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Santosh

The document defines terms related to an insurance policy including: 1) AYUSH Day Care Centre which provides treatments and procedures under supervision of registered AYUSH practitioners on an outpatient basis, maintaining daily records and having qualified staff and facilities. 2) Day Care Treatment refers to medical or surgical procedures performed in less than 24 hours without an overnight hospital stay due to technological advancement. 3) Hospitalization means admission to a hospital for a minimum of 24 consecutive hours, except for certain specified treatments requiring less time.

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0% found this document useful (0 votes)

80 views

Santosh

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iii.

Having dedicated AYUSH therapy sections as required

and/or has equipped operation theatre where surgical
procedures are to be carried out;
iv.Maintaining daily records of the patients and making them
Policy Wordings accessible to the insurance company’s authorized
b) PREAMBLE representative
AYUSH Day Care Centre means and includes Community
ICICI Lombard General Insurance Company Limited (“We / Us”), Health Centre (CHC), Primary Health Centre (PHC),
having received a Proposal and the premium from the Proposer Dispensary, Clinic, Polyclinic or any such health center which
named in Part I of the Policy (hereinafter referred to as the “Policy is registered with the local authorities, wherever applicable
Schedule”) and the said Proposal and Declaration together with and having facilities for carrying out treatment procedures and
any statement, report or other document leading to the issue of
medical or surgical/para-surgical interventions or both under
this Policy and referred to therein having been accepted and
agreed to by Us and the Proposer as the basis of this contract do, the supervision of registered AYUSH Medical Practitioner (s)
by this Policy agree, in consideration of and subject to the due on day care basis without inpatient services and must comply
receipt of the subsequent premiums, as set out in the Policy with all the following criterion:
Schedule, and further, subject to the terms and conditions a) Having qualified registered AYUSH Medical
contained in this Policy that on proof to Our satisfaction of the Practitioner(s) in charge;
compensation having become payable as set out in the Policy
Schedule to the title of the said person or persons claiming b) Having dedicated AYUSH therapy sections as required
payment or upon the happening of an event upon which one or and/or has equipped operation theatre where surgical
more benefits become payable under this Policy, the Annual Sum procedures are to be carried out;
Insured / appropriate benefit amount will be paid by Us. c) Maintaining daily records of the patients and making
them accessible to the insurance company’s authorized
representative
c) DEFINITIONS PART II OF THE POLICY
For the purposes of this Policy, the terms specified below shall Cashless Facility means a facility extended by the insurer to
have the meaning set forth wherever appearing/specified in this the insured where the payments, of the costs of treatment
Policy or related Extensions: undergone by the insured in accordance with the policy terms and
Where the context so requires, references to the singular shall conditions, are directly made to the network provider by the
also include references to the plural and references to any gender insurer to the extent preauthorization approved.
shall include references to all genders. Further any references to
statutory enactment include subsequent changes to the same. Condition Precedent shall mean a policy term or condition
upon which the Insurer's liability under the policy is conditional
i. Standard Definitions upon.
Congenital Anomaly refers to a condition(s) which is present
Accident means a sudden, unforeseen and involuntary event since birth, and which is abnormal with reference to form,
caused by external, and visible and violent means. structure or position.
Any one illness means continuous Period of illness and it i. Internal Congenital Anomaly - Congenital anomaly which is
includes relapse within 45 days from the date of last not in the visible and accessible parts of the body
consultation with the Hospital/Nursing Home where treatment ii.External Congenital Anomaly - Congenital anomaly which is
may have been taken. in the visible and accessible parts of the body
Ayush Hospital is a healthcare facility wherein Co-payment means a cost-sharing requirement under a
medical/surgical/para-surgical treatment procedures and health insurance policy that provides that the
interventions are carried out by AYUSH Medical policyholder/insured will bear a specified percentage of the
practitioner(s) comprising of any of the following: admissible claim amount. A co-payment does not reduce the
a) Central or State government AYUSH hospital; or Sum Insured.
b) Teaching hospital attached to AYUSH college Cumulative Bonus shall mean any increase or addition in the
recognized by the central government/Central council of Sum Insured granted by the insurer without an associated
Indian medicine/ Central council for Homeopathy; or increase in premium.
c) AYUSH Hospital, standalone or co-located with in- Day care center means any institution established for day care
patient healthcare facility of any recognized system of treatment of Illness and/ or injuries or a medical set - up within a
medicine, registered with the local authorities, wherever hospital and which has been registered with the local
applicable, and is under the supervision of a qualified authorities, wherever applicable, and is under the supervision
registered AYUSH medical practitioner and must comply of a registered and qualified medical practitioner AND must
with the following criterion: comply with all minimum criteria as under:-
i.Having at least 5 in-patient beds a) has qualified nursing staff under its employment;
ii.Having qualified AYUSH medical practitioner in charge b) has qualified medical practitioner(s) in charge;
round the clock c) has a fully equipped operation theatre of its own where

ICICI Lombard General Insurance Company Limited

IRDA Reg. No. 115 CIN: L67200MH2000PLC129408 UIN : ICIHLGP22083V022122 Health Shield 360
Mailing Address: Registered Office Address: Toll free no : 1800 2666
601 & 602, 6th Floor, Interface 16, ICICI Lombard House, 414, Veer Savarkar Marg, Alternate no : 86552 22666 (chargeable)
New Linking Road, Malad (West) Near Siddhi Vinayak Temple, Prabhadevi, E-mail : [email protected]
Mumbai - 400 064 Mumbai 400 025 Website : www.icicilombard.com
surgical procedures are carried out Has qualified nursing staff under its employment round the
d) Maintains daily records of patients and will make these clock;
accessible to the Insurance Company’s authorized Has qualified medical practitioner(s) in charge round the clock;
personnel. as a fully equipped operation theatre of its own where surgical
Day Care Treatment refers to medical treatment, and/or procedures are carried out Maintains daily records of patients
Surgical Procedure which is: and will make these accessible to the Insurance Company’s
a) Undertaken under General or Local Anesthesia in a authorized personnel.
Hospital/ Day care center in less than 24 hrs because of Hospitalisation means admission in a Hospital for a minimum
technological advancement, and period of 24 consecutive ‘In-patient Care’ hours except for
b) Which would have otherwise required a hospitalisation of specified procedures/ treatments, where such admission
more than 24 hours. could be for a period of less than 24 consecutive hours.
Treatment normally taken on an out-patient basis is not included Illness means a sickness or disease or pathological condition
in the scope of this definition. leading to the impairment of normal physiological function
which manifests itself during the Policy Period and requires
Deductible means a cost sharing requirement under a health
medical treatment.
insurance policy that provides that the insurer will not be
liable for a specified rupee amount in case of indemnity i. Acute condition - Acute condition is a disease, illness or
policies and for a specified number of days/hours in case of injury that is likely to respond quickly to treatment which aims
hospital cash policies which will apply before any benefits to return the person to his or her state of health immediately
are payable by the insurer. A deductible does not reduce the before suffering the disease/ illness/ injury which leads to full
Sum Insured. recovery.
Dental treatment means a treatment related to teeth or ii. Chronic condition - A chronic condition is defined as a
structures supporting teeth including examinations, fillings disease, illness, or injury that has one or more of the following
(where appropriate), crowns, extractions and surgery. characteristics:-
Disclosure to information norm: The policy shall be void 1. it needs ongoing or long-term monitoring through
and all premium paid thereon shall be forfeited to the consultations, examinations, check-ups, and /or tests
Company in the event of misrepresentation, mis-description 2. it needs ongoing or long-term control or relief of
or non-disclosure of any material fact. symptoms
Domiciliary Hospitalisation means medical treatment for an 3. it requires rehabilitation for the patient or for the
illness/ disease/ injury which in the normal course would require patient to be specially trained to cope with it
care and treatment at a hospital but is actually taken while 4. it continues indefinitely
confined at home under any of the following circumstances:
5. it recurs or is likely to recur
a) The condition of the patient is such that he/ she is not in a
Injury means any accidental physical bodily harm occurring
condition to be removed to a hospital, or
during the Policy Period, excluding illness or disease solely
b) The patient takes treatment at home on account of non- and directly cased by external, violent, visible and evident
availability of room in a hospital. means which is verified and certified by a Medical Practitioner.
Emergency care means management for an illness or injury Inpatient care means treatment for which the insured person has
which results in symptoms which occur suddenly and to stay in a Hospital for more than 24 hours for a covered event.
unexpectedly, and requires immediate care by a medical
Intensive care unit means an identified section, ward or wing of a
practitioner to prevent death or serious long term impairment
hospital which is under the constant supervision of a
of the insured person’s health
dedicated medical practitioner(s), and which is specially
Grace Period means the specified period of time immediately equipped for the continuous monitoring and treatment of
following the premium due date during which a payment can patients who are in a critical condition, or require life support
be made to renew or continue a policy in force without loss of facilities and where the level of care and supervision is
continuity benefits such as waiting periods and coverage of considerably more sophisticated and intensive than in the
pre-existing diseases. Coverage is not available for the period ordinary and other wards
for which no premium is received.
ICU (Intensive Care Unit) Charges means the amount
Hospital means any institution established for in-patient care charged by a Hospital towards ICU expenses which shall
and day care treatment of illness and/ or injuries and which has include the expenses for ICU bed, general medical support
been registered as a hospital with the local authorities under the services provided to any ICU patient including monitoring
Clinical Establishments (Registration and Regulations) Act devices, critical care nursing and intensivist charges
2010 or under enactments specified under the Schedule of
Maternity expenses shall
Section 56(1) of the said Act OR comply with all minimum
criteria as under: a) include medical treatment expenses traceable to
childbirth (including complicated deliveries and caesarean
Has at least 10 inpatient beds, in those towns having a
sections incurred during Hospitalisation);
population of less than 10,00,000 and 15 inpatient beds in all
other places; b) expenses towards lawful medical termination of

ICICI Lombard General Insurance Company Limited

IRDA Reg. No. 115 CIN: L67200MH2000PLC129408 UIN : ICIHLGP22083V022122 Health Shield 360
Mailing Address: Registered Office Address: Toll free no : 1800 2666
601 & 602, 6th Floor, Interface 16, ICICI Lombard House, 414, Veer Savarkar Marg, Alternate no : 86552 22666 (chargeable)
New Linking Road, Malad (West) Near Siddhi Vinayak Temple, Prabhadevi, E-mail : [email protected]
Mumbai - 400 064 Mumbai 400 025 Website : www.icicilombard.com
pregnancy during the policy period recommended by, or received from, a physician within 48
Medical Advice means any consultation or advice from a month prior to the effective date of the policy issued by the
Medical Practitioner including the issue of any prescription or insurer or its reinstatement.
repeat prescription. Post Hospitalisation Medical Expenses means medical
Medical Expenses means those expenses that an Insured expenses incurred during pre-defined number of days
Person has necessarily and actually incurred for medical immediately after the insured person is discharged from the
treatment on account of Illness or Accident on the advice of a hospital provided that:
Medical Practitioner, as long as these are no more than would i.Such Medical Expenses are incurred for the same condition for
have been payable if the Insured Person had not been insured which the Insured Person's Hospitalisation was required, and
and no more than other hospitals or doctors in the same locality ii.The In-patient Hospitalization claim for such Hospitalization is
would have charged for the same medical treatment. admissible by the Insurance Company.
Medically necessary Treatment is defined as any treatment, Pre Hospitalisation Medical Expenses means medical
tests medication or stay in hospital or part of a stay in Hospital expenses incurred during pre-defined number of days
which preceding the hospitalization of the Insured Person, provided
a. Is required for the medical management of the illness or Injury that:
suffered by the insured i. Such Medical Expenses are incurred for the same condition
b. Must not exceed the level of care necessary to provide safe, for which the Insured Person's Hospitalisation was required,
adequate and appropriate medical care in scope, duration or and
intensity ii. The In-patient Hospitalization claim for such
c. Must have been prescribed by a Medical practitioner Hospitalization is admissible by the Insurance Company.
d. Must conform to the professional standard widely Qualified Nurse is a person who holds a valid registration from the
accepted in international medical practice or by the medical Nursing Council of India or the Nursing Council of any state in
community in India India.
Migration means the right accorded to health insurance Reasonable and Customary Charges means the charges for
policyholders/proposers (including all members under family services or supplies, which are the standard charges for the
cover and members of group Health insurance policy), to specific provider and consistent with the prevailing charges in
transfer the credit gained for pre-existing conditions and time the geographical area for identical or similar services, taking
bound exclusions, with the same insurer. into account the nature of Illness/injury involved.
Network Provider means hospitals or health care provider Renewal defines the terms on which the contract of insurance
enlisted by an insurer or by a TPA and insurer together to can be renewed on mutual consent with a provision of grace
provide medical services to an insured on payment by a cashless period for treating the renewal continuous for the purpose of all
facility. waiting periods.
New born Baby means baby born during the Policy Period Room Rent means the amount charged by a hospital towards
and is aged upto 90 days. Room and Boarding expenses and shall include associated
Non- Network Provider means any Hospital, day care center or medical expenses.
other provider that is not part of the Network. Surgery or Surgical Procedure means manual and/or operative
Notification of Claim means the process of intimating a claim procedure(s) required for treatment of an illness or injury,
to the insurer or TPA through any of the recognized modes correction of deformities and defects, diagnosis and cure of
of communication diseases, relief of suffering or prolongation of life, performed in a
hospital or day care center by a Medical Practitioner.
OPD treatment is one in which the Insured visits a clinic/
hospital or associated facility like a consultation room for Unproven/Experimental treatment means treatment
diagnosis and treatment based on the advice of a Medical including drug experimental therapy which is not based on
Practitioner. The Insured is not admitted as a day care or in- established medical practice in India, is treatment
patient. experimental or unproven.
Portability means the right accorded to an individual health
insurance policyholder/proposers (including all members ii. Special Definitions
under family cover), to transfer the credit gained for pre- Admission means your admission in a Hospital as an inpatient
existing conditions and time bound exclusions, from one for the purpose of medical treatment of an Injury and/or Illness.
insurer to another insurer
AYUSH treatments refers to the medical aid and / or
Pre-existing Disease means any condition, ailment or injury or hospitalisation treatments given under ‘Ayurveda, Yoga and
disease Naturopathy, Unani, Siddha and Homeopathy systems
a. diagnose by physician within 48 month prior to the Annual Sum Insured means and denotes the maximum
effective date of the policy issued by insurer or its amount of cover available to You during each Policy Year of the
reinstatement or Policy Period, as stated in the Policy Schedule or any revisions
b. for which medical advice or treatment was thereof based on Claim(s) settled under the Policy.

