JCH Worker Policy

Group Health (Floater) Insurance
Customer Information Sheet
DISCLAIMER NOTE: The information mentioned below is illustrative and not exhaustive. The information must be read in
conjunction with the policy wordings. In case of any conflict between the Customer Information Sheet and the policy wordings,
the terms and conditions mentioned in the policy wordings shall prevail.
S. No Title Description Policy Clause Number

1 Product Name Group Health (Floater) Insurance
2 What am I Covered The policy provides indemnification of medical expenses a. Policy schedule
for incurred by the Insured during day care treatment,
hospitalization, domiciliary hospitalization, for any illness or
injury suffered during the Policy Period.
• Cover for Pre-Existing Diseases
• Maternity Expenses
• Out Patient Department (OPD) Expenses
• HIV
• Cost of Prescribed External Medical Aid
• Baby Day One Cover
• Critical Illnesses Cover
• Travel Expenses For Medical Treatment
• Dental Expenses
• Cover for Alternate Methods Of Treatment
• Donor Expenses
Optional Add On • Ambulance Charges d. Benefits covered under the
3
Covers • Pre and Post Hospitalization policy
• Health Check-Up
• Disease-Wise Sub-Limit
• Domiciliary Hospitalization
• Treatment Outside India
• Convalescence Benefit
• Loss of Wages/Salary Due To Hospitalization (Hospital
Daily Cash Allowance)
• Cover for Allied Hospital Charges
• Limit on Room Rent, Nursing Charges, Consultation Fees,
Diagnostic Charges, OT Charges etc.
• Wellness & Preventive Care
• Initial Waiting Period
4 Waiting Period • Pre Existing Disease : 1 year e. Exclusions
• Specific Waiting Periods Maternity Expenses: 9 months
• Pre-Existing Diseases
• Circumcision, plastic surgery Cost of spectacles, contact
lenses, hearing aids, etc.
• Dental treatment or surgery of any kind unless requiring
hospitalization.
• Convalescence, Sterility, general debility, e. Exclusions
What are the major
5 exclusions in the • Intentional self-Injury and use of intoxicating drugs and/or
alcohol
Policy
• Voluntary medical termination of pregnancy during the first
12 weeks from the date of conception
• Naturopathy treatment
• (Note: the above is a partial listing of the policy
exclusions. Please refer to the policy clauses for the
full listing)
6 Payment Basis • Cashless or Reimbursement claims of covered medical g. Other Terms and Conditions
ICICI Lombard General Insurance Company Limited

IRDA Reg. No. 115 CIN: L67200MH2000PLC129408 UIN : ICIHLGP24019V062324 GROUP HEALTH (FLOATER) INSURANCE
Mailing Address: Registered Office Address Toll free no : 1800 2666
601 & 602, 6th Floor, Interface 16 ICICI Lombard House,414, Veer Savarkar Alternate no : 86552 22666 (chargeable)
New Linking Road, Malad (West) Marg,Near Siddhi Vinayak Temple, E-mail : [email protected]
Mumbai - 400 064 Prabhadevi, Mumbai 400 025 Website : www.icicilombard.com
•
expenses up to specified Sum Insured as per the scope of
cover
7 Loss Sharing • In case of a claim, this policy requires you to share the
following costs:
Expenses exceeding the sub limits a. Policy schedule
•
• Room/ICU changes
8 Renewal Conditions • The Policy can be renewed as a separate contract under the
then prevailing ICICI Lombard Group Health (Floater)
Insurance product or its nearest substitute (in case the
product ICICI Lombard Group Health (Floater) Insurance is
f. General Terms and Clauses
withdrawn by the Company) approved by IRDA.
• The policy shall ordinarily be renewable except on grounds
of fraud, moral hazard or misrepresentation or non-
cooperation by the insured.
9 Cancellation • The Policy shall be void and all premium paid hereon shall
be forfeited to the Company, in the event of
misrepresentation, misdescription or non-disclosure of any
material fact.
• Insured or the Company may cancel this Policy by giving
the Company or the insured, as the case may be, 15 days
f. General Terms and Clauses
written notice for the cancellation of the Policy, and then
the Company shall refund premium on short term rates (if
initiated by the insured) or pro rata rates (if initiated by the
Company) for the unexpired Policy Period. The Company
shall follow the below short period scale unless otherwise
mutually agreed.
10 Claims • For Cashless Service
• Cashless treatment is only available at our Network
Provider Please refer [email protected] for updated
list of our Network Providers
• For Reimbursement of claim g. Other terms & conditions
• Claims should be intimated 48 hours prior to Hospitalization
or within 24 hours post admission in case of emergency
• Document to be submitted within 30 days from the date of
completion of treatment
11 Policy • Call the Company at the toll free number 1800 266 or email
Servicing/Grievance us at [email protected]
s/Complaints • In case of Insured is not satisfied, he/she mayapproach us
at the sub section "GrievanceRedressal" on g. Other terms & conditions
[email protected] Otherwise Insured may use IGMS
• If the issue remains unresolved, Insured may approach
Ombudsman
12 Insured's Obligations • Disclosure of Material Information during the Policy Period f. General Terms and Clauses

Group Health (Floater) Insurance 35
a. POLICY SCHEDULE
Insured Detail
Policy Number : 4016/X/262885163/01/000
Issued At : MUMBAI
Name of the Insured : JOHNSON CONTROLS-HITACHI AIR CONDITIONING INDIA LIMITED
Mailing Address of the Insured : HITACHI COMPLEX, KARAN NAGAR, KADI , GUJARAT - 382727
Politically Exposed Person (PEP)/close relative of PEP: No
Intermediary Details
Agency/Broker Code : 200007003937
Agency/Broker Name : MARSH INDIA INSURANCE BROKERS PVT LTD
Agent's/Broker's Mobile No. : 9820098200
Agent's/Broker's Email ID : [email protected]
Policy Details
Period of Insurance : From: 00:00 Hours of Oct 01, 2023 To Midnight Sep 30, 2024
Product : GROUP HEALTH (FLOATER) INSURANCE
Total Lives Insured : 2595
Sum Insured : `5,46,00,000.00
Details of Person Insured : As per Annexure Premium Computation
Basic Premium : `94,48,195.00
Stamp Duty : `0.50
*Total Premium : `1,11,48,871.00
*Premium value mentioned above is inclusive of taxes applicable
Coverages
1 Policy type Floater
2 Policy Construct Employer Employee
3 Service Category Both Cashless & Reimbursement
4 OPD/IPD IPD
5 Third Party Administrator Paramount health services Pvt Ltd
6 OTC/Non OTC Non-OTC
7 Physical Health Card No
8 Age Band 1 day to 80 years only
9 Family Definition "Family Definition - Self + Spouse + 4 Children + 2 Parent/Parent in Law
(only one set of Parents covered).Age limit - Maximum Age limit up to 80
years for self/spouse, and unmarried dependant children upto 25 years
and parents upto 95 years
10 Sum Insured SI is restricted to Rs. 1L Per Family during the policy period as per
annexure attached herewith
11 Room Rent Room Rent Restricted to INR 2000 for Normal and as peractuals for ICU
AND COVID 19 treatment
12 Maternity Benefit Normal Rs 50k and C Sec Rs.50k .Applicable for Self and Spousefor First
2 deliveries and 9 months waiting waived off
13 Baby Day 1 Baby covered from 1 day Upto the family SI
14 Pre/Post Natal Expenses Covered on IPD basis within maternity limit.
15 Add-Del of Lives Premium to be charged on Pro rata Basis for addition/deletion endorsement
16 Ambulance Service Covered maximum upto amount of INR 2000 per hospitalizatio
17 Corporate Floater Covered for 20 Lacs with sublimit of INR 2,00,000 familyfloater SI.for all
ailments except maternity and cappedailments and sublimit of INR
3,00,000 family floater SIapplicable for 8 Major CI ailments (Cancer
Coronary Artery(Bypass) Surgery First Heart Attack (Myocardial
InfarctionKidney Failure(end stage renal disease) Major
OrganTransplantation Multiple Sclerosis Paralysis and Strokeresulting in
Permanent Symptoms) only

Coverages
18 Disease wise sublimits No sublimit
19 Day care procedures As per ILHC list.
20 Organ Donor Upto Sum Insured Limit (except cost of organ and its transportation).
21 Family Transportation Benefit "Covered upto INR 5000
22 Nursing Allowance Covered for INR 100 per day upto a maximum of 15 days with a
deductible of 2 days
23 Limit on "Congenital Internal disease cover - Covered. Any Hospitalization due to
Treatment/Illness/Surgery terrorism activities will be covered upto IPD Sum Insured. Dental
Treatment Covered in case of hospitalization due to accident on IPD basis
only. Cyber knife treatment and Stem Cell Transplantation Covered with
50% Co Pay. Cochlear Implant treatment restricted to 50% of SI.
24 Mid-Term Inclusion "Mid term inclusion of dependents will be possible only in case of: a)
spouse (on account of marriage during the policy term) b) children
(childbirth during the policy term but after the child has completed 91 days
of age) subject to not more than 4 children being covered under the Policy
25 Special Condition No Refund for deletion-if lives less than minimum required & if insured
has claimed during policy
26 Special Condition "Claim must be filed within 30 days from the date of completion of
treatment. However, the Company may at its discretion consider waiver
based on merits of the claim, where there is delay in intimation or in
submission of documents due to unavoidable circumstances and it is
proved that the delay was for reasons beyond the control of the insured
and under the circumstances in which the insured was placed it was not
possible for him or any other person to give such notice or file claim within
the prescribed time-limit
27 30 Days Waiting Period,First waived off
year exclusion,9 months waiting
period
28 Exclusion "Lasik Surgery, Septoplasty, Infertility & Related Ailments incl.Male
sterility;Treatment on trial/experimental basis;
Admin/Registration/Service/Misc. Charges; Expenses on fitting of
Prosthesis; Any device/instrument/machine contributing/replacing the
function of an organ; Holter Monitoring are outside the scope of the policy
29 Domiciliary Hospitalization Excluded
30 CO-Share 70% Icici Lombard- Leader , 30% SBI follower
31 DISEASE-WISE SUBLIMITS No Limit
32 Pre existing Disease Covered
33 Pre Post Hospitilization "Pre Hospitalisation and Post Hospitalisation for 30 days & 60 days
respectively are covered.
33
Conditions
1 No. of Employees : 546

2 No. of Dependants : 2049
3 Third Party Administrator (TPA)/ In house :
For TPA Address and Contact details please visit our website
www.icicilombard.com (Download Section)
Co-Insurance Details:
Sr. No. Name of the Co-Insurer Share % Type

1 ICICI LOMBARD 70 Leader
2 SBI GIC 30 Follower
2
Policy shall stand cancelled ab initio in the event of non realisation of the premium.
Disclaimer: This document to be read in conjunction with the Schedule II & Schedule III of the policy.
GSTIN Reg. No : 24AAACI7904G1ZT
IL GIC GSTIN Address : 414, ICICI Lombard House Veer Sawarkar Marg Mumbai-Prabhadevi Maharashtra 400025
HSN SAC code : 997133 GENERAL INSURANCE SERVICES

Signed for and on behalf of the ICICI Lombard General Insurance Company Limited at Mumbai on Oct 01, 2023
Yours sincerely
Authorized Signatory
For ICICI LOMBARD GENERAL INSURANCE COMPANY LIMITED
Scan QR for Key Information Sheet and Policy-wordings.

