Revised Elevate Policy Wording Rev 4

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com or call 1800 2666
ELEVATE POLICY WORDING

b. PREAMBLE: "Condition Precedent" shall mean a Policy term or
ICICI Lombard General Insurance Company Limited (“We / condition upon which the Insurer's liability under the Policy
Us”), having received a Proposal and the premium from the is conditional upon.
Proposer named in Part a of the Policy (hereinafter referred "Congenital Anomaly" refers to a condition(s) which is
to as the “Policy Schedule”) and the said Proposal and present since birth, and which is abnormal with reference
Declaration together with any statement, report or other to form, structure or position.
document leading to the issue of this Policy and referred to a. Internal Congenital Anomaly - Congenital Anomaly
therein having been accepted and agreed to by Us and the which is not in the visible and accessible parts of the
Proposer as the basis of this contract do, by this Policy body is called Internal Congenital Anomaly.
agree, in consideration of and subject to the due receipt of
b. External Congenital Anomaly - Congenital Anomaly
the subsequent premiums, as set out in the Policy
which is in the visible and accessible parts of the body is
Schedule, and further, subject to the terms and conditions
called External Congenital Anomaly.
contained in this Policy that on proof to Our satisfaction of
the compensation having become payable as set out in the "Co-Payment" shall mean a cost sharing requirement
Policy Schedule to the title of the said person or persons under a health Insurance policy that provides that the
claiming payment or upon the happening of an event upon policy holder/insured will bear a specified percentage of
which one or more benefits become payable under this the admissible claims amount. A co-payment does not
Policy, the sum insured/ Annual Sum Insured / appropriate reduce the Sum Insured
benefit amount will be paid by Us. "Cumulative Bonus" means any increase or addition in the
Sum Insured granted by the Insurer without an associated
c. DEFINITIONS:
increase in the premium.
For the purposes of this Policy, the terms specified below
"Day care Centre" means any institution established for
shall have the meaning set forth wherever appearing /
day care treatment of Illness and / or injuries or a medical
specified in this Policy or related Add-ons/Optional Covers:
setup within a hospital and which has been registered with
Where the context so requires, references to the singular the local authorities, wherever applicable, and is under the
shall also include references to the plural and references to supervision of a registered and qualified medical
any gender shall include references to all genders. Further practitioner and must comply with all minimum criteria as
any references to statutory enactment include subsequent under:
changes to the same. i. has qualified nursing staff under its employment
i. Standard Definitions ii. has qualified medical practitioner/s in charge;
iii. has a fully equipped operation theatre of its own where
"Accident" means a sudden, unforeseen and involuntary
surgical procedures are carried out
event caused by external, visible and violent means.
iv. maintains daily records of patients and will make these
"Any one Illness" means continuous period of Illness and it accessible to the Insurance Company’s authorized
includes a relapse within 45 days from the date of last personnel.
consultation with the Hospital/Nursing Home where Day Care Centre includes an AYUSH Day Care Centre as
treatment may have been taken. defined below:
"Cashless facility" means a facility extended by the Insurer “AYUSH Day Care Centre” means and includes
to the Insured where, the payments of the costs of Community Health Centre (CHC), Primary Health Centre
treatment undergone by the Insured in accordance with (PHC), Dispensary, Clinic, Polyclinic or any such health
the Policy terms and conditions are directly made to the centre which is registered with the local authorities,
network provider by the Insurer to the extent pre- wherever applicable and having facilities for carrying out
authorization approved. treatment procedures and medical or surgical/para-
"Ayush Treatment" refers to the medical and / or surgical interventions or both under the supervision of
hospitalization treatments given under ‘Ayurveda, Yoga registered AYUSH Medical Practitioner (s) on day care
and Naturopathy, Unani, Siddha and Homeopathy basis without in-patient services and must comply with all
systems. the following criterion:
“Break in policy” means the period of gap that occurs at i. H av i n g q u a l i f i e d re g i ste re d AY U S H M e d i c a l
the end of the existing policy term / installment premium Practitioner(s) in charge;
due date, when the premium due for renewal on a given ii. Having dedicated AYUSH therapy sections as required
policy or installment premium due is not paid on or before and/or has equipped operation theatre where surgical
the premium renewal date or grace period. procedures are to be carried out;
ICICI Lombard General Insurance Company Limited

IRDA Reg. No. 115 UIN: ICIHLIP25031V012425 ELEVATE POLICY WORDING
Mailing Address: CIN: L67200MH2000PLC129408 Toll free No.: 1800 2666
601 / 602, 6th Floor, Interface Building No. 16, Registered Office Address: Alternate No.: 86552 22666 (Chargeable)
New Link Road, Malad (West), ICICI Lombard House, 414, P Balu Marg, Off Veer Website : www.iciclombard.com
Mumbai - 400 064. Savarkar Road, Nr Siddhi Vinayak Temple, E-mail : [email protected]
Prabhadevi, Mumbai - 400 025.
For Buy/ Renew/ Service/ Claim related queries Log on to www.icicilombard.com or call 1800 2666
iii. Maintaining daily records of the patients and making "Hospital" - A hospital means any institution established
them accessible to the insurance company's authorized for in-patient care and day care treatment of Illness and/ or
representative. injuries and which has been registered as a hospital with
"Day Care treatment" means medical treatment, and / or the local authorities under the Clinical Establishments
surgical procedure which is: (Registration and Regulation) Act, 2010 or under the
a. undertaken under general or local anesthesia in a enactments specified under the Schedule of Section 56(1)
hospital/day care centre in less than 24 hours because of the said Act or complies with all minimum criteria as
of technological advancement, and under:
b. which would have otherwise required a hospitalization i. has qualified nursing staff under its employment round
of more than 24 hours. the clock;
Treatment normally taken on an out-patient basis is not ii. has at least 10 in-patient beds in towns having a
included in the scope of this definition. population of less than 10,00,000 and at least 15 in-
patient beds in all other places;
"Deductible" means a cost-sharing requirement under a
health insurance Policy that provides, that the Insurer will iii. has qualified medical practitioner(s) in charge round
not be liable for a specified rupee amount in case of the clock;
indemnity policies and for a specified number of iv. has a fully equipped operation theatre of its own where
days/hours in case of hospital cash policies which will surgical procedures are carried out;
apply before any benefits are payable by the Insurer. A
v. maintains daily records of patients and makes these
deductible does not reduce the Sum Insured.
accessible to the insurance company's authorized
“Dental Treatment:” Dental treatment means a treatment personnel.
related to teeth or structures supporting teeth including
Hospital includes an AYUSH Hospital as defined below:
examinations, fillings (where appropriate), crowns,
“AYUSH Hospital” An AYUSH Hospital is a healthcare
extractions and surgery.
facility wherein medical/surgical/para-surgical treatment
"Disclosure to information norm" means the Policy shall procedures and interventions are carried out by AYUSH
be void and all premium paid hereon shall be forfeited to Medical Practitioner(s) comprising of any of the following:
the Company, in the event of misrepresentation, mis-
a. Central or State Government AYUSH Hospital; or
description or non-disclosure of any material fact.
b. Teaching hospital attached to AYUSH College
"Domiciliary hospitalization" means medical treatment
recognized by the Central Government/Central Council
for an Illness/Disease/Injury which in the normal course
of Indian Medicine/Central Council for Homeopathy; or
would require care and treatment at a hospital but is
actually taken while confined at home under any of the c. AYUSH Hospital, standalone or co-located with
following circumstances: in-patient healthcare facility of any recognized system
of medicine, registered with the local authorities,
i. the condition of the patient is such that he/she is not in a
wherever applicable, and is under the supervision of a
condition to be removed to a hospital, or
qualified registered AYUSH Medical Practitioner and
ii. the patient takes treatment at home on account of non- must comply with all the following criterion:
availability of room in a hospital.
i. Having at least 5 in-patient beds;
"Emergency care" means management for an Illness or
ii. Having qualified AYUSH Medical Practitioner in
Injury which results in symptoms which occur suddenly
charge round the clock;
and unexpectedly, and requires immediate care by a
medical practitioner to prevent death or serious long term iii. Having dedicated AYUSH therapy sections as
impairment of the Insured person's health. required and/or has equipped
“Grace Period” means the specified period of time, iv. operation theatre where surgical procedures are to
immediately following the premium due date during which be carried out;
premium payment can be made to renew or continue a v. Maintaining daily records of the patients and
policy in force without loss of continuity benefits pertaining making them accessible to the insurance
to waiting periods and coverage of pre-existing diseases. company's authorized representative.
Coverage need not be available during the period for which "Hospitalization" means admission in a hospital for a
no premium is received. minimum period of 24 consecutive “in-patient care” hours
The grace period for payment of the premium for all types except for specified procedures/ treatments, where such
of insurance policies shall be: fifteen days where premium admission could be for a period of less than 24 consecutive
payment mode is monthly and thirty days in all other cases. hours.
Provided the insurers shall offer coverage during the grace “Illness" means a sickness or a disease or pathological
period, if the premium is paid in instalments during the condition leading to the impairment of normal
policy period. physiological function and requires medical treatment.

a. Acute condition - Acute condition is a disease, Illness or cover, Medical practitioner would mean a person who
Injury that is likely to respond quickly to treatment holds a valid registration from the Medical council of the
which aims to return the person to his or her state of respective country where the treatment is being taken by
health immediately before suffering the disease/ the Insured
Illness/ Injury which leads to full recovery. "Medical expenses" means those expenses that an
b. Chronic condition - A chronic condition is defined as a Insured Person has necessarily and actually incurred for
disease, Illness, or Injury that has one or more of the medical treatment on account of Illness or Accident on the
following characteristics: advice of a Medical Practitioner, as long as these are no
more than would have been payable if the Insured Person
1. it needs ongoing or long-term monitoring through
had not been Insured and no more than other hospitals or
consultations, examinations, check-ups, and / or
doctors in the same locality would have charged for the
tests;
same medical treatment.
2. it needs ongoing or long-term control or relief of
"Medically Necessary treatment" means any treatment,
symptoms;
tests, medication, or stay in hospital or part of a stay in
3. it requires rehabilitation for the patient or for the hospital which:
patient to be specially trained to cope with it;
i. is required for the medical management of the Illness or
4. it continues indefinitely; Injury suffered by the Insured;
5. it recurs or is likely to recur ii. must not exceed the level of care necessary to provide
"Injury" means accidental physical bodily harm excluding safe, adequate and appropriate medical care in scope,
Illness or disease solely and directly caused by external, duration, or intensity;
violent, visible and evident means which is verified and iii. must have been prescribed by a medical practitioner,
certified by a Medical Practitioner.
iv. must conform to the professional standards widely
"Inpatient care" means treatment for which the Insured accepted in international medical practice or by the
person has to stay in a hospital for more than 24 hours for a medical community in India.
covered event.
“Medical Advise” means any consultation or advice from a
"Intensive Care Unit" means an identified section, ward or Medical Practitioner including the issue of any prescription
wing of a Hospital which is under the constant supervision or follow up prescription.
of a dedicated Medical Practitioner(s), and which is “Migration” means a facility provided to policyholders
specially equipped for the continuous monitoring and (including all members under family cover and group
treatment of patients who are in a critical condition, or policies), to transfer the credits gained for pre-existing
require life support facilities and where the level of care and diseases and specific waiting periods from one health
supervision is considerably more sophisticated and insurance policy to another with the same insurer.
intensive than in the ordinary and other wards.
"Network Provider" means hospitals or health care
“ICU (Intensive Care Unit) Charges” means the amount providers enlisted by an Insurer, TPA or jointly by an insurer
charged by a Hospital towards ICU expenses which shall and TPA to provide medical services to an Insured by a
include the expenses for ICU bed, general medical support cashless facility.
services provided to any ICU patient including monitoring “Newborn Baby” means baby born during the Policy
devices, critical care nursing and intensivist charges. Period and is aged upto 90 days.
"Maternity expense" means "Non- Network Provider" means any hospital, day care
a. Medical treatment expenses traceable to childbirth centre or other provider that is not part of the network.
(including complicated deliveries and caesarean "Notification of claim" means the process of intimating a
sections incurred during hospitalization). claim to the Insurer or TPA through any of the recognized
b. Expenses towards lawful medical termination of modes of communication.
pregnancy during the Policy period. “OPD treatment” means the one in which the Insured visits
“Medical Practitioner" is a person who holds a valid a clinic / hospital or associated facility like a consultation
registration from the Medical Council of any State or room for diagnosis and treatment based on the advice of a
Medical Council of India or Council for Indian Medicine or for Medical Practitioner. The Insured is not admitted as a day
Homeopathy set up by the Government of India or a State care or in-patient.
Government and is thereby entitled to practice medicine “Portability” means a facility provided to the health
within its jurisdiction and is acting within the scope and insurance policyholders (including all members under
jurisdiction of license. The term Medical Practitioner family cover), to transfer the credits gained for, pre-existing
includes a physician, specialist and surgeon, provided that diseases and specific waiting periods from one insurer to
this person is not a member of the Insured/ Insured another insurer.
Person's family who includes Father, Mother, Father-in- "Post-hospitalization Medical Expenses" means Medical
law, Mother-in-law, Son, Daughter, Son-in-law, Daughter- Expenses incurred during predefined number of days
in-law, Brother or Sister. For the purposes of worldwide immediately after the Insured Person is discharged from
the hospital provided that:
i. Such Medical Expenses are for the same condition for life, performed in a hospital or day care centre by a medical
which the Insured Person's Hospitalization was practitioner.
required, and "Unproven/Experimental treatment" means the
ii. The In-patient Hospitalization claim for such treatment, including drug Experimental therapy, which is
Hospitalization is admissible by the Insurance not based on established medical practice in India, is
Company. treatment experimental or unproven.
“Pre-existing Disease” means any condition, ailment, ii. Specific definitions (Definitions other than those
injury or disease: mentioned under c (I) above)
a. that is/are diagnosed by a physician not more than 36
“Accidental Emergency” means a traumatic bodily injury
months prior to the date of commencement of the policy
which, if not immediately diagnosed and treated, could
issued by the insurer; or
reasonably be expected to seriously jeopardize a person’s
b. fo r w h i c h m e d i ca l a d v i ce o r t re a t m e n t wa s
health or result in loss of life.
recommended by, or received from, a physician, not
more than 36 months prior to the date of “Admission” means Your admission in a Hospital as an
commencement of the policy. inpatient for the purpose of medical treatment of an Injury
"Pre-hospitalization Medical Expenses" means medical and/or Illness.
expenses incurred during predefined number of days “Altruistic surrogacy” means the surrogacy in which no
preceding the hospitalization of the Insured Person charges, expenses, fees, remuneration or monetary
provided that: incentive of whatever nature, except the medical expenses
a. Such Medical Expenses are incurred for the same and such other prescribed expenses incurred on surrogate
condition for which the Insured Person's mother and the insurance coverage for the surrogate
Hospitalization was required, and mother, are given to the surrogate mother or her
b. The In-patient Hospitalization claim for such dependents or her representative
Hospitalization is admissible by the Insurance “Commercial surrogacy” means commercialization of
Company. surrogacy services or procedures or its component services
“Qualified Nurse” means a person who holds a valid or component procedures including selling or buying of
registration from the Nursing Council of India or the human embryo or trading in the sale or purchase of human
Nursing Council of any state in India. embryo or gametes or selling or buying or trading the
"Renewal" means the terms on which the contract of services of surrogate motherhood by way of giving
insurance can be renewed on mutual consent with a payment, reward, benefit, fees, remuneration or monetary
provision of grace period for treating the renewal incentive in cash or kind, to the surrogate mother or her
continuous for the purpose of gaining credit for pre- dependents or her representative, except the medical
existing diseases, time-bound exclusions and for all expenses and such other prescribed expenses incurred on
waiting periods. the surrogate mother and the insurance coverage for the
"Reasonable and Customary charges" means the surrogate mother;
charges for services or supplies, which are the standard
"Company" means ICICI Lombard General Insurance
charges for the specific provider and consistent with the
Company Limited.
prevailing charges in the geographical area for identical or
similar services, taking into account the nature of the Illness "Commissioning couple" means an infertile married
/ Injury involved. couple who approach an assisted reproductive technology
"Room rent" means the amount charged by a hospital clinic or assisted reproductive technology bank for
towards room and boarding expenses and shall include obtaining the services authorized of the said clinic or bank;
associated medical expenses. “Couple” means the legally married Indian man and
“Specific waiting period” means a period up to 36 months woman above the age of 21 years and 18 years
from the commencement of a health insurance policy respectively;
during which period specified diseases/treatments (except “Contribution” is essentially the right of an insurer to call
due to an accident) are not covered. On completion of the
upon other insurers, liable to the same Insured, to share the
period, diseases/treatments shall be covered provided the
cost of an indemnity claim on a rateable proportion of Sum
policy has been continuously renewed without any break
Insured. This clause shall not apply to any Benefit offered
"Subrogation" means the right of the insurer to assume on fixed benefit basis.
the rights of the Insured person to recover expenses paid
out under the Policy that may be recovered from any other “Claim” means a demand made by Insured/Policyholders
source. or on Insured/Policyholders behalf for payment of Medical
Expenses or any other expenses or benefits, as covered
"Surgery” or Surgical Procedure" means manual and / or
under the Policy.
operative procedure (s) required for treatment of an Illness
or Injury, correction of deformities and defects, diagnosis "Dependent Child" means a child (natural or legally
and cure of diseases, relief of suffering or prolongation of 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 Policy Year and lapsing on the last day of such twelve-
some of its organs, interrupting or disturbing the month period, till the Policy Period End Date, as specified in
performance of the functions, and causing or threatening the Policy Schedule
pain and weakness or physical or mental disorder and “Single Private Room” means an air conditioned room in a
certified by a Medical Practitioner. Hospital where a single patient is accommodated and
"Diagnostic Tests" Investigations, such as X-Ray or blood which has an attached toilet (lavatory and bath). Such
tests, to find the cause of your symptoms and medical room type shall be the most basic and the most economical
condition. of all accommodations available as a Single room in that
"Family Floater Policy" means a Policy in terms of which, Hospital.
two or more persons of a Family are named in the Schedule “Service provider” means any person, organization,
as Insured Persons. institution, or company that has been empanelled with Us
Immediate Family means spouse, dependent children, to provide services specified under the Benefits (including
brother(s), sister(s) and dependent parent(s) of the Insured. add-ons) to The Insured person. These shall also include all
healthcare providers empanelled to form a part of network
"Insured" / “Insured Person” means the individual(s)
other than hospitals.
whose name(s) is/are specifically appearing as such in the
Policy Schedule and is/are hereinafter referred as The list of the Service Providers is available at our website
“You”/“Your”/ “Yours”/ “Yourself” (https://www.icicilombard.com/content/ilomen/service-
provider/search.asp)and is subject to amendment from
“Intending couple” means a couple who have a medical
time to time.
indication necessitating gestational surrogacy and who
intend to become parents through surrogacy; "Sum Insured" or “Annual Sum Insured” means and
denotes the maximum amount of cover available to You
“Intending woman” means an Indian woman who is a
during each Policy Year of the Policy Period, as stated in the
widow or divorcee between the age of 35 to 45 years and
Policy Schedule or any revisions thereof based on Claim
who intends to avail the surrogacy;
settled under the Policy.
“Maximum Limit of Indemnity” means the sum total of
“Surrogacy” means a practice whereby one woman bears
Annual Sum Insured, Sum Insured accrued as Guaranteed
and gives birth to a child for an intending couple with the
Cumulative Bonus (if accrued), Power Booster (if opted and
intention of handing over such child to the intending couple
accrued) Reset Benefit (If applicable) and Inflation
after the birth;
Protector (if opted and accrued)
“Surrogacy clinic” means surrogacy clinic, centre or
“Oocyte” means a developing egg in the ovary
laboratory, conducting assisted reproductive technology
“Oocyte donor” means a person who provides oocyte with services, invitro fertilisation services, genetic counselling
the objective of enabling an infertile intending couple or centre, genetic laboratory, Assisted Reproductive
intending woman to have a child Technology Banks conducting surrogacy procedure or any
“Oocyte retrieval” means a procedure of removing oocytes clinical establishment, by whatsoever name called,
from the ovaries of a woman conducting surrogacy procedures in any form;
“Period of Insurance” means the period as specifically “Surrogate mother” means a woman who agrees to bear a
appearing in the Policy Schedule and commencing from child (who is genetically related to the intending couple or
the Policy Period Start Date of the first Policy taken by You intending woman) through surrogacy from the implantation
from Us and then, running concurrent to Your current Policy of embryo in her womb and fulfils the conditions as specified
subject to Your continuous renewal of such Policy with Us. in the surrogacy (regulation) act, 2021
“Policy” means these Policy wordings, the Policy Schedule “Surrogacy procedures” means all gynaecological,
and any applicable endorsements or extensions attaching obstetrical or medical procedures, techniques, tests,
to or forming part thereof. The Policy contains details of the practices or services involving handling of human gametes
extent of cover available to You, what is excluded from the and human embryo in surrogacy
cover and the terms & conditions on which the Policy is "Third Par t y Administrator ( TPA)" means any
issued to You. organization or institution that is licensed by the IRDA as a
"Policy period" means the period commencing from the TPA and is engaged by the Company for a fee or
Policy Period Start Date, Time and ending at the Policy remuneration for providing Policy and claims facilitation
Period End Date, Time of the Policy and as specifically services to the Insured/ Insured Person as well as to the
appearing in the Policy Schedule. Company for an insurable event.
"Policy Year" means a period of twelve months beginning “Twin Sharing Room” means an air conditioned Hospital
from the Policy Period Start Date and ending on the last room where at least two patients are accommodated at
day of such twelve-month period. For the purpose of the same time. Such room shall be the most basic and the
subsequent years, “Policy Year” shall mean a period of most economical of all accommodations available as twin
twelve months beginning from the end of the previous sharing rooms in that Hospital

