Mediclaim Policy 01.09.2024 to 31.08.
2025
The features of Group Mediclaim policy for period 01.09.2024 - 31.08.2025 are as under:
Coverages:
1. This policy will be issued on named basis for all full-time permanent employees.
2. Age covered under the policy in range of day 1 – 90 years.
3. Floater Policy (within covered family members). Family comprises of Self, Spouse, first three (3) dependent
living children, Parents, Parents-in-Law, Dependent brothers & sisters subject to maximum of two.
(Dependent Children/Brothers/Sisters aged above 25 years will be covered subject to furnishing of medical
disability/full time study certificate to proof the dependency. If Daughter is unmarried then the same will
be covered based on employee declaration without age restriction. Children/Brother/Sister who are
working/married are not eligible for coverage even if age is below 25 years.
4. Male Employees can cover his parents only. If he wants to cover his parents-in-law then he is eligible
only if his wife is single child of her parents and her parents financial dependent. Female employees can
cover her parents-in-law only. If she wants to cover her parents then she is eligible only if she is the
single child of her parents and her parents financial dependent. Only one set of parents are allowed to
cover. Cross relationship is not permitted.
5. Change in composition in family is not allowed. Addition/Deletion is allowed as mentioned below under
“Special Conditions” given on next page.
6. Initially new joiners can add Self, Spouse, Children/Siblings. Parents/Parents-In-Law of new joiners (as per
policy terms & conditions mentioned above) will be allowed to add on the next renewal. If employee fail
to add on the next renewal then we will not be able to add his parents/parents-in-law in future as per
policy norms. If new joiner has valid policy for his parents from last employer then we will allow to enter
under company Mediclaim policy from day 01 at the time of nomination under company Mediclaim policy.
7. Cashless Facility is available through network hospitals. List of network hospitals can be viewed through
the portal of insurer. https://ilhc.icicilombard.com/Customer/GetHospitalList
8. Hospitalization expenses for the treatment of Corona is covered as per policy norms.
9. Aurvedic/ Homeo/ Unani treatments are covered in govt. hospitals only.
10. Pre-existing diseases are covered under the policy.
11. Coverage for Hospitalizations: the following kinds of expenses are indemnified under the policy Nursing
Expenses, Medical Practitioner/Anesthetist, consultant fees, Expense on anesthesia, blood oxygen,
operation theatre charges, Surgical appliances, medicines and drugs, diagnostic Materials & x-ray, Dialysis,
Chemotherapy, Radiotherapy, Cost of Pacemaker, Artificial Limbs & Cost of organs, expenses on vitamins
and tonics forming part of the treatment.
12. Indemnification Period: 30 days Pre-Hospitalization and 60 days Post-Hospitalization.
13. Procedures like Dialysis, Chemotherapy, Eye-Surgery, Anti Rabies Vaccination, Hysterectomy,
Appendectomy, Coronary Angiography, Coronary Angioplasty, Dilatation & Curettage (D &C) of Cervic,
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Mediclaim Policy 01.09.2024 to 31.08.2025
Fracture/dislocation etc. that do not require hospitalization, need not fulfill the 24 -Hour hospitalization
condition.
14. OPD coverage for any accidental injury subject to maximum Rs.10,000/- case. OPD accidental coverage is
not applicable for dental treatment.
15. For claiming hospitalization expenses, 24 hours admission is mandatory.
16. Employees can take any sum insured in range of Rs. 1,00,000 to Rs. 7,00,000, in the multiples of Rs 25,000.
Maximum floater sum insured per family is Rs. 7 Lacs. Level wise minimum sum insured coverage under
mediclaim policy as under for FY: 2024-25
Sr. No. Level/category Minimum Sum Insured
1 Sub-staff to Staff Rs. 01.00 lacs
2 Asst. officer (01) to Executive (E2) Rs.01.50 lacs
3 Managers (M1 – M3) Rs. 02.00 lacs
4 Chief Manager (M4) to VP Rs. 03.00 lacs
5 Sr. VP and above Rs. 04.00 lacs
17. Employee can increase his sum insured by Rs. 01 Lac only as compared to last year sum insured subject to
NIL claim in the last 2 years. However, in case of promotion, the employees can correct their sum insured
as per the table mentioned in point no. 16 above.
Special conditions:
I. Addition & Deletion during the renewal as well as in currency of the policy is not allowed except the
circumstances given below: -
▪ Midterm addition allowed in case of new joinees (Pro-Rata premium will be charged as per Calculator-
B – Inbuilt in the system), addition of spouse in case of marriage (30% of total paid premium will be
charged (premium which was paid by insured employee at the time of renewal of GMC policy. Pro-
Rata calculation will not be applicable) and new born baby is covered from day 1 without any
premium.
▪ Addition requests for new joiners/newly married/new born baby must be given through system by the
concerned HR department/employee to Corporate Insurance Department within 30 days from joining
date / marriage date / birth date. After 30 days, addition request will not be entertained.