ICICI Lombard General Insurance Company Limited

IRDA Reg. No. 115 CIN: L67200MH2000PLC129408 UIN : ICIHLGP22083V022122 Health Shield 360
Mailing Address: Registered Office Address: Toll free no : 1800 2666
601 & 602, 6th Floor, Interface 16, ICICI Lombard House, 414, Veer Savarkar Marg, Alternate no : 86552 22666 (chargeable)
New Linking Road, Malad (West) Near Siddhi Vinayak Temple, Prabhadevi, E-mail : [email protected]
Mumbai - 400 064 Mumbai 400 025 Website : www.icicilombard.com
Associated Medical Expenses means medical expenses b) Acute impairment of one or more vital organ system
such as Professional fees, OT charges, Procedure charges, (involving heart, brain, lungs, liver, kidney and pancreas or)
etc., which vary based on the room category occupied by the c) Critical care being provided, which involves high
insured person whilst undergoing treatment in some of the complexity decision making to assess manipulate and
hospitals. If Policy Holder chooses a higher room category support vital organ failures and requires interpretation of
above the eligibility defined in policy, then proportionate multiple physiological parameters and application of
deduction will apply on the Associated Medical Expenses in advanced technology or
addition to the difference in room rent. Such associated
d) Critical care being provided in critical care area such as
medical expenses do not include Cost of pharmacy and
coronary care unit, intensive care unit, respiratory care unit
consumables, Cost of implants and medical devices and Cost
or the emergency department, and certified by the attending
of diagnostics.
medical practitioner as a life threatening condition.
Proportionate deduction shall not be applicable to “ICU
Period of Insurance means the period as specifically
charges” also.
appearing in the Policy Schedule and commencing from the
Break in Policy occurs at the end of the existing policy term, Policy Period Start Date of the first Policy taken by You from
when the premium due for renewal on a given policy is not Us and then, running concurrent to Your current Policy subject
paid on or before the premium renewal date or within 30 days to the Your continuous renewal of such Policy with Us.
thereof.
Policy means these Policy wordings, the Policy Schedule and
Contribution is essentially the right of an insurer to call upon any applicable endorsements or extensions attaching to or
other insurers, liable to the same insured, to share the cost of forming part thereof. The Policy contains details of the extent
an indemnity claim on a rateable proportion of Sum Insured. of cover available to You, what is excluded from the cover and
This clause shall not apply to any Benefit offered on fixed the terms & conditions on which the Policy is issued to You.
benefit basis.
Proposer means the person(s) or the entity named in the
Claim means a demand made by You or on Your behalf for Policy Schedule who executed the Policy Schedule and is
payment of Medical Expenses or any other expenses or (are) responsible for payment of premium(s).
benefits, as covered under the Policy.
Policy Period means the period commencing from the Policy
Immediate Family means spouse, dependent children, Period Start Date, Time and ending at the Policy Period End
brother(s), sister(s) and dependent parent(s), Parents-in-law, Date, Time of the Policy and as specifically appearing in the
Son-in-law, Daughter-in-law of the insured. Policy Schedule.
Insured/Insured Person(s) means the individual(s) whose Policy Year means a period of twelve months beginning from
name(s) is/are specifically appearing as such in the Policy the Policy Period Start Date and ending on the last day of such
Schedule and is/are hereinafter referred as “You”/“Your”/ twelve-month period. For the purpose of subsequent years,
“Yours”/ “Yourself” “Policy Year” shall mean a period of twelve months beginning
Maximum limit of indemnity means the sum total of annual from the end of the previous Policy Year and lapsing on the
sum insured, additional sum insured (if any) and super no last day of such twelve-month period, till the Policy Period End
claim bonus (if opted and accrued by the insured), Sum Date, as specified in the Policy Schedule
insured protector (if opted by insured) Service Provider means any person, organization, institution,
Medical Practitioner is a person who holds a valid or company that has been empanelled with Us to provide
registration from the Medical Council of any State or Medical services specified under the Benefits (including add-ons) to
Council of India or Council for Indian Medicine or for The Insured person. These shall also include all healthcare
Homeopathy set up by the Government of India or a State providers empanelled to form a part of network other than
Government and is thereby entitled to practice medicine within hospitals.
its jurisdiction; and is acting within the scope and jurisdiction The list of the Service Providers is available on our digital
of his license. platform and is subject to amendment from time to time.
The term Medical Practitioner would include physician, You/Your/ Yours/ Yourself means the person(s) that We
specialist, anaesthetist and surgeon but would exclude You insure and is/are specifically named as Insured / Insured
and Your spouse, Your children, Your brother(s), Your Person(s) in the Policy Schedule.
sister(s) and Your parent(s).
We / Our / Ours / Us means the ICICI Lombard General
For the purposes of worldwide cover, Medical practitioner Insurance Company Limited
would mean a person who holds a valid registration from the
Medical council of the respective country where the treatment
d) WHAT WE WILL PAY (SCOPE OF COVER)
is being taken by the insured
This Policy is a contract of insurance between the Policyholder
Life threatening medical conditions means a medical and Us which is subject to the receipt of premium against each
condition suffered by the insured member which has following Benefit in full (first instalment in case the customer has opted for
characteristics Periodic Premium Payment option) in respect of the Insured
Persons and the terms, conditions and exclusions of this Policy.
a) Unstable vital parameters (blood pressure, pulse,
Claims made in respect of an Insured Person for any Benefit
temperature and respiratory rate) applicable to the Insured Person shall be subject to the

ICICI Lombard General Insurance Company Limited

A. Base Covers (Mandatory) 3 Pre-Hospitalisation and Post-Hospitalisation Expenses

1 Hospitalization Expenses We hereby agree subject to the terms, conditions and

exclusions herein contained or otherwise expressed hereon
We hereby agree subject to terms, conditions and that, we will compensate you for the relevant Medical
exclusions herein contained or otherwise expressed hereon Expenses incurred by you in relation to:
that, if during the Policy Year, You require minimum 24
hours Hospitalisation for any Illness or Injury on the written  Pre-hospitalisation Medical Expenses incurred by You
advice of a Medical Practitioner, then We will cover the for a period immediately prior to Your Hospitalisation as
Medical Expenses so incurred by you for, specified against this benefit in the policy schedule/Key
Information Sheet and
i. Room Rent, Boarding, Nursing Expenses as
provided by the Hospital / Nursing Home.  Post-hospitalisation Medical Expenses incurred by You
ii. Intensive Care Unit (ICU) / Intensive Cardiac Care for a period immediately post Hospitalisation, as
Unit (ICCU) expenses specified against this benefit in the policy schedule/Key
iii. Surgeon, Anesthetist, Medical Practitioner, Information Sheet, provided that Your Hospitalisation
Consultants, Specialist Fees whether paid directly to falls within the Policy Year and
the treating doctor / surgeon or to the hospital
iv. Anesthesia, blood, oxygen, operation theatre We have accepted Your Claim under “In-patient
charges, surgical appliances, medicines and drugs, Treatment” or “Day Care Procedures” section of the
costs towards diagnostics, diagnostic imaging Policy.
modalities and such similar other expenses.
4 In Patient AYUSH Hospitalisation
In case the group has opted for room rent capping the same We will cover expenses for AYUSH treatment only when the
shall be applicable to room rent of a hospital room, treatment has been undergone in an AYUSH Hospital or
ICU/ICCU and will be specified in policy schedule/Key AYUSH day care centre. We will not cover expenses for
Information Sheet against the benefit. hospitalisation done for evaluation or investigation only.
If the insured chooses a higher room category than the Treatment taken at a healthcare facility which is not a
category that is eligible as per terms and conditions of the Hospital are also excluded.
policy then the insured person shall bear the rateable
proportion of the total associated medical expenses. However, our total liability under this Policy for payment of
However, proportionate deductions shall not be applied in any and all Claims in aggregate during each Policy Year of
respect of the hospitals which do not follow differential billing the Policy Period shall not exceed the Maximum Limit of
or for those expenses in respect of which differential billing Indemnity as stated in the Policy Schedule
is not adopted based on the room category.
5 Unlimited Reset Benefit
Reset will be available unlimited times in a policy year in
However, our total liability under this Policy for payment of
case the annual Sum insured including accrued Additional
any and all Claims in aggregate during each Policy Year of
Sum Insured (if any) and Super No Claim Bonus (if any),
the Policy Period shall not exceed the Maximum Limit of
Sum insured protector(if any) is insufficient as a result of
Indemnity as stated in the Policy Schedule.
previous claims in that policy year, provided that:

2 Day Care Treatment /Surgeries  The total amount of reset will not exceed the Annual
Sum Insured for that policy year
We hereby agree subject to terms, conditions and  The reset amount can only be used for all future
exclusions herein contained or otherwise expressed hereon claims within the same policy year The claim will be
that, if during the Policy Year, You require Hospitalisation as admissible under the reset only if the claim is
an inpatient for less than 24 hours in a Hospital (but not in admissible as per terms and conditions of the base
the outpatient department of a Hospital) on the written policy
advice of a Medical Practitioner, then We will pay You for
 Reset will not trigger for the first claim

ICICI Lombard General Insurance Company Limited

 For any single claim during a policy year, the  If the Sum Insured has been reduced at the time of
maximum claim amount payable shall not exceed the Renewal, the applicable Cumulative Bonus shall be
sum of reduced in the same proportion to the Sum Insured.

o The Annual Sum Insured,  If the Sum Insured under the Policy has been
increased at the time of Renewal the Cumulative
o Additional Sum Insured, and Bonus shall be calculated on the Sum Insured of the
last completed Policy Year
o Super No claim Bonus (If opted and accrued)
 Additional Sum Insured accrued can be utilized only for
o Sum insured protector (If opted and accrued)) Inpatient hospitalization, day care treatment and
surgeries, pre and post hospitalization expenses,
 During a Policy Year, the aggregate claim amount
Inpatient AYUSH hospitalization, domiciliary
payable, shall not exceed the sum of:
hospitalization and donor expenses.
o The Annual Sum Insured
 Any Additional sum insured (Cumulative bonus)
o Additional Sum Insured accrued can be utilized within the geographical
boundaries of India.
o Super No claim Bonus(if opted and accrued)
7 Donor Expenses
o Sum insured Protector(if opted and accrued)
We will cover you up to the annual sum insured for the
6 Additional Sum Insured (Cumulative Bonus) Medical Expenses incurred in respect of the donor for any
of the organ transplant surgery, provided the organ donated
At the time of renewal of this Policy, We will provide an is for your use and the organ donor is an eligible donor in
additional sum insured (hereinafter referred to as “Additional accordance with “The transplantation of Human Organ Act”.
Sum Insured”) of 10% of annual sum insured of immediately We have admitted the In-patient Hospitalization Claim under
preceding policy year subject to a maximum of 100% the base plan
provided that there is no Claim under this Policy during the
We shall not be liable to pay for any claim under this Benefit
Policy Year except as an Out-patient (If opted).
which arises directly or indirectly for or in connection with
However, in the event of a Claim under the Policy during any any of the following:
subsequent Policy Year, the accrued Additional Sum i. Pre-hospitalization Medical Expenses or Post-
Insured will be reduced by 10% of the Annual Sum Insured hospitalization Medical Expenses of the organ donor.
at the time of renewal of this Policy.
ii. Screening expenses of the organ donor.
 In relation to a Floater Benefit cover, the Additional
iii. Any other Medical Expenses as a result of the harvesting
Sum Insured so accrued during the Claim-free Policy
from the organ donor.
Year(s) will also be on floater basis and will only be
available to those Insured Person(s) who were insured iv. Costs directly or indirectly associated with the
in such Claim-free Policy Year(s) and continue to be acquisition of the donor’s organ. Transplant of any
insured in the subsequent Policy Year(s). organ/tissue where the transplant is experimental or
investigational.
 If the Insured Persons in the expiring policy are
covered on an individual basis as specified in the v. Expenses related to organ transportation or
preservation.
Policy Schedule and there is an accumulated
Cumulative Bonus for each Insured Person under the vi. Expenses incurred by Insured as a donor.
expiring policy, and such expiring policy has been
vii. Any other medical treatment or complication in respect
Renewed with Us on a floater policy basis as specified
of the donor, consequent to harvesting.
in the Policy Schedule then the Cumulative Bonus to

