Key Information Sheet

(LEGAL DISCLAIMER) NOTE: The information mentioned below is illustrative and not exhaustive. The information must be read in conjunction
with the policy wordings. In case of any conflict between the Key Information Sheet and the policy wordings, the terms and conditions mentioned
in the policy wordings shall prevail.

S. NO. TITLE DESCRIPTION REFER TO POLICY

WORDINGS

1. Product Name iHealth

2. What is covered Benefit Table as per Sum Insured Opted: Part II of the Schedule
under the policy Clause 2. Scope of Cover
Sum Insured 2 lacs 3 lacs/4 lacs/5 lacs 7 lacs /10 lacs
Extension HC 7 - Domestic Road
Pre Hospitalisation 30 Days Emergency Ambulance Cover

Post Hospitalisation 60 Days

Day Care Procedures/
Treatment Covered
Domestic Road
Emergency Ambulance ` 1,500 per event of hospitalisation
Pre Existing Diseases After 4 Years After 2 Years

3. Optional Add On Add On Cover/Sum Extension HC 2 - Hospital Daily

Insured 2 lacs 3 lacs/4 lacs/5 lacs 7 lacs /10 lacs Cash
Covers
Extension HC 3 - Convalescence
Hospital Daily Cash ` 500 per day ` 1,000 per day ` 2,000 per day Benefit

Convalescence Benefit ` 10,000 Extension HC 10 - Critical Illness

Cover
Critical Illness As per Sum Insured Extension HC 9 - Donor Expenses

Donor Expenses N.A. Upto ` 50,000

4. Value Added a) Free health check-up coupon to Insured for every Policy Year, subject to a maximum of 2 Extension HC 32 - Value-
Services coupons per year for floater policies. Added Services
b) Online Chat with Medical Practitioners
c) Specialist e-Consultation with One Follow-up session
d) Diet & Nutrition e-consultation
e) Physiotherapy, Speech & Audiologist Consultation
f) Vaccination Care
g) Discount Vouchers
5. What are the major Note: Following is an indicative list of the policy exclusions. Please refer to the policy clauses Part II of the schedule
Exclusions in the for the complete list Clause 3.3 Permanent
Policy a) Naturopathy treatment, acupressure, acupuncture, magnetic and such other therapies Exclusions
b) Non-allopathic medicine, Unproven/Experimental treatment
c) Any expenses arising out of Domiciliary Treatment
d) Treatment taken outside the country
e) Cosmetic surgery
f) Sterility, venereal diseases or any sexually transmitted diseases
g) Dental treatment unless due to accident
h) Any case directly or indirectly related to criminal acts
i) Refractive error correction, hearing impairment correction
j) Substance abuse, self-inflicted injuries, STDs and HIV / AIDS
k) Hazardous sports, war, civil war or breach of law

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 6. Waiting Period a) Initial waiting period: 30 days for all illnesses (except Hospitalisation Part II of the schedule
due to injury)
Clause 3.1
b) Specific waiting periods: First 24 months, for specific Illness and
treatment. (Please refer to the policy clauses for the full listing) Clause 3.2
c) Pre-existing diseases: Covered after 48 months of continuous coverage Clause 3.3
for Annual Sum Insured of 1 lac and 2 lacs; for rest 24 months
d) 36 months waiting period for maternity benefit

7. Payout Basis a) Cashless or Reimbursement of covered medical expenses up to specified Part II of the schedule
Sum Insured as per the scope of cover 4. Claim Administration
b) Cashless Facility available at over 4000+ network hospitals

8. Sub Limit a) Sub limit options of A and B available for Sum Insured option 2 lacs and Extension HC 28 - Sub limits
Sub limit C option is available for 3 lacs /4 lacs/ 5 lacs on Medical
b) No Sub limits applicable on Sun Insured 7 lacs/10lacs Expenses/Illness/Surgeries/
Procedures

9. Renewal Condition a) Maximum renewal age - There will be life-long renewable without any Part III of the schedule18.
age restriction for the cover Renewal notice
b) Grace Period - The renewal premium shall be paid to Us on or before the
date of expiry of the Policy and in no case later than 30 days (Grace
Period) from the expiry of the Policy
c) Floater Benefit - The floater benefit under this policy is available up to
lifetime
d) Inclusion/Exclusion of insured - This Policy allows Inclusion / exclusion
of an Insured only at the time of renewal of the Policy

10. Renewal Benefits Cumulative Bonus (Additional Sum Insured) – An Additional Sum Insured Part II of the schedule2.
of10% of Annual Sum Insured provided on each renewal for every claim-free Scope of Cover
year up to a maximum of 50%. In case of a claim under the policy, the
accumulated Additional Sum Insured will be reduced by 10% of the Annual
Sum Insured in the following year"

11. Cancellation a) Disclosure to information norm The Policy shall be void and all premium Part III of the schedule
paid hereon shall be forfeited to the Company, in the event of 13. Cancellation/Termination
misrepresentation, mis-description or non-disclosure of any material
fact
b) You may cancel this Policy by giving Us 15 days written notice for the
cancellation of the Policy by registered post, and then We shall refund
premium on short term rates for the unexpired Policy Period.

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 Policy Wording
PREAMBLE i. Internal Congenital Anomaly -Congenital anomaly which is not in
ICICI Lombard General Insurance Company Limited ("We / Us"), the visible and accessible parts of the body
having received a Proposal and the premium from the Policy Holder ii. External Congenital Anomaly- Congenital anomaly which is in the
named in Part I of the Policy (hereinafter referred to as the "Policy visible parts of the body
Schedule") and the said Proposal and Declaration together with any Condition Precedent shall mean a policy term or condition upon
statement, report or other document leading to the issue of this Policy which the Insurer's liability under the policy is conditional upon.
and referred to therein having been accepted and agreed to by Us and Cashless Facility means a facility extended by the insurer to the
the Policy Holder as the basis of this contract do, by this Policy agree, insured where the payments, of the costs of treatment undergone by
in consideration of and subject to the due receipt of the subsequent the insured in accordance with the policy terms and conditions, are
premiums, as set out in the Policy Schedule, and further, subject to directly made to the network provider by the insurer to the extent pre-
the terms and conditions contained in this Policy that on proof to Our authorization approved.
satisfaction of the compensation having become payable as set out in
Claim means a demand made by You or on Your behalf for payment of
the Policy Schedule to the title of the said person or persons claiming
Medical Expenses or any other expenses or benefits, as covered
payment or upon the happening of an event upon which one or more
under the Policy.
benefits become payable under this Policy, the Annual Sum Insured /
appropriate benefit amount will be paid by Us. Cumulative Bonus shall mean any increase in the Sum Insured
granted by the insurer without an associated increase in premium.
PART II OF THE POLICY Day Care Treatment refers to medical treatment, and/or Surgical
1. DEFINITIONS Procedure which is:
For the purposes of this Policy, the terms specified below shall have i. Undertaken under General or Local Anesthesia in a Hospital/Day
the meaning set forth wherever appearing/specified in this Policy or care centre in less than 24 hrs because of technological
related Extensions/Endorsements: advancement, and
Where the context so requires, references to the singular shall also ii. Which would have otherwise required a hospitalization of more
include references to the plural and references to any gender shall than 24 hours. Treatment normally taken on an out-patient basis
include references to all genders. Further any references to statutory is not included in the scope of this definition.
enactment include subsequent changes to the same. Day care centre means any institution established for day care
Accident means a sudden, unforeseen and involuntary event caused treatment of Illness and / or injuries or a medical set -up within a
by external, and visible and violent means. hospital and which has been registered with the local authorities,
Admission means Your admission in a Hospital as an inpatient for the wherever applicable, and is under the supervision of a registered and
purpose of medical treatment of an Injury and/or Illness. qualified medical practitioner AND must comply with all minimum
criteria as under:- has qualified nursing staff under its employment;
Alternative treatments are forms of treatments other than treatment
has qualified medical practitioner (s) in charge; has a fully equipped
"Allopathy" or "modem medicine" and includes Ayurveda, Unani,
operation theatre of its own where surgical procedures are carried
Sidha and Homeopathy in the Indian context.
out- maintains daily records of patients and will make these
Annual Sum Insured means and denotes the maximum amount of accessible to the Insurance company's authorized personnel.
cover available to You during each Policy Year of the Policy Period, as
Deductible is a cost sharing requirement under a health insurance
stated in the Policy Schedule or any revisions thereof based on Claim
policy that provides that We will not be liable for specified rupee
settled under the Policy.
amount in case of indemnity policies and for a specified number of
Any one illness means continuous Period of illness and it includes days/hours in case of hospital cash policy, which will apply before
relapse within 45 days from the date of last consultation with the any benefits are payable by Us. This is to clarify that a deductible does
Hospital/Nursing Home where treatment may have been taken. not reduce the sum insured.
Break in Policy occurs at the end of the existing policy term, when Domiciliary Hospitalisation means medical treatment for an
the premium due for renewal on a given policy is not paid on or before illness/disease/injury which in the normal course would require care
the premium renewal date or within 30 days thereof. and treatment at a hospital but is actually taken while confined at
Contribution is essentially the right of an insurer to call upon other home under any of the following circumstances:
insurers, liable to the same insured, to share the cost of an indemnity i. The condition of the patient is such that he/she is not in a
claim on a ratable proportion of Sum Insured. This clause shall not condition to be removed to a hospital, or
apply to any Benefit offered on fixed benefit basis.
ii. The patient takes treatment at home on account of non
Congenital Anomaly refers to a condition(s) which is present since availability of room in a hospital.
birth, and which is abnormal with reference to form, structure or
position.