You/Your/ Yours/ Yourself means the person(s) that We then the Insured Person shall bear a rateable
insure and is/are specifically named as Insured / Insured proportion of the total Associated medical expenses
Person(s) in the Policy Schedule. (including surcharges or taxes thereon) in the
We/ Our/ Ours/ Us means the ICICI Lombard General proportion of the difference between room rent of the
Insurance Company Limited entitled room category to the room rent actually
incurred
d. Benefits covered under the Policy
a. For the purpose of this cover, “Associated medical
The coverage mentioned below differs between the
expenses” shall include room rent, nursing charges,
various plan offerings and the wordings of only the
operation theatre charges, fees of medical
relevant covers opted by the Insured Person and as
practitioner including surgeon/anesthetist /
mentioned in the Policy schedule will be applicable.
specialist within the same hospital where the
The Company hereby agrees subject to the terms, insured person has been admitted and will not
conditions and exclusions herein contained or otherwise include the cost of pharmacy and consumables,
expressed, for the period and to the extent of the Sum cost of implants, medical devices and cost of
Insured as specified in the Schedule to this Policy. The diagnostics.
Policy covers Reasonable and Customary Charges
b. Proportionate deductions are not applicable for ICU
incurred towards medical treatment taken during the
charges
Policy Period for an Illness, Accident or condition described
below if this is contracted or sustained by an Insured c. Proportionate deductions shall not be applicable for
Person during the Policy Period and subject always to the hospitals which do not follow differential billing or
Sum Insured, any subsidiary limit specified in the schedule for those expenses in respect of which differential
of Benefits, the terms, conditions, limitations and billing is not adopted based on the room category.
exclusions mentioned in the Policy and eligibility as per the ii. Expenses associated with automation machine for
insurance plan opted by Insured and as stated in the peritoneal dialysis shall not be payable
Schedule. 2. Day Care Procedures/Treatment
i. Basic cover: We will cover the Medical Expenses incurred in respect
The payment under this Basic Cover shall be limited to of the Day Care Treatment of the Insured Person during
Maximum Limit of Indemnity. the Policy Period up to the Annual Sum Insured as
1. In-patient Treatment: specified in the Policy Schedule provided that:
We will cover the following Medical Expenses incurred i. Day Care treatment requires hospitalization as an
in respect of Hospitalization of the Insured Person inpatient for less than 24 hours in a Hospital.
during the Policy Period, up to the Annual Sum Insured ii. We will also cover Medical Expenses incurred for
specified in the Policy Schedule against this In-Patient procedures including but not limited to intravenous
Care treatment: chemotherapy, radiotherapy, hemodialysis or any
i. Room Rent charges up to Single Private AC room; other therapeutic procedure, which requires a
period of specialized observation or medical care
ii. Intensive Care Unit Charges;
after completion of the procedure.
iii. Qualified Nurse charges;
iii. We will not cover any Out Patient Treatment or
iv. Medical Practitioner’s Fees; diagnostic services under this Benefit.
v. Anaesthesia, blood, oxygen, operation theatre iv. Expenses associated with automation machine for
charges, medicines, drugs and consumables (other peritoneal dialysis shall not be payable
than those specified in the list of excluded expenses
v. If the Insured Person is admitted in a room
(non-medical) in Annexure II.
category/limit that is higher than the one that is
vi. Surgical appliances and prosthetic devices specified in the Policy Schedule/ Product benefit
recommended in writing by the attending Medical table of this Policy, then the Insured Person shall
Practitioner and that are used intra operatively bear a ratable proportion of the total Associated
during a Surgical Procedure. medical expenses (including surcharges or taxes
Cost of investigative tests or prescribed diagnostic thereon) in the proportion of the difference between
procedures directly related to the Injury/Illness for room rent of the entitled room category to the room
which the Insured Person is hospitalized rent actually incurred
We will consider a claim under this Cover, subject to the a. For the purpose of this cover, “Associated
following: medical expenses” shall include room rent,
i. If the Insured Person is admitted in a room category/ nursing charges, operation theatre charges,
limit that is higher than the one that is specified in the fe e s o f m e d i c a l p r a c t i t i o n e r i n c l u d i n g
Policy Schedule/ Product benefit table of this policy, surgeon/anesthetist/ specialist within the same
hospital where the insured person has been

admitted and will not include the cost of days following the Insured Person’s discharge from
pharmacy and consumables, cost of implants, Hospital provided that:
medical devices and cost of diagnostics. i. We have accepted the claim under “Inpatient
b. Proportionate deductions are not applicable for Treatment” or “Daycare Procedures/ Treatment” or “In-
ICU charges patient AYUSH Hospitalisation” in respect of the
Insured Person.
c. Pro p o r t i o n a te d e d u c t i o n s s h a l l n ot b e
applicable for hospitals which do not follow ii. We will also consider Post-Hospitalization Medical
differential billing or for those expenses in Expenses incurred on Physiotherapy if the treating
respect of which differential billing is not Medical Practitioner advises such Physiotherapy in
writing and the same is Medically Necessar y
adopted based on the room category.
Treatment.
3. Modern Treatments
iii. This service will be provided on a reimbursement and/
We will cover the Medical Expenses incurred in respect of or cashless basis wherever applicable.
Hospitalization of the Insured Person for the below
6. In Patient AYUSH Hospitalization
mentioned Modern Treatments during the Policy Period, up
to the Annual Sum Insured. We will cover medical expenses incurred in respect of
Insured Person’s AYUSH Treatment during the Policy
Sr. No Treatment/Procedure Period up to the Annual Sum Insured specified in the Policy
Schedule provided that –
1 Uterine Artery Embolization and HIFU (High intensity
focused ultrasound) i. The Insured person is Hospitalized for AYUSH
Treatment at a Government Recognized AYUSH
2 Immunotherapy- Monoclonal Antibody to be given as
Hospital or AYUSH Day Care Centre.
injection
ii. This Cover will be provided on reimbursement basis
3 Vaporisation of the prostrate (Green laser treatment
and/or on cashless basis wherever applicable
or holmium laser treatment)
7. Domestic Road Ambulance:
4 Stem cell therapy: Hematopoietic stem cells for bone
marrow transplant for haematological conditions We will cover the expenses incurred on road ambulance
services which are offered by a healthcare or ambulance
5 Balloon Sinuplasty service provider and which have been used during the
6 Oral Chemotherapy Policy Period to transfer the Insured Person to the nearest
Hospital from the place of Accident/Illness with adequate
7 Robotic surgeries
emergency facilities for the provision of Emergency Care up
8 Stereotactic radio Surgeries to the Annual Sum Insured, provided that:
9 Deep Brain stimulation i. We have accepted a claim under “Inpatient Treatment”
10 Intra vitreal injections or “Daycare Procedures/Treatment” in respect of the
Insured Person for the same Accident/Illness for which
11 Bronchical Thermoplasty road ambulance services were availed.
12 IONM - (Intra Operative Neuro Monitoring) ii. This Benefit includes and is limited to the cost of the
transportation of the Insured Person:
4. Pre- Hospitalisation Medical Expenses
a. To the nearest Hospital with higher medical
We will cover the Pre-Hospitalization Medical Expenses
facilities which is prepared to admit the Insured
incurred in respect of the Insured Person immediately 90
Person and provide the necessary medical services
days before the Insured Person’s Admission to Hospital
if such medical services cannot satisfactorily be
provided that:
provided at a Hospital where the Insured Person is
i. We have accepted the claim under “Inpatient situated, and only if that transportation has been
Treatment”/ Daycare Procedures/ Treatment/In-Patient prescribed in writing by a Medical Practitioner and
AYUSH hospitalisation” in respect of the Insured Person. is for Medically Necessary Treatment.
ii. We shall not be liable to make any payment in respect b. From a Hospital to the nearest diagnostic center
of any Pre-Hospitalization Medical Expenses incurred during the course of Hospitalization for advanced
prior to the Policy Period Start Date of the first policy diagnostic treatment in circumstances where such
with Us in respect of the Insured Person. facility is not available in the existing Hospital.
iii. Expenses incurred on nursing care at home are iii. The ambulance / service provider providing the services
excluded from the scope of pre hospitalization should be a registered provider with road traffic
expenses. authority.
This Cover will be provided on a reimbursement basis iv. Any expenses in relation to transportation of the
and/or cashless basis wherever applicable. Insured Person from Hospital to the Insured Person’s
5. Post Hospitalization Medical Expenses residence while transferring an Insured Person after
We will cover the Post-Hospitalization Medical Expenses he/she has been discharged from the Hospital are not
payable under this Benefit.
incurred in respect of the Insured Person immediately 180

8. Donor Expenses g. Diarrhea and all type of dysenteries, including

We will cover the medical expenses incurred in respect of gastroenteritis;
an organ donor’s Hospitalization during the Policy Period h. Diabetes mellitus and insipidus;
for harvesting of the organ donated to the Insured Person i. Epilepsy;
up to the Annual Sum Insured specified in the Policy
j. Hypertension;
Schedule provided that:
k. Pyrexia of any origin
i. The organ donation confirms to the Transplantation of
Human Organs Act 1994 (and its amendments from 10. Guaranteed Cumulative Bonus:
time to time) and the organ is used for the Insured We will provide a Cumulative Bonus of 20% of expiring or
Person renewed Annual Sum Insured (whichever is lower) at the
ii. We will cover only those Medical Expenses incurred in end of each Policy Year if the expiring Policy has been claim
respect of an organ donor as an in-patient in the free and is continuously renewed with the Company. The
Hospital. Cumulative Bonus will not be accumulated for more than
100% of the Annual Sum Insured under any circumstances
iii. We have accepted a claim under Section “Inpatient
subject to the following conditions.
treatment” in respect of the Insured Person.
i. The Cumulative bonus accumulated will be on floater
We shall not be liable to pay for any claim under this Cover
basis for a floater Policy and on individual basis for an
which arises for or in connection with any of the following:
individual Policy.
i. Pre-hospitalization Medical Expenses or Post-
ii. In case where the Policy is on floater basis, the
Hospitalization Medical Expenses of the organ donor.
cumulative bonus will be accrued only if there has been
ii. Screening expenses of the organ donor. no claim made in respect of all Insured Person(s) in the
iii. Any other Medical Expenses as a result of the expiring Policy period.
harvesting from the organ donor. iii. In a floater Policy as specified in the Policy Schedule, the
iv. Costs directly or indirectly associated with the Cumulative Bonus so accrued in the previous Policy
acquisition of the donor’s organ. Year(s), will only be available to those Insured Person(s)
v. Transplant of any organ/tissue where the transplant is who were Insured in the previous Policy Year(s) and
experimental or investigational. continue to be Insured with the Company in the
subsequent Policy Year(s)
vi. Expenses related to organ transpor tation or
preservation. iv. Cumulative Bonus will not be added if the Policy is not
renewed with the Company by the end of the Grace
vii. Expenses incurred by an Insured Person as a donor.
Period,
viii. Any other medical treatment or complication in respect
v. Cumulative Bonus can only be utilized when the Annual
of the donor, consequent to harvesting.
Sum Insured is completely exhausted
9. Domiciliary Hospitalization
vi. If the Policy Period is two or three year(s), any
We will cover the Medical Expenses incurred in respect of Cumulative Bonus that has accrued for first/second
the Domiciliary Hospitalization of the Insured Person Policy Year will be credited at the end of first/ second
during the Policy Period up to the Annual Sum Insured, Policy Year, as per the Policy Period, and it will be
provided that: available for claims at the subsequent year.
The Domiciliary Hospitalization has commenced on the vii. If the Insured Persons in the expiring Policy are covered
written advice of a medical practitioner and continues for on an individual basis as specified in the Policy
at least 3 consecutive days in which case we will make Schedule and there is an accumulated Cumulative
payment under this Cover in respect of Medical Expenses Bonus for each Insured Person under the expiring
incurred from the first day of Domiciliary Hospitalization. Policy, and such expiring Policy has been renewed with
We shall not be liable to pay for any claim under this Cover the Company on a floater basis as specified in the Policy
which arises from or in connection with any of the Schedule then the Cumulative Bonus to be carried
following: forward for credit in such renewed Policy shall be the
a. Asthma, bronchitis, tonsillitis and upper respiratory lowest among all the Insured Persons.
tract infection including laryngitis and pharyngitis, viii. In case of floater Policies where Insured Person renew
cough and cold, influenza; their expiring Policy with the Company by splitting the
b. Arthritis, gout and rheumatism; Annual Sum Insured in to individual policies the
Cumulative Bonus of the expiring policy shall be
c. Ailments of spine/disc
apportioned to such renewed policies in the proportion
d. Chronic nephritis and nephritic syndrome; of the Annual Sum Insured of each renewed Policy as
e. Any liver disease; detailed in table below.
f. Peptic ulcer

Annual Accumulated Floater Revised Revised vi. The Reset Benefit will be applied only if the claim is
Floater GCB Policy Annual Accumulated made and admissible under “Inpatient Treatment” or
Sum split to Sum GCB of each “Daycare Procedure/Treatment” "or "in-patient AYUSH
Insured Individual Insured Individual
policies Hospitalization"”
of each Policy
with vii. For individual policies, reset Annual Sum Insured will be
Annual Individua
l Policy available on individual basis whereas for floater
Sum
Insured policies, it will be available on floater basis.
of 10 viii. The Reset Benefit will not be available for an Illness
Lacs /Injury or related complications including but not limited
each
20 Lac 20 Lac 10 Lac 4 Lac to any relapse within 45 days in respect of which a
claim has been paid in that Policy Year for the same
ix. The Cumulative Bonus shall be reduced in the same Insured Person
proportion in case of Annual Sum Insured reduction during
ix. Any unutilized Reset Benefit will not be carried forward
Renewal.
to any subsequent Policy Years.
Annual Accumulated Revised Revised
Annual x. Reset Benefit will not be triggered for claims made
Floater GCB Annual Accumulate
Sum outside the geographical limits of India.
Sum Sum Guaranteed
Insured
Insured Insured Cumulative 12. Bariatric Surgery Cover
reduced
Bonus (GCB) We will cover medical expenses incurred in respect of
to Rs. 10
Lacs Hospitalisation of the Insured Person for Surgical
50 Lac 50 Lac 10 Lac 10 Lac Procedure/treatment for Obesity up to Annual Sum
x. If the Annual Sum Insured under the Policy has been Insured, subject to below conditions and Eligibility criteria:
increased during renewal, the Cumulative Bonus shall be i. The surgery has to be conducted upon the advice of a
calculated on the Annual Sum Insured of the expiring Policy. Medical Practitioner
Annual Accumulated Revised Revised ii. The surgery/procedure conducted should be supported
Annual by clinical protocols
Floater GCB Annual Accumulated
Sum
Sum Sum Guaranteed iii. The Insured Person undergoing the bariatric surgery /
Insured
Insured Insured Cumulative procedure has to be 18 years of age or older
reduced
Bonus (GCB) iv. Body Mass Index (BMI) of the insured person has to be
to Rs. 10
Lacs a. Greater than or equal to 40 OR
5 Lac 5 Lac 10 Lac 5 Lac
b. Greater than or equal to 35 in conjunction with any
xi. In the event of Claim, under the Policy during any of the following severe co-morbidities following
subsequent Policy Year, the credited Cumulative Bonus will failure of less invasive methods of weight loss:
not be reduced. 1. Obesity-related cardiomyopathy
xii. Guaranteed Cumulative Bonus will not be applicable for 2. Coronary heart disease
policies with Unlimited Sum Insured. 3. Severe Sleep Apnea
4. Uncontrolled Type2 Diabetes
11. Reset Benefit
Conditions: -
We will reset up to 100% of the Annual Sum Insured, for
any illness/disease/injury for the Insured Person in a Policy i. This benefit has a waiting period of 24 months from date of
Year as stated in the Policy Schedule subject to the inception of the first policy with Us. However, the waiting
following conditions: period will be reduced to 30 days in case Insured Person
has opted for Add ons/Optional Cover 3 Jumpstart.
I. This benefit will be triggered unlimited times for any
illness/disease/injury. ii. Any kind of Additional Sum Insured accrued as a part of
Guaranteed Cumulative Bonus/Power Booster/Inflation
ii. This benefit will not be available for Policies with
Protector/Reset benefit will not be available for this cover
Unlimited Sum Insured option.
iii. The Insured Person shall mandatorily obtain cashless
iii. The Annual Sum Insured including Guaranteed
approval prior to undergoing the surgery/ treatment
Cumulative Bonus, Inflation Protector (if opted and
accrued), Power Booster (if opted and accrued) in iv. Bariatric surgery/treatment performed for cosmetic
respect of the Insured Person is insufficient as a result reasons is excluded
of previous claims paid in that Policy Year. 13. In-patient Hospitalisation for Surrogate mother:
iv. The Reset Benefit will not be triggered for the first claim We will cover the Medical Expenses incurred in respect of In
made during the Policy Year Patient Hospitalization of the Surrogate mother appointed
v. The total amount of reset will not exceed the Annual by the “Intending Couple”/ ”Intending woman” for
Sum Insured for that Policy Year complications arising out of pregnancy and post-partum

delivery complications during the Policy Period, up to a ii. This benefit is applicable to all or any female insured
maximum limit of Rs. 5 Lakhs and subject to the following person
conditions: iii. Any expenses incurred on delivery of the new born
i. Initial waiting period of 30 days will be applicable (either via normal delivery or caesarean section) are
ii. This benefit is applicable for all female Insured Persons excluded from the scope of this cover
who have opted for 3 years’ policy term iv. This coverage shall only be available if all the provisions
iii. The maximum coverage available for a surrogate as specified in The Assisted Reproductive Technology
mother is a period of thirty-six (36) continuous months (Regulation) Act, 2021, and all the rules and regulations
made thereunder are fulfilled
after the surrogacy procedure has been successful
v. The terms and conditions of In-patient Treatment shall
iv. Any expenses incurred on delivery of the new born
apply.
(either via normal delivery or caesarean section) are
excluded from the scope of this cover We will consider a claim under this Cover, subject to the
following:
v. This coverage shall only be available if all the provisions
as specified in The Surrogacy Regulation Act (2021), i. If the oocyte donor is admitted in a room category/limit
and all the rules and regulations made thereunder are that is higher than the one that is specified in the Policy
fulfilled Schedule/ Product benefit table of this policy, then the
oocyte donor shall bear a rateable proportion of the
vi. The terms and conditions of In-patient Treatment shall
total Associated medical expenses (including
apply
surcharges or taxes thereon) in the proportion of the
We will consider a claim under this Cover, subject to the difference between room rent of the entitled room
following: category to the room rent actually incurred
i. If the Surrogate mother is admitted in a room a. For the purpose of this cover, “Associated medical
category/limit that is higher than the one that is expenses” shall include room rent, nursing charges,
specified in the Policy Schedule/ Product benefit table operation theatre charges, fees of medical
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 insured person has been admitted and will not
between room rent of the entitled room category to the include the cost of pharmacy and consumables,
room rent actually incurred cost of implants, medical devices and cost of
diagnostics.
a. For the purpose of this cover, “Associated medical
expenses” shall include room rent, nursing charges, b. Proportionate deductions are not applicable for ICU
operation theatre charges, fees of medical charges
c. Proportionate deductions shall not be applicable for
hospitals which do not follow differential billing or
insured person has been admitted and will not
for those expenses in respect of which differential
include the cost of pharmacy and consumables,
cost of implants, medical devices and cost of billing is not adopted based on the room category.
diagnostics. ii. Expenses associated with automation machine for
b. Proportionate deductions are not applicable for ICU peritoneal dialysis shall not be payable
charges 15. Wellness Program
c. Proportionate deductions shall not be applicable for The wellness program provides the Insured Person with
hospitals which do not follow differential billing or the below mentioned benefits
for those expenses in respect of which differential
billing is not adopted based on the room category. i. Wellness program
ii. Expenses associated with automation machine for ii. Health Assistance [HAT]
peritoneal dialysis shall not be payable iii. Ambulance Assistance
14. In-patient Hospitalization for Oocyte donor: iv. Discounts on services and products
We will cover the Medical Expenses incurred in respect of I. Wellness program
Hospitalization of the Oocyte donor appointed by the Wellness program intends to promote, incentivize and
“Intending Couple”/”Intending woman” for complications reward the Insured Person(s) for their healthy behavior
arising due to oocyte retrieval during the Policy Period, up through various wellness services. The wellness program
to the annual sum insured subject to maximum limit of Rs.5 shall be available to each Adult Insured Person subject to a
Lakhs and subject to the following conditions: maximum of 2 Adults in a floater policy. All the wellness
i. This cover shall be available only for a period of twelve activities as mentioned below in Table A enable the Insured
months (12 months) after the oocyte retrieval Person(s) to earn wellness points which shall be monitored
procedure has been successful by the Health Coach.
The Health Coach shall only be available to a maximum of