ICICI Lombard General Insurance Company Limited

iii.The Medical Expenses incurred are Reasonable and v. Coverage/benefit associated with Section A Base
Customary Charges. covers_(Mandatory) i.e. domiciliary hospitalization,
Donor expenses, In-patient AYUSH, unlimited reset and
iv.The Domiciliary Hospitalization continues for at least 3 Additional sum insured (cumulative bonus) will be
consecutive days in which case we will make payment applicable only within the geographical boundaries of
under this Benefit in respect of Medical Expenses India.
incurred from the first day of Domiciliary
Hospitalization. vi. We will also cover the expenses associated with the
initial treatment plan for reconstructive surgery and
v.Any Medical Expenses payable shall not in aggregate
surgical implants (excluding dental), provided the same
exceed the maximum limit of indemnity.
is carried out to restore the function after an accident and
We shall not be liable to pay for any claim under this Benefit the surgery is performed at a medically appropriate
which arises directly or indirectly from or in connection with stage after the accident.
any of the following
vii. The benefit is available as cashless facility through a
a) Asthma, bronchitis, tonsillitis and upper respiratory pre-authorization by our service provider subject to
tract infection including laryngitis and pharyngitis, availability in the region of loss, as well as
cough and cold, influenza; reimbursement basis through us. However in case of
planned hospitalisation it is mandatory for the customers
b) Arthritis, gout and rheumatism;
to seek our approval before undertaking the trip
c) Ailments of spine/disc
viii. The payment of any claim under this benefit will be
d) Chronic nephritis and nephritic syndrome; based on the rate of exchange as on Date of Loss
e) Any liver disease; published by Reserve Bank of India (RBI) and shall be
used for conversion of Foreign Currency into Indian
f) Peptic ulcer rupees for payment of claims. If on the insured person’s
g) Diarrhea and all type of dysenteries, including date of loss, if the RBI rates are not published, the
gastroenteritis; exchange rates published next shall be considered for
conversion.
h) Diabetes mellitus and insipidus;
Note: The scope of this cover extends to worldwide including
i) Epilepsy; India, USA and Canada and the Maximum limit of indemnity would
j) Hypertension; be restricted to the Annual Sum insured for claims within and
outside India, in aggregate.
k) Pyrexia of any origin
Extension 1 to 5 will be available only when the Base cover
B Base Cover (Optional)
(optional) “Worldwide Including India (Hospitalization cover)” is
Worldwide cover Including India (Hospitalization cover) opted by the group. Rest of the extensions/optional covers can
also be opted along with it, but the utilization will be limited within
We will cover you for hospitalisation expenses including the geographical boundaries of India.
planned hospitalisation, incurred within India and anywhere
across the world including USA and Canada, up to the C. Extension/Optional Covers
amount specified against this benefit in the policy
schedule/Key Information Sheet subject to the terms & The Benefits listed below shall be available to the Insured
conditions specified hereunder: Person only if the requisite additional premium has been
i. A co-pay of 10% will be applied to every admissible claim received by us and the Benefit is specified to be in force for that
over and above to any other co-pay levied, if the Insured Person in the Policy Schedule/Key Information Sheet.
treatment is taken outside India Benefits under this Section are subject to the terms, conditions,

ICICI Lombard General Insurance Company Limited

c) This Benefit includes and is limited to the cost of the III. Such air ambulance providing the services, should be duly
transportation of the Insured Person: licensed to operate as such by a competent government
Authority.
I. To the nearest Hospital with higher medical facilities
which is prepared to admit you and provide the IV. This cover is limited to transportation from the area of
necessary medical services if such medical emergency to the nearest Hospital only;
services cannot satisfactorily be provided at a V. We will not cover:
Hospital where you are situated, and only if that
transportation has been prescribed in writing by a  Any transportation from one Hospital to another;
Medical Practitioner and is for Medically Necessary
Treatment.  Any transportation of yours from Hospital to your residence
after you have been discharged from the Hospital
II. From a Hospital to the nearest diagnostic center
during the course of Hospitalization for advanced  Any transportation between two countries.
diagnostic treatment in circumstances where such
facility is not available in the existing Hospital. VI. We have accepted a claim under worldwide cover
hospitalization in respect to you for the same
III. From one hospital to another hospital for the Accident/Illness for which air ambulance services were
purpose of providing better medical support to the availed.
insured during an emergency
We shall not be liable if Medically Necessary Treatment can
d) The ambulance / service provider providing the be provided at the Hospital where you are situated at the
services be a registered provider with road traffic time of requiring Emergency Care.
authority.
b) Repatriation of Mortal Remains: In the event of the death
Any expenses in relation to transportation of you from Hospital to of the insured person oversea/abroad we will pay/reimburse
the your residence while transferring you after you been the policyholder up to the amount specified in the policy
discharged from the Hospital are not payable under this Benefit schedule/Key Information Sheet against this benefit for the
Note: On opting this extension, the scope of cover extends to cost incurred towards the return of the mortal remains of the
worldwide including India, USA and Canada and the maximum insured person to his/her place of residence in India.
limit of Indemnity would be restricted to the amount as specified Documents to be submitted:
against this benefit for claims within and outside India, in
aggregate.  Death certificate of the deceased providing the details of the
place, time, circumstances and cause of death
2 International Emergency Medical Assistance (worldwide
including India):  Post-mortem certificate, if conducted

ICICI Lombard General Insurance Company Limited

b) The Hospitalization is for Medically Necessary c) This Benefit includes and is limited to the cost of the
Treatment and is commenced and continued on the transportation of the you:
written advice of the treating Medical Practitioner.
i. To the nearest Hospital with higher medical facilities
c) The medical practitioner certifies that the hospitalised which is prepared to admit you and provide the
insured member required hospitalization of minimum necessary medical services if such medical services
3 consecutive days, maximum up to 10 days cannot satisfactorily be provided at a Hospital where
you are situated, and only if that transportation has
d) We will pay for one immediate family member.
been prescribed in writing by a Medical Practitioner
and is for Medically Necessary Treatment.
Note: On opting this extension, the scope of cover extends to
ii. From a Hospital to the nearest diagnostic center during
worldwide including India, USA and Canada and the maximum
the course of Hospitalization for advanced diagnostic
limit of Indemnity would be restricted to the amount as specified
treatment in circumstances where such facility is not
against this benefit for claims within and outside India, in
available in the existing Hospital.
aggregate.
iii. From one hospital to another hospital for the purpose
of providing better medical support to you during an
4 Convalescence Benefit (Worldwide including India):
emergency.
In consideration of the payment of additional premium to us.
We will pay you an amount as specified against this benefit in d) The ambulance / service provider providing the services
the policy schedule/Key Information Sheet. If you are be a registered provider with road traffic authority.
hospitalized under worldwide cover including India Any expenses in relation to transportation of the Insured
(Hospitalization cover) for a minimum period of 10 consecutive Person from Hospital to the Insured Person’s residence
days, due to any Injury or Illness as covered under the Policy. while transferring an Insured Person after he/she has been
This benefit is payable only once to an Insured Person during discharged from the Hospital are not payable under this
each Policy Year of the Policy Period. Benefit.
Note: On opting this extension, the scope of cover extends to 7 Air Ambulance
worldwide including India, USA and Canada and the maximum
limit of Indemnity would be restricted to the amount as specified In consideration of the payment of additional premium to Us, We
against this benefit for claims within and outside India, in will cover the expenses incurred on air ambulance services in
aggregate. respect to you which are offered by a healthcare or an air
ambulance service provider and which have been used during
5 Worldwide Additional Sum Insured (Cumulative Bonus):

ICICI Lombard General Insurance Company Limited

i. Our maximum liability under this Benefit for any and all The percentage increase will be applicable only on Annual Sum
claims arising during the Policy Year will be restricted to Insured under the Policy and not on additional sum insured or
the Sum insured as stated in the Policy Schedule/Key any other benefit which leads to increase in Sum Insured.
Information Sheet;
10 Claim Protector
ii. It is for a life threatening emergency health condition/s
In consideration of payment of additional premium to Us, you can
which requires immediate and rapid ambulance avail the benefit as mentioned under claim protector. If a claim
transportation from the place where you are situated at has been accepted under the inpatient hospitalization cover,
the time of requiring Emergency Care to a hospital then the items which are not payable under the claim as per the
provided that the transportation is for Medically List of Excluded items released (Part III. 26 List of Non payables)
Necessary Treatment, is certified in writing by a Medical that is related to the particular claim will become payable. The
Practitioner, and road ambulance services cannot be maximum claim payout under this benefit shall be limited to
provided. Annual Sum Insured under your policy.

iii. Such air ambulance providing the services, should be 11 Super No Claim Bonus
duly licensed to operate as such by a competent
In consideration of payment of additional premium to us, you
government Authority.
can avail the benefit under super no claim bonus. All terms and
iv. This cover is limited to transportation from the area of conditions applicable to the additional sum insured feature will
emergency to the nearest Hospital only; apply to this cover as well, except for the below mentioned terms
and conditions:
v. We will not cover:
 If no claims have been paid in the expiring Policy year and
a) Any transportation from one Hospital to another; the policy is being renewed without any break in period the
b) Any transportation of you from Hospital to the your Insured person will be awarded a super no claim bonus viz.
residence after you have been discharged from the 50% increase in the Sum insured for each completed year,
Hospital maximum of 100% of Sum insured.
c) Any transportation or air ambulance expenses
incurred outside the geographical scope of India.  Super no claim bonus will be over and above the accrued
vi. We have accepted a claim under hospitalization additional sum insured, if any. In the event of a claim in the
expenses in respect to you for the same Accident/Illness Policy year, the super no claim bonus will reduce by 50%.
for which air ambulance services were availed.
 At the time of renewal if the Insured person opts out of this
vii. We shall not be liable if Medically Necessary Treatment optional cover, then the Super no claim bonus accrued up
can be provided at the Hospital where you are situated at until the expiring policy year will be forfeited.
the time of requiring Emergency Care.
 In case no claims are made in the Policy year, the super no
8 ASI Protector claim bonus will be credited automatically to the subsequent
policy year even in the case of multi-year policies (2 & 3 year
In consideration of payment of additional premium to Us, you can
policy tenure).
avail the benefit as mentioned under additional SI protector.
Additional sum insured(ASI) accrued by you will not be impacted  Super no claim bonus will be calculated on the previous
or reduced at renewal if any one claim or multiple claims
policy years Sum insured.
admissible in the previous policy year under the policy does not
exceed the overall amount of ₹ 50,000.  Additional Sum insured (cumulative bonus) won’t be
9 Sum Insured Protector applicable if you opt for super no claim bonus.

In consideration of payment of additional premium to Us, you can 12 Maternity Cover

avail the benefit under sum insured protector. The Sum Insured
In consideration of the payment of additional premium to us, and
protector is designed to protect the Sum Insured against rising
subject always to the amount as specified against this benefit in
inflation by linking the Sum Insured under the base plan to the
Consumer Price index (CPI). the Policy Schedule/Key Information Sheet, We will cover you
for
The Sum Insured will be increased on cumulative basis at each  Medical Expenses incurred for delivery, including a
renewal on the basis of inflation rate in previous\ year. Inflation caesarian section, during Hospitalization or lawful medical
rate would be computed as the average CPI of the entire termination of pregnancy and pre and postnatal expenses
calendar year published by the Central Statistical Organisation during the Policy Year.
(CSO). Sum Insured protector will be calculated on previous year
policy sum insured.

ICICI Lombard General Insurance Company Limited

Provided always that; b) Diagnostics test as recommended/prescribed by the medical

a) The cover under this extension shall be available after the practitioner.
specified period of time as mentioned in the policy
schedule/Key Information Sheet against the benefit has c) Pharmacy – Medicines purchased by the Insured Person
elapsed since the inception of the first Policy with Us. from a pharmacy, provided that such medicines have been
prescribed in writing by a Medical Practitioner.
b) Pre- and Post-Hospitalization expenses under A.3 will not
be covered under this extension Note: Payment of expenses towards outpatient treatment will
not prejudice the company's right to deal with a claim in case of
c) This benefit is available only under a family floater Policy. non-disclosure of material fact and / or Pre- Existing Diseases
d) This benefit is available for You or Your spouse provided in terms of the policy.
You and Your spouse, both are covered under the same
family floater Policy and have served the waiting period. Exclusion applicable to Outpatient Treatment

e) This benefit can be extended to both Individual and floater We shall not be liable to make any payment under this
plans, irrespective of you and your spouse being covered Extension in connection with or in respect of any expenses
under the same plan, if opted by the group and specified whatsoever incurred by you in connection with or in respect of:
in policy schedule/Key Information Sheet.
a) Intentional self-injury (whether arising from an attempt to
f) We will not cover ectopic pregnancy under this benefit commit suicide or otherwise)
(the same shall be covered under In-patient Treatment)

g) We will not cover expenses incurred in respect of the b) Use, misuse or abuse of intoxicating drugs or alcohol
harvesting and storage of stem cells when carried out as
a preventive measure against possible future Illnesses; c) Aesthetic treatment, cosmetic surgery and plastic surgery
including any complications arising out of or attributable to
h) On any Renewal, if an enhanced Sum Insured is applied, these, unless necessitated due to Accident or as a part of
the condition for specified months of required continuous any Illness
coverage would apply afresh, but only to the extent of the
increased amount available under this Benefit. d) Any treatment/surgery for change of sex or
treatment/surgery/complications/Illness arising as a
13 New-born baby cover
consequence thereof
In consideration of the payment of additional premium to Us, and
subject to the amount as specified against this benefit in the e) Experimental, unproven or non-standard treatment which is
Policy Schedule/Key Information Sheet. New Born Baby cover- not consistent with or incidental to the usual diagnosis and
will cover Medical Expenses incurred on the “New born Baby” treatment of any Illness or Injury
during Hospitalisation (for a minimum period of consecutive 24
hours) for a maximum period up to 91 days from the date of birth f) Vaccination procurement and administration
of the baby. This cover will be available only if maternity cover
has been opted by you. g) External medical aids are not covered under this benefit.