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Dental treatment is treatment carried out by a dental practitioner Lifetime Sum Insured means and denotes the maximum amount of
including examinations, fillings (where appropriate), crowns, cover available to You, over the Period of Insurance, as stated in the
extractions and surgery excluding any form of cosmetic Policy Schedule or any revisions thereof based on Claims settled
surgery/implants. under each Policy Year of the Policy Period under this Policy.
Grace Period means the specified period of time immediately Maternity expenses shall include -
following the premium due date during which a payment can be made i. Medical treatment expenses traceable to childbirth (including
to renew or continue a policy in force without loss of continuity complicated deliveries and caesarean sections incurred during
benefits such as waiting periods and coverage of Pre Existing Hospitalization);
Diseases. Coverage is not available for the period for which no ii. Expenses towards lawful medical termination of pregnancy
premium is received. during the policy period .
Hospital means any institution established for in- patient care and Maximum Limit of Indemnity is an amount as stated in the Policy
day care treatment of illness and / or injuries and which has been Schedule, which denotes the following:
registered as a hospital with the local authorities under the Clinical
i. Where Lifetime Sum Insured is applicable: It denotes the lower of
Establishments (Registration and Regulations) Act 2010 or under
the Annual Sum Insured (including Additional Sum Insured,
enactments specified under the Schedule of Section 56(1) of the said
where applicable and as specified in the Policy Schedule)) or the
Act OR comply with all minimum criteria as under:
Lifetime Sum Insured during each Policy Year of the Policy Period
i. Has at least 10 inpatient beds, in those towns having a
ii. Where Lifetime Sum Insured is not applicable: It denotes the
population of less than 10,00,000 and 15 inpatient beds in all
Annual Sum Insured (including Additional Sum Insured, where
other places;
applicable and as specified in the Policy Schedule) during each
ii. Has qualified nursing staff under its employment round the clock; Policy Year of the Policy Period
iii. has qualified medical practitioner (s) in charge round the clock; Medical Advise means any consultation or advice from a Medical
iv. Has a fully equipped operation theatre of its own where surgical Practitioner including the issue of any prescription or repeat
procedures are carried out prescription.
v. Maintains daily records of patients and will make these Medical Expenses means those expenses that an Insured Person
accessible to the Insurance company's authorized personnel. has necessarily and actually incurred for medical treatment on
Hospitalisation means admission in a Hospital for a minimum period account of Illness or Accident on the advice of a Medical Practitioner,
of 24 In patient Care and consecutive hours except for specified Day as long as these are no more than would have been payable if the
Care Procedures/Treatments, where such admission could be for a Insured Person had not been insured and no more than other hospitals
period of less than 24 consecutive hours.. or doctors in the same locality would have charged for the same
Inpatient care means treatment for which the insured person has to medical treatment.
stay in a Hospital for more than 24 hours for a covered event. Medical Practitioner is a person who holds a valid registration from
Illness means a sickness or disease or pathological condition leading Medical Council of any State or Medical Council of India or Council for
to the impairment of normal physiological function which manifests Indian Medicine or for Homeopathy set up by the Government of India
itself during the Policy Period and requires medical treatment. or a State Government and is thereby entitled to practice medicine
i. Acute condition - Acute condition is a disease, illness or injury within its jurisdiction; and is acting within the scope and jurisdiction
that is likely to respond quickly to treatment which aims to return of his license. The term Medical Practitioner would include physician,
the person to his or her state of health immediately before specialist, anaesthetist and surgeon but would exclude You and Your
suffering the disease/illness/injury which leads to full recovery. Immediate Family. "Immediate Family would comprise of Your
spouse, dependent children, brother(s), sister(s) and dependent
ii. Chronic condition - A chronic condition is defined as a disease,
parent(s).
illness, or injury that has one or more of the following
characteristics:-it needs ongoing or long-term monitoring Newborn Baby means baby born during the Policy Period and is aged
through consultations, examinations, check-ups, and / or tests-it between 1 day and 90 days, both days inclusive.
needs ongoing or long-term control or relief of symptoms- it Network Provider means the Hospitals, health care providers, day
requires your rehabilitation or for you to be specially trained to care centers or other providers which have been empanelled by Us or
cope with it-it continues indefinitely-it comes back or is likely to Our appointed TPA to provide services like cashless access to the
come back. Insured Person, for the provision of medical treatment. The list of the
Injury means any accidental physical bodily harm occurring during Network Porviders is available with Us/ TPA and is subject to
the Policy Period, excluding illness or disease solely and directly amendment from time to time.
cased by external, violent, visible and evident means which is verified Non- Network means any Hospital, day care centre or other provider
and certified by a Medical Practitioner. that is not part of the Network.
Insured/Insured Person(s) means the individual(s) whose name(s) Notification/Intimation of claim is the process of notifying a claim
is/are specifically appearing as such in the Policy Schedule and is/are to the insurer or TPA by specifying the timelines as well as the
hereinafter referred as "You"/"Your"/ "Yours"/ "Yourself" address / telephone number to which it should be notified.

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Out-patient means the Insured who is not hospitalized for more than ii. The In-patient Hospitalization claim for such Hospitalization is
24 consecutive hours but who visits a Hospital, clinic, or associated admissible by the Insurance Company.
facility for diagnosis or treatment. However any Insured undergoing
Qualified Nurse is a person who holds a valid registration from the
any specified "Day care surgeries/Treatment" will not be considered
Nursing Council of India or the Nursing Council of any state in India.
as an Out-patient.
Renewal defines the terms on which the contract of insurance can be
OPD treatment is one in which the Insured visits a clinic / hospital or
renewed on mutual consent with a provision of grace period for
associated facility like a consultation room for diagnosis and
treating the renewal continuous for the purpose of all waiting periods.
treatment based on the advice of a Medical Practitioner. The Insured
is not admitted as a day care or in-patient. Reasonable and Customery Charges means the charges for
services or supplies, which are the standard charges for the specific
Period of Insurance means the period as specifically appearing in
provider and consistent with the prevailing charges in the
the Policy Schedule and commencing from the Policy Period Start
geographical area for identical or similar services, taking into account
Date of the first Policy taken by You from Us and then, running
the nature of Illness/injury involved.
concurrent to Your current Policy subject to the Your continuous
renewal of such Policy with Us. Room Rent means the amount charged by a hospital for the
occupancy of a bed on per day (24 hours ) basis and shall include
Policy means these Policy wordings, the Policy Schedule and any
associated medical expenses.
applicable endorsements or extensions attaching to or forming part
thereof. The Policy contains details of the extent of cover available to Senior Citizen means any person who has completed sixty or more
You, what is excluded from the cover and the terms & conditions on years of age as on the date of commencement or renewal of a health
which the Policy is issued to You. insurance policy.

Policy Holder means the person(s) or the entity named in the Policy Subrogation shall mean the right of the insurer to assume the rights
Schedule who executed the Policy Schedule and is (are) responsible of the insured person to recover expenses paid out under the policy
for payment of premium(s). that may be recovered from any other source.