To view Policy- wordings on our website

b. Preamble Congenital anomaly which is not in the visible and accessible
parts of the body
ICICI Lombard General Insurance Company Limited ("the
Company"), having received a Proposal and the premium from b. External Congenital Anomaly
the Proposer named in the Schedule referred to herein below, and
the said Proposal and Declaration together with any statement, Congenital anomaly which is in the visible and accessible parts of
report or other document leading to the issuance of this policy and the body
referred to therein having been accepted and agreed to by the 6. Co-Payment:
Company and the Proposer as the basis of this contract do, by
this Policy agree, in consideration of and subject to the due receipt Co-payment means a cost sharing requirement under a health
of the subsequent premiums, as set out in the Schedule with all insurance policy that provides that the policyholder/insured will
its Parts, and further, subject to the terms and conditions bear a specified percentage of the admissible claims amount. A
contained in this Policy, as set out in the Schedule with all its co-payment does not reduce the Sum Insured.
Parts, that on proof to the satisfaction of the Company of the
compensation having become payable as set out in Part (a) of the 7. Cumulative Bonus:
Schedule to the title of the said person or persons claiming
Cumulative Bonus means any increase or addition in the Sum
payment or upon the happening of an event upon which one or
Insured granted by the insurer without an associated increase
more benefits become payable under this Policy, the Sum
in premium.
Insured/appropriate benefit will be paid by the Company.
8. Day Care Center:
c. DEFINITIONS
A day care center means any institution established for day care
For the purposes of this policy, the terms specified below shall treatment of illness and/or injuries or a medical setup with a
have the meaning set forth wherever appearing/specified in this hospital and which has been registered with the local
Policy or related Extensions/Endorsements: authorities, wherever applicable, and is under supervision of a
registered and qualified medical practitioner AND must
Where the context so requires, references to the singular shall
also include references to the plural and references to any gender comply with all minimum criterion as under
shall include references to all genders. Further any references to
statutory enactment include subsequent changes to the same. i) has qualified nursing staff under its employment
I. Standard Definitions whose wordings are specified by ii) has qualified medical practitioner/s in charge
IRDAI
iii) has a fully equipped operation theatre of its own where surgical
1. Accident: procedures are carried out
An accident means sudden, unforeseen and involuntary event
caused by external, visible and violent means. iv) maintains daily records of patients and will make these
accessible to the Insurance Company’s authorized personnel.
2. Any One Illness:
9. Day Care Treatment:
Any one illness means continuous period of illness and includes
relapse within 45 days from the date of last consultation with the Day care treatment means medical treatment, and/or surgical
Hospital/Nursing Home where treatment was taken. procedure which is:
3. Cashless Facility: i. undertaken under General or Local Anesthesia in a

hospital/day care centre in less than 24 hours
Cashless facility means a facility extended by the insurer to the
insured where the payments, of the costs of treatment because of technological advancement, and
undergone by the insured in accordance with the policy terms
ii. Which would have otherwise required hospitalization of
and conditions, are directly made to the network provider by the
more than 24 hours.
insurer to the extent pre- authorization approved.
Treatment normally taken on an out-patient basis is not included
4. Condition Precedent:
in the scope of this definition
Condition Precedent means a policy term or condition upon
10. Deductible:
which the Insurer's liability under the policy is conditional upon.
Deductible means a cost sharing requirement under a health
5. Congenital Anomaly:
insurance policy that provides that the insurer will not be liable
Congenital Anomaly means a condition which is present since for a specified rupee amount in case of indemnity policies and
birth, and which is abnormal with reference to form, structure or for a specified number of days/hours in case of hospital cash
position policies which will apply before any benefits are payable by the
insurer. A deductible does not reduce the Sum Insured.
a. Internal Congenital Anomaly

IRDA Reg. No. 115 CIN: L67200MH2000PLC129408 UIN : ICIHLGP24019V062324 Group Health (Floater) Insurance
Mailing Address: Registered Office Address: Toll free no : 1800 2666
601 & 602, 6th Floor, Interface 16, ICICI Lombard House, 414, P Balu Marg, Alternate no : 86552 22666 (chargeable)
New Linking Road, Malad (West) Off Veer Savarkar Road, Near Siddhi Vinayak Temple, E-mail : [email protected]
Mumbai - 400 064 Mumbai 400 025 Website : www.icicilombard.com
Deductible is applicable per year, per life or per event as stated in iv) has a fully equipped operation theatre of its own where
part I of the policy and specific benefit/cover based deductible surgical procedures are carried out;
shall be applied if specified in the part I of the policy.
v) maintains daily records of patients and make these
11. Dental treatment: accessible to the Insurance Company’s authorized personnel.
Dental treatment means a treatment related to teeth or 17. Hospitalization:

structures supporting teeth including examinations, fillings
(where appropriate), crowns, extractions and surgery Hospitalization means admission in a Hospital for a minimum
period of 24 consecutive ‘In-patient Care’ hours except for
12. Disclosure to information norm: specified procedures/ treatments, where such admission
could be for a period of less than 24 consecutive hours.
The policy shall be void and all premium paid thereon shall be
forfeited to the Company in the event of misrepresentation, mis- 18. Illness:
description or non-disclosure of any material fact.
Illness means a sickness or a disease or pathological condition
13. Domiciliary Hospitalization: leading to the impairment of normal physiological function and
requires medical treatment.
Domiciliary hospitalization means medical treatment for an
illness/disease/injury which in the normal course would require (a)Acute condition- Acute condition is a disease, illness or
care and treatment at a hospital but is actually taken while injury that is likely to respond quickly to treatment which
confined at home under any of the following circumstances aims to return the person to his or her state of health
immediately before suffering the disease/ illness/ injury
i)The condition of the patient is such that he/she is not in a which leads to full recovery.
condition to be removed to the
(b)Chronic condition- A chronic condition is defined as a
Hospital, or disease, illness, or injury that has one or more of the
following characteristics:
ii)The patient takes treatment at home on account of non-
availability of room in a hospital 1. it needs ongoing or long-term monitoring through
consultations, examinations, checkups, and / or tests
14. Emergency Care:
2. it needs ongoing or long-term control or relief of symptoms
Emergency care means management for an illness or injury
which results in symptoms which occur suddenly and 3. it requires rehabilitation for the patient or for the patient to be
unexpectedly, and requires immediate care by a medical specially trained to cope with it
practitioner to prevent death or serious long term impairment of
the insured person’s health. 4. it continues indefinitely
15. Grace Period: 5. it recurs or it likely to recur
Grace period means the specified period of time immediately 19. Injury
following the premium due date during which a payment can be
made to renew or continue a policy in force without loss of Injury means accidental physical bodily harm excluding illness
continuity benefits such as waiting periods and coverage of pre- or disease solely and directly caused by external, violent,
existing diseases. Coverage is not available for the period for visible and evident means which is verified and certified by a
which no premium is received. Medical Practitioner
16. Hospital: 20. Inpatient care:
A hospital means any institution established for in-patient care Inpatient care means treatment for which the insured person
and day care treatment of illness and/or injuries and which has has to stay in a hospital for more than 24 hours for a covered
been registered as a hospital with the local authorities under event.
Clinical Establishments (Registration and Regulation) Act
21. Intensive Care Unit:
2010 or under enactments specified under the Schedule of
Section 56(1) of the said act Or complies with all minimum Intensive care unit means an identified section, ward or wing of
criteria as under: a hospital which is under the constant supervision of a dedicated
medical practitioner(s), and which is specially equipped for the
i) has qualified nursing staff under its employment round the
continuous monitoring and treatment of patients who are in a
clock;
critical condition, or require life support facilities and where the
ii) has at least 10 in-patient beds in towns having a population level of care and supervision is considerably more sophisticated
of less than 10,00,000 and at least 15 inpatient beds in all and intensive than in the ordinary and other wards.
other places;
22. ICU Charges:
iii) has qualified medical practitioner(s) in charge round the
clock;

ICU (Intensive Care Unit) Charges means the amount charged 28. Network Provider:
by a Hospital towards ICU expenses which shall include the
expenses for ICU bed, general medical support services Network Provider means hospitals or health care providers
provided to any ICU patient including monitoring devices, critical enlisted by an insurer, TPA or jointly by an Insurer and TPA to
care nursing and intensivist charges. provide medical services to an insured by a cashless facility
23. Maternity Expenses: 29. New born Baby:
Maternity expenses means Newborn baby means baby born during the Policy Period and is
aged upto90 days.
a) Medical treatment expenses traceable to childbirth (including
complicated deliveries and caesarean sections incurred during 30. Non- Network Provider:
hospitalization)
Non-Network provider means any hospital, day care Centre or
b) Expenses towards lawful medical termination of pregnancy other provider that is not part of the network.
during the policy period
31. Notification of Claim:
24. Medical Advice:
Notification of claim means the process of intimating a claim to
Medical Advice means any consultation or advice from a the insurer or TPA through any of the
Medical Practitioner including the issuance of any prescription
recognized modes of communication.
or follow-up prescription.
32. OPD treatment:
25. Medical Expenses:
OPD treatment means the one in which the Insured visits a clinic
Medical expenses means those expenses that an Insured
/ hospital or associated facility like a consultation room for
Person has necessarily and actually incurred for medical
diagnosis and treatment based on the advice of a Medical
treatment on account of Illness or Accident on the advice of a
Practitioner. The Insured is not admitted as a day care or in-
Medical Practitioner, as long as these are no more than would
patient.
have been payable if the Insured Person had not been insured
and no more than other hospitals or doctors in the same 33. Pre-existing Disease:
locality would have charged for the same medical treatment.
Pre-existing Disease means any condition, ailment, injury or
26. Medical Practitioner: disease:
Medical Practitioner means a person who holds a valid a) That is/are diagnosed by a physician within 48 months prior to
registration from the Medical Council of any State or Medical the effective date of the policy issued by the insurer or its
Council of India or Council for Indian Medicine or for reinstatement or
Homeopathy set up by the Government of India or a State
Government and is thereby entitled to practice medicine within b) For which medical advice or treatment was recommended by,
its jurisdiction; and is acting within its scope and jurisdiction of or received from, a physician within 48 months prior to the
license. effective date of the policy issued by the insurer or its
reinstatement
The term medical practitioner would include physician,
specialist, anaesthetist and surgeon but should not be the 34. Pre Hospitalization Medical Expenses:
Insured or Insured’s Immediate Family. “Immediate Family”
Pre-hospitalization Medical Expenses means medical expenses
would comprise of spouse, children, brother(s), sister(s) and
incurred during pre-defined number of days preceding the
parent(s).
hospitalization of the Insured Person, provided that:
27. Medically Necessary Treatment:
i. Such Medical Expenses are incurred for the same condition for
Medically necessary treatment means any treatment, tests, which the Insured Person's Hospitalization was required, and
medication, or stay in hospital or part of a stay in hospital which:
ii. The In-patient Hospitalization claim for such Hospitalization is
i) is required for the medical management of the illness or injury admissible by the Insurance Company.
suffered by the insured;
35. Post Hospitalization Medical Expenses:
ii) must not exceed the level of care necessary to provide safe,
Post-hospitalization Medical Expenses means medical expenses
adequate and
incurred during pre-defined number of days immediately after the
iii) must have been prescribed by a medical practitioner; insured person is discharged from the hospital provided that:
iv) must conform to the professional standards widely accepted in i.Such Medical Expenses are for the same condition for which the
international medical practice or Insured Person's Hospitalization was required, and
by the medical community in India ii.The In-patient Hospitalization claim for such Hospitalization is
admissible by the Insurance Company.