Subject otherwise to the terms, conditions and exclusions of the h) Expenses associated with optometric therapy and
Policy associated aids like spectacles, contact lenses are also not
covered.
14 Out Patient Treatment Cover

In consideration of the payment of additional premium to us, as i) Dental treatment/ Implants and associated oral and
specified against this benefit in the policy schedule/Key maxillofacial surgical procedures Physiotherapy sessions
Information Sheet. We will cover you for the Medical Expenses and counselling
incurred by You in outpatient.
For the purpose of this extension, the following shall be covered j) Health supplements, Nutraceuticals, foods for special dietary
under this benefit use, foods for special medical purpose, foods with added

ICICI Lombard General Insurance Company Limited

You will be required to furnish the following documents in 17 Compassionate Visit

original for or in support of a Claim: In consideration of the payment of additional premium to us, as
specified against this benefit in the policy schedule/Key
 Duly completed Claim form Information Sheet. In the event of Your Hospitalization, which in
 Bills / invoices raised in Your name the opinion of the Medical Practitioner attending on You,
extends beyond a period of 5 consecutive days, We will
 Test reports and payment receipts reimburse the cost of the economy class air ticket incurred by
Your Immediate family from and to the place of origin of such
 Any other document as required by Us
immediate family or the place of residence of the immediate
15 Hospital Daily Cash family.
In consideration of the payment of additional premium to Us, If
Our liability under this benefit, however, in respect of any one
You contract an Illness or suffer an Injury due to an Accident that
event or all events of Hospitalization during the Policy Year shall
occurs during the Period of Cover and which solely and directly
not in aggregate exceed the amount (per Policy Year) as
requires the Insured Person to be hospitalized, then we will pay
specified against this benefit in the policy schedule/Key
the daily amount specified in the Policy Certificate for each
Information Sheet.
continuous and completed day of Hospitalization

This Benefit shall be payable subject to the following: 18 Convalescence Benefit

a) The Hospitalization is for Medically Necessary
In consideration of the payment of additional premium to us, We
Treatment and is commenced and continued on the
written advice of the treating Medical Practitioner. will pay You an amount as specified against this benefit in the
policy schedule/Key Information Sheet, if You are Hospitalized
b) We shall not be liable to pay the daily amount for more
for a minimum period of 10 consecutive days, due to any Injury
than the maximum number of days specified in the Policy
or Illness as covered under the Policy. This benefit is payable

ICICI Lombard General Insurance Company Limited

20 Nursing at Home 22 Dependent Accommodation

In consideration of the payment of additional premium to us. We In consideration of additional premium to us, If You contract an
will pay You for the expenses incurred by You, up to an amount Illness or suffer an Injury due to Accident during the Policy Period
as specified against this benefit in the policy schedule/Key and which solely and directly requires the You to be Hospitalized,
Information Sheet, for each day up to a maximum of 15 days We will pay the daily amount for the accommodation of the
post Hospitalization for the medical services of a Qualified dependent in the hospital only as specified in the Policy
Nurse at Your residence, provided that the nurse is employed in Schedule/Key Information Sheet against this benefit in respect of
a Hospital/Service provider and the engagement of such each continuous and completed day of your Hospitalization.
Qualified Nurse is certified as necessary by a Medical
Practitioner and relates directly to any Illness or Injury, covered For the purpose of this Extension, Dependent means immediate
under the Policy. The payment under this extension is subject family members as defined
to admissibility of Your Hospitalization Claim under the Policy.
For the purpose of this extension, the term “Qualified Nurse” Provided:
means a person who holds a valid registration from the Nursing a) We have accepted the claim under hospitalization expensed
Council of India or the Nursing Council of any state in India. in respect to You for the same Accident/Illness.

Subject otherwise to the terms, conditions and exclusions of the b) The Hospitalization is for Medically Necessary Treatment
Policy. and is commenced and continued on the written advice of the
treating Medical Practitioner. The medical practitioner
21 Home Health care certifies that the hospitalised insured member required
In this benefit we will cover the medical expenses incurred by hospitalization of minimum 3 consecutive days, maximum up
you on availing treatment at home provided that: to 10 days. We will pay only for one immediate family
member.
a) You have been advised non-emergency hospitalization
by a Medical practitioner and you out of your own 23 Voluntary Deductible
will, opts to undergo treatment at home.
b) Your condition is expected to improve in a reasonable and In case the You have opted for a voluntary deductible, as
foreseeable period of time. specified in the Policy Schedule, the Deductible will be
c) There is a continuous active line of treatment with applicable on aggregate basis for all Hospitalization expenses
monitoring of the health status by a medical practitioner during the Policy Year before it becomes payable by Us,
for each day through the duration of the home care
subject to terms, conditions and exclusions of the Policy. The
treatment.
d) Treatment that can be availed on Outpatient basis will not deductible will apply on individual basis in case of individual
be qualified to be covered under this clause. policy and on floater basis in case of floater policy. Voluntary
deductible shall not be applicable to any optional covers.

ICICI Lombard General Insurance Company Limited

b. Zone 2: Hyderabad, Secunderabad, Chhattisgarh, Madhya

Pradesh, Daman & Diu, Dadar & Nagar Haveli, Goa, 27 Health Check-up Cover
Maharashtra (excluding Mumbai, Thane District, Raigad
Expense incurred towards the cost of Health check-Up will be
District (Maharashtra), Navi Mumbai)
covered as specified against the benefit in the policy
c. Zone 3: Rest of India schedule/Key Information Sheet every year. Subject to the
conditions below
* Includes Delhi and the following districts: Faridabad,
Gurgaon/Gurugram, Mewat, Rohtak, Sonipat, Panipat,  Health checkup will be availed only at out empanelled
Jhajjhar, Palwal, Karnal, Ghaziabad, Noida/Gautam Budh service provider on cashless basis as per the available
Nagar, Bulandshahr, Baghpat, Hapur, Shamli, medical test packages.
Muzaffarnagar  The policy is renewed with us without any break.
 This benefit doesn’t not reduce sum insured or impact the
Co-pay for Co-pay for Co-pay for
Zone Opted each and each and each and accrued bonus (if any)
for every claim every claim every claim  Any unutilized test or amount can’t be carry forwarded to
in Zone I in Zone 2 in Zone 3 next policy year.
Zone 1 Nil Nil Nil Note: Payment of expenses towards cost of health check-up will
Zone 2 10% Nil Nil not prejudice the company's right to deal with a claim in case of
Zone 3 15% 5% Nil non-disclosure of material fact and / or Pre- Existing Diseases in
terms of the policy.
26 Sub Limits on Illness/ Surgeries / Procedures 28 360 Wellbeing Program
On payment of additional premium, You shall be enrolled under
In case You have opted for sublimit, our maximum liability to make
the 360 Wellbeing program which aims to empower individuals
payment for the Medical Expenses incurred during any
to manage their lifestyle and prevent complication arising from
Hospitalisation (including its related Pre and Post Hospitalization
adverse health conditions. It intends to promote, incentivize and
expenses if applicable) due to the below mentioned Surgeries /
reward You for your healthy behavior through various health and
Medical Procedures or any medical treatment pertaining to an
wellbeing activities.
Illness / Injury shall be limited as per the table below

The Health Coach shall only be available, if you are aged 21 and
S.
Particulars Sub-limits (₹) above. The Health Coach is a personalized service that shall
No.
encourage and promote optimal health and physical and mental
1 Cataract per eye As specified against wellbeing through a telephonic / digital connect. The Health
this benefit in the Coaches associated with the 360 wellbeing program shall be
2 Other Eye Surgeries policy schedule qualified nutritionist, dietician & physiotherapist with certification
on coaching, who will
3 ENT  Guide & motivate You to follow a healthy lifestyle &
promote wellbeing

ICICI Lombard General Insurance Company Limited

2. Diabetes Table A: Classification during on-boarding

3. Hyperlipidemia Medical Tests Green Amber

4. Obesity Glycosylated < 6% >6 and up to7%

5. Heart and vascular conditions Hemoglobin (HbA1c)

i. Myocardial Infarction Blood Pressure Systolic Up to Systolic

ii. Refractory heart failure reading 120 mm hg >120mm and
iii. Cardiomyopathy Diastolic Up to <140 mmhg
6. Lung Conditions 80 mm hg Diastolic > 80
mm and <90 mm
i. End stage lung Failure hg
ii. Primary(Idiopathic) pulmonary Hypertension Low Density < 100 mg/dl >100 and < or =
7. Liver conditions Lipoprotein (LDL) 190 mg/dl
High Density > or = 40 mg/dl > 20 mg/dl and
End stage liver Failure Lipoprotein (HDL) <40 mg/dl
8. Neuro/ spinal & psychiatric disease Serum cholesterol < or = 200mg/dl >200 and < or
i. Multiple sclerosis with Persisting symptoms =300 mg/dl
ii. Motor neuron disease with Permanent Triglycerides <or = 150 mg/dl > 150 and <=
250mg/dl
symptoms

ICICI Lombard General Insurance Company Limited

Systolic Up Systolic Green Category Amber category

to 120 mm >120mm and Systolic
For green category, 1st
health If you are in Amber Category
Blood Pressure hg <140 mmhg >140mm
assessment is conducted at the time of on boarding,
reading Diastolic Diastolic > 80 Diastolic > within three months from the health assessment is a part
policy start date if no adverse of 360 Wellbeing program
Up to 80 mm and <90 90 mm
health parameter is found you Health assessment will be
mm hg mm hg
will continue in green done twice a year, post on
category and wellbeing points boarding.
>100 and <
Low Density will be unlocked · 1st assessment will be
< 100 mg/dl or = 190 >190 mg/dl done between 5th to 6th
Lipoprotein (LDL)
mg/dl A second health assessment month after the policy start
(optional) is also available to date
High Density > 20 mg/dl you which will help you to
> or = 40
Lipoprotein and <40 > 40 mg/dl earn additional wellbeing · 2nd assessment will be
mg/dl
(HDL) mg/dl points. done between 11th to 12
month after policy start date
>200 and < Those who have adverse
Serum < or = >300
or =300 outcome in health 360 wellbeing point earned
cholesterol 200mg/dl mg/dl
mg/dl assessment will be advised to will be as per the outcome
upgraded to 360 wellbeing values of health assessment
<or = 150 > 150 and <= > 250 program.
Triglycerides
mg/dl 250mg/dl mg/dl Please Note:

Body Mass >32 and < or  Health assessment includes Blood test ( BP, BMI, WHR,
< or = 32 >40
Index (BMI) = 40 hbA1c, Total cholesterol) followed with an assessment by
health coach for scoring
 In case of deterioration of health condition, you may be
moved from green to amber OR amber to red category.  The assessment will be carried out by ICICI Lombard
 You will have to pay the risk based loaded premium as service providers only.
applicable for the respective category.
e) Wellbeing points structure:
 The loading percentage applicable for red category shall
be higher than the loading percentage applied for the Wellbeing points are further categorized into Be-Healthy
amber category. and Stay-Healthy points. Conditions to earn both these
 Once you have been part of amber/red category, you will points have been explained in the following sections in
have to be part of the respective category for a detail.
consecutive period of 2 years. Post the successful In case of a floater policy, maximum 2 adults aged 21
completion of 2 years in the 360 wellbeing program, your and above shall be covered in the program and the 360
health condition will be reviewed by the health coach. On wellbeing points to be awarded shall be doubled,
the basis of the health condition at the time of review, it provided, that both the Insured Persons complete their
will be decided whether you needs to continue in the respective wellbeing activities.

