion of the total Associated medical
expenses (including surcharges or taxes thereon) in the proportion of the difference
between room rent of the entitled room category to the room rent actually incurred
a. For the purpose of this cover, “Associated medical expenses” shall include
room rent, nursing charges, operation theatre charges, fees of medical
practitioner including surgeon/anesthetist/ specialist within the same hospital
where the insured person has been admitted and will not include the cost of
pharmacy and consumables, cost of implants, medical devices and cost of
diagnostics.
b. Proportionate deductions are not applicable for ICU charges
c. Proportionate deductions shall not be applicable for hospitals which do not
follow differential billing or for those expenses in respect of which differential
billing is not adopted based on the room category.
ii. Expenses associated with automation machine for peritoneal dialysis shall not be
payable

2. Day Care Procedures/Treatment

We will cover the Medical Expenses incurred in respect of the Day Care Treatment of the Insured
Person during the Policy Period up to the Annual Sum Insured as specified in the Policy Schedule
provided that:

ICICI Lombard General Insurance Company Limited

New Linking Road, Malad (West) Off Veer Savarkar Road, Nr Siddhi Vinayak Temple, E-mail: [email protected]
Mumbai - 400 064 Prabhadevi, Mumbai 400 025 Website : www.icicilombard.com
24

i. Day Care treatment requires hospitalization as an inpatient for less than 24 hours in a
Hospital.
ii. We will also cover Medical Expenses incurred for procedures including but not limited
to intravenous chemotherapy, radiotherapy, hemodialysis or any other therapeutic
procedure, which requires a period of specialized observation or medical care after
completion of the procedure.
iii. We will not cover any Out Patient Treatment or diagnostic services under this Benefit.
iv. Expenses associated with automation machine for peritoneal dialysis shall not be
payable
v. If the Insured Person is admitted in a room category/limit that is higher than the one
that is specified in the Policy Schedule/ Product benefit table of this Policy, then the
Insured Person shall bear a ratable proportion of the total Associated medical
expenses (including surcharges or taxes thereon) in the proportion of the difference
between room rent of the entitled room category to the room rent actually incurred
a. For the purpose of this cover, “Associated medical expenses” shall include
room rent, nursing charges, operation theatre charges, fees of medical
practitioner including surgeon/anesthetist/ specialist within the same hospital
where the insured person has been admitted and will not include the cost of
pharmacy and consumables, cost of implants, medical devices and cost of
diagnostics.
b. Proportionate deductions are not applicable for ICU charges
c. Proportionate deductions shall not be applicable for hospitals which do not
follow differential billing or for those expenses in respect of which differential
billing is not adopted based on the room category.

3. Technological Advancements and Treatments

We will cover the Medical Expenses incurred in respect of Hospitalization of the Insured Person
for the below mentioned Technological Advancements and Treatments during the Policy Period,
up to the Annual Sum Insured.

Sr. No Treatment/Procedure
1 Uterine Artery Embolization and HIFU (High intensity focused
ultrasound)
2 Immunotherapy- Monoclonal Antibody to be given as injection
3 Vaporisation of the prostrate (Green laser treatment or holmium laser
treatment)

ICICI Lombard General Insurance Company Limited

New Linking Road, Malad (West) Off Veer Savarkar Road, Nr Siddhi Vinayak Temple, E-mail: [email protected]
Mumbai - 400 064 Prabhadevi, Mumbai 400 025 Website : www.icicilombard.com
25

4 Stem cell therapy: Hematopoietic stem cells for bone marrow

transplant for haematological conditions
5 Balloon Sinuplasty
6 Oral Chemotherapy
7 Robotic surgeries
8 Stereotactic radio Surgeries
9 Deep Brain stimulation
10 Intra vitreal injections
11 Bronchical Thermoplasty
12 IONM - (Intra Operative Neuro Monitoring)

4. Pre- Hospitalisation Medical Expenses

We will cover the Pre-Hospitalization Medical Expenses incurred immediately before the Insured
Person’s Admission to Hospital for the number of days as specified in the Policy Schedule,
provided that:
i. We have accepted the claim under “Inpatient Treatment”/ Daycare Procedures/
Treatment/In-Patient AYUSH hospitalisation” in respect of the Insured Person.
ii. We shall not be liable to make any payment in respect of any Pre-Hospitalization
Medical Expenses incurred prior to the Policy Period Start Date of the first policy with
Us in respect of the Insured Person.
iii. Expenses incurred on nursing care at home are excluded from the scope of pre
hospitalization expenses.
iv. This Cover will be provided on a reimbursement basis and/or cashless basis wherever
applicable.

5. Post Hospitalization Medical Expenses

We will cover the Post-Hospitalization Medical Expenses incurred immediately following the
Insured Person’s discharge from Hospital for the number of days as specified in the Policy
Schedule, provided that:
i. We have accepted the claim under “Inpatient Treatment” or “Daycare Procedures/
Treatment” or “In-patient AYUSH Hospitalisation” in respect of the Insured Person.
ii. We will also consider Post-Hospitalization Medical Expenses incurred on
Physiotherapy if the treating Medical Practitioner advises such Physiotherapy in
writing and the same is Medically Necessary Treatment.
iii. This service will be provided on a reimbursement and/ or cashless basis wherever
applicable.

ICICI Lombard General Insurance Company Limited

New Linking Road, Malad (West) Off Veer Savarkar Road, Nr Siddhi Vinayak Temple, E-mail: [email protected]
Mumbai - 400 064 Prabhadevi, Mumbai 400 025 Website : www.icicilombard.com
26

6. In Patient AYUSH Hospitalization

We will cover medical expenses incurred in respect of Insured Person’s AYUSH Treatment during
the Policy Period up to the Annual Sum Insured specified in the Policy Schedule provided that –

i. The Insured person is Hospitalized for AYUSH Treatment at a Government Recognized

AYUSH Hospital or AYUSH Day Care Centre.
ii. This Cover will be provided on reimbursement basis and/or on cashless basis wherever
applicable

7. Domestic Road Ambulance

We will cover the expenses incurred on road ambulance services which are offered by a
healthcare or ambulance service provider and which have been used during the Policy Period to
transfer the Insured Person to the nearest Hospital from the place of Accident/Illness with
adequate emergency facilities for the provision of Emergency Care up to the Annual Sum Insured,
provided that:
i. We have accepted a claim under “Inpatient Treatment” or “Daycare
Procedures/Treatment” in respect of the Insured Person for the same Accident/Illness
for which road ambulance services were availed.
ii. This Benefit includes and is limited to the cost of the transportation of the Insured
Person:
a. To the nearest Hospital with higher medical facilities which is prepared to admit the
Insured Person and provide the necessary medical services if such medical
services cannot satisfactorily be provided at a Hospital where the Insured Person
is situated, and only if that transportation has been prescribed in writing by a
Medical Practitioner and is for Medically Necessary Treatment.
b. From a Hospital to the nearest diagnostic center during the course of Hospitalization
for advanced diagnostic treatment in circumstances where such facility is not
available in the existing Hospital.
iii. The ambulance / service provider providing the services should be a registered
provider with road traffic authority.
iv. Any expenses in relation to transportation of the Insured Person from Hospital to the
Insured Person’s residence while transferring an Insured Person after he/she has
been discharged from the Hospital are not payable under this Benefit.

ICICI Lombard General Insurance Company Limited

New Linking Road, Malad (West) Off Veer Savarkar Road, Nr Siddhi Vinayak Temple, E-mail: [email protected]
Mumbai - 400 064 Prabhadevi, Mumbai 400 025 Website : www.icicilombard.com
27

8. Donor Expenses

We will cover the medical expenses incurred in respect of an organ donor’s Hospitalization during
the Policy Period for harvesting of the organ donated to the Insured Person up to the Annual Sum
Insured specified in the Policy Schedule provided that:

i. The organ donation confirms to the Transplantation of Human Organs Act 1994 (and
its amendments from time to time) and the organ is used for the Insured Person

ii. We will cover only those Medical Expenses incurred in respect of an organ donor as
an in-patient in the Hospital.
iii. We have accepted a claim under Section “Inpatient treatment” in respect of the Insured
Person.

We shall not be liable to pay for any claim under this Cover which arises for or in connection with
any of the following:
i. Pre-hospitalization Medical Expenses or Post-Hospitalization Medical Expenses of the
organ donor.
ii. Screening expenses of the organ donor.
iii. Any other Medical Expenses as a result of the harvesting from the organ donor.
iv. Costs directly or indirectly associated with the acquisition of the donor’s organ.
v. Transplant of any organ/tissue where the transplant is experimental or investigational.
vi. Expenses related to organ transportation or preservation.
vii. Expenses incurred by an Insured Person as a donor.
viii. Any other medical treatment or complication in respect of the donor, consequent to
harvesting.

9. Domiciliary Hospitalization
We will cover the Medical Expenses incurred in respect of the Domiciliary Hospitalization of the
Insured Person during the Policy Period up to the Annual Sum Insured, provided that:
The Domiciliary Hospitalization has commenced on the written advice of a medical practitioner
and continues for at least 3 consecutive days in which case we will make payment under this
Cover in respect of Medical Expenses incurred from the first day of Domiciliary Hospitalization.

We shall not be liable to pay for any claim under this Cover which arises from or in connection
with any of the following:

ICICI Lombard General Insurance Company Limited

New Linking Road, Malad (West) Off Veer Savarkar Road, Nr Siddhi Vinayak Temple, E-mail: [email protected]
Mumbai - 400 064 Prabhadevi, Mumbai 400 025 Website : www.icicilombard.com
28

a) Asthma, bronchitis, tonsillitis and upper respiratory tract infection including laryngitis and
pharyngitis, cough and cold, influenza;
b) Arthritis, gout and rheumatism;
c) Ailments of spine/disc
d) Chronic nephritis and nephritic syndrome;
e) Any liver disease;
f) Peptic ulcer
g) Diarrhea and all type of dysenteries, including gastroenteritis;
h) Diabetes mellitus and insipidus;
i) Epilepsy;
j) Hypertension;
k) Pyrexia of any origin

ICICI Lombard General Insurance Company Limited

New Linking Road, Malad (West) Off Veer Savarkar Road, Nr Siddhi Vinayak Temple, E-mail: [email protected]
Mumbai - 400 064 Prabhadevi, Mumbai 400 025 Website : www.icicilombard.com
29

10. Bariatric Surgery Cover

We will cover medical expenses incurred in respect of Hospitalisation of the Insured Person for
Surgical Procedure/treatment for Obesity up to Annual Sum Insured, subject to below conditions and
Eligibility criteria:
i. The surgery has to be conducted upon the advice of a Medical Practitioner
ii. The surgery/procedure conducted should be supported by clinical protocols
iii. The Insured Person undergoing the bariatric surgery/procedure has to be 18 years
of age or older
iv. Body Mass Index (BMI) of the insured person has to be
a) Greater than or equal to 40 OR
b) 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:
1. Obesity-related cardiomyopathy
2. Coronary heart disease
3. Severe Sleep Apnea
4. Uncontrolled Type2 Diabetes

Conditions: -
i. This benefit has a waiting period of 24 months from date of inception of the first
policy with Us. However, the waiting period will be reduced to 30 days in case
Insured Person has opted for Add ons/Optional Cover 1 Jumpstart.

ii. Any kind of Additional Sum Insured accrued as a part of /Inflation Protector will not
be available for this cover
iii. The Insured Person shall mandatorily obtain cashless approval prior to undergoing
the surgery/ treatment
iv. Bariatric surgery/treatment performed for cosmetic reasons is excluded

11. In-patient Hospitalisation for Surrogate mother

We will cover the Medical Expenses incurred in respect of In Patient Hospitalization of the
Surrogate mother appointed by the “Intending Couple”/”Intending woman” for complications
arising out of pregnancy and post-partum delivery complications during the Policy Period, up to a
maximum limit of Rs. 5 Lakhs and subject to the following conditions:
i. Initial waiting period of 30 days will be applicable
ii. This benefit is applicable for all female Insured Persons who have opted for 3 years’
policy term
iii. The maximum coverage available for a surrogate mother is a period of thirty-six (36)
continuous months after the surrogacy procedure has been successful

ICICI Lombard General Insurance Company Limited

New Linking Road, Malad (West) Off Veer Savarkar Road, Nr Siddhi Vinayak Temple, E-mail: [email protected]
Mumbai - 400 064 Prabhadevi, Mumbai 400 025 Website : www.icicilombard.com
30

iv. Any expenses incurred on delivery of the new born (either via normal delivery or
caesarean section) are excluded from the scope of this cover
v. This coverage shall only be available if all the provisions as specified in The Surrogacy
Regulation Act (2021), and all the rules and regulations made thereunder are fulfilled
vi. The terms and conditions of In-patient Treatment shall apply

We will consider a claim under this Cover, subject to the following:

i. If the Surrogate mother is admitted in a room category/limit that is higher than the one
that is specified in the Policy Schedule/ Product benefit table of this policy, then the
intending couple / intending woman shall bear a rateable proportion of the total
Associated medical expenses (including surcharges or taxes thereon) in the proportion
of the difference between room rent of the entitled room category to the room rent
actually incurred
a. For the purpose of this cover, “Associated medical expenses” shall include
room rent, nursing charges, operation theatre charges, fees of medical
practitioner including surgeon/anesthetist/ specialist within the same
hospital where the insured person has been admitted and will not include
the cost of pharmacy and consumables, cost of implants, medical devices
and cost of diagnostics.
b. Proportionate deductions are not applicable for ICU charges
c. Proportionate deductions shall not be applicable for hospitals which do
not follow differential billing or for those expenses in respect of which
differential billing is not adopted based on the room category.
ii. Expenses associated with automation machine for peritoneal dialysis shall not be
payable.
Note: The cover is available only in Plan A

12. In-patient Hospitalization for Oocyte donor

We will cover the Medical Expenses incurred in respect of Hospitalization of the Oocyte donor
appointed by the “Intending Couple”/”Intending woman” for complications arising due to oocyte
retrieval during the Policy Period, up to the annual sum insured subject to maximum limit of Rs.5
Lakhs and subject to the following conditions:
i. This cover shall be available only for a period of twelve months (12 months) after the
oocyte retrieval procedure has been successful
ii. This benefit is applicable to all or any female insured person
iii. Any expenses incurred on delivery of the new born (either via normal delivery or
caesarean section) are excluded from the scope of this cover
iv. This coverage shall only be available if all the provisions as specified in The Assisted
Reproductive Technology (Regulation) Act, 2021, and all the rules and regulations
made thereunder are fulfilled

ICICI Lombard General Insurance Company Limited

New Linking Road, Malad (West) Off Veer Savarkar Road, Nr Siddhi Vinayak Temple, E-mail: [email protected]
Mumbai - 400 064 Prabhadevi, Mumbai 400 025 Website : www.icicilombard.com
31

v. The terms and conditions of In-patient Treatment shall apply.