▪ If any employee wants to delete parents/parents-in-law, it is allowed through request mail to
Corporate Insurance Department at the time of next renewal. Once deleted, re-addition of parents or
addition parent-in-law in place of parents is not allowed. Any family member who is crossing age of 90
years or in case of death depending upon the case, will be deleted at the renewal of the policy.
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Mediclaim Policy 01.09.2024 to 31.08.2025
▪ Employees joined onwards 01-08-2023 are allowed to enter under company mediclaim policy and can
submit their data through online portal “DotNet Mediclaim User”. Online portal is not available for
College/Trust/Adishwar/Devakar Employees. So, employees of these companies will submit the
mediclaim data in the standard format. After this renewal new joinees should enroll with their family
under company mediclaim policy within 30 days from the date of joining.
▪ In case of change in family definition (addition in members) compared with existing policy, premium
Calculator-B (Inbuilt in the system) named "for new members" should be used for calculating premium.
II. Sum Insured once opted by the insured member can be reduced (Subject to amount mentioned in point
no. 16) at the time of renewal subject to NIL claim in last 2 years.
III. Employee who wants to opt-out/exit from company mediclaim policy is allowed with requisite approval
subject to NIL claims in last 2 years of company mediclaim policy. Re-addition will not be allowed in future.
IV. The sum insured taken at the inception of the policy cannot be enhanced &/or reduced during the term of
the policy.
V. If the claim is spread over two policy periods, the total benefits will not exceed the sum insured of that
policy during which period the insured person was admitted to the hospital. Only that policy during which
the insured person was admitted to hospital will be considered for the claim.
VI. Maximum 50% of the sum insured of the family can be utilized for the parental claims.
VII. Maternity benefits (Only For Self In Case of Female Employee and For Spouse In Case of Male Employees)
to the tune of Rs. 35,000 or 35% of Sum insured whichever is less per member in case of caesarian and Rs.
20,000 or 20% of Sum insured whichever is less in case of normal delivery. Maternity benefit limit is
including cost of baby care during maternity hospitalization. No Pre and post-natal expenses are not
covered. New Born Baby is covered from day one within family floater sum Insured without paying extra
premium. Addition requests must be sent to Corporate Insurance Department within 30 days from date of
birth. This is applicable for first 2 kids only. No compensation is payable related to 3rd pregnancy.
VIII. There is waiting period of 9 months for new mediclaim policy holders. Accordingly, such employees shall
get the coverage for maternity benefits after 9 months of joining the company mediclaim policy.
IX. Eye Related Treatment: Utilization of sum insured is restricted upto Rs. 25,000/- per eye and for both eyes
it will be Rs. 50,000/-. Maximum sum insured can be utilized upto Rs. 50,000/- per member for both eyes.
Overall limit will be Rs. 50,000/- per family during the year. Cosmetic surgeries are not covered.
X. Knee Replacement: Utilization of sum insured is restricted upto Rs. 1,25,000/- per knee and for both knees
it will be Rs. 2,50,000/-. Overall limit will be Rs. 2,50,000/- per family during the year.
XI. Liability for Nasal Sinus Surgeries upto Rs. 35,000/-
XII. Maximum room expenses (room rent + nursing charges) allowed under the Policy is 1.5% of the Sum
insured per day and 3% of sum insured in ICU/ICCU including nursing charges. All other
treatment/hospitalization expenses shall be allowed in proportion of room rent + nursing permissible.
XIII. 2% of sum insured subject to maximum of Rs. 5000 is allowed as Ambulance expenses, wherever the same
is required.
XIV. Deductible Clause: 20% flat co-payment or Rs. 3500/- whichever is higher, will be deducted under co-pay
clause.
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Mediclaim Policy 01.09.2024 to 31.08.2025
XV. Claim Loading:
A) 10% extra premium will be charged from those employees who have taken claim in the last year
policy (2023-24).
B) 20% extra premium (Instead of 10% as mentioned above) will be charged from employees:
(i) who have taken claims during last 2 years (i.e. Both Policy Periods: 2022-23 & 2023-24) or
(ii) who have taken claims for more than Rs. 1 Lac during last year (i.e. policy period 2023-24).
C) 30% extra premium will be charged who have taken claims during last 03 years (i.e. 2021-22;
2022- 23 and 2023-24) or last year loading was 20%
D) If there is NIL claim in the last year policy then no loading will be applied.
Due to system constraints, loading amount will not be captured in the system and the same will be over
& above on system premium.
D) 50% Co-Payment for cyberknife treatment/Stem Cell Transplantation. Cochlear Implant treatment shall be
restricted to 50% of the Sum Insured.