Policy Period means the period commencing from the Policy Period Surgery or Surgical Procedure means manual and/or operative
Start Date, Time and ending at the Policy Period End Date, Time of the procedure (s) required for treatment of an illness or injury, correction
Policy and as specifically appearing in the Policy Schedule. of deformities and defects, diagnosis and cure of diseases, relief of
suffering or prolongation of life, performed in a hospital or day care
Policy Year means a period of twelve months beginning from the
centre by a Medical Practitioner.
Policy Period Start Date and ending on the last day of such twelve-
month period. For the purpose of subsequent years, "Policy Year" shall Third Party Administrator (TPA) means the services rendered by a
mean a period of twelve months beginning from the end of the TPA to an insurer under an agreement in connection with health
previous Policy Year and lapsing on the last day of such twelve-month insurance business but does not include the business of an insurance
period, till the Policy Period End Date, as specified in the Policy company or the soliciting either directly or indirectly, of health
Schedule insurance business or deciding on the admissibility of a claim or its
rejection.
Portability means transfer by an individual health insurance
policyholder (including Family cover) of the credit gainer for pre- Unproven/Experimental treatment means any treatment including
existing conditions and time-bound exclusions if he/she chooses to drug experimental therapy which is not based on established medical
switch from one insurer to another practice in India.

Pre-existing Disease means any condition, ailment or injury or You/Your/ Yours/ Yourself means the person(s) that We insure and
related condition(s) for which You had signs or symptoms, and / or is/are specifically named as Insured / Insured Person(s) in the Policy
were diagnosed, and / or received medical advice/ treatment, within Schedule.
48 months prior to the first policy issued by the insurer. We/ Our/ Ours/ Us means the ICICI Lombard General Insurance
Post Hospitalisation Medical Expenses means medical expenses Company Limited
incurred immediately after the Insured Person is discharged from the 2. WHAT WE WILL PAY (SCOPE OF COVER)
hospital, provided that: A) In-patient Treatment
i. Such Medical Expenses are incurred for the same condition for We hereby agree subject to terms, conditions and exclusions herein
which the Insured Person's Hospitalisation was required, and contained or otherwise expressed hereon that, if during the Policy
ii. The In-patient Hospitalization claim for such Hospitalization is Period, You require Hospitalization for any Illness or Injury on the
admissible by the Insurance Company. written advice of a Medical Practitioner, then We will indemnify the
Pre Hospitalisation means medical expenses incurred immediately Medical Expenses so incurred by You.
before the Insured Person is Hospitalized, provided that: However, Our total liability under this Policy for payment of any and all
i. Such Medical Expenses are incurred for the same condition for Claims in aggregate during each Policy Year of the Policy Period shall
which the Insured Person's Hospitalisation was required, and not exceed the Maximum Limit of Indemnity as stated in the Policy
Schedule.

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B) Day Care Procedures/Treatment 3.1 Any Pre-Existing condition(s) until 24 months of Your continuous
We hereby agree subject to terms, conditions and exclusions herein coverage has elapsed, since Period of Insurance Start Date.
contained or otherwise expressed hereon that, if during the Policy If the Policy is renewed for an enhanced Annual Sum Insured, then the
Period, You require Hospitalization as an inpatient for less than 24 benefit in respect of the Pre-existing Condition(s) shall be restricted
hours in a Hospital (but not in the outpatient department of a to the Maximum Limit of Indemnity that is lowest under the Period of
Hospital)on the written advice of a Medical Practitioner, then We will Insurance
pay You for the Medical Expenses incurred for undergoing such Day Any Illness contracted within 30 days of Period of Insurance Start
Care Procedure/Treatment or surgery, (as is mentioned in the list of Date, except those incurred as a result of Injury.
Day Care Procedures/Treatments annexed to this Policy and also 3.2 Any Medical Expenses incurred by You on treatment of following
available on our website www.icicilombard.com). Illnesses within the first two (2) consecutive years of Period of
However, Our total liability under this cover for payment of any and all Insurance Start Date:
Claims in aggregate during each Policy Year of the Policy Period shall i. Cataract*
not exceed the Maximum Limit of Indemnity as stated in the Policy
ii. Benign Prostatic Hypertrophy
Schedule.
iii. Myomectomy, Hysterectomy unless because of malignancy
C) Pre-Hospitalization and Post-Hospitalization Expenses
iv. All types of Hernia, Hydrocele
We hereby agree subject to the terms, conditions and exclusions
herein contained or otherwise expressed hereon that, We will v. Fissures &/or Fistula in anus, hemorrhoids/piles
compensate You for the relevant Medical Expenses incurred by You in vi. Arthritis, gout, rheumatism and spinal disorders
relation to: vii. Joint replacements unless due to accident
i. Pre-hospitalization Medical Expenses incurred by You for a 30- viii. Sinusitis and related disorders
day period immediately prior to Your Hospitalization; and ix. Stones in the urinary and billiary systems
ii. Post-hospitalization Medical Expenses incurred by You for a 60- x. Dilatation and curettage , Endometriosis
day period immediately post Hospitalization, provided that Your
xi. All types of Skin and internal tumors/ cysts/nodules/ polyps of
Hospitalization falls within the Policy Period and We have
any kind including breast lumps unless malignant
accepted Your Claim under "In-patient Treatment" or "Day Care
Procedures" section of the Policy. xii. Dialysis required for chronic renal failure

However, Our total liability under this Policy for payment of any and all xiii. Surgery on tonsils, adenoids and sinuses
Claims in aggregate during each Policy Year of the Policy Period shall xiv. Gastric and Duodenal erosions & ulcers
not exceed the Maximum Limit of Indemnity as stated in the Policy xv. Deviated Nasal Septum
Schedule. xvi. Varicose Veins/ Varicose Ulcers
Cumulative Bonus under the Policy-It is hereby declared and agreed *After two years from the Period of Insurance Start Date, Our
that notwithstanding anything to the contrary in the Policy, at the time maximum liability arising out of any Claim for a cataract treatment
of renewal of this Policy, We will provide an additional sum insured shall not exceed `20,000 per eye, during each Policy Year of the
(hereinafter referred to as "Additional Sum Insured") of 10% of Annual Policy Period
Sum Insured for all Insured persons provided that there is no Claim In case the above Illnesses are Pre-existing condition(s) at the
under this Policy during the Policy Period except as an Out-patient. commencement of this Policy, then these Illnesses shall be covered
However, in the event of a Claim under the Policy during any after 24 months of continuous coverage has elapsed, since Period of
subsequent Policy Period, the accrued Additional Sum Insured will be Insurance Start Date.
reduced by 10% of the Annual Sum Insured at the time of renewal of 3.3 Permanent Exclusions
this Policy. This extension is also subject to the following:
Unless covered by way of an appropriate Extension/Endorsement,
In relation to a Floater Benefit cover, the Additional Sum Insured so We shall not be liable to make any payment under this Policy in
accrued during the Claim-free Policy Period(s) will also be on floater connection with or in respect of any expenses whatsoever incurred
basis and will only be available to those Insured Person(s) who were by You in connection with or in respect of:
insured in such Claim-free Policy Period(s) and continue to be insured
i. Any physical, medical or mental condition or treatment or
in the subsequent Policy Period(s).
service that is specifically excluded in the Policy Schedule
3. WHAT WE WILL NOT PAY (EXCLUSIONS UNDER THE POLICY) under Special Conditions
We will not be liable for any Deductible amount, if applicable and as ii. Cost of routine medical, eye and ear examinations,
specifically defined in the Policy Schedule under the Policy preventive health check-up, cost of spectacles, laser
We shall not be liable to make any payment under this Policy in surgery for correction of refractory errors, contact lenses or
connection with or in respect of any expenses whatsoever incurred hearing aids, dentures and artificial teeth
by You in connection with or in respect of:

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iii. Any expenses incurred on prosthesis, corrective devices, the diagnosis and treatment of the positive existence or
external durable medical equipment of any kind, like presence of any Illness or Injury, whether or not requiring
wheelchairs, crutches, instruments used in treatment of Hospitalisation
sleep apnoea syndrome or continuous ambulatory xvii. Expenses on supplements, vitamins and tonics unless
peritoneal dialysis (C.A.P.D.) and oxygen concentrator for forming part of treatment for Injury or Illness as certified by
bronchial asthmatic condition, cost of cochlear implant(s) the attending Medical Practitioner
unless necessitated by an Accident or required intra- xviii. Weight management services and treatment, vitamins and
operatively Expenses incurred on all dental treatment unless tonics related to weight reduction programmes including
necessitated due to an Accident treatment of obesity (including morbid obesity), any
iv. Personal comfort, cosmetics, convenience and hygiene treatment related to sleep disorder or sleep apnoea
related items and services syndrome, general debility, convalescence, run-down
v. Naturopathy treatment, acupressure, acupuncture, condition and rest cure
magnetic and such other therapies xix. Cost incurred for any health check-up or for the purpose of
vi. Circumcision unless necessary for treatment of an Illness or issuance of medical certificates and examinations required
necessitated due to an Accident. for employment or travel or any other such purpose
vii. Vaccination or inoculation of any kind, unless it is post xx. Experimental, unproven or non-standard treatment which is
animal bite not consistent with or incidental to the usual diagnosis and
viii. Sterility, venereal disease or any sexually transmitted treatment of any Illness or Injury
disease xxi. Any case directly or indirectly related to criminal acts
ix. Intentional self-injury (whether arising from an attempt to xxii. Any expenses arising out of Domiciliary Hospitalisation
commit suicide or otherwise) and Injury or Illness due to xxiii. Treatment taken outside the country
use, misuse or abuse of intoxicating drugs or alcohol xxiv. Treatment taken from anyone not falling within the scope of
x. Any expense incurred on treatment of mental Illness, stress, definition of Medical Practitioner. Any treatment charges or
psychiatric or psychological disorders fees charged by any Medical Practitioner acting outside the
xi. Aesthetic treatment, cosmetic surgery and plastic surgery scope of licence or registration granted to him by any
including any complications arising out of or attributable to medical council
these, unless necessitated due to Accident or as a part of xxv. Any Illness or Injury resulting or arising from or occurring
any Illness during the commission of continuing perpetration of a
xii. Any treatment/surgery for change of sex or treatment violation of law by You with criminal intent
/surgery /complications/Illness arising as a consequence xxvi. Expenses related to donor screening, treatment, including
thereof surgery to remove organs from a donor in the case of
xiii. Any expense incurred on treatment arising from or traceable transplant surgery
to pregnancy (including voluntary termination of pregnancy, xxvii. Alternative treatment
childbirth, miscarriage, abortion or complications of any of xxviii. Any travel or transportation expenses including ambulance
these, including caesarean section) and any fertility, charges
infertility, sub fertility or assisted conception treatment or
xxix. Any consequential or indirect loss or expenses arising out of
sterilization or procedure, birth control procedures and
or related to Hospitalization
hormone replacement therapy. However, this exclusion
does not apply to ectopic pregnancy proved by diagnostic xxx. Any Injury or Illness directly or indirectly caused by or
means and is certified to be life threatening by the Medical arising from or attributable to war, invasion, acts of foreign
Practitioner. enemies, hostilities (whether war be declared or not), civil
war, commotion, unrest, rebellion, revolution, insurrection,
xiv. Treatment relating to birth defects and all congenital
military or usurped power or confiscation or nationalisation
Illnesses or defects or anomalies
or requisition of or damage by or under the order of any
xv. All expenses arising out of any condition directly or government or public local authority
indirectly caused to or associated with Acquired Immuno
xxxi. Any Illness or Injury directly or indirectly caused by or
Deficiency Syndrome (AIDS) whether or not arising out of
contributed to by nuclear weapons/materials or contributed
HIV, Human T-Cell Lymphotropic Virus Type III (HTLV-III or
to by or arising from ionising radiation or contamination by
IITLB-III) or Lymphadinopathy Associated Virus (LAV) or the
radioactivity by any nuclear fuel or from any nuclear waste
Mutants Derivative or Variations Deficiency Syndrome or
or from the combustion of nuclear fuel
any Syndrome or condition of a similar kind
4. CLAIM ADMINISTRATION
xvi. Charges incurred at Hospital primarily for evaluative or
diagnostic or observation purposes for which no active The fulfillment of the terms and conditions of this Policy (including
treatment is given, X-Ray or laboratory examinations or payment of premium by the due dates mentioned in the Policy
other diagnostic studies, not consistent with or incidental to

11
Schedule) insofar as they relate to anything to be done or complied documentation (written details of the quantum of any Claim
with by each of You shall be conditions precedent to admission of Our along with all original supporting documentation) as more
liability. particularly listed in CLAIM DOCUMENTS section
Further, upon the discovery or happening of any Illness or Injury that However, in both the above cases i.e. 4.1 (A) & (B), You must take
may give rise to a Claim under this Policy, then as a condition reasonable steps or measure to minimise the quantum of any Claim
precedent to the admission of Our liability, You shall undertake the that may be covered under the Policy
following: If so requested by Us or Our TPA, You will have to undergo a medical
4.1 CLAIMS PROCEDURE examination from Our nominated Medical Practitioner, as and when
A) For Cashless Settlement We or Our TPA considers reasonable and necessary. The cost of such
Cashless treatment is only available at a Network Provider (List of examination will be borne by Us.
Network Providers is available at our website). In order to avail of Settlement/Rejection of Claim - The settlement of claims would be
cashless treatment, the following procedure must be followed by You: done by Us within 30 days, after the receipt of last necessary
Pre-authorization document, any rejections if done, would be provided with proper
reasons by Us. The role of the TPA (if any) would be limited to
Prior to taking treatment and/or incurring Medical Expenses at a
facilitate the flow of information between You and Us.
Network Provider, You must contact Us or Our TPA accompanied with
full particulars namely, Policy Number, Your name, Your relationship Penal interest provision shall be as per Regulation 9(6) of (Protection
with Policy Holder, nature of Illness or Injury, name and address of the of Policyholders' Interests) Regulations, 2002.
Medical Practitioner/ Hospital and any other information that may be 4.2 CLAIM DOCUMENTS
relevant to the Illness/ Injury/ Hospitalisation. You must request pre- You shall be required to furnish the following documents for or in
authorisation at least 48 hours before a planned Hospitalization and in support of a Claim:
case of an emergency situation, within 24 hours of Hospitalization. To i. Duly completed Claim form signed by You and the Medical
avail of Cashless Hospitalization facility, you are required to produce Practitioner
the health card, as provided to You with this Policy, subject to the ii. Original bills, receipts and discharge certificate/card from the
terms and conditions for the usage of the said health card. We will Hospital/Medical Practitioner
consider Your request after having obtained accurate and complete
iii. Original bills from chemists supported by proper prescription.
information for the Illness or Injury for which cashless Hospitalization
facility is sought by You and We will confirm Your request in writing. iv. Original investigation test reports and payment receipts.
B) For Reimbursement Settlement v. Indoor case papers
i. You shall give notice to Us or Our TPA by calling the toll free vi. Medical Practitioner's referral letter advising Hospitalization in
number as specified in the Policy provided to You and also in non-Accident cases.
writing at Our address with particulars as below: vii. Any other document as required by Us or Our TPA to investigate
• Policy number; the Claim or Our obligation to make payment for it
• Your Name; 5. SPECIAL CONDITIONS APPLICABLE TO THE POLICY
• Your relationship with the Policyholder; It is hereby declared and agreed that:
• Nature of Illness or Injury; i. Any notice or declaration for Your attention shall be deemed
served if sent by Us to the Policy Holder at his/her latest known
• Name and address of the attending Medical Practitioner and
address
the Hospital;
ii. Any payment due to You under this Policy shall be paid to the
• Any other information that may be relevant to the Illness/
Policy Holder by Us. We shall not be responsible for any liability
Injury/Hospitalisation
arising out of the Policy Holder's delay or default in making
The above information needs to be provided to Us or Our TPA payment to You. However, We also reserve Our right to pay the
immediately and in any event within 10 days of Hospitalization, failing Claim directly to You or to the Hospital or to someone on Your
which We will have the right to treat the Claim as inadmissible, as We behalf. The receipt by the Policy Holder /You or Hospital or
may deem fit at Our sole discretion. someone claiming on Your behalf shall be considered as a
ii. You must immediately consult a Medical Practitioner and follow complete discharge of Our liability against any Claim under the
the advice and treatment that he recommends. Policy.
iii. You or someone claiming on Your behalf must promptly and in iii. We shall have no liability under this Policy, once the Maximum
any event within 30 days of Your discharge from a Hospital (for Limit of Indemnity, as stated in the Policy Schedule, is exhausted
post-hospitalization expenses, within 30 days from the by You.
completion of post-hospitalization period) deliver to Us the