2 Adult Insured Persons. The Health Coach is a services offered and to redeem the wellness points
personalized service that shall encourage and promote awarded.
optimal health and physical and mental wellness through a Registered Insured Person(s) on successful completion of
digital platform. The Insured Person shall have access to Health Risk Assessment [HRA] shall be evaluated by the
the health coach on downloading and registering on our Health Coach to assess and educate the Insured Person on
mobile application. This activity needs to be done within 30 adapting a healthy lifestyle.
days of Policy Start Date to ensure adequate utilization of
Table A - Journey of earning Wellness points

Policy Tenure Individual Policy 1 Year Floater Policy* 1 Year
Category Activity Details Max Points Earned per Max Points Earned per
Insured Person Insured Person
Health Risk Assessment 500 250
Undergoing Health 1,000 500
check-up & uploading the reports
Health Assessment
Face scan once a quarter 400 200
First usage of Chat with Health 100 50
Expert/ Health Coach Service
ICICI Lombard initiated Contest/ 200 100
health quiz (Any one contest)
Wellness Activities ICICI Lombard initiated Webinar 200 100
(Any one webinar)
Achieving targeted steps per month 6,000 3,000
Wellness Tasks (10/15/25 points/ day depending
on steps completed)
Participation and successful 500 (250 per challenge) 250 per challenge
Fitness Challenge completion of fitness challenge In
App
Participation in Professional 500 250
Health Events sporting events like Marathon/
Cyclathon/Swimathon 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
Policy Tenure Individual Floater
Category Activity Details 2 Years Max Points 3Years Max Points 2 Years Max Points 3 Years Max Points
Earned per Insured Earned per Insured Earned per Insured Earned per Insured
Health Risk Assessment 1,000 1,500 500 750
Undergoing Health 2,000 3,000 1,000 1,500
check-up & uploading the
Health reports
Assessment
Face scan once a quarter 800 1,200 400 600
First usage of Chat with Health 200 300 100 150
Expert/ Health Coach Service
ICICI Lombard initiated Contest 400 600 200 300
Wellness / health quiz (Any one contest)
Activities ICICI Lombard initiated 400 600 200 300
Webinar (Any one webinar)
Achieving targeted steps per 12,000 18,000 6,000 9,000
Wellness month (10/15/25 points/ day
Tasks depending on steps completed)
Participation and successful 1,000 1,500 500 750
Fitness completion of fitness challenge
Challenge In App
Participation in Professional 1,000 1,500 500 750
Health sporting events like Marathon/
Events Cyclathon/Swimathon etc.
Grand Total 18,800 28,200 9,400 14,100
* In case of a floater policy, the wellness points earned by each of the Insured Persons for every completed wellness activities shall be accrued to calculate the renewal discount.
Detailed explanation of Table A has been mentioned below-

"Detailed explanation of Table A (with respect to Individual Table B- A Journey of earning Wellness Points by achieving
Policy) has been mentioned below -” targeted steps
A. Health Assessment Average Steps Maximum Maximum Wellness Points
achieved per day Wellness Points accumulated in a year
1. Health Risk Assessment
for 20 days in a per month
The Health Risk Assessment (HRA) questionnaire is a month 1 Year 2 Year 3 Year
tool for evaluation of the Insured Person’s health and 8,000+ steps 500 6000 12000 18000
quality of life by reviewing the personal lifestyle
6,000 to 7,999 steps 300 3600 7200 10800
practices affecting the Insured Person’s health status.
The Insured Person shall be awarded a maximum of 4,000 to 5,999 steps 200 2400 4800 7200
500 wellness points per year upon taking the Health <4,000 steps Nil Nil Nil Nil
Risk Assessment activity within 90 days of Policy Start
Date on our mobile application. D. Fitness Challenge
2. Undergoing Preventive Health check-up and The Insured Person shall be awarded wellness points on
Uploading the reports participation and successful completion of a fitness
The insured person shall be awarded a maximum of challenge as initiated by the Company from time to time.
1,000 wellness points per year upon taking the Health The Insured Person shall be awarded 250 wellness points
check-up and uploading the reports on our mobile per fitness challenge and the maximum wellness points
application for verification. that can be gained by participation and completion of the
fitness challenges is 500 per policy year.
3. Face Scan once a quarter
E. Health Events
The Insured Person shall be awarded a maximum of
100 wellness points per quarter for taking Face Scan on The Insured Person shall be awarded wellness points on
our mobile application. The maximum wellness points participation and successful completion of health events
awarded shall be restricted to 400 (100x4) per policy as initiated by Us from time to time. The Insured Person
year. shall be awarded 500 wellness points per health event and
the maximum wellness points that can be gained by
4. First usage of Chat with Health Expert/ Health Coach
participation and completion of such health events is 500
Service
per policy year.
The Insured Person shall be awarded a maximum of
100 wellness points per year upon using the chat with Redemption of wellness points
Health Expert/Health Coach Service for the first time in The total wellness points earned by the Insured person(s) (as
a Policy Year on our mobile application. The Insured detailed in Table A and Table B) will be redeemed towards
Person can virtually chat with health experts like availing discount on renewal premium for the subsequent year.
physiotherapists, counsellors, dieticians etc. under this 1. For Individual Policies, the maximum discount that can be
service. availed by the Insured Person is 30%.
B. Wellness Activities 2. For Floater Policies, the 2 Adult Insured Persons can avail a
1. ICICI Lombard Initiated contest or health quiz maximum discount of 15% each. The discount percentage
calculated basis the individual Wellness Points earned by
The Insured Person can earn wellness points by each Insured Person in the Floater Policy will be added to
participating in any health related contests or quiz provide the renewal discount on the subsequent year.
conducted by ICICI Lombard. Maximum of 200 wellness Maximum discount percentage provided shall be 30% on
points per policy year can be earned through the Policy level.
participating in such activities.
Table C shows the renewal discount that can be availed against
2. ICICI Lombard initiated Webinar the accumulated wellness points.
The insured person can earn a maximum of 200 Table C- Renewal Discount against Accumulated Wellness
wellness points per policy year on successful Points
completion of any one health related webinar session
Regular Wellness points accumulated Individual Floater
conducted by ICICI Lombard. fitness per Insured Person* (Per
C. Wellness Tasks related Insured
activities 1 Year 2 Year 3 Year Person)
The Insured Person shall be awarded wellness points as Points
per the Table B mentioned below for achieving the targeted
2500- 5000- 7500- 2.5% 1.25%
steps for a minimum of 20 days in a month. Our mobile 3999 7999 11999
application has to be downloaded within 30 days of the
4000- 8000- 12000- 5% 2.5%
Policy Start Date to avail this benefit as the average step
4999 9999 14999
count completed by an Insured Person would be monitored Points 5000- 10000- 15000- 10% 5%
on this mobile application.
6999 13999 20999
In case the number of active days are insufficient, no 7000- 14000- 21000- 20% 10%
wellness points will be accumulated for that month. The 8999 17999 26999
steps achieved up to 90 days prior to due date of renewal of >9000 >18000 >27000 30% 15%
the policy shall be considered for wellness points
computation. The steps achieved after this time-line, are *For each consecutive year, an Insured Person has to accumulate a minimum of
not lost and shall be considered for the next policy year. 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 ii. The Insured Person shall notify the Company and submit
through the Wellness Discount for Floater Policies the relevant documents, reports, receipts as and when
required by the Company within 60 days of undertaking
Redemption mechanism Wellness Fresh Renewal
discount Premium premium any wellness activity.
payable iii. The Insured Person agrees that choosing to utilize any of
Discount accrued on 15% the wellness services or any information or advise
renewal premium by rendered by Our Health Service Providers or Network
Insured 1 Providers or the Company will be solely at the Insured
Discount accrued on 15% Person’s discretion and own risk and should not be, used to
renewal premium by diagnose or identify treatment for a medical or mental
Insured 2 health condition.
Total Rs. Rs. 25000 - iv. In case of expiry of Policy, the accrued wellness points will
Discount- 25,000 (Rs. 25000x30%) not be carried forward
30% =Rs.17,500
v. There shall not be any cash reimbursement or redemption
Redemption mechanism Wellness Fresh Renewal available against the wellness points accumulated by an
discount Premium premium Insured Person.
payable vi. We or Our Health Service Providers or Our Network
Discount accrued on 15% Providers do not warrant the validity, accuracy,
renewal premium by completeness, safety, quality, or applicability of the content
Insured 1 or anything said or written or any suggestions provided in
Discount accrued on 10% the course of providing the wellness services.
renewal premium by
vii. We, or our affiliates, their respective directors, officers,
Insured 2
employees, agents, vendors, shall not be responsible for or
Total Rs. Rs. 25000 - liable for, any actions, claims, demands, losses, damages,
Discount- 25,000 (Rs. 25000x25%)
costs, charges and expenses which an Insured Person may
30% =Rs.18,750
claim to have suffered, sustained or incurred, as a result of
any advice or information obtained by way of the wellness
Terms and Conditions for Redemption of Wellness Points
program or any actions chosen by the Insured Person on
i. Renewal discount will only be applicable on a per year the basis of such advice or information.
basis upon the subsequent year of the Policy. Points
viii. The wellness program offered is subject to revisions based
accumulated will be mandatorily redeemed towards
on the insurance regulatory framework from time to time.
renewal discount of the subsequent year and cannot be
carried forward to the next Policy Year. Disclaimers
ii. Renewal discount is computed based on the Wellness i. Choosing the option is purely on Insured Person’s
Points earned on 90 days before the due date of renewal. discretion and at own risk.
Residual points will be carried forward to the next Policy ii. The wellness program is intended to provide support
Year and accrued with that Policy Year’s Wellness Points. information to the Insured Person to improve well-being
Hence, these points are not lost. and habits through working towards obtaining a healthy
iii. Discount is on the individual’s premium in Individual plan lifestyle, and does not constitute medical advice and/or
and on Floater Policy Premium in Floater plans. Discount substitute the Insured Person's visit/ consultation to an
will be considered only for Insured Persons aged 18 years independent Medical Practitioner.
and above. iii. We reserve the right to remove or reduce wellness points in
iv. In case the insured has opted for a higher Policy Tenure case the same have been found to be achieved in any unfair
during renewal, the discount will be given : - manner by manipulation
a. On the first Policy Year of a 2/3 year Policy Tenure (in iv. Availing the service provided by our Health Service
case of an existing 1 year Policy Tenure), and Providers / Network Provider is at the sole discretion of the
Insured person and We are not liable, responsible or
b. On the first and second Policy Year of a 3 year Policy
deemed to be liable or responsible for any discrepancy in
Tenure (in case of an existing 2 year Policy Tenure)
the information or Medical Advice provided.
v. In case the insured has opted for a lower Policy Tenure
II. Health Assistance Team[HAT]:
during renewal, flat discount will be applied on all year
premium before tenure discount. Our Health Assistance Team (HAT) will assist the Insured
Person in understanding his/her health condition better by
Terms and conditions for availing the Wellness Program:
providing responses to any queries related to health and
i. For health risk assessment [HRA] services availed through health care providers.
mobile application/online/ digital mode on IL Platform, the
The services provided under this shall include:
Insured Person shall be required to provide the details in
order to establish authenticity and validity prior to availing • Identifying a Physician/ Specialist
such services. Any such information provided by the • Availability of hospital beds
Insured Person in this regard shall be used solely for the • Providing guidance on engaging attendants/ nurses
purpose of providing these wellness services and kept
confidential with Us/Our Network Providers/Health Service • Facilitation with respect to arrangement of mobility
Providers at all times. aids, daily living aids, medical equipment etc.

• Scheduling an appointment with any Medical • This is an assistance service and the expenses for the
Practitioner empaneled with Us same will have to be borne by the Insured Person or can
• Scheduling appointments for a second opinion be claimed under Domestic Road Ambulance Cover (if
Inpatient Treatment claim is found to be admissible)
• Providing suitable options with respect to Hospitals as
well as providing assistance in Cashless facility, Process to avail Ambulance Assistance:
wherever applicable. a. On calling Our helpline number provided below, Our
• Scheduling appointments from diagnostic labs trained customer service executive (CSE) will ask the
empaneled with Us Insured Person relevant questions to assess the
situation.
• Providing information, assistance and facilitation on
door step delivery of medicines b. The call may be redirected to a qualified Medical
Practitioner in order to evaluate the requirement for an
• Providing preventive information on ailments
ambulance with Advanced Life Support based on the
• Providing guidance on post Hospitalization care, such Insured Person’s condition.
as Physiotherapy/ Nursing at home.
c. The below mentioned details are to be made available
I. Please note that services provided under this Cover are for availing the services:
solely for assistance, and should not be construed to be a
1. UHID of Insured Person, as provided on the Health
substitute for a visit/ consultation to an independent
Card.
Medical Practitioner. Our role is limited to that of facilitation
and Health Assistance Services will not include the 2. Contact number of the Insured Person
charges for any independent Medical Practitioner / 3. Location of Insured Person
nutritionist consulted/ charges incurred on diagnostics /
consulted on HAT’s recommendation, and such charges How to Call an Ambulance?
are to be borne by the Insured Person.
An IVRS will ask Call will be
II. We do not accept any liability towards quality of the you to select option answered by an
Call 18001028136 1 or 2 depending on
services made available by our network providers/ service to reach the CBE & details like
requirement. name, UHID, nature
providers and are not liable for any defects or deficiencies Emergency
Dial 1 for Medical of emergency will
on their part Response Centre
Ambulance be asked
Services
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 Doctor may Patient will be
taken to the Emergency
calling on 040-66274205 (please note that this number is accompany
patient in the nearest hospital as Ambulance
subject to change) from 8am to 8pm from Monday to ambulance if per the predefined Transport will
Saturday except public holidays. required hospital network arrive
chart
By availing this service, the Insured Person agrees and has
no objection to the health records being maintained with
Us for internal use only.
How to Call an Ambulance? (Via Mobile Application)
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 Ambulance pick
Click on
also to decide the use (if any) to which these services is to emergency icon &
up & drop the CSE does
be put for. patient to hospital feedback Call
place request
/ health facility
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
Customer service The medical team
treatment subject to availability of services in that provides with
particular city/location. Kindly visit our website for updated executive
connects with continued
list of cities/locations where the services are provided. medical team necessary
assistance on call
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
Doctor
immediate and rapid transportation to the Hospital; as understand CSE dispatch the
certified in writing by the Medical Practitioner situation & ambulance to
advices on desired location &
• The Insured Person is in India and the treatment is in emergency Care / provide necessary
India only; Selection of details
• The ambulance service is availed within the same city ambulance

III. Discounts on services/products Policy Inception or the first renewal. The Optional
Cover shall not be applicable in case the Insured
We shall only facilitate the Insured Person in availing
Person wishes to opt for this cover at the time of
discounts on services/products including but not limited to
second renewal.
investigations/diagnostic tests/ laboratory tests /health
supplements/ medical equipment/homecare services / b. If the Policy Tenure is of 2 or 3 years, the cover has to
virtual health & wellness sessions/AYUSH products / be opted at the time of Policy inception itself to avail
Fitness & wellness related activities & products etc. at our the benefit.
empanelled diagnostic centres, drugs/medicines ordered
ii. This cover is applicable only for one claim in the lifetime of
from pharmacies etc. offered by our network providers/
the Policy, irrespective of Policy Tenure or Policy Type
health service providers. These discounts can be viewed on
(Individual or Floater), and should be admissible under In-
our mobile application and one can avail these discounts
patient Treatment/Daycare Procedures/Treatment/In-
depending on terms and conditions and subject to
patient AYUSH Hospitalization. All the conditions
availability.
applicable to the above mentioned Basic Covers shall be
ii. Add ons/ Optional Covers applicable to this Optional Cover.
The Covers listed below shall be available to the Insured iii. Once opted, the optional cover has to be opted
Person only if the additional premium has been continuously by the Insured Person until any one claim is
received by Us (except Optional Cover 19. Voluntary co- made under this cover. If the Insured Person opts out of this
payment, Optional Cover 20. Voluntary Deductible, cover during any renewal, the same cannot be opted again.
Optional Cover 29. Network Advantage, and Optional
iv. Once a claim has been made under this Optional Cover, the
Cover 30. NRI Advantage- Accidental Emergencies
cover will cease to exist and cannot be opted again upon
Cover for NRI) and the Optional Cover is specified to be
subsequent renewals.
in force for that Insured Person in the Policy Schedule.
v. The Total Sum Insured (Annual Sum Insured + Guaranteed
Covers under this Section are subject to the terms,
Cumulative Bonus (if accrued) + Power Booster (if opted
conditions, waiting periods and exclusions of this Policy
and accrued) + Inflation Protector (if opted and accrued))
and in accordance with the applicable Plan as specified
shall be utilized as per following sequence in event of a
in the Policy.
claim under this Optional Cover: -
The Reset Benefit /Pre-Hospitalisation medical
1. Annual Sum Insured
expenses/ Post hospitalization medical expenses will
not be applicable for this Section. Claims under this 2. Guaranteed Cumulative Bonus
Section will not impact the Annual Sum Insured (except
3. Power Booster
Optional cover 10. Claim Protector, Optional Cover 1.
Infinite Care, and Optional Cover 22. Durable Medical 4. Inflation Protector
Equipment Cover) or Guaranteed Cumulative Bonus
vi. After utilization of all the above mentioned Sum Insured,
(except Optional Cover 1. Infinite Care)
the Total Sum Insured shall be reduced to zero for that
The Sum Insured for each of the Optional Covers Policy Year following the payment of claim under Infinite
(except Optional cover 10. Claim Protector, & Optional Care.
Cover 22. Durable Medical Equipment Cover)shall be
vii. Optional Cover 19. Voluntary Co-payment or Optional
over and above the Annual Sum Insured of the Policy.
Cover 20. Voluntary Deductible if opted by the Insured
1. Infinite Care Person shall be applicable under this Optional Cover.
We will cover the Medical Expenses incurred in respect of viii. This cover will not be available in case the Insured Person
Hospitalization of the Insured Person under in-Patient has opted for Optional Cover 9. Worldwide Cover, Basic
Treatment / Daycare Procedures/Treatment/ in-Patient Cover 13. In-patient Hospitalisation for Surrogate Mothers,
AYUSH Hospitalization/ of the Insured Person for any one Basic Cover 14. In-patient Hospitalization for Oocyte
claim during the lifetime of the Policy without any limits on Donors and for policies with Unlimited Sum Insured option.
the Annual Sum Insured subject to the following conditions:
ix. Room category applicable under this cover shall be capped
i. The time period to opt for this optional cover shall be at Single Private AC room unless the Insured Person has
limited to 2 Policy Years (irrespective of the Policy opted for Optional Cover 27 Room Modifier.
Tenure). Such that:
a. If the Policy Tenure is of single year and is

continuously renewed as single year, the Insured
Person has to opt for this cover either at the time of