E) All Claims for reimbursement should be submitted within 30 days from the date of discharge in case of
claim for hospitalization and Pre-hospitalization. Post hospitalization claims should be submitted within 75
days from the date of discharge. In case of any delay beyond this period, the claim would invite additional
10% co-payment over and above payable amount or insurer reserve the right to repudiate the claim as per
policy terms and conditions.
Exclusions to Mediclaim:
a) Dental treatment is not covered under this policy.
b) OPD expenses except any accidental injury as explained above.
c) Cost of spectacles, lens and hearing aids, congenital disease or defects and use of intoxication
drugs/alcohol, injuries and diseases related to terrorism, war and war like operations, STD’s and HIV,
self/intentional injury, treatment related to naturopathy or aesthetic treatment, charges incurred for
diagnostic, X-ray or lab examinations, not consistent with the diagnosis, expenses on vitamins and tonics
unless forming part of treatment for injury or diseases as certified by the attending physician.
d) Domiciliary hospitalization is excluded under the policy.
e) Disease or injury caused by war, war like operation, nuclear weapons, Ionising radiation, contamination by
radioactive material nuclear fuel & or waste.
f) Cosmetic, circumcision or aesthetic treatment, plastic surgery unless required to treat any injury or illness.
g) Vaccination and Inoculation.
h) Convalescence, general debility, run down condition or rest cure, obesity treatment and its complication,
congenital external disease / defects or anomalies, treatment related to all psychiatric and psychosomatic
disorder, infertility, sterility, use of intoxicating drugs / alcohol, use of tobacco leading to cancer.
i) Bodily injury or sickness due to willful or deliberate exposure to danger, intentional self-inflicted injury,
attempted suicide and arising out of non-adherence to any medical advice.
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Mediclaim Policy 01.09.2024 to 31.08.2025
j) Bodily injury sustained whilst or result of active participation in hazardous sports of any kind.
k) Bodily injury sustained whilst or result of active participating in any criminal act.
l) Genetic disorders.
m) Treatment taken outside India.
n) Any naturopathy treatment.
o) Instruments used in treatment of Sleep Apnea Syndrome and Continuous Peritoneal Ambulatory Dialysis
and Oxygen Concentrator for Bronchial Asthmatic condition.
p) Experimental and unproven treatment.
q) All non-medical expenses including convenience items for personal comfort such as telephone, television,
Ayah, private nursing/ barber or beauty service, diet charges, baby food, cosmetics, tissue papers, diapers,
sanitary pads, toiletry items and similar incidental expenses.
All other conditions will be as per standard IRDA guidelines.
➢ Other Guidelines:
1) E-Card will be issued as per last year.
2) For reimbursement cases, complete claim documents will be sent by the employee to insurer.
3) If require, claim documents can be verified by the concerned HR team. Corporate insurance
department will intervene in case of any complexity/escalation.
4) Courier charges for the dispatch of claim documents will be borne by the employee.
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Mediclaim Policy 01.09.2024 to 31.08.2025
Reimbursement Procedure
1) Fill claim form part-A, B, C (Part-B will be filled by the hospital). Part-B is not required when insured
person is claiming only Pre-Post medical expenses.
2) Complete set of original mediclaim documents should be attached. Like: Admission Card, IPD Papers,
Original hospital bills, Original payment receipts, Original Lab Test / X-Ray/ MRI / ECG / etc.
Reports/Implant Lens Sticker & Payment receipts, Original Pharmacy Bills, Original Discharge Summary
with compete treatment details. Also, attach cancelled cheque copy (pre-printed name) of the
employee & any govt. id card copy of the patient.
3) Kindly send hard copy of complete documents on below mentioned address.
Claims Team, ICICI Lombard Health Care, ICICI Lombard General Insurance Company Limited,
5th Floor, Varun Towers-II, Opp Hyderabad Public School, Begumpet, Hyderabad -500016, Telangana
4) After receiving of claim documents at office of insurer, insured employee will get the email/sms
confirmation on email id/mobile number mentioned in the claim form by the insured employee.
5) Claim status can be checked online through below mentioned link:
https://ilhc.icicilombard.com/Customer/ClaimStatus
6) Kindly keep the photocopy or scan copy of mediclaim documents for future reference.
Claim Form A, B, Mediclaim Expenses
C.pdf Annexure.xls
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Mediclaim Policy 01.09.2024 to 31.08.2025
Mediclaim Cashless Process
Insured employees / members can avail the health claims benefits from ICICI Lombard General Insurance
Company Limited through the following cashless mode:
Insured Member Approaches Network
Hospital for Cashless
Hospital receives
cashless approval
• Insured employee / member needs to mandatorily provide Mediclaim E-Card/UHID and g o v t .
Photo identityproof of insured employee and patient to the hospital desk for cashless treatment.
• Approvals are provided as per the terms & conditions of the policy and agreement with the
networkhospital.
• Cashless facility can be availed in all the network hospitals across India. The list of network
hospitalscan be obtained from the website.
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