12
iv. For any payment to be made by US under any Claim arising under notice to or be held to bind or prejudicially affect Us notwithstanding
this Policy, We shall make the payment in India and in Indian subsequent acceptance of any premium.
rupees only. 7. Notice of charge etc.
Terms of Renewal We shall not be bound to take notice or be affected by any notice of
i. The Policy can be renewed under the then prevailing ICICI any trust, charge, lien, assignment or other dealing with or relating to
Lombard Complete Health Insurance product or its nearest this Policy, but the payment by Us to You or Your legal representative
substitute (in case the product ICICI Lombard Complete Health of any compensation or benefit under the Policy shall in all cases be an
Insurance is withdrawn by the Company) approved by IRDA. effectual discharge to Us.
ii. A health insurance policy shall ordinarily be renewable except on 8. Overriding effect of Part II of the Policy
grounds of fraud, moral hazard or misrepresentation or non- The terms and conditions contained herein and in Part II of the Policy
cooperation by the insured. shall be deemed to form part of the Policy and shall be read as if they
iii. Renewal Premium - Premium payable on renewal and on are specifically incorporated herein; however in case of any
subsequent continuation of cover are subject to change with inconsistency of any term and condition with the scope of cover
prior approval from IRDA. contained in Part II of the Policy, then the term(s) and condition(s)
iv. Maximum Renewal Age - There will be life-long renewal contained herein shall be read mutatis mutandis with the scope of
without any age restriction for the cover. In cases where, cover/terms and conditions contained in Part II of the Policy and shall
Lifetime Sum Insured gets exhausted, We will allow You to buy a be deemed to be modified accordingly or superseded in case of
new Policy subject to terms and conditions under the new Policy. inconsistency being irreconcilable.
9. Your duties on occurrence of loss
PART III OF THE POLICY On the occurrence of any loss, within the scope of cover under the
General Terms and Conditions Policy You shall:
1. Incontestability and Duty of Disclosure i. Forthwith file/submit a Claim Form in accordance with 'Claim
The Policy shall be null and void and no benefit shall be payable in the Procedure' Clause as provided in Part II of the Policy.
event of untrue or incorrect statements, misrepresentation, mis- ii. Assist and not hinder or prevent Us or any of Our representative
description or on non-disclosure in any material particular in the from taking any reasonable steps in pursuance of their duties for
proposal form, personal statement, declaration and connected ascertaining the admissibility of the Claim under the Policy.
documents, or any material information having been withheld, or a If You do not comply with the provisions of this Clause or other
Claim being fraudulent or any fraudulent means or devices being used obligations cast upon You under this Policy, in terms of the other
by You or any one acting on Your behalf to obtain any benefit under this clauses referred to herein or in terms of the other clauses in any of the
Policy. Policy documents, all benefits under the Policy shall be forfeited, at
2. Reasonable Care Our option.
You shall take all reasonable steps to safeguard Your interests against 10. Subrogation
any Injury or Illness that may give rise to the Claim. You and any claimant under this Policy shall at no cost or expense to
3. Observance of terms and conditions Us do whatever is necessary to enable Us to enforce any rights and
The due observance and fulfilment of the terms, conditions and remedies or obtain relief or indemnity from other parties to which We
endorsement of this Policy in so far as they relate to anything to be would become entitled or subrogated upon Us paying for or making
done or complied with by You, shall be a condition precedent to any of good any Claim or loss under this Policy whether such acts and things
Our liability to make any payment under this Policy. shall be or become necessary or required by Us or otherwise before or
4. Material change after Your indemnification by Us. However, this condition shall not be
You shall notify Us in writing of any material change in the risk in applicable for all the benefit based covers under the Policy, as
relation to the declarations made in the proposal form or medical applicable.
examination report at each renewal and We may, adjust the scope of 11. Contribution
cover and / or premium, if necessary, accordingly. If at the time when any Claim arises under this Policy, there is any
5. Records to be maintained other insurance which covers (or would but for the existence of this
You shall keep an accurate record containing all relevant medical Policy) and the amount to be claimed exceeds the sum insured under
records and shall allow Us to inspect such records. You shall exercise a single policy after considering the deductibles or co-pay, in the
all necessary co-operation in obtaining the medical records from the same Claim (in whole or in part), then We shall not be liable to pay or
Hospital, and furnish them, as We may require in relation to the Claim contribute more than Our rateable proportion of any Claim.
within reasonable time limit and within the time limit specified in the However, this condition shall not be applicable for all the benefit
Policy. based covers under the Policy, as applicable
6. No constructive Notice
Any knowledge or information of any circumstances or condition in
Your connection in possession of any of Our officials shall not be the

13
12. Fraudulent Claims one to be appointed by each of the parties to the dispute/difference
If any Claim is in any respect fraudulent, or if any false statement, or and the third arbitrator to be appointed by such two arbitrators.
declaration is made or used in support thereof, or if any fraudulent Arbitration shall be conducted under and in accordance with the
means or devices are used by You or anyone acting on Your behalf to provisions of the Arbitration and Conciliation Act, 1996.
obtain any benefit under this Policy, or if a Claim is made and rejected It is clearly agreed and understood that no difference or dispute shall
and no court action or suit is commenced within twelve months after be referable to arbitration, as herein before provided, if the Company
such rejection or, in case of arbitration taking place as provided has disputed or not accepted liability under or in respect of this Policy.
therein, within twelve (12) calendar months after the Arbitrator or 17. Free Look Period
Arbitrators have made their award, all benefits under this Policy shall You would be given a period of 15 days (Free Look Period) from the
be forfeited. date of receipt of the Policy to review its terms and conditions. Where
13. Cancellation/ termination the Policy Holder disagrees to any of the terms or conditions of the
1. Disclosure to information norm Policy, he has the option to return the Policy stating the reasons for his
The Policy shall be void and all premium paid hereon shall be forfeited objection, when he shall be entitled to a refund of the premium paid,
to the Company, in the event o f misrepresentation, mis-description or subject only to a deduction of the expenses incurred by Us on medical
non-disclosure of any material. examination of the Insured Person(s) and the stamp duty charges. . In
case the request for cancellation comes 15 days after the Policy
2. You may cancel this Policy by giving Us 15 days written notice for
Period start date, refund of premium would be paid to You on short
the cancellation of the Policy by registered post, and then We
term basis.
shall refund premium on short term rates for the unexpired Policy
Period as per the rates detailed below, provided no claim has 18. Renewal notice
been payable on Your behalf under the Policy: i. We shall ordinarily renew the policy except on grounds of moral
hazard, misrepresentation or fraud or non cooperation by the
Cancellation Period
Insured. We shall not be bound to give notice that the renewal
Policy Within 1 From 1 Within 3 Within 6 During During
premium is due. Every renewal premium (which shall be paid and
Period month month to month to month to 2nd year 3rd year
3 month 6 month 1 year accepted in respect of this Policy) shall be so paid and accepted
upon the distinct understanding that no alteration has taken
1 year 75% 50% 25% 0% NA NA
place in the facts contained in the proposal or declaration herein
2 year 75% 65% 50% 25% 0% NA
before mentioned and that nothing is known to You that may
3 year 75% 70% 60% 45% 11% 0% result to enhance Our risk under the guarantee hereby given. Any
14. Cause of Action/ Currency for payments change in the risk will be intimated by You to Us. Nothing herein
No Claims shall be payable under this Policy unless the cause of or otherwise shall affect Our right to impose any additional terms
action arises in India, unless otherwise specifically provided in Policy and conditions on renewal or restrict any renewal terms as to
Schedule. The cause of action can arise anywhere in the world in case premium or otherwise.
of Personal Accident Cover (Extension HC 11), if available under the ii. The Policy may be renewed by mutual consent and in such event
Policy. All Claims shall be payable in India and shall be in Indian the renewal premium shall be paid to Us on or before the date of
Rupees only. expiry of the Policy and in no case later than Grace Period of 30
15. Policy Disputes days from the expiry of the Policy.
Any dispute concerning the interpretation of the terms, conditions, 19. Notices
limitations and/or exclusions contained herein is understood and Any notice, direction or instruction given under this Policy shall be in
agreed by both You and Us to be adjudicated or interpreted in writing and delivered by hand, post, or facsimile to:
accordance with the Laws of India and only competent Courts of India In Your case, at Your last known address.
shall have the exclusive jurisdiction to try all or any matters arising
In Our case:
hereunder. The matter shall be determined or adjudicated in
accordance with the law and practice of such Court. ICICI Lombard General Insurance Company Limited

16. Arbitration clause ICICI Lombard House, 414, Veer Savarkar Marg,

If any dispute or difference shall arise as to the quantum to be paid Near Siddhi Vinayak Temple, Prabhadevi, Mumbai 400025
under this Policy (liability being otherwise admitted) such difference Notice and instructions will be deemed served 7 days after posting or
shall independently of all other questions be referred to the decision of immediately upon receipt in the case of hand delivery, facsimile or e-
a sole arbitrator to be appointed in writing by the parties to the mail.
dispute/difference, or if they cannot agree upon a single arbitrator 20. Customer Service
within 30 days of any party invoking arbitration, the same shall be If at any time You require any clarification or assistance, You may
referred to a panel of three arbitrators, comprising of two arbitrators, contact Our offices at the address specified, during normal business
hours.