ICICI Lombard General Insurance Company Limited

The Be Healthy points have been designed with the objective to Prevent
monitor your health at regular intervals. The better the health ive
status as evidenced through various health outcomes as 300 300
check
mentioned below in Table C, more of Be-Healthy points will be Diagn
up Onc
awarded. You can earn a maximum of 7000 Be-healthy points per ostic
ea
test
insured. Self- yea
under
paid r
Table C: Be-Healthy points structure as per category gone
advanc 700 700
To e check
tal up
Blood Readin
test gs Fre Points po
que earned/ 70
int Total
ncy activity 00
s

up to
750 Maxi Self-paid advance check up
5.99
Twi mum
1500 You can also earn wellness points by undergoing certain other
6.00- ce a
HbA1c 300 diagnostic tests (as suggested by Our empanelled medical
6.50 yea
experts) at any diagnostic centre at your own expenses. You shall
r
6.51- have to submit medical reports of these tests to Us.
100
7.00 Redemption of Be-Healthy Points

110-  The Be-Healthy points earned by you can be redeemed for

120/70- 750 discount in renewal premium or towards payment of non-
80 Maxi payable items which are deducted as per the list of non-
Twi mum payable items (Part III, 26 List of Non Payable).
Blood 121- 1500
ce a
pressu 130/80- 300  In case, the Health assessment results for any blood test
yea
re 85 parameter as mentioned in table C, crosses the defined
r
range, then you shall be dis-qualified for the entire reward
131- scheme under Be-Healthy points
140/86- 100
90 Stay-Healthy Points

The Stay-healthy program has been structured to reward You for

18.00 -
750 Maxi maintaining good health throughout the year. The points earned
25.00
mum as per the engagement activities and their duration has been
Twi
Body 1500 explained below. The maximum points which can be earned
25.01 – ce a
mass 300 through this program will be 6000 per Insured Person.
32.00 yea
index
r Table D: Stay-Healthy points structure:
32.01 -
100
40 Tota
Points
Parame Categor Durati Freque l
up to earned/ac
ter y on ncy Poin
150 750 tivity
ts
Total mg/dl Maxi
Advisor
choles Twi mum
1500 y on Engage Twice
terol 151mg/ ce a 2 400 800
health ment a year
dl- yea
(Trigly 300 records
200mg/ r
ceride) dl Tele- 4
Engage
consulta times 4 150 600
ment
201mg/ 100 tion a year
dl-

ICICI Lombard General Insurance Company Limited

Table G: Increase in Rupee Value of Wellbeing Points

First Renewal (2nd INR 0.21 1000 INR 210
Year of policy)
f) Redemption of 360 wellness points (Stay-Healthy+ Be-
Second Renewal INR 0.22 1000 INR 220 Healthy) Points
(3rd Year of policy)
Conditions on Redemption of 360 wellbeing point
Third Renewal (4th INR 0.23 1000 INR 230
Year of policy)
 You have to accumulate a minimum of one thousand
wellbeing points during the policy period in order to
redeem the same.
Fourth Renewal INR 0.25 1000 INR 250
(5th Year of policy
 The maximum amount of 360 wellbeing points that You
and onwards)
can redeem will be as per the Table H below:
challenges includes but are not limited to marathon, cyclothon
Table H: Maximum 360 wellbeing points
etc. Year Maximum points that Maximum points that
5 Sleep Tracking: can be redeem can be redeem under
under Be-Healthy Stay-Healthy
You can also earn Stay-Healthy points by allowing our mobile
1st Year 5500 5000
application to track Your sleep duration as explained in
2nd Year 5500 5000
below table F
3rd Year 6000 5500
Table F: Stay-Healthy points through Sleep Tracking 4th Year 6500 5500
5th Year& 7000 6000
Maximum onwards
Maximum
Average hours of sleep per day Points
Points per Balance between the maximum points earned and points
for in a month accumulated
month redeemed can be carried forward for maximum of 3 years,
in a year
provided policy is active continuously with us and shall have to be
7 hours 1 min-8 hours 100 1200 redeemed at the end of the 3rd Policy Year. In case, you does not
wish to redeem the wellbeing points earned, the same will be
6 hours 1 min-7 hours 90 1080 forfeited.

< 6 hours Nil Nil Illustration for Redemption of wellbeing Points (Policy Tenure 1
year). Below mentioned Table I is a road map journey of 5 years
for an individual with 360 wellbeing program.
6 Health Events:
You will be awarded Stay-Healthy points on participation and Table I: Illustration for redemption of wellbeing points
successful completion of health events initiated by Us from time
to time. You shall be awarded 100 points per health event and a 1 2 3 4 5
maximum of 600 points per Insured Person can be gained by
Particula Fresh 1st 2nd 3rd 4th
participation and completion of health events. rs Renew Rene Rene Rene
al wal wal wal
Health event can be defined as various events which work
1st 2nd 3rd 4th 5th
towards creating awareness, spreading knowledge about the Year Year year Year Year
benefits of a healthy lifestyle which include both physical health
and mental health. These include interactive sessions,
Be-healthy points illustration
meditation, fitness videos, health awareness and educational
sessions. A Maximu 7000 7000 7000 7000 7000
m points
7 Wellness events: earned
under
You shall be awarded =Stay-healthy points on participation and Be-
successful completion of health events initiated by Us from time Healthy
to time.
Wellness events can be understood as an engagement tool for
the customers to make them aware on their individual wellbeing
aspects. It also aims to reward them on their level of awareness
on various aspects of wellbeing. It includes health quiz, health
contest, wellness awareness sessions

ICICI Lombard General Insurance Company Limited

 For health risk assessment [HRA] services availed

Stay-Healthy points illustration through mobile application/online/ digital mode on IL
H Maximu 6000 6000 6000 6000 6000 Platform, you will be required to provide the details in
m points order to establish authenticity and validity prior to
that availing such services. Any such information provided by
earned the you in this regard shall be used solely for the purpose
under
Stay
of providing these wellbeing services and kept
Healthy confidential with Us / Our Network Providers/Health
I Maximu 5000 5000 5500 5500 6000 Service Providers at all times.
m points
that can  You shall notify Us and submit the relevant documents,
be reports, receipts as and when required by us within 60
redeeme days of undertaking any wellbeing activity.
d the
same
year  You agrees that choosing to utilize any of the wellbeing
services or any information or advise rendered by Our
Health Service Providers or Network Providers or Us will

ICICI Lombard General Insurance Company Limited

 The points accrued shall be at periodic intervals at If You are first Diagnosed with any one of the Critical Illnesses
rates/amounts declared upfront at the commencement listed below during the Period of Cover, then We will pay the Sum
of the policy and shall not be linked to any dynamic factor Insured specified in the Policy schedule/Key Information Sheet
such as interest rate. against this Benefit as a lump sum amount, in the manner
specified in the Policy schedule/Key Information Sheet, provided
 All the communication related to the 360 wellbeing that the signs or symptoms of such Critical Illness first commence
program point accrued, its redemption and associated after 90 days from the Risk Inception Date.
reminders will be through the IL take care application.
On the acceptance of a claim under this Benefit, the cover under
 IL take care application is an insurance and wellness this Benefit will terminate in relation to you, and further no
application which helps the customers to check their subsequent Renewals of this cover in the Policy will be allowed.
policy details, downloading e-card, intimation and
tracking of claims, locating network hospitals etc. It also International Second Opinion- In the event of your diagnosis
offers tracking of wellness through various features such with any of the listed critical illness during the policy period, you
as steps, sleep, active hours and stand hours tracking can avail an E-Consultation second opinion from medical
practitioner outside India within our Network with respect to the
 There shall not be any cash reimbursement or
critical illness only, subject to the following conditions
redemption available against the wellbeing points
accumulated by an Insured Person.
o It will be based on the medical records submitted by the
 We or Our Health Service Providers or Our Network insured person which should include investigation reports
Providers do not warrant the validity, accuracy, citing the final diagnosis and relevant consultation papers
completeness, safety, quality, or applicability of the o The benefit can be availed only once by the insured person
content or anything said or written or any suggestions for the listed critical illness.
provided in the course of providing the wellbeing
services. o It should be only for medical reasons and not for medico-
legal purposes.
 We, Our group entities, or affiliates, their respective
o We do not assume any liability and shall not be deemed to
directors, officers, employees, agents, vendors, shall not
assume any liability towards any loss or damage arising out
be responsible for or liable for, any actions, claims,
of or in relation to any opinion, advice, prescription, actual
demands, losses, damages, costs, charges and
or alleged errors, omissions and representations made by
expenses which you may claim to have suffered,
the Medical Practitioner.
sustained or incurred, as a result of any advice or
information obtained by way of the wellbeing program or
any actions chosen by you on the basis of such advice S. No. Body system
or information.
Heart and vascular conditions
 The 360 wellbeing program offered is subject to 1 Myocardial Infarction
revisions based on the insurance regulatory framework 2 Refractory heart failure
from time to time.
3 Cardiomyopathy
Lung Conditions
Disclaimers
4 End stage lung Failure
 Choosing the option is purely on Insured Person’s discretion 5 Primary(Idiopathic) pulmonary Hypertension
and at own risk. Liver conditions

 The wellbeing program is intended to provide supportive 6 End stage liver Failure
information to you to improve well-being and habits through Neuro/ spinal & psychiatric disease
working towards obtaining a healthy lifestyle, and does not 7 Multiple sclerosis with Persisting symptoms
constitute medical advice and/or substitute your visit/
8 Motor neuron disease with Permanent symptoms
consultation to an independent Medical Practitioner.
9 Permanent paralysis of limbs
 We reserve the right to remove or reduce 360 wellbeing 10 Stroke resulting in permanent symptoms
points in case the same have been found to be achieved in
11 Coma of specified severity
any unfair manner by manipulation
12 Alzheimer’s Disease

ICICI Lombard General Insurance Company Limited

I. The first occurrence of heart attack or myocardial 1. FEV1 test results consistently less than 1 litre
infarction, which means the death of a portion of the measured on 3 occasions 3 months apart; and
heart muscle as a result of inadequate blood supply to 2. Requiring continuous permanent supplementary
the relevant area. The diagnosis for Myocardial oxygen therapy for hypoxemia; and
Infarction should be evidenced by all of the following 3. Arterial blood gas analysis with partial oxygen
criteria pressure of 55mmHg or less (PaO2 < 55mmHg);
i. A history of typical clinical symptoms consistent and
with the diagnosis of acute myocardial infarction 4. Dyspnoea at rest.
(For e.g. typical chest pain)
5. PRIMARY (IDIOPATHIC) PULMONARY HYPERTENSION
ii. New characteristic electrocardiogram changes

iii. Elevation of infarction specific enzymes, I. An unequivocal diagnosis of Primary (Idiopathic)

Troponins or other specific biochemical markers Pulmonary Hypertension by a Cardiologist or specialist
in respiratory medicine with evidence of right ventricular
enlargement and the pulmonary artery pressure above
II. The following are excluded: 30 mm of Hg on Cardiac Cauterization. There must be
1. Other acute Coronary Syndromes permanent irreversible physical impairment to the
2. Any type of angina pectoris

ICICI Lombard General Insurance Company Limited

1. Class III: Marked limitation of physical activity.

Comfortable at rest, but less than ordinary activity 10. STROKE RESULTING IN PERMANENT SYMPTOMS
causes symptoms.
2. Class IV: Unable to engage in any physical activity I. Any cerebrovascular incident producing permanent
neurological sequelae. This includes infarction of brain
without discomfort. Symptoms may be present
tissue, thrombosis in an intracranial vessel, haemorrhage
even at rest.
and embolisation from an extracranial source. Diagnosis
has to be confirmed by a specialist medical practitioner
III. Pulmonary hypertension associated with lung disease,
and evidenced by typical clinical symptoms as well as
chronic hypoventilation, pulmonary thromboembolic
typical findings in CT Scan or MRI of the brain. Evidence
disease, drugs and toxins, diseases of the left side of the
of permanent neurological deficit lasting for at least 3
heart, congenital heart disease and any secondary
months has to be produced.
cause are specifically excluded
II. The following are excluded:
6. END STAGE LIVER FAILURE
I. Permanent and irreversible failure of liver function that 1. Transient ischemic attacks (TIA)
has resulted in all three of the following: 2. Traumatic injury of the brain
1. Permanent jaundice; and 3. Vascular disease affecting only the eye or optic
2. Ascites; and nerve or vestibular functions.
3. Hepatic encephalopathy.
11. COMA OF SPECIFIED SEVERITY
II. Liver failure secondary to drug or alcohol abuse is
excluded. I. A state of unconsciousness with no reaction or response
to external stimuli or internal needs. This diagnosis must
7. MULTIPLE SCLEROSIS WITH PERSISTING SYMPTOMS
be supported by evidence of all of the following:

I. The unequivocal diagnosis of Definite Multiple Sclerosis 1. No response to external stimuli continuously for at
confirmed and evidenced by all of the following: least 96 hours;
2. Life support measures are necessary to sustain life;
1. Investigations including typical MRI findings which
and
unequivocally confirm the diagnosis to be multiple
3. Permanent neurological deficit which must be
sclerosis and
assessed at least 30 days after the onset of the
2. There must be current clinical impairment of motor
coma.
or sensory function, which must have persisted for
a continuous period of at least 6 months.
II. The condition has to be confirmed by a specialist medical
practitioner. Coma resulting directly from alcohol or drug
II. Neurological damage due to SLE is excluded. abuse is excluded.