We will consider a claim under this Cover, subject to the following:

i. If the oocyte donor is admitted in a room category/limit that is higher than the one that is specified
in the Policy Schedule/ Product benefit table of this policy, then the oocyte donor shall bear a
rateable proportion of the total Associated medical expenses (including surcharges or taxes
thereon) in the proportion of the difference between room rent of the entitled room category to the
room rent actually incurred
a. For the purpose of this cover, “Associated medical expenses” shall include room rent, nursing
charges, operation theatre charges, fees of medical practitioner including surgeon/anesthetist/
specialist within the same hospital where the insured person has been admitted and will not
include the cost of pharmacy and consumables, cost of implants, medical devices and cost of
diagnostics.
b. Proportionate deductions are not applicable for ICU charges
c. Proportionate deductions shall not be applicable for hospitals which do not follow differential billing
or for those expenses in respect of which differential billing is not adopted based on the room
category.
ii. Expenses associated with automation machine for peritoneal dialysis shall not be payable
iii. Note: The cover is available only in Plan A

13. Home Care Treatment

We will cover the Medical Expenses incurred by the Insured Person on Home Care Treatment
up to 5% of Annual Sum Insured subject to a maximum of INR 5 Lacs provided that:
i. The Medical Practitioner advices the Insured Person in writing to undergo
treatment at home
ii. There is a continuous active line of treatment with monitoring of the health status
by a Medical Practitioner for each day through the duration of the home care
treatment.
iii. Daily monitoring chart including records of the treatment duly signed by the treating
Medical Practitioner is maintained.
iv. The condition of the Insured Person is expected to improve in a reasonable and
foreseeable period of time.
v. Prior approval from Us has been taken. The Home Care Treatment is to be availed
only on a cashless basis, subject to availability of our empaneled Service
Provider(s). Kindly visit our website for cities/locations where such services are
available.
vi. Such treatment cannot be provided on outpatient basis

ICICI Lombard General Insurance Company Limited

New Linking Road, Malad (West) Off Veer Savarkar Road, Nr Siddhi Vinayak Temple, E-mail: [email protected]
Mumbai - 400 064 Prabhadevi, Mumbai 400 025 Website : www.icicilombard.com
32

However, in case of unavailability of our empaneled Service Provider in the Insured Person’s
location, in case the Insured Person intends to avail the services of Non-network Provider and
claims for reimbursement, a prior approval from Us needs to be taken before availing such
services.

In case the Insured Person breaches the conditions of approval or fails to take the prior written
approval from Company, we are not liable to settle any claim under this section.
For the purpose of this Cover, Home Care Treatment shall include:
a. Diagnostic tests underwent at home as advised by Medical Practitioner
b. Medicines prescribed in writing by a Medical Practitioner
c. Consultation charges of the Medical Practitioner
d. Nursing charges if advised by the Medical Practitioner

Note: The cover is available only in Plan B

14. Waiver of Deductible

We will offer the Insured Person an option to waive the Deductible and shall offer any one
indemnity health insurance policy (without any Deductible) offered by Us for the same Sum
Insured without re-evaluating of health status provided that:
1. Insured Person has been insured with Us for first time under this Policy before the Age
of 50 years, and has renewed with Us continuously.

2. This option for waiver of Deductible shall be exercised by the Insured Person during
the Age group of the eldest insured member being 55 years to 65 years only, and at
the time of Renewal only; provided that it has been renewed with Us continuously
without any break.

3. Insured Person will be offered continuity of coverage in terms of waiver of waiting

periods to the extent of Benefits covered under this Policy as a result of waiver of
Deductible.

4. Premium for the opted indemnity health insurance policy (without any Deductible)
would be charged as per the Age of the Insured Person at Renewal.

ICICI Lombard General Insurance Company Limited

New Linking Road, Malad (West) Off Veer Savarkar Road, Nr Siddhi Vinayak Temple, E-mail: [email protected]
Mumbai - 400 064 Prabhadevi, Mumbai 400 025 Website : www.icicilombard.com
33

5. In all other cases, no Benefits shall accrue to any Insured Person by virtue of continuity
of coverage in the event of discontinuation of this Policy at any point of time or shifting
to any other health insurance policy with Us.

15. Wellness Program

The wellness program provides the Insured Person with the below mentioned benefits
I. Wellness program
II. Health Assistance [HAT]
III. Ambulance Assistance
IV. Discounts on services and products

I. Wellness program
Wellness program intends to promote, incentivize and reward the Insured Person(s) for their
healthy behavior through various wellness services. The wellness program shall be available to
each Adult Insured Person subject to a maximum of 2 Adults in a floater policy. All the wellness
activities as mentioned below in Table A enable the Insured Person(s) to earn wellness points
which shall be monitored by the Health Coach.

The Health Coach shall only be available to a maximum of 2 Adult Insured Persons. The Health
Coach is a personalized service that shall encourage and promote optimal health and physical
and mental wellness through a digital platform. The Insured Person shall have access to the
health coach on downloading and registering on our mobile application. This activity needs to be
done within 30 days of Policy Start Date to ensure adequate utilization of services offered and to
redeem the wellness points awarded.

Registered Insured Person(s) on successful completion of Health Risk Assessment [HRA] shall
be evaluated by the Health Coach to assess and educate the Insured Person on adapting a
healthy lifestyle

Table A- Journey of earning Wellness points

Individual Policy Floater Policy*
Category Policy Tenure
1 Year 1 Year

ICICI Lombard General Insurance Company Limited

New Linking Road, Malad (West) Off Veer Savarkar Road, Nr Siddhi Vinayak Temple, E-mail: [email protected]
Mumbai - 400 064 Prabhadevi, Mumbai 400 025 Website : www.icicilombard.com
34

Max Points Earned per Max Points Earned per

Activity Details
Insured Person Insured Person
Health Risk Assessment 500 250
Undergoing Health Check-Up
1,000 500
& uploading the reports
Health
Face scan once a quarter 400 200
Assessment
First usage of Chat with
Health Expert/ Health Coach 100 50
Service
ICICI Lombard initiated
Contest/ health quiz (Any one 200 100
Wellness
contest)
activities
ICICI Lombard initiated
200 100
Webinar (Any one webinar)
Achieving targeted steps per
Wellness month (10/15/25 points/ day
6,000 3,000
Tasks depending on steps
completed)
Participation and successful
Fitness
completion of fitness 500 (250 per challenge) 250 per challenge
challenge
challenge In App

Participation in Professional
Health sporting events like
500 250
Events Marathon/Cyclathon/Swimat
hon etc.

Grand Total 9,400 4,700

For multi-year policies with policy tenure of 2 years and 3 years, the maximum wellness points
that can be accumulated shall be as per table mentioned below

Floater*
Individual
Category Policy Tenure

2 Years 3 Years 2 Years 3 Years

ICICI Lombard General Insurance Company Limited

New Linking Road, Malad (West) Off Veer Savarkar Road, Nr Siddhi Vinayak Temple, E-mail: [email protected]
Mumbai - 400 064 Prabhadevi, Mumbai 400 025 Website : www.icicilombard.com
35

Max Points Max Points Max Points Max Points

Activity Details Earned per Earned per Earned per Earned per
Insured Insured Insured Insured
Health Risk 500 750
1,000 1,500
Assessment
Undergoing Health
Check-Up & uploading 2,000 3,000 1,000 1,500
Health the reports
Assessment Face scan once a 400 600
800 1,200
quarter
First usage of Chat with
Health Expert/ Health 200 300 100 150
Coach Service
ICICI Lombard initiated
Contest/ health quiz 400 600 200 300
Wellness (Any one contest)
activities ICICI Lombard initiated
Webinar (Any one 200 300
400 600
webinar)
Achieving targeted
steps per month 6,000 9,000
Wellness
(10/15/25 points/ day 12,000 18,000
Tasks
depending on steps
completed)
Participation and
Fitness successful completion 500 750
1,000 1,500
challenge of fitness challenge In
App

Participation in 500 750

Professional sporting
Health
events like 1,000 1,500
Events
Marathon/Cyclathon/S
wimathon etc.

Grand Total 18,800 28,200 9,400 14,100

ICICI Lombard General Insurance Company Limited

New Linking Road, Malad (West) Off Veer Savarkar Road, Nr Siddhi Vinayak Temple, E-mail: [email protected]
Mumbai - 400 064 Prabhadevi, Mumbai 400 025 Website : www.icicilombard.com
36

* In case of a floater policy, the wellness points earned by each of the Insured Persons for every
completed wellness activity shall be accrued to calculate the renewal discount.

Detailed explanation of Table A (with respect to Individual Policy) has been mentioned below -

A. Health Assessment
1. Health Risk Assessment
The Health Risk Assessment (HRA) questionnaire is a tool for evaluation of the Insured
Person’s health and quality of life by reviewing the personal lifestyle practices affecting
the Insured Person’s health status. The Insured Person shall be awarded a maximum of
500 wellness points per year upon taking the Health Risk Assessment activity within 90
days of Policy Start Date on our mobile application.
2. Undergoing Preventive Health check-up and Uploading the reports
The insured person shall be awarded a maximum of 1,000 wellness points per year upon taking
the Health Check-Up and uploading the reports on our mobile application for verification.
3. Face Scan once a quarter
The Insured Person shall be awarded a maximum of 100 wellness points per quarter for taking
Face Scan on our mobile application. The maximum wellness points awarded shall be restricted
to 400 (100x4) per policy year.
4. First usage of Chat with Health Expert/ Health Coach Service
The Insured Person shall be awarded a maximum of 100 wellness points per year upon
using the chat with Health Expert/Health Coach Service for the first time in a Policy Year
on our mobile application. The Insured Person can virtually chat with health experts like
physiotherapists, counsellors, dieticians etc. under this service.

B. Wellness Activities
1. ICICI Lombard Initiated contest or health quiz
The Insured Person can earn wellness points by participating in any health related
contests or quiz conducted by ICICI Lombard. Maximum of 200 wellness points per
policy year can be earned through participating in such activities.
2. ICICI Lombard initiated Webinar
The insured person can earn a maximum of 200 wellness points per policy year on
successful completion of any one health related webinar session conducted by ICICI
Lombard.

ICICI Lombard General Insurance Company Limited

New Linking Road, Malad (West) Off Veer Savarkar Road, Nr Siddhi Vinayak Temple, E-mail: [email protected]
Mumbai - 400 064 Prabhadevi, Mumbai 400 025 Website : www.icicilombard.com
37

C. Wellness Tasks
The Insured Person shall be awarded wellness points as per the Table B mentioned below
for achieving the targeted steps for a minimum of 20 days in a month. Our mobile
application has to be downloaded within 30 days of the Policy Start Date to avail this
benefit as the average step count completed by an Insured Person would be monitored
on this mobile application.
In case the number of active days are insufficient, no wellness points will be accumulated
for that month. The steps achieved up to 90 days prior to due date of renewal of the policy
shall be considered for wellness points computation. The steps achieved after this time-
line, are not lost and shall be considered for the next policy year.

Table B- A Journey of earning Wellness Points by achieving targeted steps

Maximum Wellness Points

accumulated in a year
Maximum
Average Steps achieved per day for
Wellness Points
20 days in a month
per month
1 Year 2 Year 3 Year

8,000+ steps 500 6000 12000 18000

6,000 to 7,999 steps 300 3600 7200 10800

4,000 to 5,999 steps 200 2400 4800 7200

<4,000 steps Nil Nil Nil Nil

D. Fitness Challenge
The Insured Person shall be awarded wellness points on participation and successful completion
of a fitness challenge as initiated by the Company from time to time. The Insured Person shall
be awarded 250 wellness points per fitness challenge and the maximum wellness points that
can be gained by participation and completion of the fitness challenges is 500 per policy year.

ICICI Lombard General Insurance Company Limited

New Linking Road, Malad (West) Off Veer Savarkar Road, Nr Siddhi Vinayak Temple, E-mail: [email protected]
Mumbai - 400 064 Prabhadevi, Mumbai 400 025 Website : www.icicilombard.com
38

E. Health Events
The Insured Person shall be awarded wellness points on participation and successful completion
of health events as initiated by Us from time to time. The Insured Person shall be awarded 500
wellness points per health event and the maximum wellness points that can be gained by
participation and completion of such health events is 500 per policy year.

Redemption of wellness points

The total wellness points earned by the Insured person(s) (as detailed in Table A and Table B)
will be redeemed towards availing discount on renewal premium for the subsequent year.
1. For Individual Policies, the maximum discount that can be availed by the Insured Person
is 30%.
2. For Floater Policies, the 2 Adult Insured Persons can avail a maximum discount of 15%
each. The discount percentage calculated basis the individual Wellness Points earned by
each Insured Person in the Floater Policy will be added to provide the renewal discount
on the subsequent year. Maximum discount percentage provided shall be 30% on the
Policy level.

Table C shows the renewal discount that can be availed against the accumulated wellness points.