2. Power Booster (Guaranteed Super Bonus) Specific Definitions for the above listed diseases / illnesses /
If the Insured Person has opted for this optional cover, We conditions are mentioned below for ease of understanding
will provide a Cumulative Bonus of 100% of expiring or and the same will be covered subject that the condition(s)
renewed Annual Sum Insured (whichever is lower) at the of the Insured Person(s) meet the criteria defined-
end of each Policy Year irrespective of a claim being 1. Asthma is a Chronic condition that affects the airways
initiated in the Policy Year, provided that the Policy has (bronchi) of the lungs, causing them to constrict (become
been continuously renewed with the Company subject to narrow) when exposed to certain triggers which results in
the conditions mentioned below: the symptoms of wheezing, coughing, tight chest and
i. The Power Booster can be accumulated up to an shortness of breath.
Unlimited Sum Insured. 2. Hypertension is the term used to describe a persistent
ii. This cover shall not be available to policies with elevated blood pressure, commonly referred to as high
Unlimited Annual sum insured blood pressure, and if this chronic disease is not treated
appropriately, is a major risk factor for heart disease,
iii. In case, the Insured Person opts out of this cover at the
stroke, kidney disease and even eye diseases.
time of renewal, all the bonus accumulated under
Power Booster will be reduced to zero 3. Hyperlipidemia is a chronic disease that refers to an
elevated level of lipids (fats), including cholesterol and
iv. All conditions applicable under Basic Cover 10.
triglycerides, in the blood and if not treated appropriately, it
Guaranteed Cumulative Bonus shall be applicable to
is a major risk factor for increased risks of heart disease,
this cover.
heart attacks, strokes and other incidents of disease.
3. Jumpstart 4. Diabetes mellitus is a chronic, progressive disease in
The company shall indemnify Medical Expenses incurred which impaired insulin production leads to high blood
for the hospitalization of the Insured Person(s) admissible glucose (sugar) levels, and without good self-management
under the Basic Cover 1 in-patient Treatment or Basic and proper treatment, the increased glucose (sugar) in the
Cover 2 Daycare Procedures /Treatments or Basic Cover 6. blood affects and damages every organ in the body, which
in-patient AYUSH Hospitalization for the below listed causes serious health consequences.
diseases / illnesses / conditions from Day 31 of the Policy 5. Obesity where Obesity means abnormal or excessive fat
Start date, provided that: accumulation that presents risk to the health (Body Mass
i. the diseases/illnesses/conditions has been declared by Index i.e. BMI is less than or equal to 39.99. This BMI limit
the Insured Person and accepted by Us, or will be modified in case of co-morbidities.)
ii. the diseases/illnesses/conditions has been detected 6. Coronary Artery Disease with PTCA done prior to 1 year:
during Pre-policy medical examination and have been
i. Coronary artery disease is the buildup of lipid-rich
accepted by Us.
plaque in the arteries that supply oxygen-rich blood to
iii. The above reduced waiting period of 30 days shall be the heart. Plaque causes a narrowing or
applicable only for specified Insured Persons who have
ii. blockage that could result in a heart attack.
opted and paid additional premium as specified in the
policy schedule. iii. PTCA (Co r o n a r y A n g i o p l a s t y ) i s d e f i n e d a s
iv. This cover will be available only during inception of the percutaneous coronary intervention by way of balloon
policy and only for the Annual Sum Insured chosen at angioplasty with or without stenting for treatment
the time of Policy Inception. iv. of the narrowing or blockage of minimum 50 % of one or
v. Deletion of this Optional cover shall not be permitted more major coronary arteries. The intervention must be
upon subsequent policy renewals. determined to be medically necessary by a cardiologist
and supported by a coronary angiogram (CAG).
vi. Exclusions Pre-Existing Diseases (Code- Excl01) shall
not apply if this Optional Cover has been opted by the v. Coronary arteries herein refer to left main stem, left
Insured Person(s). anterior descending, circumflex and right coronary
vii. This reduced waiting period of 30 days shall not be artery.
applicable for claims made under Optional Cover 9. vi. Diagnostic angiography or investigation procedures
Worldwide Cover. without angioplasty / stent insertion are excluded from
List of diseases/illnesses/conditions covered under this the scope of this definition.
optional cover- 4. Chronic Disease Management Program:
1. Asthma In case the Insured Person(s) has declared any of the listed
2. Diabetes diseases /illnesses /conditions – Asthma, Diabetes,
3. Hypertension Hypertension, Hyperlipidemia, Obesity, and/or Coronary
4. Hyperlipidemia Artery Disease (PTCA done prior to 1 year)- and the same
have been accepted by Us, the Insured Person(s) shall be
5. Obesity
enrolled under Our Chronic Disease Management
6. Coronary Artery Disease (PTCA done prior to 1 year) Program.

As a part of this program, we shall provide the below vii. Any medical Expenses incurred for management of
mentioned services to the Insured Person(s)- Ectopic Pregnancy shall not be covered under this
i. Assistance to the Insured Person(s) to track their health benefit. The claim for the same can be intimated under
through Our empaneled medical experts who will guide Inpatient treatment.
them in maintaining/ improving their health viii. Maternity Benefit shall not be available outside the
condition(s). geographical boundaries of India.
ii. Assistance to avail Dietician and nutritional counseling 6. New Born Baby Cover:
as per their health condition(s). i. We will cover the Medical Expenses incurred by the
iii. 2 Pre-defined diagnostic Health check-ups for the Insured Person on Hospitalization of a “New born
listed conditions with a gap of six months between the Baby” during each Policy Year of Policy Period subject
2 tests. The health checkups are over and above to the to the maximum limit of twice of the maternity sum
Optional Cover 16. Health Check-up if opted. Insured. This limit is over and above the maternity sum
iv. As s i st a n ce to ava i l Co u n s e l l i n g fo r l i fe st y l e insured.
modifications such as quitting tobacco/alcohol etc. ii. This add on/ Optional Cover will be provided only if You
This program shall be subject to the following have opted for the Maternity Cover and We have
conditions- accepted a claim under Maternity cover under this
policy.
1. The insured person(s) shall be enrolled to this
program only if Optional cover 3 Jumpstart has iii. This Optional Cover will cover Medical Expenses
been opted. incurred on the “New born Baby” during Hospitalization
(for a minimum period of consecutive 24 hours) for a
2. The health check-up can be availed only on a
maximum period up to 90 days from the date of birth of
cashless basis through our mobile application or by
the baby
calling at our Toll free number: 1800 2666.
7. Vaccinations for new born baby in the first year:
3. The Network Provider/Health Service Provider shall
be assigned by Us post receiving Insured Person’s i. We will cover the expenses incurred on Vaccinations of
request to avail a Health Check-up under this cover. the new born baby till one year of age during the policy
period up to 1% of the Sum Insured subject to a
4. Utilization of this Health Check-up will not impact
maximum limit of INR 10,000. This limit is over and
the Annual Sum Insured
above the Maternity Sum Insured
5. Maternity Benefit: ii. This cover is available only if Optional cover 5.
i. This optional benefit covers the medical expenses up to Maternity Cover and Optional cover 6. New Born Baby
10% of the Annual Sum Insured; subject to a maximum cover has been opted and We have accepted a
limit of INR 1 Lakh for the delivery of a baby and / or maternity claim under this Policy.
expenses related to medically recommended lawful
8. BeFit:
termination of pregnancy but only in life threatening
situation under the advice of Medical Practitioner, All benefits under the BeFit cover can be availed only on
limited to maximum of three deliveries or terminations cashless basis via our mobile application and are subject to
as said herein during the lifetime of an female the terms, conditions, and exclusions and the availability of
Insured/Insured Person as the case may be between Sum Insured under the Cover. BeFit cover can only be opted
the ages of 18 years to 50 years in the Policy. by Insured Person(s) up to the age of 65 years during first
time issuance.
ii. Pre-natal (period from conception until delivery of
baby) and post-natal (up to 30 days from date of All services shall be provided through our Empaneled
delivery of baby) expenses will be covered within the Health Service Provider subject to availability at the time of
above mentioned limits (10% of Annual Sum Insured appointment. There will be a waiting period of 30 days for
subject to a maximum of INR 1 Lakhs) provided the this cover
same have been incurred on in-patient basis Any unutilized Consultations/E- consultations/Sum
iii. This benefit will have a waiting period of 24 months Insured/ sessions cannot be carried forward to the next
from the time this cover is opted Policy Year.
iv. This Cover is available only under a family floater Policy Choosing the services under this Cover is purely upon the
v. This Cover is available for You or Your spouse, provided Insured Person’s own discretion and at own risk. The
You and Your spouse, both are covered under the same services provided under the various Covers are via third
family floater Policy and the female Insured person is party health Service Providers/ Network Providers/ and We
between age 18 to 50 years as selected by proposer. are not responsible for liability arising out of the services
provided by these third parties.
vi. In case, Insured Person has already taken a policy
without maternity benefit and would like to opt for The Insured Person(s) should seek assistance from a
maternity benefit, then this can be availed only at the medical practitioner should they still have any concerns
time of renewal about their health even post availing services from our
health service providers/network providers.

List of Minor Procedures covered under this Optional Cover #

i. Physical Consultations Drainage of abscess
We shall cover the Medical Expenses incurred during Injection including Intramuscular (Per Injection cost)
the Policy Period for out-patient consultations from a Intravenous injection(IV)
General Medical Practitioner or Specialist Medical
Sprain Management (Joint movement/exercise)
Practitioner or Super Specialist Medical Practitioner or
AYUSH Medical Practitioner in relation to any Illness Otoscopic examination (Magnifying otoscopy)
contracted or Injury suffered by the Insured Person Nasal packing for control of haemorrhage
during the Policy Period subject to the overall maximum Nebulizer therapy
number of consultations as specified against this
Removal of foreign body
Optional Cover in the Policy Schedule. These services
shall be provided through our Empaneled Health Suturing(Staple under LA)
Service Provider subject to availability at the time of Removal of suture
appointment. Stabilization of joint
This Optional Cover shall also include e-consultation Syringing ear to remove wax
given by a General Medical Practitioner or Specialist or
Application or removal of plaster cast
Super Specialist Medical Practitioner or AYUSH
Medical Practitioner through a virtual mode of Laryngoscopy
communication such as but not limited to chat, email, Minor wound management
video, online portal, or mobile application. #This includes only the cost of administration. The actual cost of
Dental treatment shall be excluded from the scope of consumables shall be covered under the pharmacy cover.
this cover. However, the said cost will have to be borne by the Insured
Physiotherapy sessions and counselling availed for Person in case the Sum Insured under the Pharmacy Cover has
psychiatric ailments or mental health issues shall be been exhausted or is out of scope of the Pharmacy Cover or in
excluded from the scope of this Optional Cover as the case the consumable is a non-payable item as per IRDAI list of
same are covered under optional cover 8 iv. non-payables
Physiotherapy sessions and optional cover. 8 v. e- iii. Pharmacy
counselling respectively. We shall cover medical expenses incurred on purchase of
ii. Routine Diagnostic and Minor Procedure Cover medicines, drugs, and medical consumables, as prescribed
We shall cover medical expenses incurred for by a Medical Practitioner under our cashless network
outpatient diagnostic tests recommended by Medical available in the mobile application for any Illness
Practitioner under our cashless network available in the contracted or Injury suffered by the Insured Person during
mobile application in relation to any Illness contracted the Policy Period, maximum up to the Sum Insured limit as
or Injury suffered by the Insured Person during the specified against this Optional Cover in the Policy Schedule
Policy Period and for listed minor procedures through our Empaneled Health Service Provider subject to
undergone at a general practitioner or specialist/super- availability on the date of the request.
specialist medical practitioner by the Insured Person Health Supplements, Nutraceuticals, foods for special
during the Policy Period maximum up to the Annual dietary use, foods for special medical purpose, foods with
Sum Insured limit as specified against this Optional added probiotics and/or foods with added prebiotics,
Cover in the Policy Schedule. These services shall be vaccinations, vitamins, tonics or other related products are
provided through our Empaneled Health Service excluded from the scope of this Optional Cover
Provider subject to availability at the time of iv. Physiotherapy Session
appointment
We shall cover medical expenses incurred by the Insured
The diagnostic tests shall include but will not be limited Person for Physiotherapy Sessions with a qualified
to histopathology, biochemistr y, hematology, physiotherapist within our cashless network to treat
immunology, microbiology, serology, pathology, Illness, injury or deformity suffered as advised by qualified
radiology, ultrasound and TMT. Genetic studies shall be Medical Practitioners during the Policy Period by physical
excluded from the scope of this cover. methods such as but not limited to massage, heat
We may even arrange for diagnostic tests to be carried treatment, ultrasound, Laser and exercises maximum up to
out at the location of the Insured Person provided such the number of visits/ sessions as specified against this
location is within the geographical reach of the Health Optional Cover in the Policy Schedule.
Service Provider on the date of the request. This service These services shall be provided through our Empaneled
shall be subject to availability of Our empaneled Health Health Service Provider subject to availability at the time of
Service provider. appointment.

The time duration of each physiotherapy session shall be application from the App Store/Play Store. Post download
restricted to thirty minutes only. the Insured Person will have to complete the registration
v. e-Counseling process and login to the home page.
We shall cover expenses incurred by the Insured Person on 2. On the home page, the Insured person will have to go to
e-counseling session(s) with a Psychologist via our mobile visit the out-patient service section like consultation,
application for providing assistance in dealing with issues diagnostics and pharmacy
such as but not limited to personal and lifestyle imbalance, A schematic representation of the claims process is as
pre-marital counselling, parenting and child care, speech below
impairment, and problems related to psychological/mental
illness/ psychiatric and psychosomatic disorders, stress, The insured person
The insured person
uploads the
anxiety maximum up to the number of sessions as Clicks on the icon to avails the
prescription .
avail consultation consultation service
specified against this Optional Cover in the Policy service through network
Digitized
prescription
Schedule. doctor
received on App
The e-counseling sessions shall be availed only through

virtual modes of chat or tele etc. via our mobile application.
Insured Person Prescription based
vi. Diet and Nutrition e-Consultation cashless
Select nearest visits centers with
We will cover expenses incurred by the Insured Person on network doctor for pre-booked slot & diagnostic/pharmac
appointment completes with y service triggered
diet and nutrition e-consultation during the Policy Period verification process from app
on a virtual platform via our mobile application for the
duration as specified against this Optional Cover in the
Policy Schedule.
Appointment
The e-consultation shall be availed only through virtual Call lands at 24*7 confirmed/Re-
Tele-consult scheduled
modes of chat or tele etc. via our mobile application. platform communication
shared
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 9. Worldwide Cover:
exclusions of the Policy and the availability of the Sum Insured. We will cover the Insured Person for Hospitalization
Cashless Facility is only available at specific Network expenses including planned Hospitalization incurred
Providers/Health Service Provider available on the mobile outside India and anywhere across the world including
application. We reserve the right to modify, add or restrict any USA and Canada, up to the Annual Sum Insured subject to
Network Provider/Health Service Provider for Cashless facility a maximum of INR. 3 Crore, subject to the terms &
at Our sole discretion. conditions specified hereunder:
• To avail of Cashless Facility at the health Service Provider / i. The sum insured for this optional cover shall be over
and above the Annual Sum Insured
Network Provider, the Insured Person/claimant is required
to produce information on the health card available on the ii. This cover can only be availed by Insured Person(s) up
application for verification and validation. The request shall to the age of 65 years and who are resident(s) of India
be considered after having obtained accurate and and are within the geographical boundaries of India
complete information for the Illness or Injury, where during Policy issuance. Non- disclosure or mis-
applicable, for which Cashless Facility is sought and We representation with respect to the above will impact
shall confirm the request digitally. claims admissibility under this Cover and lead to Policy
Cancellation.
• In case the services availed exceed the eligibility of the
Policy, the difference shall have to be paid directly to the iii. There will be a waiting period of 2 years for any claim
Hospital/Network Provider/Health Service Provider by the under this cover. There will be no waiting period for
Accidental Emergencies.
Insured Person/claimant.
iv. In case of addition of any new members to the Policy,
• To avail the benefits and services under this Optional
they will have to serve the waiting period of 2 years
Cover, Insured Person shall need to raise a request through
before availing any coverage under Worldwide Cover.
mobile application
The coverage is available for 45 consecutive days from the
• The Routine diagnostic and minor procedure cover
date of travel in a single trip and 90 days in a cumulative
/Pharmacy cover services shall only be covered for
basis as a whole in a Policy Year. Any expenses incurred
prescriptions by an empaneled Network Medical
beyond 45 days from date of travel shall not be covered
Practitioner through the Mobile Application.
in any case
How to avail the cashless services under the BeFit cover on
v. The expenses covered under this benefit will be limited
the mobile application
to Inpatient Hospitalization Expenses and Daycare
1. The Insured Person will have to download the mobile Procedures/Treatment Expenses.

vi. Expenses incurred for Pre and Post Hospitalization At the time of renewal, if the insured person opts out of the
Medical Expenses, Out- patient Treatment or any other optional cover, then the sum insured under the Inflation
Basic Covers/Optional Covers under this Policy shall not Protector cover accrued up to the expiring policy year will
be covered under Worldwide cover. be forfeited.
vii. The payment of any claim will be based on the rate of Year Annual Sum Opted for Inflation Protector Overall
exchange as on Date of Loss published by Reserve Insured inflation at renewal inflation
Bank of India (RBI) and shall be used for conversion of Protector computation# Protector
Foreign Currency into Indian rupees for payment of
claims. If on the Insured Person’s date of loss, if the RBI 0 Rs. 10,00,000 Yes Not applicable Not applicable
rates are not published, the exchange rates published
1 Rs. 10,00,000 Yes 10,00,000 X 6% = Rs. 60,000
next shall be considered for conversion.
60,000
viii. In case of planned hospitalization, prior intimation at 2 Rs. 15,00,000 Yes 10,00,000 X 6% = Rs. 60,000 +
least 7 days in advance of the travel and due approval 60,000 Rs. 60,000 =
from Us will be necessary. Rs. 1,20,000
ix. Any Additional Sum Insured as available under 3 Rs 15,00,000 Yes 15,00,000 X 6% = Rs. 1,20,000 +
90,000 Rs. 90,000 =
Guaranteed Cumulative Bonus/Power Booster / Rs. 2,10,000
Inflation Protector (if any) will not be available for
4 Rs 15,00,000 No Nil as customer Nil
worldwide cover and Hospitalization/day care opted out of the
expenses incurred will be covered only up to the Annual Optional Cover
Sum Insured under the Policy. #Considering Consumer Price Index to be 6%
x. Maternity Benefit, Infinite Care, Reset benefit, and ##Insured Person has enhanced his/her Annual Sum Insured
Claim Protector will not be available for worldwide from Rs. 10 Lakhs to Rs. 15 Lakhs
cover.
10. Claim Protector: 12. Domestic Air Ambulance Cover
We will cover the expenses incurred on Air Ambulance
If a claim has been accepted under the “Inpatient
services up to the Annual Sum Insured which are offered by
Treatment” or “Daycare Procedures/Treatment” Cover, the
a healthcare or an air ambulance service provider and
items which are included in the List I- Items for which
which have been used during the Policy Period to transfer
coverage is not available in the Policy of Annexure II, which
the Insured Person to the nearest Hospital with adequate
are non – payable, to the particular claim, will become
emergency facilities for the provision of Emergency Care,
payable.
provided that:
i. The maximum claim payable under this add
i. It is for a life threatening emergency health conditions
on/Optional Cover shall be limited to Annual Sum
of the Insured Person which requires immediate and
Insured under the Policy.
rapid ambulance transportation from the place where
ii. Claims under this add on/Optional Cover shall be the Insured Person is situated at the time of requiring
limited to treatment taken within the geographical Emergency Care to a hospital provided that the
boundaries of India. Hence, this cover is not applicable transportation is for Medically Necessary Treatment, is
to Optional Cover 9 Worldwide Cover. certified in writing by a Medical Practitioner, and
iii. Any Sum Insured accrued under Guaranteed Domestic Road Ambulance services cannot be
Cumulative Bonus/Inflation Protector/Reset benefit will provided.
not be available for Claim Protector Cover. ii. Such air ambulance providing the services, should be
11. Inflation Protector: duly licensed to operate as such by a competent
government Authority.
The Inflation Protector Cover is designed to protect the
Annual Sum Insured against rising inflation by linking the iii. This cover is limited to transportation from the area of
emergency to the nearest Hospital only;
Annual Sum Insured under the Basic Cover to the
Consumer Price index (CPI). iv. We will not cover:
The Annual Sum Insured will be increased on cumulative a. Any transportation from one Hospital to another;
basis at each Renewal on the basis of inflation rate in b. Any transportation of the Insured Person from
previous year. Inflation rate would be computed as the Hospital to the Insured Person’s residence after
average CPI of the entire calendar year published by the he/she has been discharged from the Hospital
Central Statistical Organization (CSO). c. Any transportation or Air Ambulance expenses
The % increase will be applicable only on Annual Sum incurred outside the geographical scope of India.
Insured under the Policy and not on Guaranteed v. We have accepted a claim under Inpatient Treatment in
Cumulative Bonus or any other Covers which leads to respect of the Insured Person for the same
increase in Sum Insured. Accident/Illness for which air ambulance services were
availed.