36. Qualified Nurse: supervision of a qualified registered AYUSH Medical Practitioner
and must comply with all the
Qualified nurse means a person who holds a valid registration
from the Nursing Council of India or the Nursing Council of any following criterion:
state in India.
i. Having at least 5 in-patient beds;
37. Reasonable and Customary Charges:
ii. Having qualified AYUSH Medical Practitioner in charge round
Reasonable and Customary charges means the charges for the clock;
services or supplies, which are the standard charges for the
specific provider and consistent with the prevailing charges in the iii. Having dedicated AYUSH therapy sections as required and/or
has equipped operation theatre
geographical area for identical or similar services, taking into
account the nature of the illness / injury involved where surgical procedures are to be carried out;
38. Renewal iv. Maintaining daily records of the patients and making them
accessible to the insurance company’s
Renewal means the terms on which the contract of insurance can
be renewed on mutual consent with a provision of grace period authorized representative.
for treating the renewal continuous for the purpose of gaining
44. AYUSH Day Care Centre:
credit for pre-existing diseases, time-bound exclusions and for all
waiting periods. AYUSH Day Care Centre means and includes Community Health
Centre (CHC), Primary Health Centre (PHC), Dispensary, Clinic,
39. Room Rent:
Polyclinic or any such health centre which is registered with the
Room Rent means the amount charged by a Hospital towards
local authorities, wherever applicable and having facilities for
Room and Boarding expenses and shall include the associated
carrying out treatment procedures and medical or surgical/para-
medical expenses.
surgical interventions or both under the supervision of registered
40. Subrogation:
AYUSH Medical Practitioner (s) on day care basis without in-
Subrogation means the right of the insurer to assume the rights patient services and must comply with all the following criterion:
of the insured person to recover expenses paid out under the
i. Having qualified registered AYUSH Medical Practitioner(s) in
policy that may be recovered from any other source
charge;
41. Surgery or Surgical Procedure:
ii. Having dedicated AYUSH therapy sections as required and/or
Surgery or Surgical Procedure means manual and / or operative has equipped operation theatre where surgical procedures are to
procedure (s) required for treatment of an illness or injury, be carried out;
correction of deformities and defects, diagnosis and cure of
iii. Maintaining daily records of the patients and making them
diseases, relief from suffering and prolongation of life, performed
accessible to the insurance company’s authorized representative.
in a hospital or day care center by a medical practitioner
45. Migration:
42. Unproven/Experimental treatment:
“Migration” means, the right accorded to health insurance
Unproven/Experimental treatment means the treatment including
policyholders (including all members under family cover and
drug experimental therapy which is not based on established
members of group health insurance policy), to transfer the credit
medical practice in India, is treatment experimental or unproven.
gained for pre-existing conditions and time bound exclusions, with
43. AYUSH Hospital: the same insurer.
An AYUSH Hospital is a healthcare facility wherein 46. Portability:

medical/surgical/para-surgical treatment procedures and
“Portability” means the right accorded to an individual health
interventions are carried out by AYUSH Medical Practitioner(s)
insurance policyholder (including all members under family
comprising of any of the following:
cover), to transfer the credit gained for pre-existing conditions and
a. Central or State Government AYUSH Hospital; or time bound exclusions, from one insurer to another insurer
b. Teaching hospital attached to AYUSH College recognized by Specific Definitions

the Central Government/Central
1. Admission
Council of Indian Medicine/Central Council for Homeopathy; or
Admission means admission of the insured in a Hospital as an
c. AYUSH Hospital, standalone or co-located with in-patient inpatient for the purpose of medical treatment of an Injury and/or
healthcare facility of any recognized Illness.
system of medicine, registered with the local authorities, wherever 2. Alternative treatments
applicable, and is under the

Alternative treatments are forms of treatments other than Proportionate deduction means
treatment "Allopathy" or "modem medicine" and include
Ayurveda, Unani, Siddha and Homeopathy in the Indian context. a. When higher room category is chosen, following expenses
are not allowed under 'associate medical expenses' - Cost of
3. Annual Sum Insured: pharmacy/consumables, Cost of implants/medical devices,
Cost of diagnostics.
Annual sum insured means and denotes the maximum amount
of cover available to the insured during each Policy Year of the b. Proportionate deductions not allowed for ICU expenses
Policy Period, as stated in the Policy Schedule or any revisions
thereof based on Claim settled under the Policy 12. Senior Citizen:
4. Contribution: Senior citizen means any person who has completed sixty or
more years of age as on the date of commencement or renewal
Contribution is essentially the right of an insurer to call upon of a health insurance policy.
other insurers, liable to the same insured, to share the cost of
an indemnity claim on a rate able proportion of Sum Insured. 13. Third Party Administrator (TPA):
Thisclause shall not apply to any Benefit offered on fixed benefit
Third Party Administrator (TPA) means a Company registered
basis.
with the Authority, and engaged by an insurer, for a fee or by
5. Out-patient: whatever name called and as may be mentioned in the health
services agreement, for providing health services
Out-patient means the Insured who is not hospitalized for more
than 24 consecutive hours but who visits a Hospital, clinic, or 14. Standard Nomenclature and Procedures for Critical Illnesses:
associated facility for diagnosis or treatment. However, any
"Critical Illness" for the purpose of this Policy (if covered as an
Insured undergoing any specified "Day care
extension in Part (a) of the Policy) includes the following:
surgeries/Treatment" will not be considered as an Out-patient.
1.CANCER OF SPECIFIED SEVERITY
6. Period of Insurance:
I. A malignant tumor characterized by the uncontrolled growth
Period of insurance means the period as specifically appearing
and spread of malignant cells with invasion and destruction of
in the Policy Schedule and commencing from the Policy Period
normal tissues. This diagnosis must be supported by
Start Date of the first Policy taken by the insured from the
histological evidence of malignancy. The term cancer includes
company and then, running concurrent to the current Policy
leukemia, lymphoma and sarcoma.
subject to the Insured’s continuous renewal of such Policy with
the company. II. The following are excluded –
7. Policy: i. All tumors which are histologically described as carcinoma
in situ, benign, pre-malignant, borderline malignant, low
Policy means these Policy wordings, the Policy Schedule and
malignant potential, neoplasm of unknown behavior, or non-
any applicable endorsements or extensions attaching to or
invasive, including but not limited to: Carcinoma in situ of
forming part thereof. The Policy contains details of the extent of
breasts, Cervical dysplasia CIN-1, CIN - 2 and CIN-3.
cover available to the Insured person, what is excluded from the
cover and the terms & conditions on which the Policy is issued ii. Any non-melanoma skin carcinoma unless there is evidence
to The Insured person of metastases to lymph nodes or beyond;
8. Policy Holder: iii. Malignant melanoma that has not caused invasion beyond
the epidermis;
Policy holder means the person(s) or the entity named in the
Policy Schedule who executed the Policy Schedule and is (are) iv. All tumors of the prostate unless histologically classified as
responsible for payment of premium(s). having a Gleason score greater than 6 or having progressed
to at least clinical TNM classification T2N0M0
9. Policy Period:
v. All Thyroid cancers histologically classified as T1N0M0
Policy period means period of one policy year as mentioned in
(TNM Classification) or below;
the schedule for which the Policy is issued
vi. Chronic lymphocytic leukaemia less than RAI stage 3
10. Policy Year:
vii. Non-invasive papillary cancer of the bladder histologically
Policy year means a period of twelve months beginning from the
described as TaN0M0 or of a lesser classification,
date of commencement of the policy period and ending on the
last day of such twelve-month period. For the purpose of viii. All Gastro-Intestinal Stromal Tumors histologically
subsequent years, policy year shall mean a period of twelve classified as T1N0M0 (TNM Classification) or below and with
months commencing from the end of the previous policy year mitotic count of less than or equal to 5/50 HPFs;
and lapsing on the last day of such twelve-month period, till the
policy period, as mentioned in the schedule. 2. MYOCARDIAL INFARCTION
11. Proportionate deduction: (First Heart Attack of specific severity)