Table C- Renewal Discount against Accumulated Wellness Points

Renewal discount

Regular Wellness points accumulated per Floater (Per

fitness Insured Person* Individual Insured
related
Person)
activities
1 Year 2 Year 3 Year
2500-3999 5000-7999 7500-11999 2.5%
1.25%
12000-
4000-4999 8000-9999 5%
Points 14999
2.5%
15000-
5000-6999 10000-13999 10%
20999
5%

ICICI Lombard General Insurance Company Limited

New Linking Road, Malad (West) Off Veer Savarkar Road, Nr Siddhi Vinayak Temple, E-mail: [email protected]
Mumbai - 400 064 Prabhadevi, Mumbai 400 025 Website : www.icicilombard.com
39

21000-
7000-8999 14000-17999 20%
26999 10%
>9000 >18000 >27000 30% 15%
*For each consecutive year, an Insured Person has to accumulate a minimum of 9,000 Wellness
Points in the first year, 18,000 Wellness Points in the second year, and 27,000 Wellness Points
in the third year to avail the discount.

Table D- Illustration showing Redemption Mechanism through the Wellness Discount for
Floater Policies

Fresh
Wellness
Redemption mechanism Premiu Renewal premium payable
discount
m
Discount accrued on renewal premium
by Insured 1 15%
Discount accrued on renewal premium
by Insured 2 15%
Total Discount- Rs. Rs. 25000- (Rs.
30% 25,000 25000x30%)=Rs.17,500

Fresh
Wellness
Redemption mechanism Premiu Renewal premium payable
discount
m
Discount accrued on renewal premium
by Insured 1 15%
Discount accrued on renewal premium
by Insured 2 10%
Total Discount- Rs. Rs. 25,000- (Rs.
25% 25,000 25,000x25%)=Rs. 18,750

Terms and Conditions for Redemption of Wellness Points

i. Renewal discount will only be applicable on a per year basis upon the subsequent year
of the Policy. Points accumulated will be mandatorily redeemed towards renewal
discount of the subsequent year and cannot be carried forward to the next Policy Year.

ICICI Lombard General Insurance Company Limited

New Linking Road, Malad (West) Off Veer Savarkar Road, Nr Siddhi Vinayak Temple, E-mail: [email protected]
Mumbai - 400 064 Prabhadevi, Mumbai 400 025 Website : www.icicilombard.com
40

ii. Renewal discount is computed based on the Wellness Points earned on 90 days before
the due date of renewal. Residual points will be carried forward to the next Policy Year
and accrued with that Policy Year’s Wellness Points. Hence, these points are not lost.
iv. Discount is on the individual’s premium in Individual plan and on Floater Policy
Premium in Floater plans. Discount will be considered only for Insured Persons aged
18 years and above.
v. In case the insured has opted for a higher Policy Tenure during renewal, the discount
will be given: -

a. On the first Policy Year of a 2/3 year Policy Tenure (in case of an existing 1
year Policy Tenure), and
b. On the first and second Policy Year of a 3 year Policy Tenure (in case of an
existing 2 year Policy Tenure)

vi. In case the insured has opted for a lower Policy Tenure during renewal, flat discount
will be applied on all year premium before tenure discount.

Terms and conditions for availing the Wellness Program:

i. For health risk assessment [HRA] services availed through mobile application/online/
digital mode on IL Platform, the Insured Person shall be required to provide the details
in order to establish authenticity and validity prior to availing such services. Any such
information provided by the Insured Person in this regard shall be used solely for the
purpose of providing these wellness services and kept confidential with Us/Our
Network Providers/Health Service Providers at all times.
ii. The Insured Person shall notify the Company and submit the relevant documents,
reports, receipts as and when required by the Company within 60 days of undertaking
any wellness activity.
iii. The Insured Person agrees that choosing to utilize any of the wellness services or any
information or advise rendered by Our Health Service Providers or Network Providers
or the Company will be solely at the Insured Person’s discretion and own risk and
should not be, used to diagnose or identify treatment for a medical or mental health
condition.
iv. In case of expiry of Policy, the accrued wellness points will not be carried forward
v. There shall not be any cash reimbursement or redemption available against the
wellness points accumulated by an Insured Person.
vi. We or Our Health Service Providers or Our Network Providers do not warrant the
validity, accuracy, completeness, safety, quality, or applicability of the content or

ICICI Lombard General Insurance Company Limited

New Linking Road, Malad (West) Off Veer Savarkar Road, Nr Siddhi Vinayak Temple, E-mail: [email protected]
Mumbai - 400 064 Prabhadevi, Mumbai 400 025 Website : www.icicilombard.com
41

anything said or written or any suggestions provided in the course of providing the
wellness services.
vii. We, or our affiliates, their respective directors, officers, employees, agents, vendors,
shall not be responsible for or liable for, any actions, claims, demands, losses,
damages, costs, charges and expenses which an Insured Person may claim to have
suffered, sustained or incurred, as a result of any advice or information obtained by
way of the wellness program or any actions chosen by the Insured Person on the basis
of such advice or information.
viii. The wellness program offered is subject to revisions based on the insurance regulatory
framework from time to time.

Disclaimers

i. Choosing the option is purely on Insured Person’s discretion and at own risk.
ii. The wellness program is intended to provide support information to the Insured Person
to improve well-being and habits through working towards obtaining a healthy lifestyle,
and does not constitute medical advice and/or substitute the Insured Person's visit/
consultation to an independent Medical Practitioner.
iii. We reserve the right to remove or reduce wellness points in case the same have been
found to be achieved in any unfair manner by manipulation
iv. Availing the service provided by our Health Service Providers / Network Provider is at
the sole discretion of the Insured person and We are not liable, responsible or deemed
to be liable or responsible for any discrepancy in the information or Medical Advice
provided.

II. Health Assistance Team[HAT]:

Our Health Assistance Team (HAT) will assist the Insured Person in understanding his/her health
condition better by providing responses to any queries related to health and health care providers
The services provided under this shall include:
 Identifying a Physician/ Specialist
 Availability of hospital beds
 Providing guidance on engaging attendants/ nurses
 Facilitation with respect to arrangement of mobility aids, daily living aids, medical
equipment etc.
 Scheduling an appointment with any Medical Practitioner empaneled with Us
 Scheduling appointments for a second opinion

ICICI Lombard General Insurance Company Limited

New Linking Road, Malad (West) Off Veer Savarkar Road, Nr Siddhi Vinayak Temple, E-mail: [email protected]
Mumbai - 400 064 Prabhadevi, Mumbai 400 025 Website : www.icicilombard.com
42

 Providing suitable options with respect to Hospitals as well as providing assistance in

Cashless facility, wherever applicable.
 Scheduling appointments from diagnostic labs empaneled with Us
 Providing information, assistance and facilitation on door step delivery of medicines
 Providing preventive information on ailments
 Providing guidance on post Hospitalization care, such as Physiotherapy/ Nursing at
home.

I. Please note that services provided under this Cover are solely for assistance, and should not be
construed to be a substitute for a visit/ consultation to an independent Medical Practitioner. Our
role is limited to that of facilitation and Health Assistance Services will not include the charges for
any independent Medical Practitioner/nutritionist consulted/ charges incurred on
diagnostics/consulted on HAT’s recommendation, and such charges are to be borne by the
Insured Person.
II. We do not accept any liability towards quality of the services made available by our network
providers/ service providers and are not liable for any defects or deficiencies on their part

For all services provided under this Cover, our role shall be limited to assistance only and the
charges and expenses associated with the actual service shall have to be borne by the Insured
Person

This service is available on our mobile application or by calling on 040-66274205 (please note
that this number is subject to change) from 8am to 8pm from Monday to Saturday except public
holidays.

By availing this service, the Insured Person agrees and has no objection to the health records
being maintained with Us for internal use only.

While deciding to obtain such value-added service, the Insured Person expressly notes and
agrees that it is entirely for them to decide whether to obtain these services and also to decide
the use (if any) to which these services is to be put for.

III. Ambulance Assistance

We will facilitate ground medical transportation by a Service Provider to transport the Insured
Person from the site of Accident/ Illness/ Injury to the nearest Hospital or any clinic or nursing
home for medically necessary treatment subject to availability of services in that particular

ICICI Lombard General Insurance Company Limited

New Linking Road, Malad (West) Off Veer Savarkar Road, Nr Siddhi Vinayak Temple, E-mail: [email protected]
Mumbai - 400 064 Prabhadevi, Mumbai 400 025 Website : www.icicilombard.com
43

city/location. Kindly visit our website for updated list of cities/locations where the services are
provided.

The services under this Cover are subject to the following conditions:
 The medical transportation is for a life threatening health condition of the Insured
Person which requires immediate and rapid transportation to the Hospital; as certified
in writing by the Medical Practitioner
 The Insured Person is in India and the treatment is in India only;
 The ambulance service is availed within the same city
 This is an assistance service and the expenses for the same will have to be borne by
the Insured Person or can be claimed under Domestic Road Ambulance Cover (if
Inpatient Treatment claim is found to be admissible)

Process to avail Ambulance Assistance:

a. On calling Our helpline number provided below, Our trained customer service
executive (CSE) will ask the Insured Person relevant questions to assess the situation.
b. The call may be redirected to a qualified Medical Practitioner in order to evaluate the
requirement for an ambulance with Advanced Life Support based on the Insured
Person’s condition.
c. The below mentioned details are to be made available for availing the services:
1. UHID of Insured Person, as provided on the Health Card.
2. Contact number of the Insured Person
3. Location of Insured Person

How to Call an Ambulance? (Via Call)

ICICI Lombard General Insurance Company Limited

New Linking Road, Malad (West) Off Veer Savarkar Road, Nr Siddhi Vinayak Temple, E-mail: [email protected]
Mumbai - 400 064 Prabhadevi, Mumbai 400 025 Website : www.icicilombard.com
44

An IVRS will ask you to

select option 1or 2 Call will be answered
Call 18001028136 to depending on by an CSE & details like
reach the Emergency requirement. name, UHID, nature of
Response Centre emergency will be
Dial 1 for Medical asked
Ambulance Services

Patient will be taken to

Doctor may accompany
the nearest hospital as Emergency Ambulance
patient in the
per the predefined Transport will arrive
ambulance if required
hospital network chart

How to Call an Ambulance? (Via Mobile Application)

Ambulance pick up &

Click on emergency CSE does feedback
drop the patient to
icon & place request Call
hospital / health facility

Customer service The medical team

executive connects provides with
with medical team continued necessary
assistance on call

Doctor understand CSE dispatch the

situation & advices on ambulance to desired
emergency Care / location & provide
Selection of ambulance necessary details

ICICI Lombard General Insurance Company Limited

New Linking Road, Malad (West) Off Veer Savarkar Road, Nr Siddhi Vinayak Temple, E-mail: [email protected]
Mumbai - 400 064 Prabhadevi, Mumbai 400 025 Website : www.icicilombard.com
45

III. Discounts on services/products

We shall only facilitate the Insured Person in availing discounts on services/products including
but not limited to investigations/diagnostic tests/ laboratory tests /health supplements/ /medical
equipment/homecare services/virtual health & wellness sessions/AYUSH products/Fitness &
wellness related activities & products etc. at our empanelled diagnostic centres, drugs/medicines
ordered from pharmacies etc. offered by our network providers/ health service providers. These
discounts can be viewed on our mobile application and one can avail these discounts depending
on terms and conditions and subject to availability.

ii. Add ons/ Optional Covers

The Covers listed below shall be available to the Insured Person only if the additional premium
has been received by Us (except Optional Cover 16. Network Advantage, and Optional Cover 17.
NRI Advantage- Accidental Emergencies Cover for NRI) and the Optional Cover is specified to
be in force for that Insured Person in the Policy Schedule.

Covers 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 Pre-Hospitalisation Medical Expenses/ Post Hospitalization Medical Expenses will not be
applicable for this Section. Claims under this Section will not impact the Annual Sum Insured
(except Optional cover 4. Claim Protector and Optional Cover 12. Durable Medical Equipment
Cover).

The Sum Insured for each of the Optional Covers (except Optional cover 4. Claim Protector &
Optional Cover 12. Durable Medical Equipment Cover) shall be over and above the Annual Sum
Insured of the Policy.

1. Jumpstart
The company shall indemnify Medical Expenses incurred for the hospitalization of the Insured
Person(s) admissible under the Basic Cover 1. in-patient Treatment or Basic Cover 2. Daycare
Procedures/Treatments or Basic Cover 6. in-patient AYUSH Hospitalization for the below listed
diseases/illnesses/conditions from Day 31 of the Policy Start date, provided that:

i. the diseases/illnesses/conditions has been declared by the Insured Person and accepted
by Us, or

ICICI Lombard General Insurance Company Limited

New Linking Road, Malad (West) Off Veer Savarkar Road, Nr Siddhi Vinayak Temple, E-mail: [email protected]
Mumbai - 400 064 Prabhadevi, Mumbai 400 025 Website : www.icicilombard.com
46

ii. the diseases/illnesses/conditions has been detected during Pre-policy medical

examination and have been accepted by Us.
iii. The above reduced waiting period of 30 days shall be applicable only for specified Insured
Persons who have opted and paid additional premium as specified in the policy schedule.
iv. This cover will be available only during inception of the policy and only for the Annual Sum
Insured chosen at the time of Policy Inception.
v. Once chosen, this optional cover will have to be opted for a period of 3 continuous policy
years.
vi. Exclusions Pre-Existing Diseases (Code- Excl01) shall not apply if this Optional Cover has
been opted by the Insured Person(s).