vi. We shall not be liable if Medically Necessary Treatment iii. Health check-up can be availed only once per Policy
can be provided at the Hospital where the Insured Year per Adult Insured Person.
Person is situated at the time of requiring Emergency iv. The pre-defined health check-up packages maybe
Care. modified from time to time without prior notice but the
13. Convalescence Benefit: sum insured eligibility will not be changed
In case the Insured Person is hospitalized for a continuous v. This Cover can be availed through our mobile
period of 10 days or more for treatment of any Accident / application or by calling at our Toll free number: 1800
Disease/ Illness /Injury for which a valid claim is admissible 2666
under the Policy, this benefit provides for payment to the vi. The Network Provider/Health Service Provider shall be
Insured / Insured Person of a fixed allowance of INR. 20,000 assigned by Us post receiving Insured Person’s request
and is payable only once during the policy year. to avail a Health Check-up under this cover.
If an insured person is opting for a policy tenure of 1 year vii. Utilization of this Preventive Health Check-up will not
he/she is eligible for convalescence benefit only once (i.e. impact the Annual Sum Insured
one per policy year), while if he/she is opting for policy
viii. Unutilized Health Check-up package will not be carried
tenure of 3 years, he/she is then eligible for this benefit once
forward to the next Policy Year and it will be the Insured
in each and every year (i.e. one per policy year).
Person’s choice and responsibility to utilize the same
14. Nursing at Home: with in the designated Policy Period. We shall not be
We will pay You for the expenses incurred by You, up to Rs. liable to provide any reminders or notifications for the
2,000 per day up to a maximum of 10 days post same.
Hospitalization for the medical services of a Qualified ix. In-case of long term policies (2 year or 3 years), the
Nurse at Your residence, provided that the nurse is Adult Insured Person(s) are eligible for Preventive
employed in a Hospital and the engagement of such Health Check-up once per policy year
Qualified Nurse is certified as necessary by a Medical
Please Note:
Practitioner and relate directly to any Illness or Injury,
covered under the Policy. a) We shall not hold any responsibility towards any loss or
damage arising out of or in relation to any opinion, advice,
The Claim under this Optional Cover/add on will be payable
prescription, actual or alleged errors, omissions and
only if We have admitted Our liability under “In-patient
representations made by the Medical Practitioner/
Treatment” section of the Policy.
Healthcare professional
15. Compassionate Visit:
b) Choosing the services under this Cover is purely upon the
In event of Your Hospitalization, which in the opinion of the customer’s own discretion and at own risk.
Medical Practitioner attending on You, extends beyond a
c) The Insured Person should seek assistance from a health
period of 5 consecutive days, We will indemnify the cost of
the economy class air ticket/railway ticket incurred by Your care professional when interpreting and applying them to
Immediate Family Member from and to the place of origin the Insured person’s individual circumstances. If the
of such Family Member or the place of residence of the Insured Person has any concerns about His/ her health, He/
Family Member. She may consult His/ her general practitioner.
Our liability under this Optional Cover, however, in respect d) The Health records in respect of the Insured Person shall be
of any one event or all events of Hospitalization during the saved with Us in order to award wellness points as a part
Policy Year shall not in aggregate exceed Rs. 20,000 per of the Wellness Program. They may be made available to
Policy Year of Policy Period. Insured Person(s) in their medical vault in our mobile
For the purpose of this extension, the term “Immediate application.
Family member” would mean the Insured’s Spouse, 17. Critical Illness:
Children, Parents, and Parents-in-law. We will pay You or Your Nominee / legal heir the Annual
16. Health Check-up: Sum Insured subject to a maximum limit of Rs.50 Lakhs in
Adult Insured Person(s) aged 18 years and above can avail case You are diagnosed as suffering from one or more of
Health Check-up with our Network Providers or the Critical Illnesses for the first time in your life, during the
empaneled Health Service Providers anytime during the Policy Period.
Policy Period subject to the below conditions However, We will not make any payment if You are first
i. The coverage shall be up to 0.5% of Annual Sum diagnosed as suffering from a Critical Illness within 90
Insured subject to a maximum of Rs. 5,000 on cashless days of the Period of Insurance Start Date. This add on/
basis.. Optional Cover can be claimed by You only once during
ii. Utilization of the above cover shall be via Pre-designed Your lifetime. No Claim under this Optional Cover shall be
health packages as per sum insured eligibility. Insured admissible in case any of the Critical Illnesses is a
person(s) will not be able to modify the pre-designed consequence of or arises out of any Pre-Existing
packages Condition(s)/Disease.

However, in case of diagnosis of multiple critical illnesses, v. All Thyroid cancers histologically classified as T1N0M0
the payment of critical illness benefit shall be limited to the (TNM Classification) or below;
sum insured as mentioned against this benefit in the policy vi. Chronic lymphocytic leukaemia less than RAI stage 3
schedule.
vii. Non-invasive papillar y cancer of the bladder
This cover is available only for adult members aged histologically described as TaN0M0 or of a lesser
maximum up to 50 years during first time issuance. classification,
“Critical Illness” for the purpose of this Policy includes the viii. All Gastro-Intestinal Stromal Tumors histologically
following: classified as T1N0M0 (TNM Classification) or below
1. Cancer of Specified Severity and with mitotic count of less than or equal to 5/50
2. Myocardial Infarction (First Heart Attack of Specified HPFs;
Severity) 2. Myocardial Infarction (First Heart Attack of specified
3. Coronary Artery Disease severity)
4. Open Chest CABG I. The first occurrence of heart attack or myocardial

infarction which means the death of a portion of the
5. Open Heart Replacement or Repair of Heart Valves
heart muscle as a result of inadequate blood supply to
6. Surgery to Aorta the relevant area. The diagnosis for Myocardial
7. Stroke resulting in Permanent Symptoms Infarction should be evidenced by all of the following
8. Kidney Failure requiring Regular Dialysis criteria:
9. Aplastic Anaemia i. A history of typical clinical symptoms consistent

with the diagnosis of acute myocardial Infarction
10. End Stage Lung Disease
(for e.g. typical chest pain)
11. End Stage Liver Failure
ii. New characteristic electrocardiogram changes
12. Coma of Specified Severity
iii. Elevation of infarction specific enzymes, Troponins
13. Third Degree Burns or other specific biochemical markers.
14. Major organ /bone marrow transplant The following are excluded
15. Multiple Sclerosis with Persisting Symptoms i. Other acute Coronary Syndromes
16. Fulminant Hepatitis ii. Any type of angina pectoris
17. Motor Neuron Disease with Permanent Symptoms iii. A rise in cardiac biomarkers or Troponin T or I in
18. Primary Pulmonary Hypertension absence of overt ischemic heart disease OR
19. Terminal Illness following an intra-arterial cardiac procedure.
20. Bacterial Meningitis 3. Coronary Artery Disease
1. Cancer of Specified Severity The narrowing of the lumen of at least one coronary artery
by a minimum of 75% and of two others by a minimum of
A malignant tumor characterized by the uncontrolled
60%, as proven by coronary arteriography, regardless of
growth and spread of malignant cells with invasion and
whether or not any form of coronary artery surgery has
destruction of normal tissues. This diagnosis must be
been performed. Coronary arteries herein refer to left main
supported by histological evidence of malignancy. The
stem, left anterior descending circumflex and right
term cancer includes leukemia, lymphoma and sarcoma.
coronary artery.
The following are excluded –
4. Open Chest CABG (Coronary Artery By-pass Graft)
i. All tumors which are histologically described as surgery
carcinoma in situ, benign, pre-malignant, borderline
I. The actual undergoing of heart surgery to correct
malignant, low malignant potential, neoplasm of
blockage or narrowing in one or more coronary
unknown behavior, or non-invasive, including but not
artery(s), by coronary artery bypass grafting done via a
limited to: Carcinoma in situ of breasts, Cervical
sternotomy (cutting through the breast bone) or
dysplasia CIN-1, CIN -2 and CIN-3.
minimally invasive keyhole coronary artery bypass
ii. Any non-melanoma skin carcinoma unless there is procedures. The diagnosis must be supported by a
evidence of metastases to lymph nodes or beyond; coronary angiography and the realization of surgery
iii. Malignant melanoma that has not caused invasion has to be confirmed by a cardiologist.
beyond the epidermis; II. The following are excluded:
iv. All tumors of the prostate unless histologically i. Angioplasty and/ or any other intra-arterial
classified as having a Gleason score greater than 6 or procedures
having progressed to at least clinical TNM classification
5. Open heart replacement or repair of heart valve
T2N0M0
I. The actual undergoing of open-heart valve surgery is to

replace or repair one or more heart valves, as a i. FEV1 test results consistently less than 1 litre
consequence of defects in, abnormalities of, or disease- measured on 3 occasions 3 months apart; and
affected cardiac valve(s). The diagnosis of the valve ii. Requiring continuous permanent supplementary
abnormality must be supported by an echocardiography oxygen therapy for hypoxemia; and
and the realization of surgery has to be confirmed by a
iii. Arterial blood gas analysis with partial oxygen
specialist medical practitioner. Catheter based
pressure of 55mmHg or less (PaO2 < 55mmHg);
techniques including but not limited to, balloon
and
valvotomy/ valvuloplasty are excluded.
iv. Dyspnea at rest.
6. Surgery to Aorta
11. End Stage Liver Failure
The actual undergoing of major surgery to repair or correct
aneurysm, narrowing, obstruction or dissection of the I. Permanent and irreversible failure of liver function that
aorta through surgical opening of the chest or abdomen. has resulted in all three of the following:
For the purpose of this definition aorta shall mean the i. Permanent jaundice; and
thoracic and abdominal aorta but not its branches. ii. Ascites; and
Surgery performed using only minimally invasive or intra- iii. Hepatic encephalopathy.
arterial techniques are excluded.
II. Liver failure secondary to drug or alcohol abuse is
Angioplasty and all other intra-arterial, catheter based excluded.
techniques, "keyhole" or laser procedures are excluded.
12. Coma of specified severity
7. Stroke resulting in permanent symptoms
I. A state of unconsciousness with no reaction or
I. Any cerebrovascular incident producing permanent response to external stimuli or internal needs. This
neurological sequelae. This includes infarction of brain diagnosis must be supported by evidence of all of the
tissue, thrombosis in an intracranial vessel, following:
haemorrhage and embolisation from an extracranial
i. no response to external stimuli continuously for at
source. Diagnosis has to be confirmed by a specialist
least 96 hours;
medical practitioner and evidenced by typical clinical
symptoms as well as typical findings in CT Scan or MRI ii. life support measures are necessary to sustain life;
of the brain. Evidence of permanent neurological deficit and
lasting for at least 3 months has to be produced. iii. permanent neurological deficit which must be
II. The following are excluded: assessed at least 30 days after the onset of the
coma.
i. Transient ischemic attacks (TIA)
The condition has to be confirmed by a specialist medical
ii. Traumatic Injury of the brain
practitioner. Coma resulting directly from alcohol or drug
iii. Vascular disease affecting only the eye or optic abuse is excluded.
nerve or vestibular functions
13. Third Degree Burns
8. Kidney failure requiring regular dialysis
I. There must be third-degree burns with scarring that
I. End stage renal disease presenting as chronic cover at least 20% of the body’s surface area. The
irreversible failure of both kidneys to function, as a diagnosis must confirm the total area involved using
result of which either regular renal dialysis standardized, clinically accepted, body surface area
(hemodialysis or peritoneal dialysis) is instituted or charts covering 20% of the body surface area.
renal transplantation is carried out. Diagnosis has to be
14. Major organ /bone marrow transplant
confirmed by a specialist medical practitioner.
I. The actual undergoing of a transplant of:
9. Aplastic Anaemia
i. One of the following human organs: heart, lung,
Chronic persistent bone marrow failure which results in
liver, kidney, pancreas, that resulted from
anaemia, neutropenia and thrombocytopenia requiring
irreversible end-stage failure of the relevant organ,
treatment with at least one of the following:
or
I. Blood product transfusion;
ii. Human bone marrow using hematopoietic stem
II. Marrow stimulating agents; cells. The undergoing of a transplant has to be
III. Immunosuppressive agents; or confirmed by a specialist medical practitioner.
IV. Bone marrow transplantation II. The following are excluded:
The diagnosis must be confirmed by a haematologist. i. Other stem-cell transplants
10. End Stage Lung Failure ii. Where only islets of langerhans are transplanted
I. End Stage Lung Disease, causing chronic respiratory 15. Multiple Sclerosis with persistent symptoms
failure, as confirmed and evidenced by all of the I. The unequivocal diagnosis of Definite Multiple Sclerosis
following:

confirmed and evidenced by all of the following: Bacterial infection resulting in severe inflammation of the
i. investigations including typical MRI findings which membranes of the brain or spinal cord resulting in
unequivocally confirm the diagnosis to be multiple significant, irreversible and permanent neurological deficit.
sclerosis and The neurological deficit must persist for at least 6 weeks.
This diagnosis must be confirmed by:
ii. there must be current clinical impairment of motor
or sensory function,which must have persisted for a I. The presence of bacterial infection in cerebrospinal
continuous period of at least 6 months. fluid by lumbar puncture; and
II. Other causes of neurological damage such as SLE are II. A consultant neurologist.
excluded. 18. Personal Accident:
16. Fulminant Hepatitis We will pay You or Your Nominee / legal heir, as the case
A sub-massive to massive necrosis of the liver by the may be, the Annual Sum Insured subject to a maximum
Hepatitis virus, leading precipitously to liver failure. limit of Rs.50 Lakhs, on occurrence of any Insured Event, as
specifically described hereunder, arising due to an Injury
This diagnosis must be supported by all of the following:
sustained by You during the Policy Year. This cover is
I. Rapid decreasing of liver size; available only for adult members aged maximum up to 65
II. Necrosis involving entire lobules, leaving only a years during first time issuance.
collapsed reticular framework; a. Accidental Death
III. Rapid deterioration of liver function tests; We shall pay 100% of the coverage amount of the
IV. Deepening jaundice; and Insured / Insured Person, in the event of his / her Death
V. Hepatic encephalopathy. on account of an Accident / Injury, during the Policy
Period or within twelve calendar months from the date
17. Motor Neuron Disease with permanent symptoms of occurrence of such Accident / Injury which occurred
I. Motor neuron disease diagnosed by a specialist during Policy Period.
medical practitioner as spinal muscular atrophy,
b. Permanent Total Disablement
progressive bulbar palsy, amyotrophic lateral sclerosis
or primary lateral sclerosis. There must be progressive We shall pay up to the coverage amount of the Insured
degeneration of corticospinal tracts and anterior horn Person as specified below in case of his / her permanent
cells or bulbar efferent neurons. There must be current total disablement on account of any Accident / Injury,
significant and permanent functional neurological during the Policy Period or within twelve calendar
impairment with objective evidence of motor months from the date of occurrence of such Accident /
dysfunction that has persisted for a continuous period Injury which occurred during Policy Period. The payout
of at least 3 months of the Sum Insured shall be as per table below:
Sr. Insured Events Amount
18. Primary Pulmonary Hypertension
payable = %
I. An unequivocal diagnosis of Primary (Idiopathic) of the Sum
Pulmonary Hypertension by a Cardiologist or specialist
Insured
in respiratory medicine with evidence of right
specified in
ventricular enlargement and the pulmonary artery
pressure above 30 mm of Hg on Cardiac Cauterization. the policy
There must be permanent irreversible physical schedule
impairment to the degree of at least Class IV of the New I Total and irrecoverable loss of sight of
York Heart Association Classification of cardiac both the eyes or the actual loss by physical
impairment. separation of two entire hands or feet,
II. The NYHA Classification of Cardiac Impairment are as or one entire hand and one entire foot, or
follows: the total and irrecoverable loss of sight of
i. Class III: Marked limitation of physical activity. one eye and loss by physical separation
Comfortable at rest, but less than ordinary activity of one entire hand or one entire foot. 100%
causes symptoms.
II Total and irrecoverable loss
ii. Class IV: Unable to engage in any physical activity
without discomfort. Symptoms may be present (a) use of two hands or two feet
even at rest. (b) one hand and one foot
III. Pulmonary hypertension associated with lung disease,
(c)sight of one eye and use of one hand
chronic hypoventilation,pulmonary thromboembolic
disease, drugs and toxins, diseases of the left side of the or one foot 100%
heart, and any secondary cause are specifically III Total and irrecoverable loss of sight of one
excluded. eye or the actual loss by physical separation
19. Terminal Illness of one entire hand or one entire foot 50%
The conclusive diagnosis of an Illness that is expected to IV Total and irrecoverable loss of use of one
result in the death of the insured person within 12 months. entire hand or one entire foot without
This diagnosis must be supported by a specialist and physical separation 50%
confirmed by the Company's appointed Doctor.
V Paraplegia or Quadriplegia or Hemiplegia 100%
20. Bacterial Meningitis

NOTE: For the purpose of Sr. No. I to IV in the table above, VIII Loss of ring finger
physical separation of a hand or foot shall mean separation of a) Three phalanges 5%
the hand at or above the wrist, and of the foot at or above the
b) Two phalanges 3%
ankle.
c) One phalanx 2%
For the purpose of this Benefit only:
IX Loss of little finger
(I) “Hemiplegia” means complete and irrecoverable paralysis
of the arm, leg, and trunk on the same side of the body; a) Three phalanges 4%
(II) “Paraplegia” means complete and irrecoverable paralysis b) Two phalanges 3%

of the whole of the lower half of the body (below waist) c) One phalanx 2%
including both the legs; X Loss of metacarpus
(III) “Quadriplegia” means complete and irrecoverable a) First or second 3%
paralysis of all four limbs.
b) Third, fourth or fifth 2%
c. Permanent Partial Disablement
XI Permanent partial disablement not Such % of the
We shall pay up to the coverage amount of the Insured otherwise provided for under serial no. I to X Sum Insured
Person as specified below in case of his / her permanent as determined
partial disablement on account of any Accident / Injury, in accordance
during the Policy Period or within twelve calendar months with the
from the date of occurrence of such Accident / Injury which medical
occurred during Policy Period. The payout of the Sum assessment
Insured shall be as per table below: carried out by
Sr. Insured Events Amount the Company's
payable = % Network
of the Sum Hospital that
Insured the %age
specified in under Insured
the policy event Sr. No.
schedule XI shall not
I Total and irrecoverable loss of hearing in: - exceed 50%
of the Sum
a) Both ears 75%
Insured
b) One ear 30%
II Loss of toes 19. Voluntary Co-Payment:
The Insured Person has the choice to opt for Voluntary Co-
a) All 20%
payment and avail subsequent discount on premium. In
b) Both phalanges of great toes bilateral 5% case Voluntary Co-payment is opted as mentioned in the
c) Both phalanges of one great toe 2% Policy Schedule, the Insured Person will be liable to bear
the specified Co-payment percentage of admissible claim
d) Both phalanges of other than great than
amount of each and every claim amount.
great toes for each 1%
i. Voluntary Co-payment once chosen cannot be
III III Loss of four fingers and thumb of one hand 40% modified mid-term. Modification of Co-payment may
IV Loss of four fingers of one hand 35% happen only during Renewal subject to underwriting.
ii. Voluntary Co-payment if chosen by the Insured
V Loss of thumb
Person(s) shall be applicable to all Basic Cover under
a) Both phalanges 25% the Policy except Wellness Program.
b) One phalanx 10% iii. Voluntary Co-payment shall not be applicable to Add
VI Loss of index finger Ons/Optional Covers except Optional Cover 1. Infinite
Care and Optional Cover 9. Worldwide Cover.
a) Three phalanges 10%
iv. Voluntary co-payment will not be opted in case
b) Two phalanges 8% voluntary deductible has been opted
c) One phalanx 4% 20. Voluntary Deductible:
VII Loss of middle finger The Insured Person has the choice to opt for Voluntary
a) Three phalanges 6% Deductible and avail subsequent discount on premium. In
case Voluntary Deductible is opted as mentioned in the
b) Two phalanges 4% Policy Schedule, the Insured Person will be liable to bear
c) One phalanx 2% the specified Deductible amount.
i. Voluntary Deductible will apply on aggregate basis for

all hospitalisation expenses during the policy year Optional Cover:

which fall under basic cover. 1. CPAP Machine
ii. The deductible will apply on individual basis in case of 2. Ventilator
individual policy and on floater basis in case of floater
3. Wheelchair
policy.
4. Prosthetic device
iii. Voluntary Deductible once chosen cannot be modified
mid-term. Modification of Deductible may happen only 5. Suction Machine
during Renewal subject to underwriting. 6. Commode Chairs
iv. Voluntary Deductible if chosen by the Insured Person(s) 7. Infusion pump
shall be applicable to all Basic Cover under the Policy 8. Continuous Passive motion devices in case of Knee
except Wellness Program. Replacement
v. Voluntary deductible will not be opted in case voluntary 9. Oxygen concentrator
co-payment has been opted 23. Tele Consulation(s)
21. Dependent Accommodation Benefit: We will arrange Tele Consultations and recommendations
If the Insured Person contract an Illness or suffer an Injury for routine health issues by a qualified Medical Practitioner
due to Accident during the Policy Period and which solely or health care professional. For the purpose of this Optional
and directly requires the Insured Person to be Hospitalized, Cover Tele Consultation shall mean consultation provided
We will pay the daily amount for the accommodation of the by a qualified Medical Practitioner or Health care
dependent in the hospital up to Rs. 1,000 per day, for each professional through various mode of communication like
audio, video, online portal, chat or mobile application.
continuous and completed day of your Hospitalization,
maximum up to 10 consecutive days. The services provided under this Cover will be made
available subject to the terms and conditions, and in the
For the purpose of this Optional Cover, Dependent means
manner prescribed below:
immediate family members as defined.
i. The Tele Consultation(s) can be availed via Our mobile
Provided:
application only
a. We have accepted the claim under hospitalization
ii. The Medical Practitioner may suggest / recommend /
expenses in respect of Insured Person for the same prescribe over the counter medications based on the
Accident/Illness. information provided, if required on a case to case
b. The Hospitalization is for Medically Necessary basis. However, the services under this Benefit should
Treatment and is commenced and continued on the not be construed to constitute medical advice and/or
written advice of the treating Medical Practitioner. substitute the Insured Person's visit/ consultation to an
c. The medical practitioner certifies that the hospitalized independent Medical Practitioner/Healthcare
insured member required hospitalization of minimum 3 professional*.
consecutive days, maximum up to 10 days iii. There shall be no maximum limit on the count of Tele-
Consultations that can be availed by the Insured
d. We will pay only for one immediate family member.
Person(s) in a policy year
22. Durable Medical Equipment Cover
iv. This service will be available 24 hours a day, and 365
We will cover the expenses incurred by the Insured Person days in a year.
towards renting or purchase of any of the listed durable v. We/Medical Practitioner/Healthcare professional may
medical equipment during the Policy Year only if the same refer the Insured Person to another specialist or a
has been prescribed by the treating Medical Practitioner general physician (outside of our empaneled network) if
post Hospitalisation for the same condition for which the required, and the charges for such specialist or a
Hospitalization claim was admissible. general physician will have to be borne by the Insured
Conditions: Person.
i. Claim payable shall be paid up to the Annual Sum vi. We shall not be liable for any discrepancy in the
Insured (within overall basic annual sum insured), information provided under this Cover.
maximum up to Rs. 5 Lakhs. vii. Choosing the services under this Cover is purely upon
the Insured Person’s own discretion and at own risk.
ii. We have accepted the claim under hospitalization
expenses (In-patient Treatment/Daycare Procedures / *The proposer should seek assistance from a health care
Treatment/In-patient AYUSH Hospitalization) in professional when interpreting and applying them to the
respect of Insured Person for the same Accident/Illness. Insured Person’s individual circumstances. If the Insured
Person has any concerns about His/ her health, He/ She
iii. The need for a Durable Medical Equipment has been
may consult His/ her general practitioner. We shall not
prescribed by an authorized Medical Practitioner hold any responsibility towards any loss or damage arising
during Hospitalization or within 30 days post discharge out of or in relation to any opinion, advice, prescription,
of the Insured Person from the Hospital. actual or alleged errors, omissions and representations
iv. The purchase should have been made within 30 days of made by the Medical Practitioner/ Healthcare professional
the medical recommendation. 24. Waiting Period Reduction Option (Other than those
List of Durable Medical Equipment Covered under this listed under JumpStart.)