I. The first occurrence of heart attack or myocardial infarction, II.The condition has to be confirmed by a specialist medical
which means the death of a portion of the heart muscle as a practitioner. Coma resulting directly from alcohol or drug abuse
result of inadequate blood supply to the relevant area. The is excluded.
diagnosis for Myocardial Infarction should be evidenced by all
of the following criteria: 6. KIDNEY FAILURE REQUIRING REGULAR DIALYSIS
i. A history of typical clinical symptoms consistent with the I. End stage renal disease presenting as chronic irreversible
diagnosis of acute myocardial infarction (For e.g. typical chest failure of both kidneys to function, as a result of which either
pain) regular renal dialysis (hemodialysis or peritoneal dialysis) is
instituted or renal transplantation is carried out. Diagnosis has
ii. New characteristic electrocardiogram changes to be confirmed by a specialist medical practitioner.
iii. Elevation of infarction specific enzymes, Troponins or other 7. STROKE RESULTING IN PERMANENT SYMPTOMS
specific biochemical markers. II. The following are
I.Any cerebrovascular incident producing permanent
excluded: neurological sequelae. This includes infarction of brain tissue,
thrombosis in an intracranial vessel, haemorrhage and
i. Other acute Coronary Syndromes embolisation from an extracranial source. Diagnosis has to be
confirmed by a specialist medical practitioner and evidenced
ii. Any type of angina pectoris
by typical clinical symptoms as well as typical findings in CT
iii. A rise in cardiac biomarkers or Troponin T or I in absence of Scan or MRI of the brain. Evidence of permanent neurological
overt ischemic heart disease OR following an intra-arterial deficit lasting for at least 3 months has to be produced.
cardiac procedure.
II. The following are excluded:
3. OPEN CHEST CABG
i.Transient ischemic attacks (TIA)
I.The actual undergoing of heart surgery to correct blockage or
ii.Traumatic injury of the brain
narrowing in one or more coronary artery(s), by coronary artery
bypass grafting done via a sternotomy (cutting through the breast iii.Vascular disease affecting only the eye or optic nerve or
bone) or minimally invasive keyhole coronary artery bypass vestibular functions.
procedures. The diagnosis must be supported by a coronary
angiography and the realization of surgery has to be confirmed by 8. MAJOR ORGAN / BONE MARROW TRANSPLANT
a cardiologist.
I.The actual undergoing of a transplant of:
II.The following are excluded:
i.One of the following human organs: heart, lung, liver, kidney,
i. Angioplasty and/or any other intra-arterial procedures pancreas, that resulted from irreversible end stage failure of
the relevant organ, or
4. OPEN HEART REPLACEMENT OR REPAIR OF HEART
VALVES ii.Human bone marrow using haematopoietic stem cells. The
undergoing of a transplant has to be confirmed by a specialist
I.The actual undergoing of open-heart valve surgery is to medical practitioner
replace or repair one or more heart valves, as a consequence
of defects in, abnormalities of, or disease-affected cardiac II.The following are excluded:
valve(s). The diagnosis of the valve abnormality must be
supported by an echocardiography and the realization of i.Other stem-cell transplants
surgery has to be confirmed by a specialist medical
ii.Where only islets of Langerhans are transplanted
practitioner. Catheter based techniques including but not
limited to, balloon valvotomy/valvuloplasty are excluded. 9. PERMANENT PARALYSIS OF LIMBS
5. COMA OF SPECIFIED SEVERITY I.Total and irreversible loss of use of two or more limbs as a
result of injury or disease of the brain or spinal cord. A
I. A state of unconsciousness with no reaction or response to
specialist medical practitioner must be of the opinion that the
external stimuli or internal needs. This diagnosis must be
paralysis will be permanent with no hope of recovery and must
supported by evidence of all of the following:
be present for more than 3 months.
i.no response to external stimuli continuously for at least 96
10. MOTOR NEURON DISEASE WITH PERMANENT
hours;
SYMPTOMS
ii.life support measures are necessary to sustain life; and
I.Motor neuron disease diagnosed by as specialist medical
iii.permanent neurological deficit which must be assessed at practitioner as spinal muscular atrophy, progressive bulbar
least 30 days after the onset of the coma palsy, amyotrophic lateral sclerosis or primary lateral
sclerosis. There must be progressive degeneration of
corticospinal tracts and anterior horn cells or bulbar efferent
neurons. There must be current significant and permanent

functional neurological impairment with objective evidence of For the purpose of this add-on, Outpatient means the Insured
motor dysfunction that has persisted for a continuous period person who is not hospitalized for more than 24 consecutive
of at least 3 months. hours but who visits a hospital, clinic or associated facility for
diagnosis or treatment. However, any Insured person
11. MULTIPLE SCLEROSIS WITH PERSISTING SYMPTOMS undergoing any named day care procedure/ treatment will not
be considered as an Outpatient.
I. The unequivocal diagnosis of Definite Multiple Sclerosis
confirmed and evidenced by all of the following: 4. Cost of Prescribed External Medical Aid: The Company
will reimburse Insured for the charges incurred by Insured
i. investigations including typical MRI findings which
during the Policy Period on account of procuring medically
unequivocally confirm the diagnosis to be multiple
necessary prosthetic or artificial devices or any medical
sclerosis
equipment including but not limited to hearing aids,
and spectacles, contact lenses etc.
ii. there must be current clinical impairment of motor or 5. Baby Day One Cover: This add-on will cover medical
sensory function, which must have persisted for a expenses incurred on the "new born baby" only as an in-
continuous period of at least 6 months. patient in hospital for a maximum period up to 91 days.
II. Neurological damage due to SLE is excluded 6. Critical Illnesses Cover: The Company will pay the sum
insured for this add-on, in case Insured is diagnosed as
suffering from one or more of the Critical Illnesses for the first
d. Benefits covered under the policy time in life, during the Policy Period.
Insured may also avail the following additional covers/add-ons
This benefit can be availed only by the Insured only once
under the policy. Risk Premium would be charged as per the
during his lifetime.
cover provided in Part (a) of the Policy:
7. Travel Expenses for Medical Treatment: The Company
1. Cover for Pre-Existing Diseases: By way of this add-on,
will reimburse the travel expense incurred outside the city of
Pre-existing Diseases shall be covered after 1 year (or as
residence at a nearest place as prescribed by treating Medical
stated in Part (a) of the Policy).
Practitioner wherein the treatment is not possible in his place.
For the purpose of avoidance of doubt, it is to clarified that,
8. Dental Expenses: The Company will reimburse the
The term 'Pre-existing Disease' means any condition, ailment medical expenses related to dental treatment incurred by the
or injury or disease Insured during the Policy Period.
a. diagnose by physician within 48 month prior to the 9. Cover for Alternate Methods of Treatment: By way of this
effective date of the policy issued by insurer or its add-on, the Company will reimburse the Insured for medical
reinstatement or expenses incurred on homeopathic, Ayurvedic, Siddha,
Unani, Acupressure, Acupuncture, Yoga and Naturopathy
b. For which medical advice or treatment was treatment provided that such treatment is administered by
recommended by, or received from, a physician within 48 medical practitioner.
month prior to the effective date of the policy issued by the
insurer or its reinstatement 10. Donor Expenses: The Company will indemnify the
Insured for the medical expenses incurred in respect of donor
2. Maternity Expenses: This add-on provides cover for for any of the organ transplant surgery during the Policy
medical expenses incurred for delivery, during hospitalization Period, provided the organ donated is for Insured's use and
or lawful medical termination of pregnancy during the Policy the claim is considered admissible by the Company.
Period This coverage may be offered with or without any
waiting period. The cover also extends to provide child birth 11. Ambulance Charges: Ambulance charges would include
related expenses up to a specified limit and pre-post natal transportation cost to the nearest hospital in case of life
expenses as specifically stated in Part (a) of the Policy. threatening emergency conditions.
Provided that-
12. Pre and Post Hospitalization: By way of this add-on, the
a) The cover under this add-on shall be available after 9 Company will pay medical expenses incurred 30 days prior to
months (or as stated in Part (a) of the Policy) of continuous hospitalization and 60 days after hospitalization or as stated
coverage have elapsed since the inception of the first in Part (a) of the Policy.
Policy with the Company
13. Health Check-Up: The Company by way of this add-on,
b) Expenses incurred in connection with voluntary medical will cover the cost of health check-up incurred by the Insured
termination of pregnancy during the first 12 weeks from the for medical examination undergone being a requirement from
date of conception are not covered. employer. Such medical examination is generally conducted
to understand health status of the employee.
3. Out Patient Department (OPD) Expenses: The
Company will reimburse medical expenses incurred by the
Insured as an Outpatient.

14. Disease-Wise Sub-Limit: By way of this add- on, the  Disease Management Programs: Eg Diabetes,
company can introduce sub-limits on certain diseases based Healthy Heart, Stress Management etc
on the claim experience and the requirement of the Insured.  Lifestyle/Wellness Management Programs: Eg
Maternity, Quit Smoking PHR - Personalized
15. Domiciliary Hospitalization: The Company will reimburse Health Records Health Assistance Services :
the Insured for medical expenses incurred by the Insured Opinions - Doctor on call/home - Ambulance-
during domiciliary hospitalization. Health tools
16. Treatment Outside India (along with traveling cost &  Health & Wellness Reminder Services Health
boarding & lodging of the attendant): This add-on covers the Concierge Desk
cost of medical treatment along with the travelling cost and  Others
cost pertaining to boarding and lodging of the cost and cost
pertaining to boarding and lodging of the attendant in a
country outside India when required and prescribed by e. EXCLUSION
treating Medical Practitioner. The Company shall not be liable to make any payment under this
17. Convalescence Benefit: The Company will pay the policy in connection with or in respect of any expenses
Insured up to a certain amount as stated in Part (a) of the whatsoever incurred by any Insured Person in connection with or
Policy if the Insured is hospitalized for a minimum period of in respect of:
consecutive days as specified in Part (a) of the Policy, due to
any injury or illness as covered under the Policy. This benefit i. Standard exclusions for which standard wordings
is payable only once to an Insured person during the Policy are specified by IRDAI
period.
A. Pre-Existing Diseases - Code- Excl01
18. Loss of wages/salary due to hospitalization (Hospital
Daily Cash Allowance): The Company will pay the Insured a a) Expenses related to the treatment of a pre-existing Disease
fixed amount for each day of his hospitalization to compensate (PED) and its direct complications shall be excluded until the
against the loss of wage/salary incurred by Insured on account expiry of 48 months of continuous coverage after the date of
of hospitalization. inception of the first policy with insurer.
19. Cover for allied hospital charges: By way of this add-on, b) In case of enhancement of sum insured the exclusion shall
Company will reimburse either one or combinations of the apply afresh to the extent of sum insured increase.
expenses incurred on the allied hospital charges such as
ambulance charges, administration charges, service charges c) If the Insured Person is continuously covered without any break
and miscellaneous charges, boarding/lodging charges, as defined under the portability norms of the extant IRDAI (Health
including transportation costs of machine/medical instruments Insurance) Regulations, then waiting period for the same would
of any special medical team to the city of the insured or any be reduced to the extent of prior coverage.
such other charges wherever prescribed by medical
practitioner. d) Coverage under the policy after the expiry of 48 months for any
pre-existing disease is subject to the same being declared at the
20. Limit on room rent, nursing charges, consultation fees, time of application and accepted by Insurer.
diagnostic charges, OT charges etc.: This add-on restricts the
coverage for respective heads up to a specified amount. In B. Specific disease/procedure waiting period- Code-Excl02
cases, where the claim amount exceeds this amount, the a) Expenses related to the treatment of the listed Conditions,
entire admissible claim amount which includes various surgeries/treatments shall be excluded until the expiry of 12
hospital bills etc, will be reduced in the proportion which the months of continuous coverage after the date of inception of the
eligible room rent limit bears to the actual room rent. first policy with us. This exclusion
21. Wellness & Preventive Care: By way of this add-on the shall not be applicable for claims arising due to an accident.
insured can avail any or all of the below mentioned:
b) In case of enhancement of sum insured the exclusion shall
 Health Risk Assessment apply afresh to the extent of sum insured increase.
 Health Check-up's (add-on of report evaluation
service) c) If any of the specified disease/procedure falls under the waiting
 Medical Centre Management Diet & Nutrition Plans period specified for pre-Existing diseases, then the longer of the
 Online Doctor Chat two waiting periods shall apply.
 Health Camps - on campus Expert Sessions - on
d) The waiting period for listed conditions shall apply even if
campus
contracted after the policy or declared and accepted without a
 Second Opinions: Domestic and International
specific exclusion.
markets
 Discounted offerings - on health and wellness e) If the Insured Person is continuously covered without any break
services ( Eg Gyms, Diagnostic Canters, as defined under the applicable norms on portability stipulated by
Medicines, Beauty clinics etc) IRDAI, then waiting period for the same would be reduced to the
extent of prior coverage.