List of diseases/illnesses/conditions covered under this optional cover-

1. Asthma
2. Diabetes
3. Hypertension
4. Hyperlipidemia
5. Obesity
6. Coronary Artery Disease (PTCA done prior to 1 year)

Specific Definitions for the above listed diseases/illnesses/conditions are mentioned below for
ease of understanding and the same will be covered subject that the condition(s) of the Insured
Person(s) meet the criteria defined-

1. Asthma is a Chronic condition that affects the airways (bronchi) of the lungs, causing them to
constrict (become narrow) when exposed to certain triggers which results in the symptoms of
wheezing, coughing, tight chest and shortness of breath.
2. Hypertension is the term used to describe a persistent elevated blood pressure, commonly
referred to as high blood pressure, and if this chronic disease is not treated appropriately, is a
major risk factor for heart disease, stroke, kidney disease and even eye diseases.
3. Hyperlipidemia is a chronic disease that refers to an elevated level of lipids (fats), including
cholesterol and triglycerides, in the blood and if not treated appropriately, it is a major risk factor
for increased risks of heart disease, heart attacks, strokes and other incidents of disease.
4. Diabetes mellitus is a chronic, progressive disease in which impaired insulin production leads to
high blood glucose (sugar) levels, and without good self-management and proper treatment, the

ICICI Lombard General Insurance Company Limited

New Linking Road, Malad (West) Off Veer Savarkar Road, Nr Siddhi Vinayak Temple, E-mail: [email protected]
Mumbai - 400 064 Prabhadevi, Mumbai 400 025 Website : www.icicilombard.com
47

increased glucose (sugar) in the blood affects and damages every organ in the body, which
causes serious health consequences.
5. Obesity where Obesity means abnormal or excessive fat accumulation that presents risk to the
health (Body Mass Index i.e. BMI is less than or equal to 39.99. This BMI limit will be modified in
case of co-morbidities.)
6. Coronary Artery Disease with PTCA done prior to 1 year:
i. Coronary artery disease is the buildup of lipid-rich plaque in the arteries that supply
oxygen-rich blood to the heart. Plaque causes a narrowing or
ii. blockage that could result in a heart attack.
iii. PTCA (Coronary Angioplasty) is defined as percutaneous coronary intervention by
way of balloon angioplasty with or without stenting for treatment
iv. of the narrowing or blockage of minimum 50 % of one or more major coronary arteries.
The intervention must be determined to be medically necessary by a cardiologist and
supported by a coronary angiogram (CAG).
v. Coronary arteries herein refer to left main stem, left anterior descending, circumflex
and right coronary artery.
vi. Diagnostic angiography or investigation procedures without angioplasty / stent
insertion are excluded from the scope of this definition.

2. Chronic Disease Management Program

In case the Insured Person(s) has declared any of the listed diseases /illnesses /conditions –
Asthma, Diabetes, Hypertension, Hyperlipidemia, Obesity, and/or Coronary Artery Disease
(PTCA done prior to 1 year)- and the same have been accepted by Us, the Insured Person(s)
shall be enrolled under Our Chronic Disease Management Program.

As a part of this program, we shall provide the below mentioned services to the Insured Person(s)-
i. Assistance to the Insured Person(s) to track their health through Our empaneled medical
experts who will guide them in maintaining/ improving their health condition(s).
ii. Assistance to avail Dietician and nutritional counseling as per their health condition(s).
iii. 2 Pre-defined diagnostic Health check-ups for the listed conditions with a gap of six
months between the 2 tests. The health checkups are over and above to the Optional
Cover 16. Health Check-up if opted.
iv. Assistance to avail Counselling for lifestyle modifications such as quitting tobacco/alcohol
etc.

This program shall be subject to the following conditions-

ICICI Lombard General Insurance Company Limited

New Linking Road, Malad (West) Off Veer Savarkar Road, Nr Siddhi Vinayak Temple, E-mail: [email protected]
Mumbai - 400 064 Prabhadevi, Mumbai 400 025 Website : www.icicilombard.com
48

1. The insured person(s) shall be enrolled to this program only if Optional cover 1 Jumpstart
has been opted.
2. The health check-up can be availed only on a cashless basis through our mobile
application or by calling at our Toll free number: 1800 2666.
3. The Network Provider/Health Service Provider shall be assigned by Us post receiving
Insured Person’s request to avail a Health Check-up under this cover.
4. Utilization of this Health Check-Up will not impact the Annual Sum Insured.

3. BeFit
All benefits under the BeFit cover can be availed only on cashless basis via our mobile application
and are subject to the terms, conditions, and exclusions and the availability of Sum Insured under
the Cover. BeFit cover can only be opted by Insured Person(s) up to the age of 65 years during
first time issuance.

All services shall be provided through our Empaneled Health Service Provider subject to
availability at the time of appointment. There will be a waiting period of 30 days for this cover

Any unutilized Consultations/E- consultations/ Sum Insured/ Sessions cannot be carried forward
to the next Policy Year.

Choosing the services under this Cover is purely upon the Insured Person’s own discretion and
at own risk. The services provided under the various Covers are via third party health Service
Providers/ Network Providers/ and We are not responsible for liability arising out of the services
provided by these third parties.

The Insured Person(s) should seek assistance from a medical practitioner should they still have
any concerns about their health even post availing services from our health service
providers/network providers.

i. Physical Consultations

We shall cover the Medical Expenses incurred during the Policy Period for out-patient
consultations from a General Medical Practitioner or Specialist Medical Practitioner or
Super Specialist Medical Practitioner or AYUSH Medical Practitioner in relation to any

ICICI Lombard General Insurance Company Limited

New Linking Road, Malad (West) Off Veer Savarkar Road, Nr Siddhi Vinayak Temple, E-mail: [email protected]
Mumbai - 400 064 Prabhadevi, Mumbai 400 025 Website : www.icicilombard.com
49

Illness contracted or Injury suffered by the Insured Person during the Policy Period subject
to the overall maximum number of consultations as specified against this Optional Cover
in the Policy Schedule. These services shall be provided through our Empaneled Health
Service Provider subject to availability at the time of appointment.

This Optional Cover shall also include e-consultation given by a General Medical
Practitioner or Specialist or Super Specialist Medical Practitioner or AYUSH Medical
Practitioner through a virtual mode of communication such as but not limited to chat, email,
video, online portal, or mobile application.

Dental treatment shall be excluded from the scope of this cover.

Physiotherapy sessions and counselling availed for psychiatric ailments or mental health
issues shall be excluded from the scope of this Optional Cover as the same are covered
under optional cover 8 iv. Physiotherapy sessions and optional cover. 8 v. e-counselling
respectively.

ii. Routine Diagnostic and Minor Procedure Cover

We shall cover medical expenses incurred for outpatient diagnostic tests recommended
by Medical Practitioner under our cashless network available in the mobile application in
relation to any Illness contracted or Injury suffered by the Insured Person during the Policy
Period and for listed minor procedures undergone at a general practitioner or
specialist/super-specialist medical practitioner by the Insured Person during the Policy
Period maximum up to the limit as specified against this Optional Cover in the Policy
Schedule. These services shall be provided through our Empaneled Health Service
Provider subject to availability at the time of appointment

The diagnostic tests shall include but will not be limited to histopathology, biochemistry,
hematology, immunology, microbiology, serology, pathology, radiology, ultrasound and
TMT. Genetic studies shall be excluded from the scope of this cover.

We may even arrange for diagnostic tests to be carried out at the location of the Insured
Person provided such location is within the geographical reach of the Health Service
Provider on the date of the request. This service shall be subject to availability of Our
empaneled Health Service provider.

ICICI Lombard General Insurance Company Limited

New Linking Road, Malad (West) Off Veer Savarkar Road, Nr Siddhi Vinayak Temple, E-mail: [email protected]
Mumbai - 400 064 Prabhadevi, Mumbai 400 025 Website : www.icicilombard.com
50

List of Minor Procedures covered under this Optional Cover #

Drainage of abscess
Injection including Intramuscular (Per Injection cost)
Intravenous injection(IV)
Sprain Management (Joint movement/exercise)
Otoscopic examination (Magnifying otoscopy)
Nasal packing for control of haemorrhage
Nebulizer therapy
Removal of foreign body
Suturing(Staple under LA)
Removal of suture
Stabilization of joint
Syringing ear to remove wax
Application or removal of plaster cast
Laryngoscopy
Minor wound management

#This includes only the cost of administration. The actual cost of consumables shall be
covered under the pharmacy cover. However, the said cost will have to be borne by the
Insured Person in case the Sum Insured under the Pharmacy Cover has been exhausted
or is out of scope of the Pharmacy Cover or in case the consumable is a non-payable item
as per the list of non-payables

iii. Pharmacy

We shall cover medical expenses incurred on purchase of medicines, drugs, and medical
consumables, as prescribed by a Medical Practitioner under our cashless network
available in the mobile application for any Illness contracted or Injury suffered by the

ICICI Lombard General Insurance Company Limited

New Linking Road, Malad (West) Off Veer Savarkar Road, Nr Siddhi Vinayak Temple, E-mail: [email protected]
Mumbai - 400 064 Prabhadevi, Mumbai 400 025 Website : www.icicilombard.com
51

Insured Person during the Policy Period, maximum up to the limit as specified against this
Optional Cover in the Policy Schedule through our Empaneled Health Service Provider
subject to availability on the date of the request.
Health Supplements, Nutraceuticals, foods for special dietary use, foods for special
medical purpose, foods with added probiotics and/or foods with added prebiotics,
vaccinations, vitamins, tonics or other related products are excluded from the scope of this
Optional Cover

iv. Physiotherapy Session

We shall cover medical expenses incurred by the Insured Person for Physiotherapy
Sessions with a qualified physiotherapist within our cashless network to treat Illness, injury
or deformity suffered as advised by qualified Medical Practitioners during the Policy Period
by physical methods such as but not limited to massage, heat treatment, ultrasound, Laser
and exercises maximum up to the number of visits/ sessions as specified against this
Optional Cover in the Policy Schedule.
These services shall be provided through our Empaneled Health Service Provider subject
to availability at the time of appointment.
The time duration of each physiotherapy session shall be restricted to thirty minutes only.

v. e-Counseling

We shall cover expenses incurred by the Insured Person on e-counseling session(s) with
a Psychologist via our mobile application for providing assistance in dealing with issues
such as but not limited to personal and lifestyle imbalance, pre-marital counselling,
parenting and child care, speech impairment, and problems related to
psychological/mental illness/ psychiatric and psychosomatic disorders, stress, anxiety
maximum up to the number of sessions as specified against this Optional Cover in the
Policy Schedule.
The e-counseling sessions shall be availed only through virtual modes of chat or tele etc.
via our mobile application.

vi. Diet and Nutrition e-Consultation

We will cover expenses incurred by the Insured Person on diet and nutrition e-consultation
during the Policy Period on a virtual platform via our mobile application for the duration as
specified against this Optional Cover in the Policy Schedule.

ICICI Lombard General Insurance Company Limited

New Linking Road, Malad (West) Off Veer Savarkar Road, Nr Siddhi Vinayak Temple, E-mail: [email protected]
Mumbai - 400 064 Prabhadevi, Mumbai 400 025 Website : www.icicilombard.com
52

The e-consultation shall be availed only through virtual modes of chat or tele etc. via our
mobile application.

Claim Procedure for BeFit

All claims will be adjudicated only on cashless basis via our mobile application and are subject to
the terms, conditions, and exclusions of the Policy and the availability of the Sum Insured.
Cashless Facility is only available at specific Network Providers/Health Service Provider available
on the mobile application. We reserve the right to modify, add or restrict any Network
Provider/Health Service Provider for Cashless facility at Our sole discretion.
 To avail of Cashless Facility at the health Service Provider / Network Provider, the Insured
Person/claimant is required to produce information on the health card available on the
application for verification and validation. The request shall be considered after having
obtained accurate and complete information for the Illness or Injury, where applicable, for
which Cashless Facility is sought and We shall confirm the request digitally.
 In case the services availed exceed the eligibility of the Policy, the difference shall have
to be paid directly to the Hospital/Network Provider/Health Service Provider by the Insured
Person/claimant.
 To avail the benefits and services under this Optional Cover, Insured Person shall need
to raise a request through mobile application
 The Routine diagnostic and minor procedure cover /Pharmacy cover services shall only
be covered for prescriptions by an empaneled Network Medical Practitioner through the
Mobile Application.

How to avail the cashless services under the BeFit cover on the mobile application :

1. The Insured Person will have to download the mobile application from the App Store/Play
Store. Post download the Insured Person will have to complete the registration process and
login to the home page.

2. On the home page, the Insured person will have to go to visit the out-patient service section
like consultation, diagnostics and pharmacy

A schematic representation of the claims process is as below-

ICICI Lombard General Insurance Company Limited

New Linking Road, Malad (West) Off Veer Savarkar Road, Nr Siddhi Vinayak Temple, E-mail: [email protected]
Mumbai - 400 064 Prabhadevi, Mumbai 400 025 Website : www.icicilombard.com
53

The insured person The insured person

Clicks on the icon to avail avails the consultation uploads the prescription .
consultation service service through network Digitized prescription
doctor received on App

Prescription based
Insured Person visits
cashless
Select nearest network centers with pre-booked
diagnostic/pharmacy
doctor for appointment slot & completes with
service triggered from
verification process
app

Appointment
Call lands at 24*7 Tele-
confirmed/Re-scheduled
consult platform
communication shared

4. Claim Protector
If a claim has been accepted under the “Inpatient Treatment” or “Daycare Procedures/Treatment”
Cover, the items which are included in the List I- Items for which coverage is not available in
the Policy of Annexure II, which are non – payable, to the particular claim, will become payable.

i. The maximum claim payable under this add on/Optional Cover shall be limited to Annual
Sum Insured under the Policy.
ii. Claims under this add on/Optional Cover shall be limited to treatment taken within the
geographical boundaries of India.
iii. Any Sum Insured accrued under Inflation Protector will not be available for Claim Protector
Cover.

ICICI Lombard General Insurance Company Limited

New Linking Road, Malad (West) Off Veer Savarkar Road, Nr Siddhi Vinayak Temple, E-mail: [email protected]
Mumbai - 400 064 Prabhadevi, Mumbai 400 025 Website : www.icicilombard.com
54

5. Inflation Protector
The Inflation Protector Cover is designed to protect the Annual Sum Insured against rising inflation
by linking the Annual Sum Insured under the Basic Cover to the Consumer Price index (CPI). The
Annual Sum Insured will be increased on cumulative basis at each Renewal on the basis of
inflation rate in previous year. Inflation rate would be computed as the average CPI of the entire
calendar year published by the Central Statistical Organization (CSO).

The % increase will be applicable only on Annual Sum Insured under the Policy and not on any
other Covers which leads to increase in Sum Insured.