If the Insured Person has opted for this Optional Cover, the specified in the Policy Schedule/ Product benefit table
waiting period applicable under Exclusion- Pre-Existing of this policy, then the Insured Person shall bear a
Diseases (Code- Excl01) for any declared and accepted rateable proportion of the total Associated medical
pre-existing diseases shall be reduced from 36 months to expenses (including surcharges or taxes thereon) in the
24 months or 12 months as opted. This cover will be proportion of the difference between room rent of the
available only during inception of the policy and only for the entitled room category to the room rent actually
Annual Sum Insured chosen at the time of Policy Inception. incurred
The reduced waiting period shall not be applicable for a. For the purpose of this cover, “Associated medical
claims made under Optional Cover 9. Worldwide Cover. expenses” shall include room rent, nursing charges,
Once chosen, this optional cover will have to be opted for a operation theatre charges, fees of medical
period of 3 continuous policy years. practitioner including surgeon/anesthetist /
25. Maternity Waiting Period Reduction Option specialist within the same hospital where the
insured person has been admitted and will not
If the Insured Person has opted for this Optional Cover, the include the cost of pharmacy and consumables,
waiting period applicable under the Add Ons/Optional cost of implants, medical devices and cost of
Cover 5. Maternity Benefit shall be reduced from 24 months diagnostics.
to 12 months. This cover will be available only during
inception of the policy and only for the Annual Sum Insured b. Proportionate deductions are not applicable for ICU
chosen at the time of Policy Inception charges
All the conditions mentioned under the Add Ons/Optional c. Proportionate deductions shall not be applicable for
Cover 5. Maternity Benefit shall be applicable to this cover. hospitals which do not follow differential billing or
Once chosen, this optional cover will have to be opted for a for those expenses in respect of which differential
period of 2 continuous policy years. billing is not adopted based on the room category.
26. Specific Illness Waiting Period Reduction Option 29. Network Advantage
If the Insured Person has opted for this Optional Cover, the If the Insured Person has opted for this Optional Cover, the
waiting period applicable under Exclusion- Specified Insured Person shall be entitled for a discount of 10% on
disease/procedure waiting period (Code- Excl02) shall be premium (including the first year premium), subject to the
reduced from 24 months to 12 months. This cover will be following conditions
available only during inception of the policy and only for the I. The treatment as applicable under In-patient
Annual Sum Insured chosen at the time of Policy Inception. Treatment or Daycare Procedures/Treatment /In-
The reduced waiting period shall not be applicable for patient AYUSH Hospitalization is taken in a hospital
claims made under Optional Cover 9. Worldwide Cover. listed under the “Preferred Provider Network” List
Once chosen, this optional cover will have to be opted for a available on Our website www.icicilombard.com and
period of 2 continuous policy years. on Our Mobile Application.
27. Worldwide Cover Waiting Period Reduction Option II. A co-payment of 20% will be applicable on each and
If the Insured Person has opted for this Optional Cover, the every claim in case the treatment is taken in a hospital
waiting period applicable under the Add Ons/Optional which is not included in the “Preferred Provider
Cover 9. Worldwide cover shall be reduced from 24 months Network” List.
to 12 months. This cover will be available only during 30. NRI Advantage- Accidental Emergencies Cover for NRI
inception of the policy and only for the Annual Sum Insured
We will provide cover to Non Resident Indians/Overseas
chosen at the time of Policy Inception
Citizens of India under this policy only for Accidental
All the conditions mentioned under the Add Ons/Optional Emergencies and no claim will be admissible under any
Cover 9. Worldwide cover shall be applicable to this cover. other cover of this policy. Further, we will provide a 25%
Once chosen, this optional cover will have to be opted for a discount on premium if this cover has been opted, provided
period of 2 continuous policy years. that the Insured Person(s)-
28. Room Modifier i. Provides declaration upon Policy Issuance and
If the Insured Person has opted for this Optional Cover, the subsequent renewals that they are based abroad in
Insured Person shall have an option: entirety for the Policy Year
A. To Modify the room rent eligibility to any room category ii. Provides proof of overseas residence for the upcoming
without any restriction or year upon each renewal to continue availing the
B. To modify the room rent eligibility to twin sharing room discount
or iii. Possesses and provides other relevant identity proof
C. To Modify the room rent eligibility to a room rent documents as mandated for Citizenship of India
capping of 1% of Annual Sum Insured for normal room iv. Has an Indian bank account for premium/claims
and 2% of Annual Sum Insured for ICU per day. payment.
This cover shall be available across all Annual Sum Insured If the Insured person ceases to reside outside India, then no
options, subject to the following: further discount shall be applicable upon renewal. This
discount can be availed only for a maximum period of five
i. If the Insured Person is admitted in a room
continuous Policy Years and the same will be applicable on
category/limit that is higher than the one that is
a Policy level. Worldwide cover cannot be availed by Non

Resident Indians/Overseas Citizens of India. All waiting 11. Fistulae in anus

periods as per the policy terms and conditions will be 12. Fissure in anus
applicable for the Insured Persons.
13. Fibromyoma
e. EXCLUSIONS:
14. Hysterectomy
i. Standard Exclusions
15. Surgery for any skin ailment
1. Pre-Existing Diseases - Code- Excl01
16. Surgery on all internal or external tumours/ cysts/
a. Expenses related to the treatment of a pre- nodules/polyps of any kind including breast lumps with
existing Disease (PED) and its direct exception of Malignancy
complications shall be excluded until the expiry
17. Dialysis required for Chronic Renal Failure.
of 36 months of continuous coverage after the
date of inception of the first policy with insurer 18. Joint Replacement Surgeries unless necessitated by
as selected by the Insurer Accident happening after the Policy risk inception date.
b. In case of enhancement of sum insured the 19. Dilatation and curettage
exclusion shall apply afresh to the extent of sum 20. Varicose Veins and Varicose Ulcers
insured increase. 21. Non Infective Arthritis and other form arthritis
c. If the Insured Person is continuously covered 22. Gout and Rheumatism
without any break as defined under the
portability / migration norms of the extant IRDAI 23. Prolapse inter Vertebral Disc and Spinal Diseases
(Health Insurance) Regulations, then waiting including spondylitis/spondylosis unless arising from
period for the same would be reduced to the Accident
extent of prior coverage. 3. a. Expenses related to the treatment of the below
d. Coverage under the policy after the expiry of 36 mentioned illness within 90 days from the first
months for any pre-existing disease is subject to policy commencement date shall be excluded
the same being declared at the time of unless they are pre-existing and disclosed at the
application and accepted by Insurer. time of underwriting
2. Specified disease/procedure waiting period- I. Hypertension
Code- Excl02 ii. Diabetes
a. Expenses related to the treatment of the listed iii. Cardiac Conditions
Conditions, surgeries/treatments shall be b. This exclusion shall not, however, apply if the
excluded until the expiry of 24 months of Insured Person has continuous coverage for more
continuous coverage after the date of inception than twelve months.
of the first policy with us. This exclusion shall not
The within referred waiting period is made applicable
be applicable for claims arising due to an
to the enhanced Sum Insured in the event of granting
accident.
higher sum insured subsequently.
b. In case of enhancement of sum insured the
4. 30-day waiting period- Code- Excl03
exclusion shall apply afresh to the extent of sum
insured increase. a. Expenses related to the treatment of any illness
within 30 days from the first policy commencement
c. If any of the specified disease/procedure falls
date shall be excluded except claims arising due to
under the waiting period specified for pre-
an accident, provided the same are covered.
Existing diseases, then the longer of the two
waiting periods shall apply. b. This exclusion shall not, however, apply if the
Insured Person has Continuous Coverage for more
d. The waiting period for listed conditions shall
than twelve months.
apply even if contracted after the policy or
declared and accepted without a specific c. The within referred waiting period is made
exclusion. applicable to the enhanced sum insured in the event
of granting higher sum insured subsequently.
e. If the Insured Person is continuously covered
without any break as defined under the 5. Investigation & Evaluation- Code- Excl04
applicable norms on portability stipulated by a. Expenses related to any admission primarily for
IRDAI, then waiting period for the same would diagnostics and evaluation purposes only are
be reduced to the extent of prior coverage. excluded.
f. List of specific diseases/procedures b. Any diagnostic expenses which are not related or
1. Any types of gastric or duodenal ulcers not incidental to the current diagnosis and
treatment are excluded.
2. Benign prostatic hypertrophy
6. Rest Cure, rehabilitation and respite care- Code- Excl05
3. All types of sinuses
a. Expenses related to any admission primarily for
4. Hemorrhoids
enforced bed rest and not for receiving treatment.
5. Dysfunctional uterine bleeding This also includes:
6. Endometriosis i. Custodial care either at home or in a nursing
7. Stones in the urinary and biliary systems facility for personal care such as help with
activities of daily living such as bathing,
8. Surgery on ears/tonsils/adenoids/ paranasal sinuses dressing, moving around either by skilled nurses
9. Cataracts, or assistant or non-skilled persons.
10. Hernia of all types and Hydrocele

ii. Any services for people who are terminally ill to establishments or where admission is arranged wholly
address physical, social, emotional and spiritual or partly for domestic reasons. Code- Excl13
needs. 15. Dietary supplements and substances that can be
7. Obesity/ Weight Control: Code- Excl06 purchased without prescription, including but not
limited to Vitamins, minerals and organic substances
Expenses related to the surgical treatment of obesity
unless prescribed by a medical practitioner as part of
that does not fulfil all the below conditions:
hospitalization claim or day care procedure. Code-
1. Surgery to be conducted is upon the advice of the Excl14
Doctor 16. Refractive Error: Code- Excl15
2. The surgery/Procedure conducted should be Expenses related to the treatment for correction of eye
supported by clinical protocols sight due to refractive error less than 7. 5 dioptres.
3. The member has to be 18 years of age or older and 17. Unproven Treatments: Code- Excl 16
4. Body Mass Index (BMI); Expenses related to any unproven treatment, services
a. greater than or equal to 40 or and supplies for or in connection with any treatment.
Unproven treatments are treatments, procedures or
b. greater than or equal to 35 in conjunction with supplies that lack significant medical documentation to
any of the following severe co-morbidities support their effectiveness.
following failure of less invasive methods of
weight loss: 18. Sterility and lnfertility: Code- Excl 17
Expenses related to sterility and infertility. This
i. Obesity-related cardiomyopathy includes:
ii. Coronary heart disease a. Any type of contraception, sterilization
iii. Severe Sleep Apnea b. Assisted Reproduction services including artificial
iv. Uncontrolled Type2 Diabetes i n s e m i n a t i o n a n d a d va n ce d r e p r o d u c t i ve
technologies such as IVF, ZIFT, GIFT, ICSI
8. Change-of-Gender treatments: Code- Excl07
c. Gestational Surrogacy
Expenses related to any treatment, including surgical
management, to change characteristics of the body to d. Reversal of sterilization
those of the opposite sex. The above exclusion part b. Assisted Reproduction
services including artificial insemination and advanced
9. Cosmetic or plastic Surgery: Code- Excl08 reproductive technologies such as IVF, ZIFT, GIFT, ICSI
Expenses for cosmetic or plastic surgery or any shall not apply to claims which are otherwise
t re a t m e n t to c h a n g e a p p e a ra n ce u n l e s s fo r admissible under Basic Cover 14 “In-patient
reconstruction following an Accident, Burn(s) or Cancer Hospitalisation for Oocyte Donor” which pertains to
or as part of medically necessary treatment to remove a Medical Expenses incurred in respect of Hospitalization
direct and immediate health risk to the insured. For this of the Oocyte donor for complications arising due to
to be considered a medical necessity, it must be oocyte retrieval process”
certified by the attending Medical Practitioner. The above exclusion part c. Gestational surrogacy shall
10. Hazardous or Adventure sports: Code- Excl09 not apply to claims which are otherwise admissible
Expenses related to any treatment necessitated due to under Basic Cover 13 “In-patient Hospitalisation for
participation as a professional in hazardous or Surrogate Mother” which pertains to Medical Expenses
adventure sports, including but not limited to, para- incurred in respect of Hospitalization of the Surrogate
jumping, rock climbing, mountaineering, rafting, motor mother for complications arising out of pregnancy and
racing, horse racing or scuba diving, hand gliding, sky post-partum delivery complications”
diving, deep-sea diving. 19. Maternity: Code Excl18
11. Breach of law: Code- Excl10 i. Medical treatment expenses traceable to childbirth
Expenses for treatment directly arising from or (including complicated deliveries and caesarean
consequent upon any Insured Person committing or sections incurred during hospitalization) except
attempting to commit a breach of law with criminal ectopic pregnancy;
intent. ii. Expenses towards miscarriage (unless due to an
12. Excluded providers: Code- Excl11 accident ) and lawful medical termination of
Expenses incurred towards treatment in any hospital or pregnancy during the policy period.
by any Medical Practitioner or any other provider
specifically excluded by the insurer and disclosed in its This exclusion will not be applicable in case optional
website / notified to the policyholders are not cover 5 Maternity Benefit has been opted
admissible. However, in case of life threatening ii. Specific Exclusions (Exclusions other than those
situations or following an accident, expenses up to the specified under e. I. above)
stage of stabilization are payable but not the complete
claim. 20. War (whether declared or not) and war like occurrence
or invasion, acts of foreign enemies, hostilities, civil war,
(The list of excluded providers/delisted hospitals is
available on our website www.icicilombard.com and is rebellion, revolutions, insurrections, mutiny, military or
timely updated.) usurped power, seizure, capture, arrest, restraints and
13. Treatment for, Alcoholism, drug or substance abuse or detainment of all kinds.
any addictive condition and consequences thereof. 21. Nuclear, chemical or biological attack or weapons,
Code- Excl12 contributed to, caused by, resulting from or from any
14. Treatments received in heath hydros, nature cure other cause or event contributing concurrently or in any
clinics, spas or similar establishments or private beds other sequence to the loss, claim or expense. For the
registered as a nursing home attached to such

purpose of this exclusion: disclosure of any material fact by the policyholder.

a. Nuclear attack or weapons means the use of any (Explanation: "Material facts" for the purpose of this
nuclear weapon or device or waste or combustion of policy shall mean all relevant information sought by
nuclear fuel or the emission, discharge, dispersal, the company in the proposal form and other
release or escape of fissile/ fusion material emitting connected documents to enable it to take informed
a level of radioactivity capable of causing any decision in the context of underwriting the risk)
Illness, incapacitating disablement or death. 2. Condition Precedent to Admission of Liability:
b. Chemical attack or weapons means the emission, The terms and conditions of the policy must be
discharge, dispersal, release or escape of any solid, fulfilled by the insured person for the Company to
liquid or gaseous chemical compound which, when make any payment for claim(s) arising under the
suitably distributed, is capable of causing any policy.
Illness, incapacitating disablement or death.
3. Claim Settlement (provision for Penal Interest)
c. Biological attack or weapons means the emission,
i. The Company shall settle or reject a claim, as the
discharge, dispersal, release or escape of any
case may be, within 30 days from the date of
pathogenic (disease producing) micro-organisms
receipt of last necessary document.
and/or biologically produced toxins (including
genetically modified organisms and chemically ii. In the case of delay in the payment of a claim, the
synthesized toxins) which are capable of causing Company shall be liable to pay interest to the
any Illness, incapacitating disablement or death. policyholder from the date of receipt of last
necessary document to the date of payment of
22. Any expenses incurred on Out Patient treatment. This
claim at a rate 2% above the bank rate.
exclusion will not be applicable in case optional cover 8.
BeFit has been opted iii. However, where the circumstances of a claim
warrant an investigation in the opinion of the
23. Any expenses incurred on prosthesis, corrective
Company, it shall initiate and complete such
devices, external durable medical equipment of any
investigation at the earliest, in any case not later
kind, like wheelchairs, crutches, instruments used in
than 30 days from the date of receipt of last
treatment of sleep apnoea syndrome or cost of cochlear
necessary document. In such cases, the
implant(s) unless necessitated by an Accident or
Company shall settle or reject the claim within
required intra-operatively.
45 days from the date of receipt of last
24. Treatment, procedures and preventive, diagnostic, necessary document.
restorative, cosmetic services related to disease, iv. In case of delay beyond stipulated 45 days, the
disorder and conditions related to natural teeth and Company shall be liable to pay interest to the
gingiva except if required by an Insured Person while policyholder at a rate 2% above the bank rate
Hospitalized due to an Accident. from the date of receipt of last necessary
25. Treatment taken outside the geographical limits of document to the date of payment of claim.
India. This exclusion shall not be applicable in case
(Explanation: "Bank rate" shall mean the rate fixed
optional cover 9. Worldwide cover has been opted
by the Reserve Bank of lndia (RBl) at the beginning
26. Personal comfort, cosmetics, convenience and hygiene
of the financial year in which claim has fallen due)
related items and services
27. Acupressure, acupuncture, magnetic and other 4. Fraud:
therapies If any claim made by the insured person, is in any
28. Circumcision unless necessary for treatment of an respect fraudulent, or if any false statement, or
Illness or necessitated due to an Accident. declaration is made or used in support thereof, or if
29. Expenses for venereal disease or any sexually any fraudulent means or devices are used by the
transmitted disease except HIV. insured person or anyone acting on his/her behalf to
30. Screening, counselling or Treatment relating to external obtain any benefit under this policy, all benefits
birth defects and external congenital Illnesses or under this policy and the premium paid shall be
defects or anomalies forfeited.
31. Intentional self-injury (whether arising from an attempt Any amount already paid against claims made
to commit suicide or otherwise) under this policy but which are found fraudulent
32. Any ailment/ illness/ injury/ condition or treatment or later shall be repaid by all recipient (s) / policyholder
service that is specifically excluded in the Policy (s), who has made that particular claim, who shall
Schedule under Special Conditions.
be jointly and severally liable for such repayment to
f. GENERAL Terms and CONDITIONS: the insurer.
i. Standard General Terms and clauses For the purpose of this clause, the expression
1. Disclosure of Information: "fraud" means any of the following acts committed
The policy shall be Void and all premium paid by the insured person or by his agent or the
thereon shall be forfeited to the Company in the hospital/doctor/any other party acting on behalf of
event of misrepresentation, mis description or non- 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 the Company on medical examination of the insured
and which the insured person does not believe person.
to be true;
b) the active concealment of a fact by the insured
person having knowledge or belief of the fact;
c) any other act fitted to 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
7. Cancellation:
forfeit the policy benefits on the ground of Fraud, if
a. The policyholder may cancel this policy by giving
the insured person / beneficiary can prove that the
15days’ written notice and in such an event, the
misstatement was true to the best of his knowledge
Company shall refund premium for the unexpired
and there was no deliberate intention to suppress policy period as detailed below.
the fact or that such misstatement of or suppression
of material fact are within the knowledge of the
Cancellation Period Refund % for Refund % for Refund % for
insurer.
1 year tenure 2 years 3 years
5. Multiple policies policy tenure policy tenure policy
i. In case of multiple policies taken by an insured Within 1 month* 80.00% 80.00% 80.00%
person during a period from one or more
insurers to indemnify treatment costs, the From 1 month to 3 60.00% 70.00% 75.00%
insured person shall have the right to require a months
settlement of his/her claim in terms of any of From 3 months to 6 40.00% 60.00% 67.50%
his/her policies. In all such cases the insurer months
chosen by the insured person shall be obliged to From 6 months to 9 20.00% 50.00% 60.00%
settle the claim as long as the claim is within the months
limits of and according to the terms of the From 9 months to 12 0.00% 40.00% 52.50%
chosen policy. months
ii. Insured person having multiple policies shall From 12 months to 15 NA 30.00% 47.50%
also have the right to prefer claims under this months
policy for the amounts disallowed under any From 15 months to 18 NA 20.00% 40.00%
other policy / policies even if the sum insured is months
n o t e x h a u ste d . T h e n t h e i n s u re r s h a l l From 18 months to 21 NA 10.00% 32.50%
independently settle the claim subject to the months
terms and conditions of this policy. From 21 months to 24 NA 0.00% 25.00%
iii. If the amount to be claimed exceeds the sum months
insured under a single policy, the insured person From 24 months to 27 NA NA 20.00%
shall have the right to choose insurer from months
whom he/she wants to claim the balance From 27 months to 30 NA NA 12.50%
amount. months
iv. Where an insured person has policies from more From 30 months to 33 NA NA 5.00%
than one insurer to cover the same risk on months
indemnity basis, the insured person shall only be From 33 months to 36 NA NA 0.00%
indemnified the treatment costs in accordance months
with the terms and conditions of the chosen
*Not applicable for policies with free look period;
policy.
Premium refund for cancellations during the free
6. Free Look Period: look period will be provided as per the Free look
The Free Look Period shall be applicable only on the clause.
new health insurance policies and not on renewals Notwithstanding anything contained herein or
or at the time of porting/migrating the policy. The otherwise, no refunds of premium shall be made in
insured person shall be allowed Free Look period of respect of Cancellation where, any claim has been
thirty days from date of receipt of the policy admitted or has been lodged or any benefit has
documents whether received electronically or been availed by the insured person under the policy.
otherwise to review the terms and conditions of the b. The Company may cancel the policy at any time on
policy, and to return the same if not acceptable. If grounds of misrepresentation non-disclosure of
the insured has not made any claim during the Free material facts, fraud by the insured person by giving
Look Period, the insured shall be entitled to a refund 15 days’ written notice. There would be no refund of
of the premium paid less any expenses incurred by premium on cancellation on grounds of
misrepresentation, non-disclosure of material facts
or fraud.