f) List of specific diseases/procedures G. Gender treatments: Code- Excl07
Cataract, Benign Prostatic Hypertrophy, Hysterectomy for Expenses related to any treatment, including surgical
Menorrhagia or Fibromyoma, Hernia, Hydrocele, Congenital management, to change characteristics of the body to those of
Internal Diseases, Fistula in anus, piles, Sinusitis and related the opposite sex.
disorders
H. Cosmetic or plastic Surgery: Code-Excl08
C.30-day waiting period- Code- Excl03
Expenses for cosmetic or plastic surgery or any treatment to
a) Expenses related to the treatment of any illness within 30 change appearance unless for reconstruction following an
days from the first policy commencement date shall be Accident, Burn(s) or Cancer or as part of medically necessary
excluded except claims arising due to an accident, provided treatment to remove a direct and immediate health risk to the
the same are covered. insured. For this to be considered a medical necessity, it must
be certified by the attending Medical Practitioner.
b) This exclusion shall not, however, apply if the Insured Person
has Continuous Coverage for more than twelve months. I. Hazardous or Adventure sports: Code- Excl09
c) The within referred waiting period is made applicable to the Expenses related to any treatment necessitated due to
enhanced sum insured in the event of granting higher sum participation as a professional in hazardous or adventure sports,
insured subsequently. including but not limited to, para-jumping, rock climbing,
mountaineering, rafting, motor racing, horse racing or scuba
D. Investigation & Evaluation- Code- Excl04 diving, hand gliding, sky diving, deep-sea diving.
a) Expenses related to any admission primarily for diagnostics J. Breach of law: Code- Excl10
and evaluation purposes only are excluded.
Expenses for treatment directly arising from or consequent upon
b) Any diagnostic expenses which are not related or not any Insured Person committing or attempting to commit a
incidental to the current diagnosis and treatment are excluded. breach of law with criminal intent.
E. Rest Cure, rehabilitation and respite care- Code- Excl05 K. Excluded Providers: Code- Excl11
a) Expenses related to any admission primarily for enforced Expenses incurred towards treatment in any hospital or by any
bed rest and not for receiving treatment. This also includes: Medical Practitioner or any other provider specifically excluded by
the Insurer and disclosed in its website / notified to the
I. Custodial care either at home or in a nursing facility for
policyholders are not admissible. However, in case of life
personal care such as help with activities of daily living such
threatening situations or following an accident, expenses up to the
as bathing, dressing, moving around either by skilled nurses
stage of stabilization are payable but not the complete claim
or assistant or non-skilled persons.
L. Treatment for, Alcoholism, drug or substance abuse or any
II. Any services for people who are terminally ill to address
addictive condition and consequences thereof. Code- Excl12
physical, social, emotional and spiritual needs.
M. Treatments received in heath hydros, nature cure clinics, spas
F. Obesity/ Weight Control: Code- Excl06
or similar establishments or private beds registered as a nursing
Expenses related to the surgical treatment of obesity that does home attached to such establishments or where admission is
not fulfil all the below conditions: arranged wholly or partly for domestic reasons. Code- Excl13
1) Surgery to be conducted is upon the advice of the Doctor N. Dietary supplements and substances that can be purchased
without prescription, including but not limited to Vitamins, minerals
2) The surgery/Procedure conducted should be supported by and organic substances unless prescribed by a medical
clinical protocols practitioner as part of hospitalization claim or day care procedure.
Code- Excl14
3) The member has to be 18 years of age or older and
O. Refractive Error: Code- Excl15
4) Body Mass Index (BMI);
Expenses related to the treatment for correction of eye sight due
a) greater than or equal to 40 or
to refractive error less than 7.5 dioptres.
b) greater than or equal to 35 in conjunction with any of the
P. Unproven Treatments: Code- Excl16
following severe co- morbidities following failure of less
invasive methods of weight loss: Expenses related to any unproven treatment, services and
supplies for or in connection with any treatment. Unproven
i. Obesity-related cardiomyopathy
treatments are treatments, procedures or supplies that lack
ii. Coronary heart disease significant medical documentation to support their effectiveness.
iii. Severe Sleep Apnea Q. Sterility and Infertility: Code- Excl17
iv. Uncontrolled Type2 Diabetes Expenses related to sterility and infertility. This includes:

(i)Any type of contraception, sterilization foreign enemy, war like operations (whether war be declared or
not).
(ii)Assisted Reproduction services including artificial insemination
and advanced reproductive technologies If any Add-On has been opted as mentioned in Part (a) of the
Policy, then the respective Exclusion as mentioned above will not
such as IVF, ZIFT, GIFT, ICSI be applicable
(iii)Gestational Surrogacy f. . General Terms and Clauses
(iv)Reversal of sterilization Standard General Terms and Clauses (General Terms and
clauses whose wordings are specified by IRDAI)
R. Maternity: Code Excl18
1. Claim Settlement (provision for Penal Interest)
i. Medical treatment expenses traceable to childbirth (including
complicated deliveries and caesarean sections (i)The Company shall settle or reject a claim, as the case may
be, within 30 days from the date of receipt of last necessary
incurred during hospitalization) except ectopic pregnancy;
document.
ii. Expenses towards miscarriage (unless due to an accident) and
(ii)In the case of delay in the payment of a claim, the Company
lawful medical termination of pregnancy
shall be liable to pay interest to the policyholder from the date
during the policy period of receipt of last necessary document to the date of payment of
claim at a rate 2% above the bank rate.
ii. Specific Exclusions other than those mentioned under e (i)
above (iii)However, where the circumstances of a claim warrant an
investigation in the opinion of the Company, it shall initiate and
1. Circumcision whether or not necessitated by vaccination or complete such investigation at the earliest, in any case not later
inoculation or change of life or cosmetic or aesthetic treatment of than 30 days from the date of receipt of last necessary
any description, plastic surgery unless necessary for treatment of document- ln such cases, the Company shall settle or reject the
a disease not excluded by the terms of the policy or as may be claim within 45 days from the date of receipt of last necessary
necessitated due to treatment of an accident. document.
2. The cost of spectacles and contact lenses, hearing aids. (iv)ln case of delay beyond stipulated 45 days, the Company
shall be liable to pay interest to the policyholder at a rate 2%
3. Dental treatment or surgery of any kind unless requiring
above the bank rate from the date of receipt of last necessary
hospitalization.
document to the date of payment of claim. Interest provision
4. Convalescence, general debility, run-down condition or rest shall be as per IRDAI (Protection of Policyholders’ Interests)
cure, congenital external disease or defects or anomalies, Regulations, 2017 or any amendments made thereto from time
intentional self-injury (whether arising from an attempt to suicide to time.
or otherwise) and use of intoxicating drugs and/or alcohol.
2. LIMITATION PERIOD
5. Charges incurred at Hospital or Nursing Home primarily for In no case whatsoever shall the Company be liable for any claim
diagnostic, X-Ray or laboratory examinations or other diagnostic under the Policy, if the requirement of Clause V (1) (b) (iii) (b)
studies not consistent with or incidental to the diagnosis and above are not complied with, unless the claim is the subject of
treatment of the positive existence or presence of any diseases pending action or arbitration; it being expressly agreed and
illness or injury whether or not requiring declared that if the Company shall disclaim liability for any claim
Hospitalization/Domiciliary Hospitalization. hereunder and such claim shall not within 12 calendar months
from the date of the disclaimer have been made the subject matter
6. Expenses on vitamins and tonics unless forming part of
of a suit in court of law then the claim shall for all purposes be
treatment for injury or disease as certified by the attending
deemed to have been abandoned and shall not thereafter be
Medical Practitioner.
recoverable hereunder.
7. Diseases, illness, accident or injuries directly or indirectly
3. Condition Precedent to Admission of Liability
caused by or contributed to by nuclear weapons/materials or
contributed to by or arising from ionising radiation or The terms and conditions of the policy must be fulfilled by the
contamination by radioactivity by any nuclear fuel or from any insured person for the Company to make any payment for claim(s)
nuclear waste or from the combustion of nuclear fuel. arising under the policy
8. Voluntary medical termination of pregnancy during the first 12 4. Complete Discharge
weeks from the date of conception.
Any payment to the policyholder, insured person or his/ her
9. Naturopathy treatment nominees or his/ her legal representative or assignee or to the
Hospital, as the case may be, for any benefit under the policy shall
10.Diseases, illness, accident or injuries directly or indirectly
be a valid discharge towards payment of claim by the Company
caused by or arising from or attributable to war, invasion, act of
to the extent of that amount for the particular claim.