14
21. Grievances Extensions/endorsements applicable under the Plan
In case You are aggrieved in any way, the Insured should do the Mandatory Extensions/Endorsements under the Plan
following: Extension HC 1 -(A) Floater Benefit
i. Call the Company at toll free number: 1800 2666 or email us at Floater Benefit means that the aggregate Maximum Limit of
[email protected] Indemnity, as specified in the Policy Schedule, is available to You or
ii. If You are not satisfied with the resolution then You may Your Immediate Family members, as covered under this Policy at the
successively write to the manager- service quality, corporate Policy Period Start Date, for any and all Claims made in aggregate
manager- service quality, national manager- operations & finally during each Policy Year of the Policy Period.
director-services and business development at the following It is hereby declared and agreed that notwithstanding anything to the
address: contrary in the Policy, We will pay You or Your Immediate Family
ICICI Lombard General Insurance Company Limited members, for any and all Claims subject to the Maximum Limit of
ICICI Lombard House, 414, Veer Savarkar Marg, Indemnity, made in aggregate by You or Your Immediate Family
Near Siddhi Vinayak Temple, Prabhadevi, Mumbai 400025 members under the Floater Benefit, provided such Claim is
admissible under the Policy.
If the issue still remains unresolved, You may, subject to vested
jurisdiction, approach Insurance Ombudsman for the redressal of For the purpose of this extension the term "Immediate Family" will
Your grievance. include Your spouse, dependent children, brothers, sisters, and
dependent parents, whose name(s) are specifically appearing as
The details of Insurance Ombudsman are available below:
Insured Person(s) in the Policy Schedule.
Ombudsman Offices
Subject otherwise to the terms, conditions and exclusions of the
Delhi, Rajasthan 2/2 A, 1st Floor, Universal Insurance Bldg., Policy
Asaf Ali Road, New Delhi - 110 002
Extension HC 7 - Domestic Road Emergency Ambulance Cover
West Bengal, Bihar 29, N. S. Road, 3rd Fl., North British Bldg.
In consideration of the payment of additional premium to Us, it is
Kolkata -700 001
hereby declared and agreed that notwithstanding anything to the
Maharashtra 3rd Flr., Jeevan Seva Annexe, S.v. Road, contrary in the Policy and subject always to the Annual Sum Insured
Santa Cruz (w), Mumbai - 400 054 for this Extension, We will reimburse You up to a maximum of `1500/-
Tamil Nadu, Fatima Akhtar Court, 4th Flr., 453(old 312 ), per Hospitalization, for the reasonable expenses incurred by You on
Pondicherry Anna Salai, Teynampet, Chennai -600 018 availing ambulance services offered by a Hospital or by an ambulance
Andhra Pradesh 6-2-46, 1st Floor, Moin Court, Lane Opp. service provider for Your necessary transportation to the nearest
Saleem Function Palace A.c. Guards, Hospital in case of a life threatening emergency condition, provided
Lakdi-ka-pool, Hyderabad - 500 004. however that, a Claim under this extension shall be payable by Us
Gujarat 2nd Flr., Ambica House, Nr.c.u. Shah College, only when:
5 , N a v y u g C o l o n y, A s h r a m Ro a d , i. Such life threatening emergency condition is certified by the
Ahmedabad-380 014 Medical Practitioner, and
Kerla, Karnataka 2nd Flr., Cc 27/ 2603, Pulinatbuilding, Opp. ii. We have accepted Your Claim under "In-patient Treatment" or
Cochin Shipyard, M.g. Road, Ernakulam "Day Care Procedures" section of the Policy.
682 015 Subject otherwise to the terms, conditions and exclusions of the
North Eastern States Aquarius, Bhaskar Nagar, R.g. Baruah Rd. Policy
Guwahati Extension HC 32 - Value-Added Services
Uttar Pradesh Jeevan Bhawan, Phase 2, 6th Floor, Nawal Notwithstanding anything to the contrary in the Policy, We at your
Kishore Rd., Hazartganj, Lucknow - 226 001 request will arrange for You or will facilitate You in availing any of the
Madhya Pradesh 1st Floor, 117, Zone Ii, (above D.m. Motors following additional services from the service provider, subject to a
Pvt. Ltd.) Maharana Pratap Nagar, Bhopal limit as specified in the Policy Schedule, on issuance or upon renewal
462 011 of the Policy for a continuous period from Period of Insurance Start
Punjab, Haryana, S.c.o. No. 101,102 & 103, 2nd Floor, Batra Date, as specified in the Policy Schedule, including but not limited to:-
Himachal Pradesh, Building, Sector 17- d, Chandigarh i. One Free health check-up coupon to insured for every Policy Year,
J & K, Chandigarh -160 017 subject to a maximum of 2 coupons per year for floater policies.
Orissa 62, Forest Park, Bhubaneswar - 751 009 ii. Specialist e-Consultation with One Follow-up session
The updated details of Insurance Ombudsman are also available on iii. Diet & Nutrition e-consultation
IRDA website: www.irdaindia.org, on the website of General iv. Online Chat with Medical Practitioners
Insurance Council: www.generalinsurancecouncil.org.in, website of v. Discount Vouchers
the company www.icicilombard.com or from any of the offices of the
Company