12. ALZHEIMER’S DISEASE

8. MOTOR NEURON DISEASE WITH PERMANENT Progressive and permanent deterioration of memory and
SYMPTOMS intellectual capacity as evidenced by accepted standardised
questionnaires and cerebral imaging.
I. Motor neuron disease diagnosed by a specialist medical
practitioner as spinal muscular atrophy, progressive bulbar The diagnosis of Alzheimer’s Disease must be confirmed by
palsy, amyotrophic lateral sclerosis or primary lateral an appropriate consultant and supported by a Medical
sclerosis. There must be progressive degeneration of Practitioner appointed by Us. There must be significant
corticospinal tracts and anterior horn cells or bulbar reduction in mental and social functioning requiring the
efferent neurons. There must be current significant and continuous supervision of the Insured Person. There must
permanent functional neurological impairment with also be an inability of the Insured Person to perform
objective evidence of motor dysfunction that has persisted (whether aided or unaided) at least three of the Activities of
for a continuous period of at least 3 months. Daily Living, for a continuous period of at least 3 months:

9. PERMANENT PARALYSIS OF LIMBS For the purpose of this clause, Activities of Daily Living are
defined as:

ICICI Lombard General Insurance Company Limited

IRDA Reg. No. 115 CIN: L67200MH2000PLC129408 UIN : ICIHLGP22083V022122 Health Shield 360
Mailing Address: Registered Office Address: Toll free no : 1800 2666
601 & 602, 6th Floor, Interface 16, ICICI Lombard House, 414, Veer Savarkar Marg, Alternate no : 86552 22666 (chargeable)
New Linking Road, Malad (West) Near Siddhi Vinayak Temple, Prabhadevi, E-mail : [email protected]
Mumbai - 400 064 Mumbai 400 025 Website : www.icicilombard.com
15. BENIGN BRAIN TUMOR
1. Washing – the ability to wash in the bath or shower I. Benign brain tumor is defined as a life threatening, non-
(including getting into and out of the bath or shower) or cancerous tumor in the brain, cranial nerves or meninges
wash satisfactorily by other means; within the skull. The presence of the underlying tumor
2. Dressing – the ability to put on, take off, secure and must be confirmed by imaging studies such as CT scan
unfasten all garments and, as appropriate, any braces, or MRI.
artificial limbs or other surgical appliances;
3. Transferring – the ability to move from a bed to an II. This brain tumor must result in at least one of the
upright chair or wheelchair and vice versa; following and must be confirmed by the relevant medical
4. Toileting – the ability to use the lavatory or otherwise specialist.
manage bowel and bladder functions so as to maintain
a satisfactory level of personal hygiene; 1. Permanent Neurological deficit with persisting
5. Feeding – the ability to feed oneself once food has clinical symptoms for a continuous period of at least
been prepared and made available. 90 consecutive days or
6. Mobility - the ability to move from room to room without 2. Undergone surgical resection or radiation therapy
requiring any physical assistance.
to treat the brain tumor.
The following are excluded:
III. The following conditions are excluded:
Cysts, Granulomas, malformations in the arteries or
• Any other type of irreversible organic
veins of the brain, hematomas, abscesses, pituitary
disorder/dementia
tumors, tumors of skull bones and tumors of the spinal
• Alcohol-related brain damage.
cord.
13. PARKINSON’S DISEASE
16. CREUTZFELDT-JAKOB DISEASE (CJD)
I. The occurrence of Parkinson’s Disease where there is an
A diagnosis of Creutzfeldt Jakob Disease must be made by
associated Neurological Deficit that results in permanent
a specialist Medical Practitioner who is a neurologist and the
inability to perform independently at least three of the
diagnosis must be substantiated by CSF examination, EEG,
Activities of Daily Living, for a continuous period of at least
CT Brain and MRI of the brain. There must be permanent
3 months:
clinical loss of the ability in mental, physical and social
functioning for a minimum period of 30 days to the extent
For the purpose of this clause, Activities of Daily Living are
that permanent supervision or assistance by a third party is
defined as:
required
1. Washing: the ability to wash in the bath or shower
17. MAJOR HEAD TRAUMA
(including getting into and out of the bath or shower) or
I. Accidental head injury resulting in permanent Neurological
wash satisfactorily by other means
deficit to be assessed no sooner than 3 months from the
2. Dressing: the ability to put on, take off, secure and
date of the accident. This diagnosis must be supported by
unfasten all garments and, as appropriate, any braces, unequivocal findings on Magnetic Resonance Imaging,
artificial limbs or other surgical appliances; Computerized Tomography, or other reliable imaging
3. Transferring: the ability to move from a bed to an upright techniques. The accident must be caused solely and directly
chair or wheelchair and vice versa; by accidental, violent, external and visible means and
4. Mobility: the ability to move indoors from room to room on independently of all other causes
level surfaces;
5. Toileting: the ability to use the lavatory or otherwise II. The Accidental Head injury must result in an inability to
manage bowel and bladder functions so as to maintain perform at least three (3) of the following Activities of Daily
a satisfactory level of personal hygiene; Living either with or without the use of mechanical
6. Feeding: the ability to feed oneself once food has been equipment, special devices or other aids and adaptations in
prepared and made available. use for disabled persons. For the purpose of this Benefit, the
word “permanent” shall mean beyond the scope of recovery
with current medical knowledge and technology.
The following is excluded:
 Parkinson’s Disease accompanied with drug and/or
III. The Activities of Daily Living are:
alcohol abuse.
I. Washing: the ability to wash in the bath or shower
14. APALLIC SYNDROME (including getting into and out of the bath or shower)
Universal non-functioning of the brain cortex, with the brain or wash satisfactorily by other means;
stem intact. Diagnosis of Apallic Syndrome must be II. Dressing: the ability to put on, take off, secure and
definitely confirmed by a registered Medical Practitioner who unfasten all garments and, as appropriate, any
is also a neurologist and substantiated by clinical and braces, artificial limbs or other surgical appliances;
investigation findings. This condition must be documented III. Transferring: the ability to move from a bed to an
for a continuous period of at least one month. upright chair or wheelchair and vice versa;

ICICI Lombard General Insurance Company Limited

I. End stage renal disease presenting as chronic irreversible 21. POLIOMYELITIS

failure of both kidneys to function, as a result of which The occurrence of Poliomyelitis, where the following
either regular renal dialysis (haemodialysis or peritoneal conditions are met:
dialysis) is instituted or renal transplantation is carried out.
Diagnosis has to be confirmed by a specialist medical I. Poliovirus is identified as the cause through
practitioner. laboratory investigation
II. Paralysis of the limb muscles or respiratory muscles
19. MEDULLARY CYSTIC DISEASE must be present and persist for at least 3 months.
I. Medullary Cystic Disease where the following criteria are
met: The diagnosis of Poliomyelitis must be confirmed by a
i. The presence in the kidney of multiple cysts in the registered Medical Practitioner who is a neurologist.
renal medulla accompanied by the presence of
tubular atrophy and interstitial fibrosis; 22. APLASTIC ANAEMIA
ii. Clinical manifestations of anaemia, polyuria, and Irreversible persistent bone marrow failure which results in
progressive deterioration in kidney function; and anaemia, neutropenia and thrombocytopenia requiring
iii. The diagnosis of Medullary Cystic Disease is treatment with at least two (2) of the following:
confirmed by renal biopsy along with specialist
Medical Practitioner opinion. 1. Blood product transfusion;
2. Marrow stimulating agents;
II. The following are excluded 3. Immunosuppressive agents; or
4. Bone marrow transplantation.
i. Isolated or benign kidney cysts are specifically
excluded from this Benefit The diagnosis of Aplastic anaemia must be confirmed by a
ii. Any condition is which cysts are absent bone marrow biopsy. Atleast two of the following values
should be present:
20. MUSCULAR DYSTROPHY
Diagnosis of muscular dystrophy by a registered Medical 1. Absolute Neutrophil count of 500 per cubic
Practitioner who is a neurologist based on the presence of millimetre or less;
following conditions: 2. Absolute Reticulocyte count of 20,000 per cubic
millimetre or less; and
1. Clinical presentation including weakness and loss of 3. Platelet count of 20,000 per cubic millimetre or less.
muscle mass, absence of sensory disturbance, normal
cerebrospinal fluid and mild tendon reflex reduction; 23. Systemic lupus erythematosus (SLE) with renal
2. Characteristic electromyogram involvement
3. Clinical suspicion confirmed by muscle biopsy. I. Multi-system, autoimmune disorder characterized by the
development of auto-antibodies, directed against
The condition must result in the inability of the Insured various self-antigens. For purposes of the definition of
Person to perform (whether aided or unaided) at least three “SLE” under this policy is restricted to only those forms
of the Activities of Daily Living, for a continuous period of at of systemic lupus erythematosus, which involve the
least 6 months. kidneys and are characterized as Class III, Class IV,
Class V or Class VI lupus nephritis under the
For the purpose of this clause, Activities of Daily Living are Abbreviated International Society of Nephrology/Renal
defined as: Pathology Society (ISN/RPS) classification of lupus
nephritis (2003) below based on renal biopsy.
1. Washing – the ability to wash in the bath or shower
(including getting into and out of the bath or shower) or
wash satisfactorily by other means;

ICICI Lombard General Insurance Company Limited

24. MYASTHENIA GRAVIS 1. Corrected visual acuity being 3/60 or less in both
I. An acquired autoimmune disorder of neuromuscular eyes or ;
transmission leading to fluctuating muscle weakness 2. The field of vision being less than 10 degrees in
and fatigability, where all of the following criteria are met: both eyes.
1. Presence of permanent muscle weakness
III. The diagnosis of blindness must be confirmed and must
categorized as Class IV or V according to the not be correctable by aids or surgical procedure.
Myasthenia Gravis Foundation of America Clinical
Classification below; and 28. DEAFNESS
2. The diagnosis of Myasthenia Gravis and
categorization are confirmed by a registered I. Total and irreversible loss of hearing in both ears as a
Medical Practitioner who is a neurologist. result of illness or accident. This diagnosis must be
Myasthenia Gravis Foundation of America Clinical supported by pure tone audiogram test and certified by
Classification is as follows: an Ear, Nose and Throat (ENT) specialist. Total means
“the loss of hearing to the extent that the loss is greater
Class I: Any eye muscle weakness, possible ptosis, no than 90 decibels across all frequencies of hearing” in
other evidence of muscle weakness elsewhere. both ears.
Class II: Eye muscle weakness of any severity, mild
weakness of other muscles. 29. CANCER OF SPECIFIED SEVERITY
Class III: Eye muscle weakness of any severity,
moderate weakness of other muscles. I. A malignant tumour characterized by the uncontrolled
Class IV: Eye muscle weakness of any severity, severe growth & spread of malignant cells with invasion &
weakness of other muscles. destruction of normal tissues. This diagnosis must be
Class V: Intubation needed to maintain airway. supported by histological evidence of malignancy. The term
cancer includes leukemia, lymphoma and sarcoma.
II. The following are excluded:
II. The following are excluded –
1. Congenital myasthenic syndrome i. All tumors which are histologically described as
2. Transient neonatal or juvenile myasthenia gravis carcinoma in situ, benign, pre-malignant, borderline
malignant, low malignant potential, neoplasm of
25. SCLERODERMA
unknown behavior, or non-invasive, including but not
A systemic collagen-vascular Illness causing progressive
limited to: Carcinoma in situ of breasts, Cervical
diffuse fibrosis in the skin, blood vessels and visceral
dysplasia CIN-1, CIN 2 and CIN-3
organs. This diagnosis must be unequivocally supported by
biopsy and serological evidence and the disorder must have ii. Any non-melanoma skin carcinoma unless there is
reached systemic proportions to involve the heart, lungs or evidence of metastases to lymph nodes or beyond;
kidneys.
iii. Malignant melanoma that has not caused invasion
The following conditions are excluded:
beyond the epidermis;
1. Localised scleroderma (linear scleroderma or
iv. All tumours of the prostate unless histologically
morphea);
classified as having a Gleason score greater than 6
2. Eosinophilic fascitis; and
or having progressed to at least clinical TNM
3. CREST syndrome.
classification T2N0M0
26. GOOD PASTURES SYNDROME with lung or renal v. All Thyroid cancers histologically classified as
involvement T1N0M0 (TNM Classification) or below
Goodpastures Syndrome is an autoimmune disease in
which antibodies attack the lungs and kidneys, leading to
permanent lung and kidney damage. The permanent

ICICI Lombard General Insurance Company Limited

vii. Non-invasive papillary cancer of the bladder Exclusions

histologically described as TaN0M0 or of a lesser We shall not be liable to make any payment for any claim under
classification, Critical illness cover of this Policy in respect of an Insured Person,
directly or indirectly for, caused by, arising from or in any way
viii. All Gastro-Intestinal Stromal Tumors histologically attributable to any of the following:
classified as T1N0M0 (TNM Classification) or below
and with mitotic count of less than or equal to 5/50 1. Any Critical Illness where the symptoms indicative of
HPFs; such Critical Illness have first manifested or first
occurred prior to the Risk Inception Date or arisen within
30. THIRD DEGREE BURNS
first 90 days of commencement of the Period of Cover.

There must be third-degree burns with scarring that cover at 2. Any Critical Illness arising on account of or in connection
least 20% of the body’s surface area. The diagnosis must
with any Pre-Existing Disease(s).
confirm the total area involved using standardized, clinically
accepted, body surface area charts covering 20% of the
3. Any Critical Illness arising out of any Congenital
body surface area.
Anomaly of the Insured Person.
31. LOSS OF SPEECH
4. Any physical, medical or mental condition or treatment
I. Total and irrecoverable loss of the ability to speak as a or service that is specifically excluded in the Policy
result of injury or disease to the vocal cords. The inability
schedule under the head “Special Conditions”.
to speak must be established for a continuous period of
12 months. This diagnosis must be supported by medical 5. Any claim made without a medical certificate from the
evidence furnished by an Ear, Nose, throat (ENT) treating Medical Practitioner evidencing the diagnosis of
specialist. such Critical Illness.