5. POLICY RELATED TERMS AND CONDITIONS 7. Possibility of Revision of Terms of the Policy including the
Premium Rates- the Company, with prior approval of IRDAI, may
a) Claim must be filed within 30 days from the date of completion revise or modify the terms of the policy including the premium
of treatment. However, the Company may at its discretion rates. The insured person shall be notified three months before
consider waiver based on merits of the claim, where there is the changes are effected.
delay in intimation or in submission of documents due to
unavoidable circumstances and it is proved that the delay was 8. Incontestability and Duty of Disclosure
for reasons beyond the control of the insured and under the
The policy shall be null and void and no benefit shall be payable
circumstances in which the insured was placed it was not
in the event of untrue or incorrect statements,
possible for him or any other person to give such notice or file
misrepresentation, misdescription or on non-disclosure in any
claim within the prescribed time-limit.
material particular in the proposal form, personal statement,
b) The Insured Person shall obtain and furnish the Company declaration and connected documents, or any material
with all original bills, receipts and other documents upon which information having been withheld, or a claim being fraudulent or
a claim is based and shall also give the Company such any fraudulent means or devices being used by the Insured or
additional information and assistance as the Company may any one acting on his behalf to obtain any benefit under this
require in dealing with the claim. policy.
c) Any medical practitioner authorised by the Company shall be 9. Observance of terms and conditions
allowed to examine the Insured Person in case of any alleged
The due observance and fulfilment of the terms, conditions and
diseases, illness, accident or injuries requiring Hospitalisation or
endorsement of this policy in so far as they relate to anything to
Domiciliary Hospitalisation when and so often as the same may
be done or complied with by the Insured, shall be a condition
reasonably be required on behalf of the Company.
precedent to any liability of the Company to make any payment
d) All medical/surgical treatment under this policy shall have to under this policy.
be taken in India (unless agreed upon in Part (a) of the Policy)
10. No constructive Notice
and admissible claims thereof shall be payable in Indian
currency. Any of the circumstances in relation to these conditions coming
to the knowledge of any official of the Company shall not be the
e)Low Claim Ratio Discount (Bonus): Low Claim Ratio Discount
notice to or be held to bind or prejudicially affect the Company
will be allowed on the total premium at renewal depending upon
notwithstanding subsequent acceptance of any premium.
the incurred claims ratio for the entire group insured under the
Group Mediclaim Insurance Policy as mutually agreed by the 11. Notice of Charge etc.
insured and the insurer.
The Company shall not be bound to notice or be affected by any
f)High Claim Ratio loading (Malus): The Total Premium payable notice of any trust, charge, lien, assignment or other dealing
at renewal of the Group Policy will be loaded depending upon with or relating to this policy but the receipt of the Insured or his
the incurred claims ratio for the entire group insured under the legal personal representative shall in all cases be an effectual
Group Mediclaim Insurance Policy as mutually agreed by the discharge to the company.
insured and the insurer.
12. Special Provisions
Note: Incurred claim would mean claims paid, claims
outstanding and claims incurred but not reported (IBNR) in Any special provisions subject to which this policy has been
respect of the entire group insured under the policy during the entered into and endorsed in the policy or in any separate
relevant period. instrument shall be deemed to be part of this policy and shall
have effect accordingly.
6. TERMS OF RENEWAL
13. Overriding effect of Part (c to g) of the Policy
a)The Policy can be renewed as a separate contract under the
then prevailing ICICI Lombard Group Health Insurance product The terms and conditions contained herein and in Part (c to g)
or its nearest substitute (in case the product ICICI Lombard of the Policy shall be deemed to form part of the policy and shall
Group Health Insurance is withdrawn by the Company) be read as if they are specifically incorporated herein; however
approved by IRDA. in case of any inconsistency of any term and condition with the
scope of cover contained in Part (c to g) of the Policy, then the
b) The policy shall ordinarily be renewable except on grounds term(s) and condition(s) contained herein shall be read mutatis
of fraud, moral hazard or misrepresentation or non- cooperation mutandis with the scope of cover/terms and conditions
by the insured. contained in Part (c to g) of the Policy and shall be deemed to
c) The policy could be subject to certain changes in terms and be modified accordingly or superseded in case of inconsistency
conditions including change in premium rate. being irreconcilable. In case of any inconsistency in terms and
conditions mentioned in Part (c to g) of the Policy with Part (a)
Possibility of Revision of Terms of the Policy including the of the Policy then terms and conditions contained in Part (a) of
Premium Rates- the Company, with prior approval of lRDAl, the Policy will prevail over Part (c to g) of the Policy.
may revise or modify the terms of the policy including the
premium rates. The insured person shall be notified three 14. Electronic Transactions
months before the changes are effected.

The Insured agrees to adhere to and comply with all such terms Short Period Scales- Policy Cancellation*
and conditions as the Company may prescribe from time to
time, and hereby agrees and confirms that all transactions Covered Upto Days % of Refund
effected by or through facilities for conducting remote 7 Up to 90%
transactions including the Internet, World Wide Web, electronic
30 Up to 75%
data interchange, call canters, teleservice operations (whether
voice, video, data or combination thereof) or by means of 60 Up to 65%
electronic, computer, automated machines network or through
90 Up to 50%
other means of telecommunication, established by or on behalf
of the Company, for and in respect of the policy or its terms, or 120 Up to 40%
the Company's other products and services, shall constitute 180 Up to 25%
legally binding and valid transactions when done in adherence
to and in compliance with the Company's terms and conditions 240 Up to 15%
for such facilities, as may be prescribed from time to time. The Exceeding 240 Up to 0%
Insured agrees that the Company may exchange, share or part
with any information to or with other ICICI Group Companies or
Notwithstanding anything contained herein or otherwise, no
any other person in connection with the Policy, as may be
refunds of premium shall be made in respect of Cancellation
determined by the Company and shall not hold the Company
where, any claim has been admitted or has been lodged or
liable for such use/application.
any benefit has been availed by the Insured person under the
15. Fraud Policy.
b. The Company may cancel the Policy at any time on
If any claim made by the insured person, is in any respect
grounds of misrepresentation, non-disclosure of material
fraudulent, or if any false statement, or declaration is made or
facts, fraud by the Insured Person, by giving 15 days' written
used in support thereof, or if any fraudulent means or devices
notice. There would be no refund of premium on cancellation
are used by the insured person or anyone acting on his/her
on grounds of misrepresentation, non-disclosure of material
behalf to obtain any benefit under this policy, all benefits under
facts or fraud.
this policy shall be forfeited. Any amount already paid against
claims which are found fraudulent later under this policy shall be 17. Portability
repaid by all person(s) named in the policy schedule, who shall
be jointly and severally liable for such repayment. For the The Insured Person will have the option to port the Policy to
purpose of this clause, the expression "fraud" means any of the other insurers as per extant Guidelines related to portability. If
following acts committed by the Insured Person or by his agent, such person is presently covered and has been continuously
with intent to deceive the insurer or to induce the insurer to issue covered without any lapses under any health insurance plan
a insurance Policy:- with an Indian General/Health insurer as per Guidelines on
portability, the proposed Insured Person will get all the accrued
a. the suggestion ,as a fact of that which is not true and which continuity benefits in waiting periods as under:
the Insured Person does not believe to be true;
i. The waiting periods specified in Section 6 shall be
b. the active concealment of a fact by the Insured Person reduced by the number of continuous preceding years of
having knowledge or belief of the fact; coverage of the Insured Person under the previous health
c. any other act fitted to deceive; and insurance Policy.
d.any such act or omission as the law specially declares to be ii. Portability benefit will be offered to the extent of sum of
fraudulent previous sum insured and accrued bonus (as part of the base
sum insured), portability benefit shall not apply to any other
The company shall not repudiate the policy on the ground of additional increased Sum Insured.
fraud, if the insured person / beneficiary can prove that the
misstatement was true to the best of his knowledge and there For Detailed Guidelines on Portability, kindly refer the link
was no deliberate intention to suppress the fact or that such mis-
statement of or suppression of material fact are within the https://www.irdai.gov.in/ADMINCMS/cms/frmGuidelines_La
knowledge of the insurer. Onus of disproving is upon the yout.aspx?page=PageNo3987
policyholder, if alive, or beneficiaries.
16. Cancellation 18. Migration:
a. The Insured may cancel this Policy by giving 15days' The Insured Person will have the option to migrate the Policy to
written notice, and in such an event, the Company shall refund other health insurance products/plans offered by the company
premium on short term rates for the unexpired Policy Period as per extant Guidelines related to Migration. If such person is
as per the rates detailed below. presently covered and has been continuously covered without
any lapses under any health insurance product/plan offered by
the company, as per Guidelines on migration, the proposed
Insured Person will get all the accrued continuity benefits in
waiting periods as per below:

i. The waiting periods specified in Section 6 shall be v. In case of instalment premium due not received within
reduced by the number of continuous preceding years of the grace Period, the Policy will get cancelled.
coverage of the Insured Person under the previous health
insurance Policy. 21. Free Look Period-
ii. Migration benefit will be offered to the extent of sum of The Free Look Period shall be applicable on new individual
previous sum insured and accrued bonus/multiplier benefit (as health insurance policies and not on renewals or at the time of
part of the base sum insured), migration benefit shall not apply porting/migrating the policy. The insured person shall be
to any other additional increased Sum Insured. allowed free look period of fifteen days from date of receipt of
the policy document to review the terms and conditions of the
For Detailed Guidelines on Migration, kindly refer the link policy, and to return the same if not acceptable. lf the insured
has not made any claim during the Free Look Period, the
https://www.irdai.gov.in/ADMINCMS/cms/frmGuidelines_Layout.as insured shall be entitled to
px?page=PageNo3987
i. a refund of the premium paid less any expenses incurred
19. Multiple Policies- by the Company on medical examination of the insured
person and the stamp duty charges or
i. in case of multiple policies taken by an insured person
during a period from one or more insurers to indemnify ii. Where the risk has already commenced and the option
treatment costs, the insured person shall have the right to of return of the policy is exercised by the insured person, a
require a settlement of his/her claim in terms of any of his/her deduction towards the proportionate risk premium for period
policies. In all such cases the insurer chosen by the insured of cover or
person shall be obliged to settle the claim as long as the claim
iii. Where only a part of the insurance coverage has
is within the limits of and according to the terms of the chosen
commenced, such proportionate premium commensurate with
policy.
the insurance coverage during such period
ii. insured person having multiple policies shall also have Policies would however be subject to all limits, sub limits, co-
the right to prefer claims under this policy for the amounts payments as per the policy.
disallowed under any other policy / policies even if the sum
insured is not exhausted. Then the insurer shall independently 22. Arbitration Clause
settle the claim subject to the terms and conditions of this
policy. If any dispute or difference shall arise as to the quantum to be
paid under this policy (liability being otherwise admitted) such
iii. lf the amount to be claimed exceeds the sum insured difference shall independently of all other questions be referred
under a single policy, the insured person shall have the right to the decision of a sole arbitrator to be appointed in writing by
to choose insurer from whom he/she wants to claim the the parties to the dispute/difference or if they cannot agree upon
balance amount. a single arbitrator within 30 days of any party invoking
arbitration, the same shall be referred to a panel of three
iv. Where an insured person has policies from more than arbitrators, comprising of two arbitrators, one to be appointed by
one insurer to cover the same risk on indemnity basis, the each of the parties to the dispute/difference and the third
insured person shall only be indemnified the treatment costs arbitrator to be appointed by such two arbitrators. Arbitration
in accordance with the terms and conditions of the chosen shall be conducted under and in accordance with the provisions
policy. of the Arbitration and Conciliation Act, 1996.
20. Premium Payment in Instalments: It is clearly agreed and understood that no difference or dispute
If the insured person has opted for Payment of Premium on an shall be preferable to arbitration, as herein before provided, if
instalment basis i.e. Half Yearly, Quarterly or Monthly, as the Company has disputed or not accepted liability under or in
mentioned in Your Policy Schedule/Certificate of Insurance, the respect of this policy.
following Conditions shall apply (notwithstanding any terms It is hereby expressly stipulated and declared that it shall be a
contrary elsewhere in the Policy) condition precedent to any right of action or suit upon this policy
i. Grace Period of 15 days would be given to pay the that the award by such arbitrator/ arbitrators of the amount of
instalment premium due for the Policy. the loss or damage shall be first obtained.
23. Renewal Notice