8. Renewal of Policy: vi. In the event of a claim, all subsequent premium

The policy shall ordinarily be renewable except on instalments shall immediately become due and
grounds of established fraud, misrepresentation by the payable.
insured person provided the policy is not withdrawn vii. The company has the right to recover and deduct all
and also subject to moratorium conditions. the pending installments from the claim amount
due under the policy.
i. The Company shall endeavor to give notice for
renewal. However, the Company is not under 10. Portability
obligation to give any notice for renewal. The insured person will have the option to port the
ii. Renewal shall not be denied on the ground that the policy to other insurers by applying to such insurer to
insured person had made a claim or claims in the port the entire policy along with all the members of the
preceding policy years. family, if any, at least 45 days before, but not earlier
than 60 days from the policy renewal date as per lRDAl
iii. Request for renewal along with requisite premium guidelines related to portability. If such person is
shall be received by the Company before the end of presently covered and has been continuously covered
the policy period without any lapses under any health insurance policy
iv. At the end of the policy period, the policy shall with an Indian General/Health insurer, the proposed
terminate and can be renewed within the Grace insured person will get the accrued continuity benefits
Period of 30 days to maintain continuity of benefits in waiting periods as per lRDAl guidelines on
without break in policy. Coverage is not available portability.
during the grace period. For Detailed Guidelines on portability, kindly refer the link
v. For individual products, the loadings on renewal https://www.irdai.gov.in/ADMINCMS/cms/frmGuidelin
premium shall be at portfolio and not based upon es_Layout.aspx?page=PageNo3987
any individual policy claim experience. However, 11. Migration
discount in premium may be provided by the The insured person will have the option to migrate the
Company to individual policyholders for good policy to other health insurance products/plans offered
claims experience. by the company by applying for migration of the policy
vi. No fresh underwriting at renewal stage where there at least 30 days before the policy renewal date as per
is no change in sum insured offered shall be lRDAl guidelines on Migration. If such person is
applicable. Provided that where there is an presently covered and has been continuously covered
improvement in the risk profile, the company may without any lapses under any health insurance
endeavour to recognize that for removal of loadings product/plan offered by the company, the insured
at the point of renewal. person will get the accrued continuity benefits in
waiting periods as per lRDAl guidelines on migration.
9. Premium payment in instalments:
The insurer may underwrite the proposal in case of
If the insured person has opted for Payment of Premium
migration, if the insured person is not continuously
on an installment basis i.e. Half Yearly, Quarterly or covered for 36 months
Monthly, as mentioned in Your Policy Schedule /
For Detailed Guidelines on migration, kindly refer the link
certificate of insurance, the following Conditions shall https://www.irdai.gov.in/ADMINCMS/cms/frmGuidelin
apply (notwithstanding any terms contrary elsewhere es_Layout.aspx?page=PageNo3987
in the Policy)
12. Withdrawal of Policy
i. Grace Period for payment of premiums shall be
i. In the likelihood of this product being withdrawn in
fifteen days where premium payment mode is future, the Company will intimate the insured
monthly and thirty days in all other cases. person about the same 90 days prior to expiry of the
ii. The grace period for payment of premium for all policy.
types of insurance policies shall be fifteen days ii. Insured Person will have the option to migrate to
where premium payment mode is monthly and similar health insurance product available with the
thirty days in all other cases .Provided the insurers Company at the time of renewal with all the accrued
shall offer coverage during grace period, if the continuity benefits such as cumulative bonus,
premium is paid in installments during the policy waiver of waiting period as per lRDAl guidelines,
period. provided the policy has been maintained without a
iii. The insured person will get the accrued continuity break.
benefit in respect of the ‘Waiting Periods’, ‘Specific 13. Moratorium Period
Waiting Periods’ in the event of payment of
After completion of sixty continuous months of
premium within the stipulated grace Period
coverage (including portability and migration) in health
iv. No interest will be charged If the installment
insurance policy, no policy and claim shall be
premium is not paid on due date.
contestable by the insurer on grounds of non-
v. In case of installment premium due not received disclosure, misrepresentation, except on grounds of
within the grace Period, the Policy will get
established fraud. This period of sixty continuous
cancelled.
months is called as moratorium period. The moratorium

would be applicable for the sums insured of the first ICICI Lombard General Insurance Company Limited,
policy. Wherever, the sum insured is enhanced, ICICI Lombard House,
completion of sixty continuous months would be
414, P Balu Marg, Off Veer Savarkar Road,
applicable from the date of enhancement of sums
Near Siddhi Vinayak Temple,
insured only on the enhanced limits.
Prabhadevi, Mumbai 400025
14. Possibility of Revision of Terms of the Policy Including
the Premium Rates For updated details of grievance officer, kindly refer the link
The Company, with prior approval of lRDAl/Product https://www.icicilombard.com/grievance-redressal.com
Management Committee of the Company, may revise or lf lnsured person is not satisfied with the redressal of
modify the terms of the policy including the premium grievance through above methods, the insured person may
rates. The insured person shall be notified three months also approach the office of lnsurance Ombudsman of the
before the changes are effected. respective area/region for redressal of grievance as per
lnsurance Ombudsman Rules 2017.
15. Nomination Grievance may also be lodged at IRDAI lntegrated
The policyholder is required at the inception of the Grievance Management System -
policy to make a nomination for the purpose of payment https://www.irdai.gov.in/ADMINCMS/cms/NormalData_La
of claims under the policy in the event of death of the yout.aspx?page=PageNo225&mid=14.2
policyholder. Any change of nomination shall be LIST OF INSURANCE OMBUDSMEN
communicated to the company in writing and such The contact details of the Insurance Ombudsman offices are
change shall be effective only when an endorsement on mentioned as an Annexure I to this policy. These details can
the policy is made. In the event of death of the also be found at http://www.cioins.co.in/ombudsman.html.
policyholder, the Company will pay the nominee {as
17. Complete Discharge
named in the Policy Schedule/Policy Certificate /
Any payment to the policyholder, insured person or his/
Endorsement (if any)} and in case there is no subsisting
her nominees or his/ her legal representative or
nominee, to the legal heirs or legal representatives of assignee or to the Hospital, as the case may be, for any
the policyholder whose discharge shall be treated as benefit under the policy shall be a valid discharge
full and final discharge of its liability under the policy. towards payment of claim by the Company to the
16. Grievance Redressal Procedure: extent of that amount for the particular claim.
In case of any grievance the insured person (including ii. Specific terms and clauses (terms and other clauses
senior citizen) may contact the company through other than those mentioned under f.i above)
Website: www.icicilombard.com 18. Zone based premium

Toll Free: 1800 2666 For the purpose of premium computation, the country
E-Mail: [email protected] has been divided into 4 zones.
Courier: ICICI Lombard General Insurance Company Ltd.
ICICI Lombard House,
414, P Balu Marg, Off Veer Savarkar Road,
Zone State/District
Near Siddhi Vinayak Temple,
Zone A Delhi, Mumbai (including Thane district, Navi Mumbai) ,
Prabhadevi, Mumbai- 400025
Gurugram district, Karnal district, Sonipat district, Rohtak
There is an interactive voice response (IVR) facility for district, Bhiwani district, Chakri Dadri district, Mahendragarh
district, Daman & Diu, Dadra Nagar, Ahmedabad, Surat,
senior citizens’ grievance redressal for easy and faster Noida City, Ghaziabad district, Hapur district, Meerut district,
resolution. Muzaffarnagar district, Shamali district
Zone B Pune, Kolkata, Telangana (incl. Hyderabad), Madhya
Insured person may also approach the grievance cell at
Pradesh, Goa, Gujarat (excl. Ahmedabad and Surat ),
any of the company's branches with the details of Bangalore, Chennai, Andhra Pradesh, Chattisgarh,
grievance Pondicherry, Uttarakand
Zone C Rest of India (Punjab, Rajasthan (excl. NCR region),
lf lnsured person is not .satisfied with the redressal of Chandigarh, Himachal Pradesh, Jammu & Kashmir, Ladakh,
grievance through one of the above methods, insured Lakshadweep, Kerala, Tamil Nadu (excl. Chennai,
person may contact the grievance officer at Pondicherry), Odisha, Arunachal Pradesh, Assam, Manipur,
Meghalaya, Mizoram, Nagaland, Tripura, Sikkim, Andaman &
Manager- Service Quality, Nicobar, Rest of Karnataka, West Bengal (excl. Kolkata),
Corporate Manager- Service Quality, Bihar, Jharkhand, Maharashtra (excl. Mumbai and Pune), UP
(excl. NCR Region), Haryana (excl. NCR region)
National Manager- Operations & finally
Zone D Rest of NCR (Alwar district, Bagpat district, Bharatpur
Director-services and Business development at the district, Bulandshahr district, Faridabad district, Gautam
following address: Buddha Nagar district excl. Noida, Jhajjar district, Jind district,
Nuh district, Panipat district, Rewari district, Mewat district,
Palwal district)

The premium will depend on the city of residence and b. Upon exhaustion of Sum Insured and any other
pincode of the insured person. Please inform us additional sum insured (if any), for the Policy Year.
immediately in case of any change in the same. Not doing However, the Policy is subject to Renewal on the
so, may impact your claim admissibility. There shall be no due date as per the applicable terms and conditions.
zone-based co-payment applicable. 24. Territorial Jurisdiction
19. Material Change: All disputes or differences under or in relation to the
The Insured Person shall notify the Company in writing interpretation of the terms, conditions, validity,
of any material change in the risk in relation to the construct, limitations and/or exclusions contained in the
declaration made in the proposal form or medical Policy shall be determined by the Indian court and
examination report at each Renewal and the Company according to Indian law.
may, adjust the scope of cover and/or premium, if
25. Arbitration
necessary, accordingly.
If any dispute or difference shall arise as to the quantum
20. Records to be Maintained to be paid by the Policy, (liability being otherwise
The Insured Person shall keep an accurate record admitted) such difference shall independently of all
containing all relevant medical records and shall allow other questions, be referred to the decision of a sole
the Company or its representatives to inspect such arbitrator to be appointed in writing by the parties here
records. The Proposer or Insured Person shall furnish to or if they cannot agree upon a single arbitrator within
such information as the Company may require for thirty days of any party invoking arbitration, the same
settlement of any claim under the Policy, within shall be referred to a panel of three arbitrators,
reasonable time limit and within the time limit specified comprising two arbitrators, one to be appointed by
in the Policy. each of the parties to the dispute/difference and the
21. Notice & Communication third arbitrator to be appointed by such two arbitrators
Any notice, direction, instruction or any other and arbitration shall be conducted under and in
communication related to the Policy should be made in accordance with the provisions of the Arbitration and
writing. Conciliation Act 1996, as amended by Arbitration and
Conciliation (Amendment) Act, 2015 (No. 3 of 2016).
Such communication shall be sent to the address of the
Company or through any other electronic modes It is clearly agreed and understood that no difference or
specified in the Policy Schedule. dispute shall be preferable to arbitration as herein
before provided, if the Company has disputed or not
The Company shall communicate to the Insured at the
accepted liability under or in respect of the policy, iii. It is
address or through any other electronic mode
hereby expressly stipulated and declared that it shall
mentioned in the schedule.
be a condition precedent to any right of action or suit
22. Territorial Limit upon the policy that award by such arbitrator /
All medical treatment for the purpose of this insurance arbitrators of the amount of expenses shall be first
will have to be taken in India only. unless Optional Cover obtained.
9. Worldwide Cover has been opted for.
26. Policy Alignment
23. Automatic change in Coverage under the policy
a. Policy Alignment option will be available in cases
The coverage for the Insured Person(s) shall wherein insured(s) with two separate health
automatically terminate: indemnity policies with Us, having different policy
a. In the case of his/ her (Insured Person) demise. end dates but want to align the Policy Start Dates.
I. However, the cover shall continue for the We can align the policies by extending the coverage
remaining Insured Persons till the end of Policy of one Policy till the end date of the other Policy.
Period. The other Insured Persons may also b. Such policies will be charged with premium on pro
apply to renew the Policy. In case, the other rata basis though the Sum Insured under the Policy
Insured Person is minor, the Policy shall be shall remain constant.
renewed only through any one of his/her natural 27. Endorsements (Changes in Policy)
guardian or guardian appointed by court. All
a. This policy constitutes the complete contract of
relevant particulars in respect of such person
insurance. This Policy cannot be modified by
(including his/her relationship with the Insured
anyone (including an insurance agent or broker)
Person) must be submitted to the company
except the company. Any change made by the
along with the application. Provided no claim
has been made, and termination takes place on company shall be evidenced by a written
account of death of the Insured Person, pro-rata endorsement signed and stamped.
refund of premium of the deceased Insured b. Any change in plan, add-ons/Optional Covers opted
Person for the balance period of the Policy will may happen only during Renewal subject to
be effective. underwriting.

c. The proposer may be changed only at the time of ii. The voluntary deductible (if opted) shall be applied
Renewal. The new proposer must be the legal to aggregate of all claims that are either paid or
heir/immediate family member. Such change would payable (not excluded) under this policy. Our liability
be subject to acceptance by the Company and to make payment shall commence only once the
payment of premium (if any). The renewed Policy aggregate amount of all claims payable or paid
shall be treated as having been renewed without exceed the voluntary deductible. Voluntary Co-
break. payment shall not be applied incase voluntary
d. The proposer may be changed during the Policy deductible has been opted for.
Period only in case of his/her demise or him/her iii. Voluntary Co-payment shall be applicable on the
moving out of India. amount payable by Us and our liability to make
e. Mid- term endorsement of addition of member in payment shall then be arrived at.
the Policy shall only be allowed for newly wedded The claim amount assessed above would be deducted
spouse by marriage and new born baby with from the following amounts in the following
relevant documentation progressive order:
28. Change of Sum Insured 1. Annual Sum Insured
Sum insured can be changed (increased/ decreased) 2. Guaranteed Cumulative Bonus (if accrued and
only at the time of Renewal or at any time, subject to available)
underwriting by the Company. For any increase in Sum 3. Power Booster (if accrued and available)
Insured, the waiting period shall start afresh only for the
4. Inflation Protector (if accrued and available)
enhanced portion of the Sum Insured
5. Reset Sum Insured (if applicable)
29. Non Payables
Further, upon the discovery or happening of any Illness
The non-payable items applicable in the policy are
or Injury that may give rise to a Claim under this Policy,
mentioned as Annexure II. The list may be updated as
then as a condition precedent to the admission of Our
per the direction of Authority, for updated list please
liability, You shall undertake the following
visit Our website: www.iciciclombard.com
1. Claims Procedure
g. Other Terms and Conditions
A. For Cashless Settlement
I. Claim Administration
Cashless treatment is only available at a Network
The fulfilment of the terms and conditions of this Policy
Provider (List of Network Providers is available at our
(including payment of premium by the due dates
website). In order to avail of cashless treatment, the
mentioned in the Policy Schedule) insofar as they relate
following procedure must be followed by You:
to anything to be done or complied with by each of You
shall be conditions precedent to admission of Our Pre-authorization
liability. You are requested to go through our list of de- Prior to taking treatment and/ or incurring Medical
listed/excluded providers which is available on our Expenses at a Network Provider, You must contact Us
website. As the list is dynamic, please refer to the latest or Our in house claim processing team accompanied
list. with full particulars namely, Policy Number, Your name,
The claim pay-out would be adjudicated in following Your relationship with Policy Holder, nature of Illness or
sequence: Injury, name and address of the Medical Practitioner/
Hospital and any other information that may be
i. If a room accommodation has been opted for where
relevant to the Illness/ Injury/ Hospitalisation. You must
the room rent or category is higher than the eligible
request preauthorization at least 48 hours before a
limit as applicable for the Insured Person, then the
planned Hospitalization and in case of an emergency
associated medical expenses payable shall be pro-
situation, within 24 hours of Hospitalization.
rated as per applicable limits.
To avail of Cashless Hospitalization facility, you are
a. Associated medical expenses means those
required to produce the health card, as provided to You
expenses as listed below which vary in
with this Policy, subject to the terms and conditions for
accordance with the room rent or room category
the usage of the said health card Or You can seek pre
or ICU Charges in a Hospital:
authorization by providing Your Policy number and ID
i. Room, boarding, nursing and operation proof to the hospital who can co-ordinate with Our
theatre expenses as charged by the Hospital claim team to provide cashless facility. We will consider
where the Insured Person availed treatment Your request after having obtained accurate and
ii. Fees charged by surgeon, anesthetist, complete information for the Illness or Injury for which
Medical Practitioner cashless Hospitalization facility is sought by You and
iii. Investigation expenses We will confirm Your request in writing.