15
While deciding to obtain such value-added service, You expressly "Critical Illness" for the purpose of this Policy includes the following:
note and agree that it is entirely for You to decide whether to obtain 1) CANCER OF SPECIFIED SEVERITY
these services and also to decide the use (if any) to which these i. A malignant tumour characterised by the uncontrolled growth &
services is to be put for spread of malignant cells with invasion & destruction of normal
Extension HC 2 - Hospital Daily Cash tissues. This diagnosis must be supported by histological
In consideration of the payment of additional premium to Us, it is evidence of malignancy & confirmed by a pathologist. The term
hereby declared and agreed that notwithstanding anything to the cancer includes leukemia, lymphoma and sarcoma.
contrary in the Policy and subject always to the Annual Sum Insured ii. The following are excluded -
for this Extension, We will pay You a daily cash amount, as stated • Tumours showing the malignant changes of carcinoma in
against this Extension in the Policy Schedule, for each and every situ & tumours which are histologically described as
completed day of Hospitalization up to a maximum of 10 consecutive premalignant or non invasive, including but not limited to:
days, if such Hospitalization is at least for a minimum of 3 consecutive Carcinoma in situ of breasts, Cervical dysplasia CIN-1, CIN -
days and it falls within the Policy Period. The Claim under this 2 & CIN-3.
extension will be payable only if We have admitted Our liability under
• Any skin cancer other than invasive malignant melanoma
"In-patient Treatment" section of the Policy.
• All tumours of the prostate unless histologically classified as
Subject otherwise to the terms, conditions and exclusions of the
having a Gleason score greater than 6 or having progressed
Policy
to at least clinical TNM classification T2N0M0
Extension HC 3 - Convalescence Benefit
• Papillary micro - carcinoma of the thyroid less than 1 cm in
In consideration of the payment of additional premium to Us, it is diameter
hereby declared and agreed that notwithstanding anything to the
• Chronic lymphocyctic leukaemia less than RAI stage 3
contrary in the Policy, We will pay You an amount of `10,000 if You are
Hospitalized for a minimum period of 10 consecutive days, due to any • Microcarcinoma of the bladder
Injury or Illness as covered under the Policy. This benefit is payable • All tumours in the presence of HIV infection.
only once to an Insured Person during each Policy Year of the Policy 2) OPEN CHEST CABG
Period. The actual undergoing of open-heart valve surgery is to replace or
Subject otherwise to the terms, conditions and exclusions of the repair one or more heart valves, as a consequence of defects in,
Policy abnormalities of, or disease-affected cardiac valve(s). The diagnosis
Extension HC 9 - Donor Expenses of the valve abnormality must be supported by an echocardiography
In consideration of the payment of additional premium to Us, it is and the realization of surgery has to be confirmed by a specialist
hereby declared and agreed that notwithstanding anything to the medical practitioner. Catheter based techniques including but not
contrary in the Policy, We will indemnify You up to an amount not limited to, balloon valvotomy/valvuloplasty are excluded.
exceeding ` 50,000 for the Medical Expenses incurred in respect of 3) FIRST HEART ATTACK - OF SPECIFIED SEVERITY
the donor for any of the organ transplant surgery, provided the organ The first occurrence of myocardial infarction which means the death
donated is for Your use and We have admitted Your Hospitalization of a portion of the heart muscle as a result of inadequate blood supply
Claim under the Policy. to the relevant area. The diagnosis for this will be evidenced by all of
Subject otherwise to the terms, conditions and exclusions of the the following criteria:
Policy i. A history of typical clinical symptoms consistent with the
Extension HC 10 - Critical Illness Cover diagnosis of Acute Myocardial Infarction (for e.g. typical chest
In consideration of the payment of additional premium to Us, it is pain)
hereby declared and agreed that notwithstanding anything to the ii. New characteristic electrocardiogram changes
contrary in the Policy, We will pay You the sum insured as stated iii. Elevation of infarction specific enzymes, Troponins or other
against this Extension in the Policy Schedule, in case You are specific biochemical markers.
diagnosed as suffering from one or more of the Critical Illnesses for The following are excluded:
the first time in your life, during the Policy Period.
i. Non-ST-segment elevation myocardial infarction (NSTEMI) with
However, We will not make any payment if You are first diagnosed as elevation of Troponin I or T
suffering from a Critical Illness within 90 days of the Period of
ii. Other acute Coronary Syndromes
Insurance Start Date. This benefit can be availed by You only once
during Your lifetime. No Claim under this Extension shall be iii. Any type of angina pectoris.
admissible in case any of the Critical Illnesses is a consequence of or 4) KIDNEY FAILURE REQUIRING REGULAR DIALYSIS
arises out of any Pre-Existing Condition(s)/Disease. End stage renal disease presenting as chronic irreversible failure of
both kidneys to function, as a result of which either regular renal

16
dialysis (hemodialysis or peritoneal dialysis) is instituted or renal Note: In the event of a Claim arising out of any of the Critical Illness or
transplantation is carried out. Diagnosis has to be confirmed by a medical procedures as covered under this Extension, You should
specialist medical practitioner. intimate Us within thirty (30) days from the date of first diagnosis of
5) MAJOR ORGAN /BONE MARROW TRANSPLANT such Illness or from the date of surgical procedure or from date of
The actual undergoing of a transplant of: occurrence of the medial event as the case may be (irrespective of
Your coverage under any other health insurance policy).
i. One of the following human organs: heart, lung, liver, kidney,
pancreas, that resulted from irreversible end-stage failure of the Further, You should arrange for submission of the Claim Documents*
relevant organ, or as stated in the Policy including the confirmation from the Medical
Practitioner that the Critical Illness or medical procedure or medical
ii. Human bone marrow using haematopoietic stem cells. The
event for which a Claim has been lodged under this Extension, does
undergoing of a transplant has to be confirmed by a specialist
not relate to any Pre-Existing Condition/Disease(s) or any Illness or
medical practitioner.
Injury which existed within the first 3 months of the Period of
The following are excluded: Insurance Start Date.
i. Other stem-cell transplants *In case You are covered under any health policy of other insurance
ii. Where only islets of langerhans are transplanted company and become entitled to a Claim under such policy, then for
6) STROKE RESULTING IN PERMANENT SYMPTOMS this Extension, You may submit to Us the copies of such Claim
Any cerebrovascular incident producing permanent neurological Documents provided they are duly certified by such insurance
sequelae.This includes infarction of brain tissue, thrombosis in an company or any hospital where You are getting treated, as applicable
intracranial vessel, haemorrhage and embolisation from an The cover under this extension shall terminate in the event of Your
extracranial source. Diagnosis has to be confirmed by a specialist Claim becoming admissible hereunder. In consequence thereof no
medical practitioner and evidenced by typical clinical symptoms as benefit shall be payable to You under this extension of the policy
well as typical findings in CT Scan or MRI of the brain. Evidence of thereafter.
permanent neurological deficit lasting for at least 3 months has to be Extension HC 28 - Sub Limits on Medical Expenses/ Illness/
produced. Surgeries / Procedures
The following are excluded: Notwithstanding anything to the contrary in the Policy and subject to
i. Transient ischemic attacks (TIA) the Maximum Limit of Indemnity, Our maximum liability to make
ii. Traumatic injury of the brain payment for the Medical Expenses incurred during any
Hospitalisation (including its related Pre and Post Hospitalization
iii. Vascular disease affecting only the eye or optic nerve or
expenses if applicable) due to the below mentioned Surgeries /
vestibular functions.
Medical Procedures or any medical treatment pertaining to an Illness
7) PERMANENT PARALYSIS OF LIMBS / Injury shall be limited as per the table below:
Total and irreversible loss of use of two or more limbs as a result of
S. No. Surgeries / Medical Procedures Sub-limits (`)
injury or disease of the brain or spinal cord. A specialist medical
practitioner must be of the opinion that the paralysis will be A B C
permanent with no hope of recovery and must be present for more 1 Cataract per eye 10,000 15,000 20,000
than 3 months. 2 Other Eye Surgeries 15,000 22,000 35,000
8) OPEN HEART REPLACEMENT OR REPAIR OF HEART VALVES 3 ENT 15,000 22,000 35,000
The actual undergoing of open-heart valve surgery is to replace or 4 Surgeries for - Tumors/ 20,000 30,000 60,000
repair one or more heart valves, as a consequence of defects in, Cysts/Nodule/Polyp
abnormalities of, or disease-affected cardiac valve(s). The diagnosis 5 Stone in Urinary System 20,000 30,000 40,000
of the valve abnormality must be supported by an echocardiography
6 Hernia Related 20,000 30,000 60,000
and the realization of surgery has to be confirmed by a specialist
medical practitioner. Catheter based techniques including but not 7 Appendisectomy 20,000 30,000 40,000
limited to, balloon valvotomy/valvuloplasty are excluded. 8 Knee Ligament 40,000 60,000 90,000
9) End Stage Liver Disease Reconstruction Surgery

End stage liver disease resulting in cirrhosis and which is evidenced 9 Hysterectomy 20,000 30,000 60,000
by all of the following symptoms/criteria: 10 Fissures/Piles/Fistulas 15,000 22,000 35,000
i. Permanent jaundice 11 Spine & Vertebrae related 40,000 60,000 90,000
ii. Ascites 12 Cellulites/Abscess 15,000 22,000 35,000
iii. Encephalopathy
iv. Portal hypertension
Liver disease caused due to alcohol or drugs misuse is excluded from
this definition.