ii. During such grace period, Coverage will not be available
from the instalment premium payment due date till the date a) The policy shall ordinarily be renewable except on
of receipt of premium by Company. misrepresentation by the insured person on grounds of fraud,
iii. The Benefits provided under - "Waiting Periods", The Company shall endeavour to give notice for renewal.
"Specific Waiting Periods" Sections shall continue in the However, the Company is not under obligation to give any
event of payment of premium within the stipulated grace notice for renewal. Renewal shall not be denied on the ground
Period. that the insured person had made a claim or claims in the
preceding policy years. Request for renewal along with
iv. No interest will be charged If the instalment premium is requisite premium shall be received by the Company before
not paid on due date. the end of the policy period. At the end of the policy period,

the policy shall terminate and can be renewed within the Insured Person shall contract any disease or suffer from Any One
Grace Period of 30 days to maintain continuity of benefits Illness or sustain any bodily injury through accident, and if such
without break in policy. Coverage is not available during the disease, illness, accident or injury shall require any such Insured
grace period. No loading shall apply on renewals based on Person, upon the advice of a Medical Practitioner to incur
individual claims experience Hospitalisation or Domiciliary Hospitalisation expenses or
Outpatient department expenses as stated in Part (a) of the
b) The policy may be renewed by mutual consent and in Policy, the Company will pay to the Insured Person, the amount
such event the renewal premium shall be paid to the Company of such expenses as are reasonably and necessarily incurred
on or before the date of expiry of the previous year policy and thereof, by or on behalf of such Insured Person but not exceeding
in no case later than Grace Period of 30 days from the expiry the sum insured for the person as mentioned in the Part (a) of the
of the Policy However, risk coverage shall not be available for Policy hereto, to the extent and the manner hereinafter provided.
such a period. The Company would be liable for the add-on coverage's
mentioned in Part (a) of the Policy only if the Insured purchases
24. Moratorium Period
the same in terms of the policy.
After completion of eight continuous years under the policy no 2. CLAIM ADMINISTRATION
look back to be applied. This period of eight years is called as
moratorium period. The moratorium would be applicable for the The fulfilment of the terms and conditions of this Policy (including
sums insured of the first policy and subsequently completion of 8 payment of premium by the due dates mentioned in the Policy
continuous years would be applicable from date of enhancement
Schedule) insofar as they relate to anything to be done or
of sums insured only on the enhanced limits. After the expiry of
complied with by each of the insured shall be conditions
Moratorium Period no health insurance claim shall be contestable
except for proven fraud and permanent exclusions specified in the precedent to admission of the Company's liability. Further, upon
policy contract. The policies would however be subject to all limits, the discovery or happening of any Illness or Injury that may give
sub limits, co-payments, deductibles as per the policy contract. rise to a Claim under this Policy, then as a condition precedent to
The policies would however be subject to all limits, sub limits, co- the admission of the Company's liability, the insured shall
payments as per the policy. undertake the following:
25. Policy Disputes 1. Claims Procedure
a. For Cashless Settlement

Any dispute concerning the interpretation of the terms,
conditions, limitations and/or exclusions contained herein is Cashless treatment is only available at a Network Provider (List
understood and agreed to by both the Insured and the Company of Network Providers is available at our website). In order to
to be subject to Indian Law. Each party agrees to submit to the avail of cashless treatment, the following procedure must be
jurisdiction of the Courts in India and to comply with all followed by the insured:
requirements necessary to give such Court the jurisdiction. All
matters arising hereunder shall be determined in accordance with Pre-authorization
the law and practice of such Court.
Prior to taking treatment and/or incurring Medical Expenses at
26. Cause of Action/ Currency for Payments a Network Provider, the insured must contact the company or
the TPA accompanied with full particulars namely,
No Claims shall be payable under this policy unless the cause of
action arises in India, unless otherwise specifically provided in i. Policy Number,
Part (c to g) of the Schedule to this policy. All claims shall be
payable in India in Indian Rupees only. ii. Name of the insured,
iii. Your relationship with Policy Holder,

27. Withdrawal of Policy-
iv. Nature of Illness or Injury, name and
In the likelihood of this product being withdrawn in future, the
v. address of the Medical Practitioner/Hospital and any other
Company will intimate the insured person about the same 90
days prior to expiry of the policy. Insured Person will have the information that may be relevant to the Illness/ Injury/
option to migrate to similar health insurance product available Hospitalization.
with the Company at the time of renewal with all the accrued
Request for pre- authorisation should be received at least 48
continuity benefits such as cumulative bonus, waiver of waiting
period. As per IRDAI guidelines, provided the policy has been hours before a planned Hospitalization and in case of an
maintained without a break. emergency situation, within 24 hours of Hospitalization. To avail
of Cashless Hospitalization facility, the insured is required to
produce the health card, as provided to him/her with this Policy,
g. Other terms & conditions: subject to the terms and conditions for the usage of the said
1. SCOPE OF COVER health card. The request of insured shall be considered after
having obtained accurate and complete information for the
The Company hereby agrees subject to the terms, conditions and Illness or Injury for which cashless hospitalization facility is
exclusions herein contained or otherwise expressed herein, that, sought by the insured and the Company will confirm the request
if during the policy period stated in Part (a) of the Policy, any in writing.

b. For Reimbursement Settlement b. Claim documents:
(i) All claims have to be intimated 48 hours prior to The Insured shall be required to furnish the following for or in
hospitalization or within 24 hours post admission in case of support of a claim:
emergency for prompt settlement of claims.
(i) Duly completed claim form signed by the insured
(ii) The insured shall give notice to the TPA by calling the
toll free number as specified in the Policy provided to the (ii) Original bills, receipts and discharge certificate/card from
insured and also in writing at the Company's address with the Hospital
particulars as below:
(iii) Original bills from Chemists supported by proper
 Policy number; prescription
 Name of the insured; (iv) Original investigation test reports and payment receipts
 Relationship of the proposer with the Policyholder;
 Nature of Illness or Injury; (iv) Indoor case papers
 Name and address of the attending Medical
(v) Medical Practitioner's referral letter advising
Practitioner and the Hospital;
Hospitalization in non-Accident cases
 Any other information that may be relevant to the
Illness / Injury/Hospitalisation (vi) Account details for Electronic Fund Transfer (EFT
mandate form and cancelled cheque)
(iii) The procedure for lodging the claim shall be as under:
(viii) Any other document as required by the Company or the
Upon the happening of any event giving rise or likely to give TPA to investigate the Claim or the Company's
rise to a claim under this policy: obligation to make payment for it.
a) The Insured shall give immediate notice thereof in 3. Notices
writing to the Company.
Any notice, direction or instruction given under this policy shall
b) The Insured shall deliver to the Company, within 30 days be in writing to:
from the date of completion of treatment, a detailed
statement in writing as per the claim form together with bills,  In case of the Insured, at the address specified in Part
vouchers and any other material particular, relevant to the (a) of the Policy.
making of such claim.  In case of the Company:
c) The Insured shall tender to the Company all reasonable ICICI Lombard General Insurance Company Limited ICICI
information, assistance and proofs in connection with any Lombard House, 414, Veer Savarkar Marg, Near Siddhi
claim hereunder. Vinayak Temple,Prabhadevi, Mumbai 400025
2. Basis of assessment of claims Notice and instructions will be deemed served 7 days after
posting or immediately upon receipt in the case of hand delivery
a) Basis of assessment of the claim shall be as under: or e-mail.
The benefit payable shall be such expenses reasonably and 4. Customer Service
necessarily incurred by or on behalf of the Insured Person
under the following categories but not exceeding the Sum If at any time the Insured requires any clarification or assistance,
Insured in respect of such Insured person as specified in Part the Insured may contact the offices of the Company at the
(a) of the Policy. address specified, during normal business hours.
Heads of compensation payable: 5. Redressal of Grievance-
(i) Room and Boarding Expenses as incurred at the In case of any grievance, the insured person may contact the
Hospital/ Nursing Home; company through Website: www.icicilombard.com
(ii) Nursing Expenses; Toll Free: 1800 2666
(iii) Fee paid to Medical Practitioner, Surgeon, E-Mail: "[email protected]"

Anaesthetics, Consultants and Specialist
Courier: ICICI Lombard General Insurance Company Limited.
(iv) Anaesthesia, Blood, Oxygen, Operation Theatre
Charges, Surgical Appliances, Medicines & drugs, ICICI Lombard House, 414, Veer Savarkar Marg,
Diagnostic Materials and X - Ray, Dialysis, chemotherapy,
Near Siddhi Vinayak Temple, Prabhadevi,Mumbai- 400025.
Radiotherapy, Cost of Pacemaker, Artificial Limbs & Cost of
Organs and similar expenses; and /or insured person may also approach the grievance cell at any of
the company's branches with the details of grievance lf insured
(v) Pre Hospitalisation and Post Hospitalisation expenses,
person is not satisfied with the redressal of grievance through
wherever applicable.