At the time of renewal, if the insured person opts out of the optional cover, then the sum insured
under the Inflation Protector cover accrued up to the expiring policy year will be forfeited.

Illustration-
Year Annual Opted for Inflation Inflation Protector at renewal Overall Inflation
Sum Protector computation # Protector
Insured
0 Rs. Yes Not applicable Not applicable
10,00,000
1 Rs. Yes 10,00,000x6% = 60,000 Rs. 60,000
10,00,000
2## Rs. Yes 10,00,000x6% = 60,000 Rs. 60,000 + Rs. 60,000
15,00,000 = Rs. 1,20,000
3 Rs Yes 15,00,000x6%=90,000 Rs. 1,20,000 + Rs.
15,00,000 90,000 = Rs. 2,10,000
4 Rs. No Nil as customer opted out of the Nil
15,00,000 Optional Cover
#Considering Consumer Price Index to be 6%
##Insured Person has enhanced his/her Annual Sum Insured from Rs. 10 Lakhs to Rs. 15 Lakhs

ICICI Lombard General Insurance Company Limited

New Linking Road, Malad (West) Off Veer Savarkar Road, Nr Siddhi Vinayak Temple, E-mail: [email protected]
Mumbai - 400 064 Prabhadevi, Mumbai 400 025 Website : www.icicilombard.com
55

6. Domestic Air Ambulance Cover

We will cover the expenses incurred on Air Ambulance services up to the Annual Sum Insured
which are offered by a healthcare or an air ambulance service provider and which have been
used during the Policy Period to transfer the Insured Person to the nearest Hospital with adequate
emergency facilities for the provision of Emergency Care, provided that:
i. It is for a life threatening emergency health conditions of the Insured Person which
requires immediate and rapid ambulance transportation from the place where the
Insured Person is situated at the time of requiring Emergency Care to a hospital
provided that the transportation is for Medically Necessary Treatment, is certified in
writing by a Medical Practitioner, and Domestic Road Ambulance services cannot be
provided.
ii. Such air ambulance providing the services, should be duly licensed to operate as such
by a competent government Authority.
iii. This cover is limited to transportation from the area of emergency to the nearest
Hospital only;
iv. We will not cover:
a. Any transportation from one Hospital to another;
b. Any transportation of the Insured Person from Hospital to the Insured Person’s
residence after he/she has been discharged from the Hospital
c. Any transportation or Air Ambulance expenses incurred outside the
geographical scope of India.
v. We have accepted a claim under Inpatient Treatment in respect of the Insured Person
for the same Accident/Illness for which air ambulance services were availed.
vi. We shall not be liable if Medically Necessary Treatment can be provided at the
Hospital where the Insured Person is situated at the time of requiring Emergency Care.

7. Nursing at Home
We will pay You for the expenses incurred by You, up to Rs. 2,000 per day up to a maximum of
10 days post Hospitalization for the medical services of a Qualified Nurse at Your residence,
provided that the nurse is employed in a Hospital and the engagement of such Qualified Nurse is
certified as necessary by a Medical Practitioner and relate directly to any Illness or Injury, covered
under the Policy. The Claim under this Optional Cover/add on will be payable only if We have
admitted Our liability under “In-patient Treatment” section of the Policy.

Note: This cover is available only in Plan B

ICICI Lombard General Insurance Company Limited

New Linking Road, Malad (West) Off Veer Savarkar Road, Nr Siddhi Vinayak Temple, E-mail: [email protected]
Mumbai - 400 064 Prabhadevi, Mumbai 400 025 Website : www.icicilombard.com
56

8. Compassionate Visit
In event of Your Hospitalization, which in the opinion of the Medical Practitioner attending on You,
extends beyond a period of 5 consecutive days, We will indemnify the cost of the economy class
air ticket/railway ticket incurred by Your Immediate Family Member from and to the place of origin
of such Family Member or the place of residence of the Family Member.
Our liability under this Optional Cover, however, in respect of any one event or all events of
Hospitalization during the Policy Year shall not in aggregate exceed Rs. 20,000 per Policy Year
of Policy Period. For the purpose of this extension, the term “Immediate Family member” would
mean the Insured’s Spouse, Children, Parents, and Parents-in-law.

Note: This cover is available only in Plan B

9. Health Check-up
Adult Insured Person(s) aged 18 years and above can avail Health Check-Up with our Network
Providers or empaneled Health Service Providers anytime during the Policy Period subject to the
below conditions
i. The coverage shall be up to 0.5% of Annual Sum Insured subject to a maximum of Rs.
5,000.
ii. Utilization of the above cover shall be via Pre-designed health packages as per sum
insured eligibility. Insured person(s) will not be able to modify the pre-designed packages
iii. Health Check-Up can be availed only once per Policy Year per Adult Insured Person.
iv. The pre-defined health check-up packages maybe modified from time to time without prior
notice but the sum insured eligibility will not be changed
v. This Cover can be availed through our mobile application or by calling at our Toll free
number: 1800 2666
vi. The Network Provider/Health Service Provider shall be assigned by Us post receiving
Insured Person’s request to avail a Preventive Health Check-up under this cover.
vii. Utilization of this Preventive Health Check-up will not impact the Annual Sum Insured
viii. Unutilized Health Check-up package will not be carried forward to the next Policy Year
and it will be the Insured Person’s choice and responsibility to utilize the same with in the
designated Policy Period. We shall not be liable to provide any reminders or notifications
for the same.
ix. In-case of long term policies (2 year or 3 years), the Adult Insured Person(s) are eligible
for Preventive Health Check-up once per policy year

ICICI Lombard General Insurance Company Limited

New Linking Road, Malad (West) Off Veer Savarkar Road, Nr Siddhi Vinayak Temple, E-mail: [email protected]
Mumbai - 400 064 Prabhadevi, Mumbai 400 025 Website : www.icicilombard.com
57

Please Note:
a) We shall not hold any responsibility towards any loss or damage arising out of or in relation
to any opinion, advice, prescription, actual or alleged errors, omissions and
representations made by the Medical Practitioner/ Healthcare professional
b) Choosing the services under this Cover is purely upon the customer’s own discretion and
at own risk.
c) The Insured Person should seek assistance from a health care professional when
interpreting and applying them to the Insured person’s individual circumstances. If the
Insured Person has any concerns about His/ her health, He/ She may consult His/ her
general practitioner.
d) The Health records in respect of the Insured Person shall be saved with Us in order to
award wellness points as a part of the Wellness Program. They may be made available to
Insured Person(s) in their medical vault in our mobile application.

Note: This cover is available only in Plan B

10. Dependent Accommodation Benefit

If the Insured Person contract an Illness or suffer an Injury due to Accident during the Policy
Period and which solely and directly requires the Insured Person to be Hospitalized, We will pay
the daily amount for the accommodation of the dependent in the hospital up to Rs. 1,000 per day,
for each continuous and completed day of your Hospitalization, maximum up to 10 consecutive
days. For the purpose of this Optional Cover, Dependent means immediate family members as
defined.

Provided:
a) We have accepted the claim under hospitalization expenses in respect of Insured Person
for the same Accident/Illness.
b) The Hospitalization is for Medically Necessary Treatment and is commenced and
continued on the written advice of the treating Medical Practitioner.
c) The medical practitioner certifies that the hospitalized insured member required
hospitalization of minimum 3 consecutive days, maximum up to 10 days

ICICI Lombard General Insurance Company Limited

New Linking Road, Malad (West) Off Veer Savarkar Road, Nr Siddhi Vinayak Temple, E-mail: [email protected]
Mumbai - 400 064 Prabhadevi, Mumbai 400 025 Website : www.icicilombard.com
58

d) We will pay only for one immediate family member.

Note: This cover is available only in Plan B

11. Durable Medical Equipment Cover

We will cover the expenses incurred by the Insured Person towards renting or purchase of any of
the listed durable medical equipment during the Policy Year only if the same has been prescribed
by the treating Medical Practitioner post Hospitalisation for the same condition for which the
Hospitalization claim was admissible.

Conditions:
i. Claim payable shall be paid up to the Annual Sum Insured (within overall basic annual
sum insured), maximum up to Rs. 5 Lakhs.

ii. We have accepted the claim under hospitalization expenses (In-patient

Treatment/Daycare Procedures/Treatment/In-patient AYUSH Hospitalization) in respect
of Insured Person for the same Accident/Illness.
iii. The need for a Durable Medical Equipment has been prescribed by an authorized Medical
Practitioner during Hospitalization or within 30 days post discharge of the Insured Person
from the Hospital.
iv. The purchase should have been made within 30 days of the medical recommendation.

List of Durable Medical Equipment Covered under this Optional Cover:

1. CPAP Machine
2. Ventilator
3. Wheelchair
4. Prosthetic device
5. Suction Machine
6. Commode Chairs
7. Infusion pump
8. Continuous Passive motion devices in case of Knee Replacement
9. Oxygen concentrator

ICICI Lombard General Insurance Company Limited

New Linking Road, Malad (West) Off Veer Savarkar Road, Nr Siddhi Vinayak Temple, E-mail: [email protected]
Mumbai - 400 064 Prabhadevi, Mumbai 400 025 Website : www.icicilombard.com
59

12. Tele Consultation(s)

We will arrange Tele Consultations and recommendations for routine health issues by a qualified
Medical Practitioner or health care professional. For the purpose of this Optional Cover Tele
Consultation shall mean consultation provided by a qualified Medical Practitioner or Health care
professional through various mode of communication like audio, video, online portal, chat or
mobile application.

The services provided under this Cover will be made available subject to the terms and conditions,
and in the manner prescribed below:

i. The Tele Consultation(s) can be availed via Our mobile application only
ii. The Medical Practitioner may suggest/recommend/prescribe over the counter medications
based on the information provided, if required on a case to case basis. However, the
services under this Benefit should not be construed to constitute medical advice and/or
substitute the Insured Person's visit/ consultation to an independent Medical
Practitioner/Healthcare professional*.
iii. There shall be no maximum limit on the count of Tele-Consultations that can be availed
by the Insured Person(s) in a policy year
iv. This service will be available 24 hours a day, and 365 days in a year.
v. We/Medical Practitioner/Healthcare professional may refer the Insured Person to another
specialist or a general physician (outside of our empaneled network) if required, and the
charges for such specialist or a general physician will have to be borne by the Insured
Person.
vi. We shall not be liable for any discrepancy in the information provided under this Cover.
vii. Choosing the services under this Cover is purely upon the Insured Person’s own discretion
and at own risk.

*The proposer should seek assistance from a health care professional when interpreting and
applying them to the Insured Person’s individual circumstances. If the Insured Person has any
concerns about His/ her health, He/ She may consult His/ her general practitioner. We shall not
hold any responsibility towards any loss or damage arising out of or in relation to any opinion,
advice, prescription, actual or alleged errors, omissions and representations made by the Medical
Practitioner/ Healthcare professional

ICICI Lombard General Insurance Company Limited

New Linking Road, Malad (West) Off Veer Savarkar Road, Nr Siddhi Vinayak Temple, E-mail: [email protected]
Mumbai - 400 064 Prabhadevi, Mumbai 400 025 Website : www.icicilombard.com
60

13. Waiting Period Reduction Option (Other than those listed under JumpStart.)
If the Insured Person has opted for this Optional Cover, the waiting period applicable under
Exclusion- Pre-Existing Diseases (Code- Excl01) for any declared and accepted pre-existing
diseases shall be reduced from 36 months to 24 months or 12 months as opted. This cover will
be available only during inception of the policy and only for the Annual Sum Insured chosen at
the time of Policy Inception. Once chosen, this optional cover will have to be opted for a period of
3 continuous policy years.

14. Specific Illness Waiting Period Reduction Option

If the Insured Person has opted for this Optional Cover, the waiting period applicable under
Exclusion- Specified disease/procedure waiting period (Code- Excl02) shall be reduced from
24 months to 12 months. This cover will be available only during inception of the policy and only
for the Annual Sum Insured chosen at the time of Policy Inception.. Once chosen, this optional
cover will have to be opted for a period of 2 continuous policy years.

15. Room Modifier

If the Insured Person has opted for this Optional Cover, the Insured Person shall have an option:
A. To Modify the room rent eligibility to any room category without any restriction or
B. To modify the room rent eligibility to twin sharing room or
C. To Modify the room rent eligibility to a room rent capping of 1% of Annual Sum Insured for
normal room and 2% of Annual Sum Insured for ICU per day.

This cover shall be available across all Annual Sum Insured options, subject to the following:
i. If the Insured Person is admitted in a room category/limit that is higher than the one that is
specified in the Policy Schedule/ Product benefit table of this policy, then the Insured
Person shall bear a rateable proportion of the total Associated medical expenses
(including surcharges or taxes thereon) in the proportion of the difference between room
rent of the entitled room category to the room rent actually incurred
a. For the purpose of this cover, “Associated medical expenses” shall include
room rent, nursing charges, operation theatre charges, fees of medical
practitioner including surgeon/anesthetist/ specialist within the same hospital
where the insured person has been admitted and will not include the cost of
pharmacy and consumables, cost of implants, medical devices and cost of
diagnostics.
b. Proportionate deductions are not applicable for ICU charges

ICICI Lombard General Insurance Company Limited

New Linking Road, Malad (West) Off Veer Savarkar Road, Nr Siddhi Vinayak Temple, E-mail: [email protected]
Mumbai - 400 064 Prabhadevi, Mumbai 400 025 Website : www.icicilombard.com
61

c. Proportionate deductions shall not be applicable for hospitals which do not

follow differential billing or for those expenses in respect of which differential
billing is not adopted based on the room category.

16. Network Advantage

If the Insured Person has opted for this Optional Cover, the Insured Person shall be entitled for a
discount of 10% on every renewal premium (including the first year premium), subject to the
following conditions
I. The treatment as applicable under In-patient Treatment or Daycare Procedures/Treatment
or in-patient AYUSH Hospitalization is taken in a hospital listed under the “Preferred
Provider Network” List available on Our website www.icicilombard.com and on Our Mobile
Application.
II. A co-payment of 20% will be applicable on each and every claim in case the treatment is
taken in a hospital which is not included in the “Preferred Provider Network” List.