6. Any Critical Illness traceable to pregnancy, childbirth,

32. LOSS OF LIMBS abortion, or related consequences.
The physical separation of two or more limbs, at or above the On the occurrence of an Insured Event which may give rise to a
wrist or ankle level as a result of injury or disease. This will claim under this Benefit, We shall be provided with the necessary
include medically necessary amputation necessitated by and mandatory information specified in “A” for all claims, and
injury or disease. The separation has to be permanent additional documentation specified in “B” in relation to the
without any chance of surgical correction. Loss of Limbs particular Critical Illness being claimed, within 30 days of
resulting directly or indirectly from self-inflicted injury, alcohol occurrence of the Insured Event:
or drug abuse is excluded.
A: Common documents required for all claims under
33. LOSS OF INDEPENDENT EXISTENCE this Benefit:
Confirmation by a Consultant Physician of the loss of 1.
Claim Form duly filled and signed by Insured
independent existence due to illness or trauma, lasting for a Person/Nominee/claimant
minimum period of 6 months and resulting in a permanent 2. Paper
EMS
inability to perform at least three of the Activities of Daily
3.
Discharge Card/Summary papers
Living, with no hope of recovery
4. Case papers
Indoor
For the purpose of this clause, Activities of Daily Living are 5.
Hospital Bills
defined as:
All Investigation Reports – blood, pathology, radiology, etc.
6.
1. Washing – the ability to wash in the bath or shower Certificate
7. by treating Medical Practitioner confirming
diagnosis
(including getting into and out of the bath or shower)
8.
Current and past consultation papers
or wash satisfactorily by other means;
2. Dressing – the ability to put on, take off, secure and Certificate
9. of Medical Cause of Death issued by last
unfasten all garments and, as appropriate, any attending Medical Practitioner (wherever applicable)
braces, artificial limbs or other surgical appliances; Certificate
10. from last attending Medical Practitioner /medical
3. Transferring – the ability to move from a bed to an authority for underlying medical condition/s leading to death
upright chair or wheelchair and vice versa; of the Insured Person
4. Toileting – the ability to use the lavatory or otherwise Post
11. Mortem Report, FSL Report, Viscera and Chemical
manage bowel and bladder functions so as to Analysis Report, Histopathoilogy Report (wherever
maintain a satisfactory level of personal hygiene; applicable)
5. Feeding – the ability to feed oneself once food has Any
12.other specific investigation / document to support the
diagnosis of such Critical Illness, as may be reasonably
been prepared and made available.

ICICI Lombard General Insurance Company Limited

Complete loss Visual Field Testing, Vision Acuity b) Permanent Total Disablement (PTD) Benefit
of Testing, Certificate from Civil We will pay You or Your Nominee / legal heir, as the case may
27
vision(Blindne Surgeon confirming the diagnosis be, the Annual Sum Insured as specified against this benefit
ss) and disability in the Policy Schedule/Key Information Sheet if you suffer
from an Injury due to an Accident that occurs during the Period
of Cover and that Injury solely and directly results in the

ICICI Lombard General Insurance Company Limited

i. If the Insured Person dies before a claim has been % OF SUM

SR
admitted under this Benefit, then no amount will be LOSSES COVERED INSURED
No.
payable under this Benefit, but a claim will be payable
considered under Death benefit, if in force for the 1 Loss of one entire hand 70
Insured Person.
ii. If the Insured Person suffers Injuries resulting in more 2 Loss of one entire foot 70
than one of the Permanent Total Disablements, then 3 Loss of use of one eye 50
Our maximum, total and cumulative liability under this
4 Loss of all toes 20
Benefit shall be limited to the Sum Insured.
iii. If We have admitted a claim for Permanent Total 5 Loss of great toe - both phalanges 5
Disablement in accordance with this Benefit, then We
6 Loss of great toe - one phalanx 2
shall not be liable to make any payment under the
Policy under Death Benefit on the death of the Insured Other than great toe if more than one toe
7 5
lost each
Person, if the Insured Person subsequently dies.
However, any other applicable Benefits which may 8 Loss of use of both ears 75
get triggered will be considered in accordance with 9 Loss of use of one ear 30
the terms and conditions of the applicable Benefits.
Loss of four fingers and thumb of one
iv. We will only accept one claim under this Benefit in the 10 40
hand
lifetime of the Insured Person. On the acceptance of
11 Loss of four fingers 35
a claim under this Benefit, all cover under this Benefit
in respect of the Insured Person shall immediately 12 Loss of thumb - both phalanges 25
and automatically cease.
13 Loss of thumb - one phalanx 10
On the acceptance of a claim under this Benefit, insurance 14 Loss of index finger - three phalanges 10
cover under any other applicable Benefits under this Policy
15 Loss of index finger - two phalanges 8
whether in the present Period of Cover or any subsequent
Period of Cover shall continue subject to the availability of the 16 Loss of index finger - one phalanx 4
Sum Insured and the terms, conditions and exclusions of the 17 Loss of middle finger - three phalanges 6
Policy.
18 Loss of middle finger - two phalanges 4
Claims Document Required 19 Loss of middle finger - one phalanx 2
 Claim form duly filled and signed by You 20 Loss of ring finger - three phalanges 5
 MLC or FIR 21 Loss of ring finger - two phalanges 4
 Police Final Charge Sheet / Court Final Order
 Spot / Inquest Panchnama 22 Loss of ring finger - one phalanx 2
 Disability Certificate issued by civil or government 23 Loss of little finger - three phalanges 4
hospital
24 Loss of little finger - two phalanges 3
 Indoor case papers
 Medical Certificate/Reports 25 Loss of little finger - one phalanx 2
 Discharge certificate, Original bills and receipts form the Loss of metacarpus - first or second
26 3
hospital/Medical Practitioner (additional)
 Photo of Insured Person showing the disability 27
Loss of metacarpus - third, fourth or fifth
2
 Any other document as may be required by Us. (additional)

This Benefit shall be payable subject to the following:

c) Permanent Partial Disablement Benefit (PPD)
We will pay the percentage of the Sum Insured (specified i. If the Insured Person dies before a claim has been
against this Benefit in the Policy Schedule/Key Information admitted under this Benefit, then no amount will be
Sheet in the manner which is specified in the table below if payable under this Benefit, but a claim will be
you suffer an Injury due to an Accident that occurs during the considered under Death Benefit
Period of Cover and that Injury solely and directly results in
the Permanent Partial Disablement of the Insured Person ii. If a claim is accepted under this Benefit in respect of an
(which is of the nature specified in the table below) within 365 Insured Person and the amount due under this claim
days from the date of the Accident. and claims already admitted under the Benefit in
respect of the Insured Person will cumulatively lead to
the Sum Insured being exceeded then Our maximum,

ICICI Lombard General Insurance Company Limited

IRDA Reg. No. 115 CIN: L67200MH2000PLC129408 UIN : ICIHLGP22083V022122 Health Shield 360
Mailing Address: Registered Office Address: Toll free no : 1800 2666
601 & 602, 6th Floor, Interface 16, ICICI Lombard House, 414, Veer Savarkar Marg, Alternate no : 86552 22666 (chargeable)
New Linking Road, Malad (West) Near Siddhi Vinayak Temple, Prabhadevi, E-mail : [email protected]
Mumbai - 400 064 Mumbai 400 025 Website : www.icicilombard.com
total and cumulative liability under any and all such 8 Any Accidental Injury / Illness directly or indirectly
claims will be limited to the annual Sum Insured. caused by venereal disease
9 Injury sustained whilst engaging in Adventure Sports
iii. On the acceptance of a claim under this Benefit, the
10 Any Injury that has occurred prior to the commencement
Insured Person’s insurance cover under this Benefit
of Policy of Cover whether or not the same has been
and the Policy shall continue, subject to the availability
of the Annual Sum Insured and the terms, conditions treated, or medical advice, diagnosis, care or treatment
and exclusions of this Policy. has been sought
11 Payment of compensation in respect of death,
disablement (whether of a permanent nature or of a
Claims Document required temporary nature), Injury, Illness or Hospitalization of the
 Claim form duly filled and signed by You Insured Person resulting directly from, or indirectly
 MLC or FIR caused by, or contributed to or aggravated or prolonged
 Police Final Charge Sheet / Court Final Order by, childbirth or pregnancy or in consequence thereof.
 Spot / Inquest Panchnama 12 Payment of compensation in respect of death,
 Disability Certificate issued by civil or government disablement (whether of a permanent nature or of a
hospital
temporary nature), Injury, Illness or Hospitalization of
 Indoor case papers
Insured Person due to animal or insect or reptile attack.
 Medical Certificate
13 Death, disablement (whether of a permanent nature or
 Photo of Insured Person showing the disability
of a temporary nature), Injury, Illness or Hospitalization
 Any other document as may be required by Us.
arising from or caused by ionizing radiation or
EXCLUSIONS AND LIMITATIONS APPLICABLE TO DEATH contamination by radioactivity from any nuclear fuel
BENEFIT, PERMANENT TOTAL DISABLEMENT AND (explosive or hazardous form) or resulting from or from
PERMANENT PARTIAL DISABLEMENT. any other cause or event contributing concurrently or in
any other sequence to the loss, claim or expense from
We shall not be liable to make any payment for any claim under any nuclear waste from the combustion of nuclear fuel,
this cover in respect of an Insured Person, directly or indirectly nuclear, chemical or biological attack.
for, caused by, arising from or in any way attributable to any of
the following: 31 Recovery Benefit
1 War, invasion, act of foreign enemy hostilities or warlike In consideration of the payment of additional premium to us .We
operations (whether war be declared or not) or civil will pay the you 1% of Sum insured maximum up to ₹ 50,000 as
commotion or rebellion, revolution, insurrection, mutiny,
specified against this Benefit in the Policy Schedule/Key
arrests, detainments of all kinds and political gatherings,
Information Sheet, if you suffer an Injury due to an Accident that
engaging in aviation other than as a passenger (fare
occurs during the Period of Cover and that solely and directly
paying or otherwise) in any licensed standard type of
results in your hospitalization for at least 7 continuous days.
aircraft
2 Any Injury sustained while performing duty in army, This Benefit shall be payable subject to the following:
navy, air force, paramilitary force, police or any other i. We will accept multiple claims under this Benefit during the
such institution. Period of Cover in respect of you. However Our maximum,
3 Any event which occurs whilst the Insured Person is total and cumulative liability for claims arising in respect to
operating or learning to operate any aircraft or common you under this Benefit during the Period of Cover shall be
carrier, or performing duties as a member of the crew on 1% of Sum Insured maximum up to ₹ 50,000 as specified
any aircraft, or scheduled airlines or is engaging in against this Benefit in the Policy Certificate.
aviation, or whilst the Insured Person is mounting into,
or dismounting from or traveling in any balloon or ii. We have accepted a claim under hospitalization expenses
aircraft other than as a passenger (fare-paying or in respect to you for the same Accident for which this benefit
otherwise) in any scheduled airline anywhere in the is being availed.
world. 32 Mobility Benefit
4 Breach of law or while being involved in any unlawful
activity. In consideration of the payment of additional premium to us .We
5 Any Injury / Illness arising from intentional self- Injury, will pay you 1% of sum insured maximum up to ₹50,000 under
suicide or attempted suicide. this Benefit to you towards modification of home, office and / or
6 Any Injury / Illness arising whilst under the influence of vehicle or towards purchase of an Artificial Limb or any
alcohol or intoxicating drugs or substance abuse of any prosthesis or any other expenses because of Permanent Total
kind. Disablement or Permanent Partial Disablement (which is only of
the nature specified in the table below) covering the disabilities
7 Any Injury / Illness occurring whilst working in
mentioned in the table below suffered by the Insured Person.
underground mines or explosives magazines, or
However, Our liability for payment of all claims under this
involving electrical installation with high tension supply,
Benefit in aggregate for Period of Cover shall in no case exceed
or as jockeys or circus personnel

ICICI Lombard General Insurance Company Limited

3.2 Code- Excl02: Specified disease/procedure waiting

This Benefit shall be payable subject to the following:
period
a) We have accepted Your claim under PTD or PPD. a) Expenses related to the treatment of the listed
Conditions, surgeries/treatments shall be excluded
b) We will only accept only one claim under this Benefit
until the expiry of specified months of continuous
in your lifetime. On the acceptance of a claim under
coverage after the date of inception of the first policy
this Benefit, all cover under this Benefit in respect to
you shall immediately and automatically cease but with us. This exclusion shall not be applicable for
insurance cover under any other applicable Benefits claims arising due to an accident.
under this Policy during the Period of Cover shall b) In case of enhancement of sum insured the exclusion
continue subject to the availability of the Sum Insured shall apply afresh to the extent of sum insured
and the terms, conditions and exclusions of the increase.
Policy. c) If any of the specified disease/procedure falls under
the waiting period specified for pre-Existing diseases,
c) The Modification of the house or vehicle are carried
then the longer of the two waiting periods shall apply.
out to facilitate your activities of daily living.
d) The waiting period for listed conditions shall apply
d) The modification is carried out in the house where even if contracted after the policy or declared and
you resides after injury. accepted without a specific exclusion.
e) If the Insured Person is continuously covered without
e) The vehicle should be the one which was being used
any break as defined under the applicable norms on
by you before the occurrence of the injury
portability stipulated by IRDAI, then waiting period for
f) The expenses are not related to the repair, the same would be reduced to the extent of prior
renovation or improvisation of the existing coverage.
establishment or vehicle List of specific diseases/procedure:

g) The modification is carried out within three months • Cataract

form your intimation of claim. • Benign Prostatic Hypertrophy
• Myomectomy, Hysterectomy unless because of
malignancy
e) WHAT WE WILL NOT PAY (EXCLUSIONS UNDER THE
• All types of Hernia, Hydrocele
POLICY)
• Fissures &/or Fistula in anus, hemorrhoids/piles
• Arthritis, gout, rheumatism and spinal disorders
We will not be liable for any Deductible amount, if applicable
• Joint replacements unless due to accident
and as specifically defined in the Policy Schedule under the
• Sinusitis and related disorders
Policy
• Stones in the urinary and billiary systems
We shall not be liable to make any payment under this Policy
• Dilatation and curettage , Endometriosis
in connection with or in respect of any expenses whatsoever
• All types of Skin and internal tumors/
incurred by You in connection with or in respect of:
cysts/nodules/ polyps of any kind including breast
i. Standard Exclusions lumps unless malignant
• Dialysis required for chronic renal failure
3.1 Code- Excl01: Pre-Existing Diseases • Surgery on tonsils, adenoids and sinuses