one of the above methods, insured person may contact the Near New Market,
grievance officer at Manager- Service Quality, Bhopal – 462 003.
Tel.: 0755 - 2769201 / 2769202
Corporate Manager- Service Quality, National Manager- Fax: 0755 - 2769203
Operations & finally Director-services and Business Email:
development at the following address: [email protected]
4 BHUBANESHWAR - Shri Orissa.
ICICI Lombard General Insurance Company Limited, ICICI Suresh Chandra Panda
Lombard House, 414, Veer Savarkar Marg, Near Siddhi Office of the Insurance
Vinayak Temple, Prabhadevi, Mumbai- 400025 Ombudsman,
62, Forest park,
For updated details of grievance officer, kindly refer the link: Bhubneshwar – 751 009.
https://www.icicilombard.com/grievance-redressal Tel.: 0674 - 2596461 /2596455
Fax: 0674 - 2596429
If insured person is not satisfied with the redressal of grievance
Email:
through above methods, the insured person may also approach bimalokpal.bhubaneswar@cioins
the office of insurance Ombudsman of the respective area/region .co.in
for redressal of grievance as per insurance Ombudsman Rules 5 CHANDIGARH - Mr. Atul Punjab,
2017. Jerath Haryana,
Office of the Insurance Himachal
Grievance may also be lodged at IRDAI integrated Grievance Pradesh,
Ombudsman,
Management System Jammu &
S.C.O. No. 101, 102 & 103, 2nd
Floor, Kashmir,
- https:/ligms. irda.qov. in/
Batra Building, Sector 17 – D, Chandigarh.
If the issue still remains unresolved, the insured may, subject to Chandigarh – 160 017.
vested jurisdiction, approach Insurance Ombudsman for the Tel.: 0172 - 2706196 / 2706468
redressal of the grievance. Fax: 0172 - 2708274
Email:
The details of Insurance Ombudsman are available below:- [email protected]
o.in
S Name of office of insurance Territorial Area of 6 CHENNAI - Shri M. Vasantha Tamil Nadu,
no Ombudsman jurisdiction Krishna Pondicherry Town
. Office of the Insurance and
1 AHMEDABAD - Shri Kuldip Gujarat, Dadra & Ombudsman, Karaikal (which
Singh Nagar Haveli, Fatima Akhtar Court, 4th Floor, are part of
Office of the Insurance Daman and Diu. 453, Pondicherry).
Ombudsman, Jeevan Prakash Anna Salai, Teynampet,
Building, 6th floor, CHENNAI – 600 018.
Tilak Marg, Relief Road, Tel.: 044 - 24333668 / 24335284
Ahmedabad – 380 001. Tel.: 079 Fax: 044 - 24333664
- 25501201/02/05/06 Email:
Email: [email protected]
[email protected] 7 DELHI - Shri Sudhir Krishna Delhi
o.in Office of the Insurance
2 BENGALURU - - Mr. Vipin Karnataka Ombudsman,
Anand 2/2 A, Universal Insurance
Office of the Insurance Building,
Ombudsman, Asaf Ali Road,
Jeevan Soudha Building,PID No. New Delhi – 110 002.
57-27- Tel.: 011 - 23232481/23213504
N-19 Email:
Ground Floor, 19/19, 24th Main [email protected]
Road, 8 GUWAHATI - Shri Somnath Assam,
JP Nagar, Ist Phase, Ghosh Meghalaya,
Bengaluru – 560 078. Office of the Insurance Manipur,
Tel.: 080 - 26652048 / 26652049 Ombudsman, Mizoram,
Email: Jeevan Nivesh, 5th Floor, Arunachal
[email protected]. Nr. Panbazar over bridge, S.S. Pradesh,
in Road, Nagaland and
3 BHOPAL – Shri R M Singh Madhya Pradesh Guwahati – 781001(ASSAM). Tripura.
Office of the Insurance Chattisgarh. Tel.: 0361 - 2632204 / 2602205
Ombudsman, Email:
Janak Vihar Complex, 2nd Floor, [email protected]
6, Malviya Nagar, Opp. Airtel n
Office, 9 HYDERABAD – Shri N Andhra Pradesh,

Sankaran Telangana, Lakhimpur,
Office of the Insurance Yanam and Bahraich,
Ombudsman, part of Territory of Barabanki,
6-2-46, 1st floor, "Moin Court", Pondicherry. Raebareli,
Lane Opp. Saleem Function Sravasti,
Palace, Gonda, Faizabad,
A. C. Guards, Lakdi-Ka-Pool, Amethi,
Hyderabad - 500 004. Kaushambi,
Tel.: 040 - 67504123 / 23312122 Balrampur, Basti,
Fax: 040 – 23376599 Ambedkarnagar,
Email: Sultanpur,
[email protected] Maharajgang,
.in Santkabirnagar,
Azamgarh,
10 JAIPUR - Smt. Rajiv Dutta Rajasthan. Kushinagar,
Sharma Gorkhpur,
Office of the Insurance Deoria, Mau,
Ombudsman, Ghazipur,
Jeevan Nidhi – II Bldg., Gr. Floor, Chandauli,
Bhawani Singh Marg, Ballia,
Jaipur - 302 005. Sidharathnagar.
Tel.: 0141 - 2740363 14 MUMBAI - Shri Bharatkumar S. Goa,
Email: Pandya Mumbai
[email protected] Office of the Insurance Metropolitan
11 ERNAKULAM - Shri G Kerala, Ombudsman, Region
Radhakrishnan Lakshadweep, 3rd Floor, Jeevan Seva Annexe, excluding Navi
Office of the Insurance Mahe-a part of S. V. Road, Santacruz (W), Mumbai & Thane.
Ombudsman, Pondicherry. Mumbai - 400 054.
2nd Floor, Pulinat Bldg., Tel.: 022 - 26106552 / 26106960
Opp. Cochin Shipyard, M. G. Fax: 022 - 26106052
Road, Email:
Ernakulam - 682 015. [email protected]
Tel.: 0484 - 2358759 / 2359338 15 NOIDA - Shri Chandra Shekhar State of
Fax: 0484 - 2359336 Prasad Uttaranchal and
Email: Office of the Insurance the following
[email protected]. Ombudsman, Districts of Uttar
in Bhagwan Sahai Palace Pradesh:
4th Floor, Main Road, Agra, Aligarh,
12 KOLKATA - Shri P. K. Rath West Bengal, Naya Bans, Sector 15, Bagpat, Bareilly,
Office of the Insurance Sikkim, Distt: Gautam Buddh Nagar, Bijnor, Budaun,
Ombudsman, Andaman & U.P-201301. Bulandshehar,
Hindustan Bldg. Annexe, 4th Nicobar Islands. Tel.: 2514252 / 2514253 Etah,
Floor, Email: Kanooj, Mainpuri,
4, C.R. Avenue, [email protected] Mathura, Meerut,
KOLKATA - 700 072. Moradabad,
Tel.: 033 - 22124339 / 22124340 Muzaffarnagar,
Fax : 033 - 22124341 Oraiyya,
Email: Pilibhit, Etawah,
[email protected] Farrukhabad,
Firozbad,
13 LUCKNOW -Shri Justice Anil Districts of Uttar Gautambodhanag
Kumar Srivastava Pradesh : ar,
Office of the Insurance Laitpur, Jhansi, Ghaziabad,
Ombudsman, Mahoba, Hardoi,
6th Floor, Jeevan Bhawan, Hamirpur, Shahjahanpur
Phase-II, Banda, 16 PATNA - Shri N. K. Singh Bihar,
Nawal Kishore Road, Hazratganj, Chitrakoot, Office of the Insurance Jharkhand.
Lucknow - 226 001. Allahabad, Ombudsman,
Tel.: 0522 - 2231330 / 2231331 Mirzapur, 1st Floor,Kalpana Arcade
Fax: 0522 - 2231310 Sonbhabdra, Building,,
Email: Fatehpur, Bazar Samiti Road,
[email protected] Pratapgarh, Bahadurpur,
Jaunpur,Varanasi, Patna 800 006.
Gazipur, Jalaun, Tel.: 0612-2680952
Kanpur, Lucknow, Email:
Unnao, Sitapur, [email protected]

Statutory Warning: Prohibition of Rebates (Under Section 41 of
17 PUNE - Shri Vinay Sah Maharashtra, Insurance Act, 1938) as amended by the Insurance Laws
Office of the Insurance Area of Navi (Amendment) Act, 2015.
Ombudsman, Mumbai and
Jeevan Darshan Bldg., 3rd Floor, Thane 1) No person shall allow or offer to allow, either directly or
C.T.S. No.s. 195 to 198, excluding Mumbai indirectly as an inducement to any person to take out or renew
N.C. Kelkar Road, Narayan Peth, Metropolitan or continue an insurance in respect of any kind of risk relating
Pune – 411 030. Region. to lives or property, in India, any rebate of the whole or part of
Tel.: 020-41312555 the commission payable or any rebate of the premium shown
Email: on the policy, nor shall any person taking out or renewing or
[email protected] continuing a Policy accept any rebate, except such rebate as
may be allowed in accordance with the published prospectuses
or tables of the Insurer.
The updated details of Insurance Ombudsman are available on
IRDA website: www.irdaindia.org, on the website of General 2) Any person making default in complying with the
Insurance Council: www.gbic.co.in, website of the Company provisions of this section shall be liable for a penalty, which may
www.icicilombard.com or can be obtained from any of the offices extended to ten lakh rupees.
of the Company.


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Group Health (Floater) Insurance

Customer Information Sheet

S. No Title Description Policy Clause Number

ICICI Lombard General Insurance Company Limited

ICICI Lombard General Insurance Company Limited

Politically Exposed Person (PEP)/close relative of PEP: No

*Premium value mentioned above is inclusive of taxes applicable

ICICI Lombard General Insurance Company Limited

1 No. of Employees : 546

Sr. No. Name of the Co-Insurer Share % Type

ICICI Lombard General Insurance Company Limited

Scan QR for Key Information Sheet and Policy-wordings.

ICICI Lombard General Insurance Company Limited

3. Cashless Facility: i. undertaken under General or Local Anesthesia in a

ICICI Lombard General Insurance Company Limited

Dental treatment means a treatment related to teeth or 17. Hospitalization:

15. Grace Period: 5. it recurs or it likely to recur

16. Hospital: 20. Inpatient care:

ICICI Lombard General Insurance Company Limited

23. Maternity Expenses: 29. New born Baby:

ICICI Lombard General Insurance Company Limited

An AYUSH Hospital is a healthcare facility wherein 46. Portability:

b. Teaching hospital attached to AYUSH College recognized by Specific Definitions

ICICI Lombard General Insurance Company Limited

11. Proportionate deduction: (First Heart Attack of specific severity)

ICICI Lombard General Insurance Company Limited

ICICI Lombard General Insurance Company Limited

ICICI Lombard General Insurance Company Limited

ICICI Lombard General Insurance Company Limited

iii. Severe Sleep Apnea Q. Sterility and Infertility: Code- Excl17

ICICI Lombard General Insurance Company Limited

ICICI Lombard General Insurance Company Limited

ICICI Lombard General Insurance Company Limited

16. Cancellation 18. Migration:

ICICI Lombard General Insurance Company Limited

23. Renewal Notice

ICICI Lombard General Insurance Company Limited

25. Policy Disputes 1. Claims Procedure

a. For Cashless Settlement

iii. Your relationship with Policy Holder,

ICICI Lombard General Insurance Company Limited

Heads of compensation payable: 5. Redressal of Grievance-

(ii) Nursing Expenses; Toll Free: 1800 2666

(iii) Fee paid to Medical Practitioner, Surgeon, E-Mail: "[email protected]"

ICICI Lombard General Insurance Company Limited

ICICI Lombard General Insurance Company Limited

ICICI Lombard General Insurance Company Limited

ICICI Lombard General Insurance Company Limited

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