17. NRI Advantage - Accidental Emergencies Cover for NRI

We will provide cover to Non Resident Indians/Overseas Citizens of India under this policy only
for Accidental Emergencies and no claim will be admissible under any other cover of this policy.
Further, we will provide a 25% discount on premium if this cover has been opted, provided that
the Insured Person(s)-
i. Provides declaration upon Policy Issuance and subsequent renewals that they are based
abroad in entirety for the Policy Year
ii. Provides proof of overseas residence for the upcoming year upon each renewal to continue
availing the discount
iii. Possesses and provides other relevant identity proof documents as mandated for Citizenship
of India
iv. Has an Indian bank account for premium/claims payment.

If the Insured person ceases to reside outside India, then no further discount shall be applicable
upon renewal. This discount can be availed only for a maximum period of five continuous Policy
Years and the same will be applicable on a Policy level. All waiting periods as per the policy terms
and conditions will be applicable for the Insured Persons.

ICICI Lombard General Insurance Company Limited

New Linking Road, Malad (West) Off Veer Savarkar Road, Nr Siddhi Vinayak Temple, E-mail: [email protected]
Mumbai - 400 064 Prabhadevi, Mumbai 400 025 Website : www.icicilombard.com
62

18. Guaranteed Deductible Reduction

We will reduce the deductible applicable by 10% of the deductible as applicable to the expiring or
renewed Policy as specified in the Policy Schedule at the end of each Policy Year if the expiring
Policy has been continuously renewed with Us. The reduction in deductible shall be continued
until the deductible is reduced to 50% of the deductible opted during first policy issuance subject
to the following conditions. This optional cover is available only for policies with minimum
deductible of 5 lakhs.
i. The guaranteed deductible reduction option has to be chosen at the time of Policy
inception. Any modification in the same, will not be permitted
ii. In a floater Policy as specified in the Policy Schedule, the reduction in deductible will be
available to the Insured Person(s) who were Insured in the previous Policy Year(s) and
continue to be Insured with the Company in the subsequent Policy Year(s)
iii. Reduction in deductible shall not be provided if the Policy is not renewed with Us by the
end of the Grace Period.
iv. If the Policy Period is two or three year(s), any reduction in deductible for the policy years
shall be provided at the time of renewal of the policy and it will be applicable for claims at
the subsequent year.
v. In case of floater Policies where Insured Person renew their expiring Policy with the
Company by splitting the Annual Sum Insured in to individual policies the deductible shall
be applicable to such renewed policies.
vi. Even in the event of Claim, under the Policy during any subsequent Policy Year, the
deductible shall continue to reduce until the same is reduced to 50% of the deductible as
opted during policy issuance.

Illustration
Year Annual Sum Deductible Claim Deductible Revised
insured (in INR) (in INR) at renewal
1 1 Crore 10 Lakhs No Yes
2 1 Crore 9 Lakhs No Yes
3 1 Crore 8 Lakhs No Yes
4 1 Crore 7 Lakhs Yes Yes
5 1 Crore 6 Lakhs No Yes
6 1 Crore 5 Lakhs Yes No

ICICI Lombard General Insurance Company Limited

New Linking Road, Malad (West) Off Veer Savarkar Road, Nr Siddhi Vinayak Temple, E-mail: [email protected]
Mumbai - 400 064 Prabhadevi, Mumbai 400 025 Website : www.icicilombard.com
63

7 1 Crore 5 Lakhs No No

e. EXCLUSIONS:

i. Standard Exclusions

1. Pre-Existing Diseases - Code- Excl01

a. Expenses related to the treatment of a pre-existing Disease (PED) and its direct complications
shall be excluded until the expiry of 36 months of continuous coverage after the date of
inception of the first policy with insurer as selected by the 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 / migration norms of the extantas per applicable regulatory prescription, then waiting
period for the same would be reduced to the extent of prior coverage.
d. Coverage under the policy after the expiry of 36 months for any pre-existing disease is subject
to the same being declared at the time of application and accepted by Insurer.

2. Specified disease/procedure waiting period/Specific waiting period- Code- Excl02

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, then waiting period for the same would be reduced to the
extent of prior coverage.
f. List of specific diseases/procedures
1. Any types of gastric or duodenal ulcers
2. Benign prostatic hypertrophy
3. All types of sinuses
4. Hemorrhoids

ICICI Lombard General Insurance Company Limited

New Linking Road, Malad (West) Off Veer Savarkar Road, Nr Siddhi Vinayak Temple, E-mail: [email protected]
Mumbai - 400 064 Prabhadevi, Mumbai 400 025 Website : www.icicilombard.com
64

5. Dysfunctional uterine bleeding

6. Endometriosis
7. Stones in the urinary and biliary systems
8. Surgery on ears/tonsils/adenoids/ paranasal sinuses
9. Cataracts,
10. Hernia of all types and Hydrocele
11. Fistulae in anus
12. Fissure in anus
13. Fibromyoma
14. Hysterectomy
15. Surgery for any skin ailment
16. Surgery on all internal or external tumours/ cysts/ nodules/polyps of any kind including
breast lumps with exception of Malignancy
17. Dialysis required for Chronic Renal Failure.
18. Joint Replacement Surgeries unless necessitated by Accident happening after the Policy
risk inception date.
19. Dilatation and curettage
20. Varicose Veins and Varicose Ulcers
21. Non Infective Arthritis and other form arthritis
22) Gout and Rheumatism
23) Prolapse inter Vertebral Disc and Spinal Diseases including spondylitis/spondylosis
unless arising from Accident

3.
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.
The within referred waiting period is made applicable to the enhanced Sum Insured in the event
of granting higher sum insured subsequently.

4. 30-day waiting period- Code- Excl03

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.

ICICI Lombard General Insurance Company Limited

New Linking Road, Malad (West) Off Veer Savarkar Road, Nr Siddhi Vinayak Temple, E-mail: [email protected]
Mumbai - 400 064 Prabhadevi, Mumbai 400 025 Website : www.icicilombard.com
65

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. Investigation & Evaluation- Code- Excl04

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. Rest Cure, rehabilitation and respite care- Code- Excl05

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. Obesity/ Weight Control: Code- Excl06

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);
a. greater than or equal to 40 or
b. 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:
i. Obesity-related cardiomyopathy
ii. Coronary heart disease
iii. Severe Sleep Apnea
iv. Uncontrolled Type2 Diabetes

8. Change-of-Gender treatments: Code- Excl07

Expenses related to any treatment, including surgical management, to change characteristics of
the body to those of the opposite sex.

9. Cosmetic or plastic Surgery: Code- Excl08

ICICI Lombard General Insurance Company Limited

New Linking Road, Malad (West) Off Veer Savarkar Road, Nr Siddhi Vinayak Temple, E-mail: [email protected]
Mumbai - 400 064 Prabhadevi, Mumbai 400 025 Website : www.icicilombard.com
66

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
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. Hazardous or Adventure sports: Code- Excl09

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. Breach of law: Code- Excl10

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. Excluded providers: Code- Excl11

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 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.
(The list of excluded providers/delisted hospitals is available on our website
www.icicilombard.com and is timely updated.)

13.
Treatment for, Alcoholism, drug or substance abuse or any addictive condition and consequences
thereof. Code- Excl12

14. 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. Code- Excl13

15. 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 hospitalization claim or day care procedure. Code- Excl14

16. Refractive Error: Code- Excl15

Expenses related to the treatment for correction of eye sight due to refractive error less than
7. 5 dioptres.

17. Unproven Treatments: Code- Excl 16

ICICI Lombard General Insurance Company Limited

New Linking Road, Malad (West) Off Veer Savarkar Road, Nr Siddhi Vinayak Temple, E-mail: [email protected]
Mumbai - 400 064 Prabhadevi, Mumbai 400 025 Website : www.icicilombard.com
67

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. Sterility and lnfertility: Code- Excl 17

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. Maternity: Code Excl18

i. Medical treatment expenses traceable to childbirth (including complicated deliveries and
caesarean sections incurred during hospitalization) except ectopic pregnancy;
ii. Expenses towards miscarriage (unless due to an accident) and lawful medical termination of
pregnancy during the policy period.

ii. Specific Exclusions (Exclusions other than those specified under e. i. above)

20. War (whether declared or not) and war like occurrence or invasion, acts of foreign enemies,
hostilities, civil war, rebellion, revolutions, insurrections, mutiny, military or usurped power,
seizure, capture, arrest, restraints and detainment of all kinds.

21. Nuclear, chemical or biological attack or weapons, contributed to, caused by, resulting from
or from any other cause or event contributing concurrently or in any other sequence to the
loss, claim or expense. For the purpose of this exclusion:
a. Nuclear attack or weapons means the use of any nuclear weapon or device or waste
or combustion of nuclear fuel or the emission, discharge, dispersal, release or
escape of fissile/ fusion material emitting a level of radioactivity capable of causing
any Illness, incapacitating disablement or death.
b. Chemical attack or weapons means the emission, discharge, dispersal, release or
escape of any solid, liquid or gaseous chemical compound which, when suitably
distributed, is capable of causing any Illness, incapacitating disablement or death.
c. Biological attack or weapons means the emission, discharge, dispersal, release or
escape of any pathogenic (disease producing) micro-organisms and/or biologically
produced toxins (including genetically modified organisms and chemically
synthesized toxins) which are capable of causing any Illness, incapacitating
disablement or death.

ICICI Lombard General Insurance Company Limited

New Linking Road, Malad (West) Off Veer Savarkar Road, Nr Siddhi Vinayak Temple, E-mail: [email protected]
Mumbai - 400 064 Prabhadevi, Mumbai 400 025 Website : www.icicilombard.com
68

22. Any expenses incurred on Out Patient treatment. This exclusion will not be applicable in
case optional cover 3. BeFit has been opted

23. 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 cost of cochlear implant(s) unless necessitated by an Accident or
required intra-operatively.

24. Treatment, procedures and preventive, diagnostic, restorative, cosmetic services related to
disease, disorder and conditions related to natural teeth and gingiva except if required by
an Insured Person while Hospitalized due to an Accident.

25. Treatment taken outside the geographical limits of India.

26. Personal comfort, cosmetics, convenience and hygiene related items and services

27. Acupressure, acupuncture, magnetic and other therapies

28. Circumcision unless necessary for treatment of an Illness or necessitated due to an

Accident.

29. Expenses for venereal disease or any sexually transmitted disease except HIV.

30. Screening, counselling or Treatment relating to external birth defects and external
congenital Illnesses or defects or anomalies

31. Intentional self-injury (whether arising from an attempt to commit suicide or otherwise)

32. Any ailment/ illness/ injury/ condition or treatment or service that is specifically excluded in
the Policy Schedule under Special Conditions.

33. Deductible: We shall not be liable for the Deductible amount as specifically defined in Policy
Schedule
We are not liable for any payment unless the aggregate medical expenses exceed the
deductible.
Deductible shall not be applicable for optional covers, if any.

ICICI Lombard General Insurance Company Limited

New Linking Road, Malad (West) Off Veer Savarkar Road, Nr Siddhi Vinayak Temple, E-mail: [email protected]
Mumbai - 400 064 Prabhadevi, Mumbai 400 025 Website : www.icicilombard.com
69

f. GENERAL Terms and CONDITIONS:

i. Standard General Terms and clauses

1. Disclosure of Information:

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. Fraud:

If 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;

ICICI Lombard General Insurance Company Limited

New Linking Road, Malad (West) Off Veer Savarkar Road, Nr Siddhi Vinayak Temple, E-mail: [email protected]
Mumbai - 400 064 Prabhadevi, Mumbai 400 025 Website : www.icicilombard.com
70

b) the active concealment of a fact by the insured person having knowledge or belief of the
fact;
c) any other act fitted to deceivee; 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.

4. Multiple policies

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 treated as the primary Insurer and 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.

5. Free Look Period:

Every insured of new health insurance policies, except for those policies with tenure of less than
a year, shall be provided a free look period of 30 days beginning from the date of receipt of policy
document, whether received electronically or otherwise, to review the terms and conditions of such
policy. If the insured cancels the policy within free look period then the insured shall be entitled
to a refund of the premium paid subject only to a deduction of a proportionate risk premium for
the period of cover and the expenses, if any, incurred by the insurer on medical examination of the
insured and stamp duty charges.

6. Cancellation:

a) The policyholder may cancel this policy by giving 7 days’ written notice and in such an event,
the Company shall refund premium for the unexpired policy period as detailed below-

i. Refund proportionate premium for unexpired policy period, if the term of

policy up to one year and there is no claim (s) made during the policy
period.

ICICI Lombard General Insurance Company Limited

New Linking Road, Malad (West) Off Veer Savarkar Road, Nr Siddhi Vinayak Temple, E-mail: [email protected]
Mumbai - 400 064 Prabhadevi, Mumbai 400 025 Website : www.icicilombard.com
71

ii. Refund premium for the unexpired policy period, in respect of policies
with term more than 1 year and risk coverage for such policy years has not
commenced.

Note: Above mentioned refund clause shall not be applicable for policies with free look period;
Premium refund for cancellations during the free look period will be provided as per the Free
look clause.

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.

b) 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 7 days’ written notice. There
would be no refund of premium on cancellation on grounds of misrepresentation, non-disclosure
of material facts or fraud.

7. Renewal of Policy:

The policy shall ordinarily be renewable except on grounds of established fraud,

misrepresentation by the insured person provided the policy is not withdrawn and also subject to
moratorium conditions: -

i. Renewal shall not be denied on the ground that the insured person had made a claim
or claims in the preceding policy years.
ii. Request for renewal along with requisite premium shall be received by the Company
before the end of the policy period
iii. 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.

8. Premium payment in instalments:

If the insured person has opted for Payment of Premium on an installment basis i.e. Half Yearly,
Quarterly or Monthly, as mentioned in Your Policy Schedule/certificate of insurance, the following
Conditions shall apply (notwithstanding any terms contrary elsewhere in the Policy)
i. Grace Period for payment of premiums shall be fifteen days where premium payment
mode is monthly and thirty days in all other cases.