17
 Other Surgeries & Procedures 25,000 37,000 55,000
v. Multiple Sclerosis
All Medical Expenses for any
vi. Stroke Resulting in Permanent Symptoms
treatment not involving surgery/
medical procedure 10,000 15,000 25,000 viii. Permanent Paralysis of Limbs
viii. All brain related surgeries
Any complications resulting from or arising out of any surgery or
medical procedure shall be subject to the overall sub-limit, as The sub-limits mentioned above shall be applicable for each
applicable Hospitalization. For the purpose of applicability of the said sub-limits,
multiple Hospitalizations pertaining to the same Illness or medical
No Sub-limits shall be applicable on any Major Medical Illness &
procedure / surgery occurring within a period of 45 days from the date
Procedures and Joint Replacement Surgery. Major Medical Illness &
of discharge of the first Hospitalization shall be considered as one
Procedures for the purpose of this Policy shall mean and include the
Hospitalization.
following:
Subject otherwise to the terms, conditions and exclusions of the
i. Cancer of Specified Severity
Policy
ii. Kidney Failure Requiring Dialysis
iii. Major Organ /Bone marrow Transplant
iv. All cardiac surgeries / conditions including but not limited Open
Chest CABG

Mailing Address : ICICI Lombard General Insurance Company Limited, 4th, Floor, Interface -11, Office No. 401 & 402, New Linking Road, Malad (W), Mumbai - 400 064.
013351PW/SC

Corporate Office : ICICI Lombard General Insurance Company Limited, ICICI Lombard House, 414, Veer Savarkar Marg, Near Siddhi Vinayak Temple, Prabhadevi, Mumbai 400 025.
Visit us at www.icicilombard.com • Mail us at [email protected]
Now One Number for all your Insurance needs 1800 2666 (Toll Free also accessible from your mobile)
Insurance is the subject matter of the solicitation. IRDA Reg. No. 115, Misc 128.

18
 List of Day Care Procedures / Treatments
1 Stapedotomy
2 Stapedectomy
3 Revision Of A Stapedectomy
4 Other Operations On The Auditory Ossicles
5 Myringoplasty (Type -I Tympanoplasty)
6 Tympanoplasty (Closure Of An Eardrum Perforation/Reconstruction Of The Auditory Ossicles)
7 Revision Of A Tympanoplasty
8 Other Microsurgical Operations On The Middle Ear
9 Myringotomy
10 Removal Of A Tympanic Drain
11 Incision Of The Mastoid Process And Middle Ear
12 Mastoidectomy
13 Reconstruction Of The Middle Ear
14 Other Excisions Of The Middle And Inner Ear
15 Fenestration Of The Inner Ear
16 Revision Of A Fenestration Of The Inner Ear
17 Incision (Opening) And Destruction (Elimination) Of The Inner Ear
18 Other Operations On The Middle And Inner Ear
19 Excision And Destruction Of Diseased Tissue Of The Nose
20 Operations On The Turbinates (Nasal Concha)
21 Other Operations On The Nose
22 Nasal Sinus Aspiration
23 Incision Of Tear Glands
24 Other Operations On The Tear Ducts
25 Incision Of Diseased Eyelids
26 Excision And Destruction Of Diseased Tissue Of The Eyelid
27 Operations On The Canthus And Epicanthus
28 Corrective Surgery For Entropion And Ectropion
29 Corrective Surgery For Blepharoptosis
30 Removal Of A Foreign Body From The Conjunctiva
31 Removal Of A Foreign Body From The Cornea
32 Incision Of The Cornea
33 Operations For Pterygium

19
 34 Other Operations On The Cornea
35 Removal Of A Foreign Body From The Lens Of The Eye
36 Removal Of A Foreign Body From The Posterior Chamber Of The Eye
37 Removal Of A Foreign Body From The Orbit And Eyeball
38 Operation Of Cataract
39 Incision Of A Pilonidal Sinus
40 Other Incisions Of The Skin And Subcutaneous Tissues
41 Surgical Wound Toilet (Wound Debridement) And Removal Of Diseased Tissue Of The Skin And Subcutaneous Tissues
42 Local Excision Of Diseased Tissue Of The Skin And Subcutaneous Tissues
43 Other Excisions Of The Skin And Subcutaneous Tissues
44 Simple Restoration Of Surface Continuity Of The Skin And Subcutaneous Tissues
45 Free Skin Transplantation, Donor Site
46 Free Skin Transplantation, Recipient Site
47 Revision Of Skin Plasty
48 Other Restoration And Reconstruction Of The Skin And Subcutaneous Tissues
49 Chemosurgery To The Skin
50 Destruction Of Diseased Tissue In The Skin And Subcutaneous Tissues
51 Incision, Excision And Destruction Of Diseased Tissue Of The Tongue
52 Partial Glossectomy
53 Glossectomy
54 Reconstruction Of The Tongue
55 Other Operations On The Tongue
56 Incision And Lancing Of A Salivary Gland And A Salivary Duct
57 Excision Of Diseased Tissue Of A Salivary Gland And A Salivary Duct
58 Resection Of A Salivary Gland
59 Reconstruction Of A Salivary Gland And A Salivary Duct
60 Other Operations On The Salivary Glands And Salivary Ducts
61 External Incision And Drainage In The Region Of The Mouth, Jaw And Face
62 Incision Of The Hard And Soft Palate
63 Excision And Destruction Of Diseased Hard And Soft Palate
64 Incision, Excision And Destruction In The Mouth
65 Plastic Surgery To The Floor Of The Mouth
66 Palatoplasty
67 Other Operations In The Mouth
68 Transoral Incision And Drainage Of A Pharyngeal Abscess
69 Tonsillectomy Without Adenoidectomy
70 Tonsillectomy With Adenoidectomy
71 Excision And Destruction Of A Lingual Tonsil
72 Other Operations On The Tonsils And Adenoids

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73 Incision On Bone, Septic And Aseptic
74 Closed Reduction On Fracture, Luxation Or Epiphyseolysis With Osteosynthesis
75 Suture And Other Operations On Tendons And Tendon Sheath
76 Reduction Of Dislocation Under Ga
77 Arthroscopic Knee Aspiration
78 Incision Of The Breast
79 Operations On The Nipple
80 Incision And Excision Of Tissue In The Perianal Region
81 Surgical Treatment Of Anal Fistulas
82 Surgical Treatment Of Haemorrhoids
83 Division Of The Anal Sphincter (Sphincterotomy)
84 Other Operations On The Anus
85 Ultrasound Guided Aspirations
86 Sclerotherapy Etc
87 Incision Of The Ovary
88 Insufflation Of The Fallopian Tubes
89 Other Operations On The Fallopian Tube
90 Dilatation Of The Cervical Canal
91 Conisation Of The Uterine Cervix
92 Other Operations On The Uterine Cervix
93 Incision Of The Uterus (Hysterotomy)
94 Therapeutic Curettage
95 Culdotomy
96 Incision Of The Vagina
97 Local Excision And Destruction Of Diseased Tissue Of The Vagina And The Pouch Of Douglas
98 Incision Of The Vulva
99 Operations On Bartholin’S Glands (Cyst)
100 Incision Of The Prostate
101 Transurethral Excision And Destruction Of Prostate Tissue
102 Transurethral And Percutaneous Destruction Of Prostate Tissue
103 Open Surgical Excision And Destruction Of Prostate Tissue
104 Radical Prostatovesiculectomy
105 Other Excision And Destruction Of Prostate Tissue
106 Operations On The Seminal Vesicles
107 Incision And Excision Of Periprostatic Tissue
108 Other Operations On The Prostate
109 Incision Of The Scrotum And Tunica Vaginalis Testis
110 Operation On A Testicular Hydrocele
111 Excision And Destruction Of Diseased Scrotal Tissue

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 112 Plastic Reconstruction Of The Scrotum And Tunica Vaginalis Testis
113 Other Operations On The Scrotum And Tunica Vaginalis Testis
114 Incision Of The Testes
115 Excision And Destruction Of Diseased Tissue Of The Testes
116 Unilateral Orchidectomy
117 Bilateral Orchidectomy
118 Orchidopexy
119 Abdominal Exploration In Cryptorchidism
120 Surgical Repositioning Of An Abdominal Testis
121 Reconstruction Of The Testis
122 Implantation, Exchange And Removal Of A Testicular Prosthesis
123 Other Operations On The Testis
124 Surgical Treatment Of A Varicocele And A Hydrocele Of The Spermatic Cord
125 Excision In The Area Of The Epididymis
126 Epididymectomy
127 Reconstruction Of The Spermatic Cord
128 Reconstruction Of The Ductus Deferens And Epididymis
129 Other Operations On The Spermatic Cord, Epididymis And Ductus Deferens
130 Operations On The Foreskin
131 Local Excision And Destruction Of Diseased Tissue Of The Penis
132 Amputation Of The Penis
133 Plastic Reconstruction Of The Penis
134 Other Operations On The Penis
135 Cystoscopical Removal Of Stones
136 Lithotripsy
137 Coronary Angiography
138 Haemodialysis
139 Radiotherapy For Cancer
140 Cancer Chemotherapy

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