B. For Reimbursement Settlement 1. Duly completed Claim form signed by You and the
i. You shall give notice to Us or Our in house claim processing Medical Practitioner. The claim form can be
team by calling the toll free number 1800 2666 or emailing downloaded from our website www.icicilombard.com
us at [email protected] as specified 2. Original bills, receipts and discharge certificate/ card
in the Policy provided to You and also in writing at Our from the Hospital/ Medical Practitioner
address with particulars as below: 3. Original bills from chemists supported by proper
• Policy number; prescription.
• Your Name; 4. Original investigation test reports and payment
• Your relationship with the Policyholder; receipts.
• Nature of Illness or Injury; 5. Indoor case papers
• Name and address of the attending Medical 6. Medical Practitioner's referral letter advising
Practitioner and the Hospital; Hospitalization in non-Accident cases.
• Any other information that may be relevant to the 7. Any other document as required by Us or to investigate
Illness/ Injury/ Hospitalisation the Claim or Our obligation to make payment for it
The above information needs to be provided to Us or The relevant documents can be sent to
Our in house claim processing team immediately and in ICICI Lombard Health Care,
any event within 10 days of Hospitalization, failing 1st, 4th (Half) , 5th and 6th floors,
which We will have the right to treat the Claim as
Varun Towers- II , Opp. Hyderabad Public school,
inadmissible, as We may deem fit at Our sole discretion.
Begumpet, Hyderabad, District Hyderabad,
ii. You must immediately consult a Medical Practitioner
and follow the advice and treatment that he Telangana Pin code -500016
recommends. 3. Claim Service Guarantee
iii. You or someone claiming on Your behalf must promptly We provide You Claim Service Guarantee as follows
and in any event within 30 days of Your discharge from A. For Reimbursement Claims: We shall make the
a Hospital (for post-hospitalization expenses, within 30 payment of admissible claim (as per terms & conditions
days from the completion of post-hospitalization of Policy) OR communicate non admissibility of claim
period) deliver to Us the documentation (written details within 14 days after You submit complete set of
of the quantum of any Claim along with all original documents & information in respect of the claims. In
supporting documentation) as more particularly listed case We fail to make the payment of admissible claims
in Claim documents section. In case there is a delay or to communicate non admissibility of claim within the
beyond 30 days in submission of claim documents, we time period, We shall pay 2% interest over and above
may condone the delay provided the insured person the rate defined as per IRDAI (Protection of
submits a valid reason justifying the delay to us in Policyholder's interest) Regulation 2017.
writing.
B. For Cashless Claims: If You notify pre authorization
However, in both the above cases i.e. g. Claim request for cashless facility through any of Our
Administration I. 1. (A) & (B), You must take reasonable empanelled network hospitals along with complete set
steps or measure to minimise the quantum of any Claim of documents & information, We will respond within 2
that may be covered under the Policy. hours of the actual receipt of such pre authorization
If so requested by Us, You will have to undergo a medical request with:
examination from Our nominated Medical Practitioner, as a. Approval, or
and when We or Our in house claim processing team b. Rejection, or
considers reasonable and necessary. The cost of such
c. Query seeking further information
examination will be borne by Us.
In case the request is for enhancement, i.e. Request for
Claim falling in two Policy periods
increase in the amount already authorized, We will
If the claim event falls within two Policy periods, the claims respond to it within 2 hours.
shall be paid taking into consideration the available Sum
In case of delay in response by Us beyond the time period
Insured in the two Policy periods, including the Deductibles
as stated above for cashless claims, We shall be liable to
for each Policy Period. Such eligible claim amount to be
pay ₹1,000 to You. Our maximum liability in respect of a
payable to the Insured shall be reduced to the extent of
single hospitalization shall, at no time exceed ₹1,000.
premium to be received for the Renewal/due date of
premium of health insurance Policy, if not received earlier. We will not be liable to make any payments under this
Claim Service Guarantee in case of any force majeure,
2. Claim Documents natural event or manmade disturbance which impedes Our
You shall be required to furnish the following documents for inability to make a decision or to communicate such
or in support of a Claim: decisions to You.
The service guarantee shall not be applicable for any cases
delayed on account of reasonable apprehension of fraud or Jurisdiction of

fraudulent claims or cases referred to/by any adjudicative Office Details Office Union
forum for necessary disposal. Territory, District)
You may lodge claim separately for the hospitalization DELHI Delhi & Following
claim, Pre-Post hospitalization. In such scenario, if delay Office of the Insurance Ombudsman, Districts of Haryana
happens beyond the time period as specified above, the 2/2 A, Universal Insurance Building, - Gurugram,
interest amount calculated will be on the net sanctioned Asaf Ali Road, New Delhi – 110 002. Faridabad, Sonepat
Tel.: 011 - 23232481/23213504 & Bahadurgarh
amount of respective transaction and not the total amount
Email: [email protected]
paid for the entire claim.
Any amounts paid towards interest under Claim Service GUWAHATI Assam, Meghalaya,
Office of the Insurance Ombudsman, Jeevan Manipur, Mizoram,
Guarantee will not affect the Annual Sum Insured as
Nivesh, 5th Floor, Nr. Panbazar over bridge, Arunachal Pradesh,
specified in the Schedule. Nagaland and Tripura
S.S. Road, Guwahati – 781001(ASSAM).
If you are not eligible for 'Claim Service Guarantee' for the Tel.: 0361 - 2632204 / 2602205
reasons stated above, We will inform the same to You, Email: [email protected]
within 14 days in case of A. For Reimbursement claims and
within 2 hours in case of B. For Cashless claims above HYDERABAD Andhra Pradesh,
Office of the Insurance Ombudsman, Telangana, Yanam
6-2-46, 1st floor, "Moin Court", Lane Opp. and part of Territory
Annexure I Saleem Function Palace, A. C. Guards, of Pondicherry.
Jurisdiction of Lakdi-Ka-Pool, Hyderabad - 500 004.
Office Union Tel.: 040 - 23312122 Fax: 040 - 23376599
Office Details
Territory, District)
AHMEDABAD Gujarat, Dadra & JAIPUR Rajasthan.
Office of the Insurance Ombudsman, Nagar Haveli, Daman Office of the Insurance Ombudsman, Jeevan
Jeevan Prakash Building, 6th floor, Tilak and Diu. Nidhi – II Bldg., Gr. Floor, Bhawani Singh
Marg, Relief Road, Ahmedabad – 380 001. Marg, Jaipur - 302 005.
Tel.: 079 - 25501201/02/05/06 Tel.: 0141 - 2740363
Email: [email protected] Email: [email protected]
BENGALURU Karnataka. ERNAKULAM Kerala, Lakshadweep,

Office of the Insurance Ombudsman, 2nd Mahe-a part of
Office of the Insurance Ombudsman, Jeevan Pondicherry
Soudha Building,PID No. 57-27-N-19, Floor, Pulinat Bldg., Opp. Cochin Shipyard,
Ground Floor, 19/19, 24th Main Road, JP M. G. Road, Ernakulam - 682 015.
Nagar, Ist Phase, Bengaluru – 560 078. Tel.: Tel.: 0484 - 2358759 / 2359338
080 - 26652048 / 26652049 Email: Fax: 0484 - 2359336
[email protected] Email: [email protected]
BHOPAL Madhya Pradesh KOLKATA West Bengal, Sikkim,

Chattisgarh. Office of the Insurance Ombudsman, Andaman & Nicobar
Office of the Insurance Ombudsman, Janak
Hindustan Bldg. Annexe, 4th Floor, 4, C.R. Islands
Vihar Complex, 2nd Floor, 6, Malviya Nagar,
Opp. Airtel Office, Near New Market, Avenue, KOLKATA - 700 072.
Bhopal – 462 003. Tel.: 033 - 22124339 / 22124340
Tel.: 0755 - 2769201 / 2769202 Fax : 033 - 22124341
Fax: 0755 - 2769203 Email: [email protected]
LUCKNOW Districts of Uttar
BHUBANESHWAR Orissa. Office of the Insurance Ombudsman, 6th Pradesh : Lalitpur,
Floor, Jeevan Bhawan, Phase-II, Nawal Jhansi, Mahoba,
Office of the Insurance Ombudsman, 62,
Kishore Road, Hazratganj, Hamirpur, Banda,
Forest park, Bhubneshwar – 751 009.
Tel.: 0674 - 2596461 /2596455 Lucknow - 226 001. Chitrakoot, Allahabad,
Fax: 0674 - 2596429 Tel.: 0522 - 2231330 / 2231331 Mirzapur, Sonbhabdra,
Email: [email protected] Fax: 0522 - 2231310 Email: Fatehpur, Pratapgarh,
[email protected] Jaunpur,Varanasi,
CHANDIGARH Punjab, Gazipur, Jalaun, Kanpur,
Office of the Insurance Ombudsman, S.C.O. Haryana(excluding Lucknow, Unnao,
No. 101, 102 & 103, 2nd Floor, Gurugram, Faridabad, Sitapur, Lakhimpur,
Batra Building, Sector 17 – D, Sonepat and Bahraich, Barabanki,
Chandigarh – 160 017. Bahadurgarh) Raebareli, Sravasti,
Tel.: 0172 - 2706196 / 2706468 Himachal Pradesh, Gonda, Faizabad,
Fax: 0172 - 2708274 Union Territories of Amethi, Kaushambi,
Email: [email protected] Jammu & Kashmir, Balrampur, Basti,
Ladakh & Chandigarh Ambedkarnagar,
Sultanpur,
CHENNAI Tamil Nadu
Maharajgang,
Office of the Insurance Ombudsman, Fatima PuducherryTown and
Karaikal (which are Santkabirnagar,
Akhtar Court, 4th Floor, 453, Anna Salai, Azamgarh, Kushinagar,
Teynampet, CHENNAI – 600 018. part of Puducherry)
Gorkhpur, Deoria, Mau,
Tel.: 044 - 24333668 / 24335284
Ghazipur, Chandauli,
Fax: 044 - 24333664 Email:
Ballia, Sidharathnagar
[email protected]

Jurisdiction of SI No. Item

Office Details Office Union
Territory, District) 8 EMAIL / INTERNET CHARGES
MUMBAI Goa, Mumbai 9 FOOD CHARGES (OTHER THAN PATIENT's DIET

Office of the Insurance Ombudsman, 3rd Metropolitan Region PROVIDED BY HOSPITAL)
Floor, Jeevan Seva Annexe, S. V. Road, excluding Navi
Santacruz (W), Mumbai - 400 054. Mumbai & Thane 10 LEGGINGS
Tel.: 022 - 26106552 / 26106960
Fax: 022 - 26106052 11 LAUNDRY CHARGES
12 MINERAL WATER
NOIDA State of Uttaranchal 13 SANITARY PAD
Office of the Insurance Ombudsman, and the following
Bhagwan Sahai Palace, 4th Floor, Main Districts of Uttar 14 TELEPHONE CHARGES
Road, Naya Bans, Sector 15, Distt: Pradesh: Agra,
Aligarh, Bagpat, 15 GUEST SERVICES
Gautam Buddh Nagar, U.P-201301.
Tel.: 0120-2514252 / 2514253 Bareilly, Bijnor,
Budaun, 16 CREPE BANDAGE
Bulandshehar, Etah, 17 DIAPER OF ANY TYPE
Kanooj, Mainpuri,
Mathura, Meerut, 18 EYELET COLLAR
Moradabad,
Muzaffarnagar, 19 SLINGS
Oraiyya, Pilibhit,
Etawah,
20 BLOOD GROUPING AND CROSS MATCHING OF
Farrukhabad, DONORS SAMPLES
Firozbad,
Gautambodhanagar
21 SERVICE CHARGES WHERE NURSING CHARGE
, Ghaziabad, Hardoi, ALSO CHARGED
Shahjahanpur,
22 TELEVISION CHARGES
Hapur, Shamli,
Rampur, Kashganj, 23 SURCHARGES
Sambhal, Amroha,
Hathras, 24 ATTENDANT CHARGES
Kanshiramnagar,
Saharanpur 25 EXTRA DIET OF PATIENT (OTHER THAN THAT WHICH
FORMS PART OF BED CHARGE)
PATNA Bihar, Jharkhand
26 BIRTH CERTIFICATE
Office of the Insurance Ombudsman, 1st
Floor,Kalpana Arcade Building, Bazar 27 CERTIFICATE CHARGES
Samiti Road, Bahadurpur, Patna 800 006.
Tel.: 0612-2680952 28 COURIER CHARGES
29 CONVEYANCE CHARGES
PUNE Maharashtra,
30 MEDICAL CERTIFICATE
Office of the Insurance Ombudsman, Area of Navi
Jeevan Darshan Bldg., 3rd Floor, C.T.S. Mumbai and Thane 31 MEDICAL RECORDS
No.s. 195 to 198, N.C. Kelkar Road, excluding Mumbai
Narayan Peth, Pune – 411 030. Metropolitan Region 32 PHOTOCOPIES CHARGES
Tel.: 020-41312555 33 MORTUARY CHARGES
34 WALKING AIDS CHARGES
Annexure II
35 OXYGEN CYLINDER (FOR USAGE OUTSIDE THE
List I- Items for which coverage is not available in the Policy HOSPITAL)
SI No. Item 36 SPACER
1 BABY FOOD 37 SPIROMETRE
2 BABY UTILITIES CHARGES 38 NEBULIZER KIT
3 BEAUTY SERVICES 39 STEAM INHALER
4 BELTS/ BRACES 40 ARMSLING
5 BUDS 41 THERMOMETER
42 CERVICAL COLLAR
6 COLD PACK/HOT PACK
43 SPLINT
7 CARRY BAGS

SI No. Item SI No. Item

44 DIABETIC FOOT WEAR 11 TISSUE PAPER
45 KNEE BRACES (LONG/ SHORT/ HINGED) 12 TOOTH PASTE
46 KNEE IMMOBILIZER/SHOULDER IMMOBILIZER 13 TOOTH BRUSH
47 LUMBO SACRAL BELT 14 BED PAN
48 NIMBUS BED OR WATER OR AIR BED CHARGES 15 FACE MASK
49 AMBULANCE COLLAR 16 FLEX I MASK
50 AMBULANCE EQUIPMENT 17 HAND HOLDER
51 ABDOMINAL BINDER 18 SPUTUM CUP
52 PRIVATE NURSES CHARGES- SPECIAL NURSING 19 DISINFECTANT LOTIONS
CHARGES
20 LUXURY TAX
53 SUGAR FREE Tablets
21 HVAC
54 CREAMS POWDERS LOTIONS (Toiletries are not
22 HOUSE KEEPING CHARGES
payable, only prescribed medical pharmaceuticals
payable) 23 AIR CONDITIONER CHARGES
55 ECG ELECTRODES 24 IM IV INJECTION CHARGES
56 GLOVES 25 CLEAN SHEET
57 NEBULISATION KIT 26 BLANKETS/VARMER BLANKET
58 ANY KIT WITH NO DETAILS MENTIONED [DELIVERY 27 ADMISSION KIT

KIT, ORTHOKIT, RECOVERY KIT, ETC] 28 DIABETIC CHART CHARGES
59 KIDNEY TRAY 29 DOCUMENTATION CHARGES / ADMINISTRATIVE
60 MASK EXPENSES
61 OUNCE GLASS 30 DISCHARGE PROCEDURE CHARGES
62 OXYGEN MASK 31 DAILY CHART CHARGES
63 PELVIC TRACTION BELT 32 ENTRANCE PASS / VISITORS PASS CHARGES
64 PAN CAN 33 EXPENSES RELATED TO PRESCRIPTION ON

DISCHARGE
65 TROLLY COVER
34 FILE OPENING CHARGES
66 UROMETER, URINE JUG
35 INCIDENTAL EXPENSES / MISC. CHARGES (NOT
67 AMBULANCE
EXPLAINED)
68 VASOFIX SAFETY
36 PATIENT IDENTIFICATION BAND / NAME TAG
List II- Items that are to be subsumed into Room Charges 37 PULSEOXYMETER CHARGES
SI No. Item List III - Items that are to be subsumed into Procedure Charges
1 BABY CHARGES (UNLESS SPECIFIED/INDICATED) SI No. Item
2 HAND WASH 1 HAIR REMOVAL CREAM
3 SHOE COVER 2 DISPOSABLES RAZORS CHARGES (for site
4 CAPS preparations)
5 CRADLE CHARGES 3 EYE PAD
6 COMB 4 EYE SHEILD
7 EAU-DE-COLOGNE / ROOM FRESHNERS 5 CAMERA COVER
8 FOOT COVER 6 DVD, CD CHARGES
9 GOWN 7 GAUSE SOFT
10 SLIPPERS 8 GAUZE

SI No. Item List IV - Items that are to be subsumed into costs of treatment
9 WARD AND THEATRE BOOKING CHARGES SI No. Item
10 ARTHROSCOPY AND ENDOSCOPY INSTRUMENTS 1 ADMISSION/REGISTRATION CHARGES
11 MICROSCOPE COVER 2 HOSPITALISATION FOR EVALUATION/ DIAGNOSTIC

PURPOSE
12 SURGICAL BLADES, HARMONICSCALPEL,SHAVER
3 URINE CONTAINER
13 SURGICAL DRILL 4 BLOOD RESERVATION CHARGES AND ANTE NATAL
14 EYE KIT BOOKING CHARGES
15 EYE DRAPE 5 BIPAP MACHINE

6 CPAP/ CAPD EQUIPMENTS
16 X-RAY FILM
7 INFUSION PUMP— COST
17 BOYLES APPARATUS CHARGES
8 HYDROGEN PEROXIDE\SPIRITS DISINFECTANTS ETC
18 COTTON 9 NUTRITION PLANNING CHARGES - DIETICIAN
19 COTTON BANDAGE CHARGES- DIET CHARGES
20 SURGICAL TAPE 10 HIV KIT

11 ANTISEPTIC MOUTHWASH
21 APRON
12 LOZENGES
22 TORNIQUET
13 MOUTH PAINT
23 ORTHOBUNDLE, GYNAEC BUNDLE 14 VACCINATION CHARGES
15 ALCOHOL SWABES
16 SCRUB SOLUTION/STERILLIUM
17 GLUCOMETER& STRIPS
18 URINE BAG


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For Buy/ Renew/ Service/ Claim related queries Log on to www.icicilombard.

com or call 1800 2666

ELEVATE POLICY WORDING

ICICI Lombard General Insurance Company Limited

ICICI Lombard General Insurance Company Limited

ICICI Lombard General Insurance Company Limited

ICICI Lombard General Insurance Company Limited

ICICI Lombard General Insurance Company Limited

ICICI Lombard General Insurance Company Limited

8. Donor Expenses g. Diarrhea and all type of dysenteries, including

ICICI Lombard General Insurance Company Limited

ICICI Lombard General Insurance Company Limited

ICICI Lombard General Insurance Company Limited

Table A - Journey of earning Wellness points

ICICI Lombard General Insurance Company Limited

ICICI Lombard General Insurance Company Limited

ICICI Lombard General Insurance Company Limited

ICICI Lombard General Insurance Company Limited

a. If the Policy Tenure is of single year and is

ICICI Lombard General Insurance Company Limited

ICICI Lombard General Insurance Company Limited

ICICI Lombard General Insurance Company Limited

List of Minor Procedures covered under this Optional Cover #

ICICI Lombard General Insurance Company Limited

The e-counseling sessions shall be availed only through

ICICI Lombard General Insurance Company Limited

ICICI Lombard General Insurance Company Limited

ICICI Lombard General Insurance Company Limited

4. Open Chest CABG I. The first occurrence of heart attack or myocardial

9. Aplastic Anaemia i. A history of typical clinical symptoms consistent

20. Bacterial Meningitis 3. Coronary Artery Disease

ICICI Lombard General Insurance Company Limited

ICICI Lombard General Insurance Company Limited

ICICI Lombard General Insurance Company Limited

(II) “Paraplegia” means complete and irrecoverable paralysis b) Two phalanges 3%

ICICI Lombard General Insurance Company Limited

all hospitalisation expenses during the policy year Optional Cover:

ICICI Lombard General Insurance Company Limited

ICICI Lombard General Insurance Company Limited

Resident Indians/Overseas Citizens of India. All waiting 11. Fistulae in anus

ICICI Lombard General Insurance Company Limited

ICICI Lombard General Insurance Company Limited

purpose of this exclusion: disclosure of any material fact by the policyholder.

ICICI Lombard General Insurance Company Limited

ICICI Lombard General Insurance Company Limited

8. Renewal of Policy: vi. In the event of a claim, all subsequent premium

ICICI Lombard General Insurance Company Limited

Website: www.icicilombard.com 18. Zone based premium

ICICI Lombard General Insurance Company Limited

ICICI Lombard General Insurance Company Limited

ICICI Lombard General Insurance Company Limited

• Nature of Illness or Injury; 5. Indoor case papers

delayed on account of reasonable apprehension of fraud or Jurisdiction of

BENGALURU Karnataka. ERNAKULAM Kerala, Lakshadweep,

BHOPAL Madhya Pradesh KOLKATA West Bengal, Sikkim,

ICICI Lombard General Insurance Company Limited

Jurisdiction of SI No. Item

MUMBAI Goa, Mumbai 9 FOOD CHARGES (OTHER THAN PATIENT's DIET

3 BEAUTY SERVICES 39 STEAM INHALER

4 BELTS/ BRACES 40 ARMSLING