ICICI Lombard General Insurance Company Limited

New Linking Road, Malad (West) Off Veer Savarkar Road, Nr Siddhi Vinayak Temple, E-mail: [email protected]
Mumbai - 400 064 Prabhadevi, Mumbai 400 025 Website : www.icicilombard.com
72

ii. The grace period for payment of premium for all types of insurance policies shall be fifteen
days where premium payment mode is monthly and thirty days in all other cases.
Provided the insurers shall offer coverage during grace period, if the premium is paid in
installments during the policy period.
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 If the installment premium is not paid on due date.
v. In case of installment premium due not received within the grace Period, the Policy
will get cancelled.
vi. In 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.

9. Portability

a. The insured has the choice to port his / her policies from one Insurer to another. An Insured desirous
of porting his/her policy to another insurer shall apply to such insurer to port the entire policy along
with all the members of the family, if any, at least 30 days before, but not earlier than 60 days from
the due date for renewal.
b. The insured is entitled to transfer the credits gained to the extent of the sum insured and the
benefits available in the previous policy, subject to the underwriting policy of the Company
c. The Company shall decide and communicate on the proposal upon receipt of information from
Existing insurer within prescribed timelines .
d. This benefit is not applicable for enhanced sum insured

10. Migration

In case of migration of indemnity based health insurance policy (except Personal Accident and
Travel Policies) with the same Insurer, the insured can transfer the credits gained to the extent of
the Sum Insured and benefits available in the previous policy to the migrated policy. The Company
may underwrite the proposal in case of migration, if the insured is not continuously covered for 36
months.

11. Withdrawal of Policy

ICICI Lombard General Insurance Company Limited

New Linking Road, Malad (West) Off Veer Savarkar Road, Nr Siddhi Vinayak Temple, E-mail: [email protected]
Mumbai - 400 064 Prabhadevi, Mumbai 400 025 Website : www.icicilombard.com
73

i. In 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. Insured 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
waiver of waiting period as per regulatory prescriptions, provided the policy has been
maintained without a break.

12. Moratorium Period

After completion of sixty continuous months of coverage (including portability and migration) in
health insurance policy, no policy and claim shall be contestable by the insurer on grounds of
non-disclosure, misrepresentation, except on grounds of established fraud. This period of sixty
continuous months is called as moratorium period. The moratorium would be applicable for the
sums insured of the first policy. Wherever, the sum insured is enhanced, completion of sixty
continuous months would be applicable from the date of enhancement of sums insured only on
the enhanced limits.

13. Possibility of Revision of Terms of the Policy Including the Premium Rates

The Company, with prior approval Product Management Committee of the Company, may revise
or modify the terms of the policy including the premium rates.

14. 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 shall be communicated to the company in writing and such change shall be effective
only when an endorsement on the policy is made. In 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.

15. Grievance Redressal Procedure:

ln case of any grievance the insured person may contact the Company through
Website: www.icicilombard.com Toll free: 1800 2666 Email:

ICICI Lombard General Insurance Company Limited

New Linking Road, Malad (West) Off Veer Savarkar Road, Nr Siddhi Vinayak Temple, E-mail: [email protected]
Mumbai - 400 064 Prabhadevi, Mumbai 400 025 Website : www.icicilombard.com
74

[email protected]
ICICI Lombard General Insurance Co. Ltd. Ground floor- Interface 11, Sixth floor-
Interface 16 ,
Office no 601 & 602, New linking Road, Malad (West), Mumbai – 400064

There is an interactive voice response (IVR) facility for senior citizens’ grievance
redressal for easy and faster resolution

lnsured person may also approach the grievance cell at any of the company's
branches with the details of grievance. For branch details, please visit
https://www.icicilombard.com/docs/default-source/policy-wordings-product-
brochure/final-gro-mapping.pdf.

lf lnsured person is not satisfied with the redressal of grievance ,insured person may
contact the grievance redressal officer at the details provided in the below link:

https://www.icicilombard.com/grievanceredressal.com

lf lnsured person is not satisfied with the redressal of grievance, the insured person
may also approach Insurance Regulatory and Development Authority of India
(IRDAI) through the Bima Bharosa Portal - https://bimabharosa.irdai.gov.in/ or IRDA
Grievance Call Centre(IGCC) at their toll free no. 1800 4254 732 / 155255

Insured may also approach Insurance Ombudsman, subject to vested jurisdiction, for
the redressal of grievance. Details of Insurance Ombudsman offices are available at
IRDAI website: www.irdai.gov.in, or on the Company’s website at
www.icicilombard.com or on https://www.cioins.co.in/Ombudsman

16. Complete Discharge

ICICI Lombard General Insurance Company Limited

New Linking Road, Malad (West) Off Veer Savarkar Road, Nr Siddhi Vinayak Temple, E-mail: [email protected]
Mumbai - 400 064 Prabhadevi, Mumbai 400 025 Website : www.icicilombard.com
75

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.

ii. Specific terms and clauses (terms and other clauses other than those mentioned
under f.i above)

17. Zone based premium

For the purpose of premium computation, the country has been divided into 4 zones.

Zone State/District

Zone A Delhi, Mumbai (including Thane district, Navi Mumbai) , Gurugram district,
Karnal district, Sonipat district, Rohtak district, Bhiwani district, Chakri Dadri
district, Mahendragarh district, Daman & Diu, Dadra Nagar, Ahmedabad,
Surat, Noida City, Ghaziabad district, Hapur district, Meerut district,
Muzaffarnagar district, Shamali district
Zone B Pune, Kolkata, Telangana (incl. Hyderabad), Madhya Pradesh, Goa, Gujarat
(excl. Ahmedabad and Surat), Bangalore, Chennai, Andhra Pradesh,
Chattisgarh, Pondicherry, Uttarakand

Zone C Rest of India (Punjab, Rajasthan (excl. NCR region), Chandigarh, Himachal
Pradesh, Jammu & Kashmir, Ladakh, Lakshadweep, Kerala, Tamil Nadu
(excl. Chennai, Pondicherry), Odisha, Arunachal Pradesh, Assam, Manipur,
Meghalaya, Mizoram, Nagaland, Tripura, Sikkim, Andaman & Nicobar, Rest of
Karnataka, West Bengal (excl. Kolkata), Bihar, Jharkhand, Maharashtra (excl.
Mumbai and Pune), UP (excl. NCR Region), Haryana (excl. NCR region)
Zone D Rest of NCR (Alwar district, Bagpat district, Bharatpur district, Bulandshahr
district, Faridabad district, Gautam Buddha Nagar district excl. Noida, Jhajjar
district, Jind district, Nuh district, Panipat district, Rewari district, Mewat
district, Palwal district)

ICICI Lombard General Insurance Company Limited

New Linking Road, Malad (West) Off Veer Savarkar Road, Nr Siddhi Vinayak Temple, E-mail: [email protected]
Mumbai - 400 064 Prabhadevi, Mumbai 400 025 Website : www.icicilombard.com
76

The premium will depend on the city of residence and pin code of the insured person. Please
inform us immediately in case of any change in the same. Not doing so, may impact your claim
admissibility. There shall be no zone-based co-payment applicable.

18. Material Change:

The Insured Person 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.

19. 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.

20. Notice & Communication

Any notice, direction, instruction or any other communication related to the Policy should be made
in writing.
Such communication shall be sent to the address of the Company or through any other electronic
modes specified in the Policy Schedule.
The Company shall communicate to the Insured at the address or through any other electronic
mode mentioned in the schedule.

21. Territorial Limit

All medical treatment for the purpose of this insurance will have to be taken in India only.

22. Automatic change in Coverage under the policy

The coverage for the Insured Person(s) shall automatically terminate:

a. In the case of his/ her (Insured Person) demise.
i. However, the cover shall continue for the remaining Insured Persons till
the end of Policy Period. The other Insured Persons may also apply to
renew the Policy. In case, the other Insured Person is minor, the Policy
shall be renewed only through any one of his/her natural guardian or

ICICI Lombard General Insurance Company Limited

New Linking Road, Malad (West) Off Veer Savarkar Road, Nr Siddhi Vinayak Temple, E-mail: [email protected]
Mumbai - 400 064 Prabhadevi, Mumbai 400 025 Website : www.icicilombard.com
77

guardian appointed by court. All relevant particulars in respect of such

person (including his/her relationship with the Insured Person) must be
submitted to the company along with the application. Provided no claim
has been made, and termination takes place on account of death of the
Insured Person, pro-rata refund of premium of the deceased Insured
Person for the balance period of the Policy will be effective.
b. Upon exhaustion of Sum Insured and any other additional sum insured (if any),
for the Policy Year. However, the Policy is subject to Renewal on the due date
as per the applicable terms and conditions.

23. Territorial Jurisdiction

All disputes or differences under or in relation to the interpretation of the terms, conditions, validity,
construct, limitations and/or exclusions contained in the Policy shall be determined by the Indian
court and according to Indian law.

24. Arbitration

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).

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.

25. Policy Alignment

a. 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

ICICI Lombard General Insurance Company Limited

New Linking Road, Malad (West) Off Veer Savarkar Road, Nr Siddhi Vinayak Temple, E-mail: [email protected]
Mumbai - 400 064 Prabhadevi, Mumbai 400 025 Website : www.icicilombard.com
78

Dates. We can align the policies by extending the coverage of one Policy till the end date of
the other Policy.
b. Such policies will be charged with premium on pro rata basis though the Sum Insured under
the Policy shall remain constant.

26. Endorsements (Changes in Policy)

a. 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.
b. Any change in plan, add-ons/Optional Covers opted may happen only during Renewal
subject to underwriting.
c. 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 shall be treated as having
been renewed without break.
d. The proposer may be changed during the Policy Period only in case of his/her demise or
him/her moving out of India.
e. 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

27. 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 Sum Insured, the waiting period
shall start afresh only for the enhanced portion of the Sum Insured

28. Non Payables

The non-payable items applicable in the policy are mentioned as Annexure II. The list may be
updated as per the direction of Authority, for updated list please visit Our website:
www.iciciclombard.com

g. Other Terms and Conditions

I. Claim Administration
The fulfilment 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

ICICI Lombard General Insurance Company Limited

New Linking Road, Malad (West) Off Veer Savarkar Road, Nr Siddhi Vinayak Temple, E-mail: [email protected]
Mumbai - 400 064 Prabhadevi, Mumbai 400 025 Website : www.icicilombard.com
79

with by each of You shall be conditions precedent to admission of Our liability. You are requested
to go through our list of de-listed/excluded providers which is available on our website. As the list
is dynamic, please refer to the latest list.

The claim pay-out would be adjudicated in following sequence:

i. If a room accommodation has been opted for where the room rent or category is
higher than the eligible limit as applicable for the Insured Person, then the
associated medical expenses payable shall be pro-rated as per applicable limits.
a. Associated medical expenses means those expenses as listed below
which vary in accordance with the room rent or room category or ICU
Charges in a Hospital:
i. Room, boarding, nursing and operation theatre expenses as
charged by the Hospital where the Insured Person availed
treatment
ii. Fees charged by surgeon, anesthetist, Medical Practitioner
iii. Investigation expenses
The claim amount assessed above would be deducted from the following amounts in the
following progressive order:
1. Annual Sum Insured
2. Inflation Protector (if accrued and available)
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. Claims Procedure

A. For Cashless Settlement

Cashless treatment is only available at a Network Provider (List of Network Providers is available
at our website). In order to avail of cashless treatment, the following procedure must be followed
by You:

Pre-authorization

ICICI Lombard General Insurance Company Limited

New Linking Road, Malad (West) Off Veer Savarkar Road, Nr Siddhi Vinayak Temple, E-mail: [email protected]
Mumbai - 400 064 Prabhadevi, Mumbai 400 025 Website : www.icicilombard.com
80

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/ Injury/ Hospitalisation. You must request preauthorization 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 claim 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.

B. For Reimbursement Settlement

i. 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 [email protected] 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 or Injury;
 Name and address of the attending Medical Practitioner and the Hospital;
 Any other information that may be relevant to the Illness/ Injury/ Hospitalisation

ii. You must immediately consult a Medical Practitioner and follow the advice and treatment
that he recommends.
iii. 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 collected from the hospital at the time of
discharge along with the claim form

ICICI Lombard General Insurance Company Limited

New Linking Road, Malad (West) Off Veer Savarkar Road, Nr Siddhi Vinayak Temple, E-mail: [email protected]
Mumbai - 400 064 Prabhadevi, Mumbai 400 025 Website : www.icicilombard.com
81

However, in both the above cases i.e. g. Claim Administration I. 1. (A) & (B), You must take
reasonable steps or measure to minimize the quantum of any Claim that may be covered under
the Policy.

If so requested by Us, 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.

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.

2. Claim Documents

You shall be required to furnish the following documents for or in support of a reimbursement Claim:

1. Duly completed Claim form signed by You and the Medical Practitioner. The claim form
can be downloaded from our website www.icicilombard.com
2. Original bills, receipts and discharge certificate/ card from the Hospital/ Medical Practitioner
3. Original bills from chemists supported by proper prescription.
4. Original investigation test reports and payment receipts.
5. Indoor case papers
6. Medical Practitioner's referral letter advising Hospitalization in non-Accident cases.
7. Any other document as required by Us or to investigate the Claim or Our obligation to make
payment for it

The relevant documents to be sent to -

ICICI Lombard Health Care,

1st, 4th (Half) , 5th and 6th floors,
Varun Towers- II , Opp. Hyderabad Public school,
Begumpet, Hyderabad, District Hyderabad, Telangana Pin code -500016

ICICI Lombard General Insurance Company Limited

New Linking Road, Malad (West) Off Veer Savarkar Road, Nr Siddhi Vinayak Temple, E-mail: [email protected]
Mumbai - 400 064 Prabhadevi, Mumbai 400 025 Website : www.icicilombard.com
82

Annexure I

Jurisdiction of Office Union Territory,

Office Details
District)
AHMEDABAD
Office of the Insurance Ombudsman,
Jeevan Prakash Building, 6th floor,
Gujarat,
Tilak Marg, Relief Road,
Dadra & Nagar Haveli,
Ahmedabad – 380 001.
Daman and Diu.
Tel.: 079 - 25501201/02/05/06
Email:
[email protected]
BENGALURU
Office of the Insurance Ombudsman,
Jeevan Soudha Building, PID No. 57-
27-N-19
Ground Floor, 19/19, 24th Main Road,
Karnataka.
JP Nagar, Ist Phase,
Bengaluru – 560 078.
Tel.: 080 - 26652048 / 26652049
Email:
[email protected]
BHOPAL
Insurance Ombudsman
Office of the Insurance Ombudsman,
1st floor,"Jeevan Shikha",
Madhya Pradesh
60-B,Hoshangabad Road, Opp. Chhattisgarh.
Gayatri Mandir,
Bhopal – 462 011.
Tel.: 0755 - 2769201 / 2769202
Email: [email protected]
BHUBANESHWAR
Office of the Insurance Ombudsman, Orissa.
62, Forest park,

ICICI Lombard General Insurance Company Limited

New Linking Road, Malad (West) Off Veer Savarkar Road, Nr Siddhi Vinayak Temple, E-mail: [email protected]
Mumbai - 400 064 Prabhadevi, Mumbai 400 025 Website : www.icicilombard.com
83

Bhubaneswar – 751 009.

Tel.: 0674 - 2596461 /2596455
Fax: 0674 - 2596429
Email:
[email protected]
CHANDIGARH
Mr. Atul Jerath
Insurance Ombudsman
Office of the Insurance Ombudsman, Punjab,
Haryana (excluding Gurugram, Faridabad, Sonepat
Jeevan Deep Building SCO 20-27, and Bahadurgarh)
Ground Floor Sector- 17 A, Himachal Pradesh, Union Territories of Jammu &
Kashmir,
Chandigarh – 160 017. Ladakh & Chandigarh.
Tel.: 0172 - 4646394 / 2706468
Email:
[email protected]
CHENNAI
Office of the Insurance Ombudsman,
Fatima Akhtar Court, 4th Floor, 453,
Tamil Nadu,
Anna Salai, Teynampet,
Tamil Nadu
CHENNAI – 600 018.
Puducherry Town and
Tel.: 044 - 24333668 / 24335284
Karaikal (which are part of Puducherry).
Fax: 044 - 24333664
Email:
[email protected]
DELHI
Office of the Insurance Ombudsman,
2/2 A, Universal Insurance Building, Delhi &
Asaf Ali Road, Following Districts of Haryana - Gurugram,
New Delhi – 110 002. Faridabad, Sonepat & Bahadurgarh.
Tel.: 011 - 23232481/23213504
Email: [email protected]
GUWAHATI
Office of the Insurance Ombudsman, Assam,
Jeevan Nivesh, 5th Floor, Meghalaya,
Nr. Panbazar over bridge, S.S. Road, Manipur,

ICICI Lombard General Insurance Company Limited

New Linking Road, Malad (West) Off Veer Savarkar Road, Nr Siddhi Vinayak Temple, E-mail: [email protected]
Mumbai - 400 064 Prabhadevi, Mumbai 400 025 Website : www.icicilombard.com
84

Guwahati – 781001(ASSAM). Mizoram,

Tel.: 0361 - 2632204 / 2602205 Arunachal Pradesh,
Email: Nagaland and Tripura.
[email protected]
HYDERABAD
Office of the Insurance Ombudsman,
6-2-46, 1st floor, "Moin Court",
Lane Opp. Saleem Function Palace, Andhra Pradesh,
A. C. Guards, Lakdi-Ka-Pool, Telangana,
Hyderabad - 500 004. Yanam and
Tel.: 040 - 23312122 part of Union Territory of Puducherry.
Fax: 040 - 23376599
Email:
[email protected]
JAIPUR
Office of the Insurance Ombudsman,
Jeevan Nidhi – II Bldg., Gr. Floor,
Bhawani Singh Marg, Rajasthan.
Jaipur - 302 005.
Tel.: 0141 - 2740363
Email: [email protected]
KOCHI
Insurance Ombudsman
Office of the Insurance Ombudsman,
10th Floor, Jeevan Prakash,LIC
Building,
Kerala, Lakshadweep, Mahe- a part of Union
Opp to Maharaja's College Territory of Puducherry.
Ground,M.G.Road,
Kochi - 682 011.
Tel.: 0484 - 2358759
Email:
[email protected]

ICICI Lombard General Insurance Company Limited

New Linking Road, Malad (West) Off Veer Savarkar Road, Nr Siddhi Vinayak Temple, E-mail: [email protected]
Mumbai - 400 064 Prabhadevi, Mumbai 400 025 Website : www.icicilombard.com
85

KOLKATA
Office of the Insurance Ombudsman,
Hindustan Bldg. Annexe, 7th Floor,
West Bengal,
4, C.R. Avenue,
Sikkim,
KOLKATA - 700 072.
Andaman & Nicobar Islands.
Tel.: 033 - 22124339 / 22124340
Fax : 033 - 22124341
Email: [email protected]
LUCKNOW Districts of Uttar Pradesh :
Office of the Insurance Ombudsman, Lalitpur, Jhansi, Mahoba, Hamirpur, Banda,
6th Floor, Jeevan Bhawan, Phase-II, Chitrakoot, Allahabad, Mirzapur, Sonbhabdra,
Nawal Kishore Road, Hazratganj, Fatehpur, Pratapgarh, Jaunpur, Varanasi, Gazipur,
Lucknow - 226 001. Jalaun, Kanpur, Lucknow, Unnao, Sitapur,
Tel.: 0522 - 2231330 / 2231331 Lakhimpur, Bahraich, Barabanki, Raebareli,
Fax: 0522 - 2231310 Sravasti, Gonda, Faizabad, Amethi, Kaushambi,
Email: Balrampur, Basti, Ambedkarnagar, Sultanpur,
[email protected] Maharajgang, Santkabirnagar, Azamgarh,
Kushinagar, Gorkhpur, Deoria, Mau, Ghazipur,
Chandauli, Ballia, Sidharathnagar.
MUMBAI
Office of the Insurance Ombudsman,
3rd Floor, Jeevan Seva Annexe,
S. V. Road, Santacruz (W), Goa,
Mumbai - 400 054. Mumbai Metropolitan Region
Tel.: 022 - 26106552 / 26106960 excluding Navi Mumbai & Thane.
Fax: 022 - 26106052
Email:
[email protected]
NOIDA State of Uttarakhand and the following Districts of
Office of the Insurance Ombudsman, Uttar Pradesh:
Bhagwan Sahai Palace Agra, Aligarh, Bagpat, Bareilly, Bijnor, Budaun,
4th Floor, Main Road, Bulandshehar, Etah, Kanooj, Mainpuri, Mathura,
Naya Bans, Sector 15, Meerut, Moradabad, Muzaffarnagar, Oraiyya,
Distt: Gautam Buddh Nagar, Pilibhit, Etawah, Farrukhabad, Firozbad,
U.P-201301. Gautambodhanagar, Ghaziabad, Hardoi,
Tel.: 0120-2514252 / 2514253 Shahjahanpur, Hapur, Shamli, Rampur, Kashganj,
Email: [email protected] Sambhal, Amroha, Hathras, Kanshiramnagar,
Saharanpur.

ICICI Lombard General Insurance Company Limited

New Linking Road, Malad (West) Off Veer Savarkar Road, Nr Siddhi Vinayak Temple, E-mail: [email protected]
Mumbai - 400 064 Prabhadevi, Mumbai 400 025 Website : www.icicilombard.com
86

PATNA
Insurance Ombudsman
Office of the Insurance Ombudsman,
2nd Floor, Lalit Bhawan, Bihar,
Bailey Road, Jharkhand.
Patna 800 001.
Tel.: 0612-2547068
Email: [email protected]
PUNE
Office of the Insurance Ombudsman,
Jeevan Darshan Bldg., 3rd Floor,
Maharashtra,
C.T.S. No.s. 195 to 198,
Area of Navi Mumbai and Thane
N.C. Kelkar Road, Narayan Peth,
excluding Mumbai Metropolitan Region.
Pune – 411 030.
Tel.: 020-41312555
Email: [email protected]

The updated details of Insurance Ombudsman are also available on IRDAI

website: www.irdai.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.

For updated list of ombudsman details kindly visit https://www.cioins.co.in/Ombudsman

Annexure II

List I- Items for which coverage is not available in the Policy

S.No. Item
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

ICICI Lombard General Insurance Company Limited

New Linking Road, Malad (West) Off Veer Savarkar Road, Nr Siddhi Vinayak Temple, E-mail: [email protected]
Mumbai - 400 064 Prabhadevi, Mumbai 400 025 Website : www.icicilombard.com
87

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
CHARGE)
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)
36 SPACER
37 SPIROMETRE
38 NEBULIZER KIT
39 STEAM INHALER
40 ARMSLING

ICICI Lombard General Insurance Company Limited

New Linking Road, Malad (West) Off Veer Savarkar Road, Nr Siddhi Vinayak Temple, E-mail: [email protected]
Mumbai - 400 064 Prabhadevi, Mumbai 400 025 Website : www.icicilombard.com
88

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 ANY KIT WITH NO DETAILS MENTIONED [DELIVERY KIT,
ORTHOKIT, RECOVERY KIT, ETC]
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

List II- Items that are to be subsumed into Room Charges

ICICI Lombard General Insurance Company Limited

New Linking Road, Malad (West) Off Veer Savarkar Road, Nr Siddhi Vinayak Temple, E-mail: [email protected]
Mumbai - 400 064 Prabhadevi, Mumbai 400 025 Website : www.icicilombard.com
89

S.No. Item
1 BABY CHARGES (UNLESS SPECIFIED/INDICATED)
2 HAND WASH
3 SHOE COVER
4 CAPS
5 CRADLE CHARGES
6 COMB
7 EAU-DE-COLOGNE / ROOM FRESHNERS
8 FOOT COVER
9 GOWN
10 SLIPPERS
11 TISSUE PAPER
12 TOOTH PASTE
13 TOOTH BRUSH
14 BED PAN
15 FACE MASK
16 FLEX I MASK
17 HAND HOLDER
18 SPUTUM CUP
19 DISINFECTANT LOTIONS
20 LUXURY TAX
21 HVAC
22 HOUSE KEEPING CHARGES
23 AIR CONDITIONER CHARGES
24 IM IV INJECTION CHARGES
25 CLEAN SHEET
26 BLANKETS/VARMER BLANKET
27 ADMISSION KIT
28 DIABETIC CHART CHARGES
29 DOCUMENTATION CHARGES / ADMINISTRATIVE
EXPENSES
30 DISCHARGE PROCEDURE CHARGES
31 DAILY CHART CHARGES
32 ENTRANCE PASS / VISITORS PASS CHARGES
33 EXPENSES RELATED TO PRESCRIPTION ON DISCHARGE
34 FILE OPENING CHARGES

ICICI Lombard General Insurance Company Limited

New Linking Road, Malad (West) Off Veer Savarkar Road, Nr Siddhi Vinayak Temple, E-mail: [email protected]
Mumbai - 400 064 Prabhadevi, Mumbai 400 025 Website : www.icicilombard.com
90

35 INCIDENTAL EXPENSES / MISC. CHARGES (NOT

EXPLAINED)
36 PATIENT IDENTIFICATION BAND / NAME TAG
37 PULSEOXYMETER CHARGES

List III — Items that are to be subsumed into Procedure Charges

S.No. Item
1 HAIR REMOVAL CREAM
2 DISPOSABLES RAZORS CHARGES (for site preparations)
3 EYE PAD
4 EYE SHEILD
5 CAMERA COVER
6 DVD, CD CHARGES
7 GAUSE SOFT
8 GAUZE
9 WARD AND THEATRE BOOKING CHARGES
10 ARTHROSCOPY AND ENDOSCOPY INSTRUMENTS
11 MICROSCOPE COVER
12 SURGICAL BLADES, HARMONICSCALPEL,SHAVER
13 SURGICAL DRILL
14 EYE KIT
15 EYE DRAPE
16 X-RAY FILM
17 BOYLES APPARATUS CHARGES
18 COTTON
19 COTTON BANDAGE
20 SURGICAL TAPE
21 APRON
22 TORNIQUET
23 ORTHOBUNDLE, GYNAEC BUNDLE

List IV — Items that are to be subsumed into costs of treatment

S.No. Item
1 ADMISSION/REGISTRATION CHARGES
2 HOSPITALISATION FOR EVALUATION/ DIAGNOSTIC
PURPOSE

ICICI Lombard General Insurance Company Limited

New Linking Road, Malad (West) Off Veer Savarkar Road, Nr Siddhi Vinayak Temple, E-mail: [email protected]
Mumbai - 400 064 Prabhadevi, Mumbai 400 025 Website : www.icicilombard.com
91

3 URINE CONTAINER
4 BLOOD RESERVATION CHARGES AND ANTE NATAL
BOOKING CHARGES
5 BIPAP MACHINE
6 CPAP/ CAPD EQUIPMENTS
7 INFUSION PUMP— COST
8 HYDROGEN PEROXIDE\SPIRITS DISINFECTANTS ETC
9 NUTRITION PLANNING CHARGES - DIETICIAN CHARGES-
DIET CHARGES
10 HIV KIT
11 ANTISEPTIC MOUTHWASH
12 LOZENGES
13 MOUTH PAINT
14 VACCINATION CHARGES
15 ALCOHOL SWABES
16 SCRUB SOLUTION/STERILLIUM
17 GLUCOMETER & STRIPS
18 URINE BAG

ICICI Lombard General Insurance Company Limited

New Linking Road, Malad (West) Off Veer Savarkar Road, Nr Siddhi Vinayak Temple, E-mail: [email protected]
Mumbai - 400 064 Prabhadevi, Mumbai 400 025 Website : www.icicilombard.com

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