ICICI Lombard General Insurance Company Limited

IRDA Reg. No. 115 CIN: L67200MH2000PLC129408 UIN : ICIHLGP22083V022122 Health Shield 360
Mailing Address: Registered Office Address: Toll free no : 1800 2666
601 & 602, 6th Floor, Interface 16, ICICI Lombard House, 414, Veer Savarkar Marg, Alternate no : 86552 22666 (chargeable)
New Linking Road, Malad (West) Near Siddhi Vinayak Temple, Prabhadevi, E-mail : [email protected]
Mumbai - 400 064 Mumbai 400 025 Website : www.icicilombard.com
• Gastric and Duodenal erosions & ulcers II. Any services for people who are terminally ill
• Deviated Nasal Septum to address physical, social, emotional and
• Varicose Veins/ Varicose Ulcers spiritual needs.
• All types of internal congenital anomalies/
illness/defects such as but not limited to iii. Code- Excl06: Obesity/ Weight Control Expenses
congenital heart disease like VSD, ASD, related to the surgical treatment of obesity that does
TOF,PDA, Cryptorchidism, Congenital hernia, not fulfil all the below conditions:
Achalasia cardia, Spinal defects like spina bifida 1) Surgery to be conducted is upon the advice of the
Doctor
3.3 2) The surgery/Procedure conducted should be
a) Expenses related to the treatment of the below supported by clinical protocols
mentioned illness within 90 days from the first policy 3) The member has to be 18 years of age or older
commencement date shall be excluded unless they and
are pre-existing and disclosed at the time of 4) Body Mass Index (BMI);
underwriting 5) greater than or equal to 40 or
i. Hypertension 6) greater than or equal to 35 in conjunction with any
ii. Diabetes of the following severe co-morbidities following
iii. Cardiac Conditions failure of less invasive methods of weight loss:
b) This exclusion shall not, however, apply if the Insured o Obesity-related cardiomyopathy
Person has continuous coverage for more than twelve o Coronary heart disease
months. o Severe Sleep Apnea
The within referred waiting period is made applicable to o Uncontrolled Type2 Diabetes
the enhanced sum insured in the event of granting
higher sum insured subsequently. iv. Code- Excl07: Change of Gender treatments
Expenses related to any treatment, including surgical
3.4 Code- Excl03: 0 or 30-day waiting period management, to change characteristics of the body to
a) Expenses related to the treatment of any illness those of the opposite sex.
within 30 days from the first policy commencement
v. Code- Excl08: Cosmetic or plastic Surgery
date shall be excluded except claims arising due to
Expenses for cosmetic or plastic surgery or any
an accident, provided the same are covered.
treatment to change appearance unless for
b) This exclusion shall not, however, apply if the
reconstruction following an Accident, Burn(s) or
Insured Person has Continuous Coverage for more
Cancer or as part of medically necessary treatment to
than twelve months.
remove a direct and immediate health risk to the
c) The within referred waiting period is made
insured. For this to be considered a medical necessity,
applicable to the enhanced sum insured in the event
it must be certified by the attending Medical
of granting higher sum insured subsequently.
Practitioner.
3.5 Permanent Exclusions vi. Code- Excl09: Hazardous or Adventure sports
i. Code- Excl04: Investigation & Evaluation Expenses related to any treatment necessitated due
a) Expenses related to any admission primarily for to participation as a professional in hazardous or
diagnostics and evaluation purposes only are adventure sports, including but not limited to, para-
excluded. jumping, rock climbing, mountaineering, rafting, motor
b) Any diagnostic expenses which are not related or racing, horse racing or scuba diving, hand gliding, sky
not incidental to the current diagnosis and diving, deep-sea diving.
treatment are excluded.
vii. Code- Excl10: Breach of law
Expenses for treatment directly arising from or
ii. Code- Excl05: Exclusion Name: Rest Cure,
consequent upon any Insured Person committing or
rehabilitation and respite care
attempting to commit a breach of law with criminal
a) Expenses related to any admission primarily for
intent.
enforced bed rest and not for receiving treatment.
This also includes:
viii. Code- Excl11: Excluded Providers
I. Custodial care either at home or in a nursing
Expenses incurred towards treatment in any hospital
facility for personal care such as help with
or by any Medical Practitioner or any other provider
activities of daily living such as bathing,
specifically excluded by the Insurer and disclosed in
dressing, moving around either by skilled
its website / notified to the policyholders/proposers are
nurses or assistant or non-skilled persons.
not admissible. However, in case of life threatening

ICICI Lombard General Insurance Company Limited

ix. Code- Excl12: Treatment for, Alcoholism, drug or c) Expenses incurred on all dental treatment unless
substance abuse or any addictive condition and necessitated due to an Accident
consequences thereof.
d) Personal comfort, cosmetics, convenience and hygiene
x. Code- Excl13: Treatments received in heath related items and services
hydros, nature cure clinics, spas or similar
establishments or private beds registered as a nursing e) Acupressure, acupuncture, magnetic and other therapies
home attached to such establishments or where
admission is arranged wholly or partly for domestic f) Circumcision unless necessary for treatment of an Illness or
reasons. necessitated due to an Accident. Expenses for venereal disease
or any sexually transmitted disease
xi. Code- Excl14: Dietary supplements and substances
that can be purchased without prescription, g) Treatment relating to birth defects and external congenital
including but not limited to Vitamins, minerals and Illnesses or defects or anomalies such as but not limited to
organic substances unless prescribed by a medical Cleft lip, Combination of cleft lip and cleft palate, Tongue Tie,
practitioner as part of hospitalisation claim or day care CTEV (Club foot), Congenital Torticollis, Morphological
procedure. abnormalities like congenital kyphosis, congenital scoliosis
etc., and Phimosis
xii. Code- Excl15: Refractive Error: Expenses related to
the treatment for correction of eye sight due to h) Any expenses arising out of Domiciliary Hospitalisation
refractive error less than 7.5 dioptres treatment
xiii. Code- Excl16: Unproven Treatments: Expenses
related to any unproven treatment, services and i) Treatment taken outside the country
supplies for or in connection with any treatment.
Unproven treatments are treatments, procedures or j) Intentional self-injury (whether arising from an attempt to
supplies that lack significant medical documentation to commit suicide or otherwise)
support their effectiveness.
k) Expenses related to donor screening, treatment, including
xiv. Code- Excl17: Sterility and Infertility: Expenses surgery to remove organs from a donor in the case of transplant
related to, sterility and infertility. This includes: surgery
a) Any type of contraception, sterilization
b) Assisted Reproduction services including l) Any injury or illness caused by or arising from or attributed to
artificial insemination and advanced reproductive war, invasion, acts of foreign enemies, hostilities (whether war
technologies such as IVF, ZIFT, GIFT, ICSI be declared or not), civil war, commotion, unrest, rebellion,
c) Gestational Surrogacy revolution, military or usurped power or confiscation or
d) Reversal of sterilization nationalisation or requisition of or damage by or under the order
of any government or public local authority
xv. Code- Excl18: Maternity: Medical treatment
expenses traceable to childbirth (including m) Any Illness or Injury caused by or contributed to by nuclear
complicated deliveries and caesarean sections weapons/materials or contributed to by or arising from ionising
incurred during hospitalisation) except ectopic radiation or contamination by radioactivity by any nuclear fuel or
pregnancy. Expenses towards miscarriage (unless from any nuclear waste or from the combustion of nuclear fuel
due to an accident) and lawful medical termination of
pregnancy during the policy period *some of the exclusion will be waived off if the add on cover is
opted for the same.
ii. Specific Exclusions
PART III OF THE POLICY
a) Any ailment / illness, injury, condition or treatment or service
that is specifically excluded in the Policy Schedule under f) GENERAL TERMS AND CONDITIONS
Special Conditions.
i. Standard General Terms and Clauses
b) Any expenses incurred on prosthesis, corrective devices,
external durable medical equipment of any kind, like 1. Disclosure of Information

ICICI Lombard General Insurance Company Limited

IRDA Reg. No. 115 CIN: L67200MH2000PLC129408 UIN : ICIHLGP22083V022122 Health Shield 360
Mailing Address: Registered Office Address: Toll free no : 1800 2666
601 & 602, 6th Floor, Interface 16, ICICI Lombard House, 414, Veer Savarkar Marg, Alternate no : 86552 22666 (chargeable)
New Linking Road, Malad (West) Near Siddhi Vinayak Temple, Prabhadevi, E-mail : [email protected]
Mumbai - 400 064 Mumbai 400 025 Website : www.icicilombard.com
The policy shall be void and all premium paid thereon shall be ii. lnsured person having multiple policies shall also have
forfeited to the Company in the event of misrepresentation, mis the right to prefer claims under this policy for the
description or non-disclosure of any material fact by the amounts disallowed under any other policy / policies
policyholder. even if the sum insured is not exhausted. Then the
insurer shall independently settle the claim subject to
(Explanation: "Material facts" for the purpose of this policy shall the terms and conditions of this policy.
mean all relevant information sought by the company in the iii. lf the amount to be claimed exceeds the sum insured
proposal form and other connected documents to enable it to under a single policy, the insured person shall have the
take informed decision in the context of underwriting the risk) right to choose insurer from whom he/she wants to
claim the balance amount.
2. Condition Precedent to Admission of Liability iv. Where an insured person has policies from more than
The terms and conditions of the policy must be fulfilled by the one insurer to cover the same risk on indemnity basis,
insured person for the Company to make any payment for the insured person shall only be indemnified the
claim(s) arising under the policy. treatment costs in accordance with the terms and
conditions of the chosen policy.
3. Claim settlement(provision for penal interest)
I. The Company shall settle or reject a claim, as the
6. Fraud
case may be, within 30 days from the date of receipt
lf any claim made by the insured person, is in any respect
of last necessary document
fraudulent, or if any false statement, or declaration is made or
II. ln the case of delay in the payment of a claim, the
used in support thereof, or if any fraudulent means or devices
Company shall be liable to pay interest to the
are used by the insured person or anyone acting on his / her
policyholder from the date of receipt of last
behalf to obtain any benefit under this policy, all benefits under
necessary document to the date of payment of claim
this policy and the premium paid shall be forfeited.
at a rate 2% above the bank rate.
III. However, where the circumstances of a claim
Any amount already paid against claims made under this
warrant an investigation in the opinion of the
policy but which are found fraudulent later shall be repaid by
Company, it shall initiate and complete such
all recipient(s)/policyholder(s), who has made that particular
investigation at the earliest, in any case not later
claim, who shall be jointly and severally liable for such
than 30 days from the date of receipt of last
repayment to the insurer.
necessary document- ln such cases, the Company
shall settle or reject the claim within 45 days from the
For the purpose of this clause, the expression "fraud" means
date of receipt of last necessary document.
any of the following acts committed by the insured person or
IV. ln case of delay beyond stipulated 45 days, the
by his agent or the hospital/doctor/any other pa(y acting on
Company shall be liable to pay interest to the
behalf of the insured person, with intent to deceive the insurer
policyholder at a rate 2% above the bank rate from
or to induce the insurer to issue an insurance policy:
the date of receipt of last necessary document to the
a) the suggestion, as a fact of that which is not true and
date of payment of claim.
which the insured person does not believe to be true;
(Explanation: "Bank rate" shall mean the rate fixed by b) the active concealment of a fact by the insured person
the Reserve Bank of lndia (RBl) at the beginning of the having knowledgeor belief of the fact;
financial year in which claim has fallen due) c) any other act fitted to deceive; and
d) any such act or omission as the law specially declares
4. Complete Discharge to be fraudulent
Any payment to the policyholder, insured person or his/ her
nominees or his/ her legal representative or assignee or to The Company shall not repudiate the claim and / or forfeit the
the Hospital, as the case may be, for any benefit under the policy benefits on the ground of Fraud, if the insured person /
policy shall be a valid discharge towards payment of claim beneficiary can prove that the misstatement was true to the
by the Company to the extent of that amount for the best of his knowledge and there was no deliberate intention to
particular claim. suppress the fact or that such misstatement of or suppression
of material fact are within the knowledge of the insurer.
5. Multiple Policies
i. ln case of multiple policies taken by an insured person
7. Cancellation
during a period from one or more insurers to indemnify
a) The Insured may cancel this Policy by giving 15days'
treatment costs, the insured person shall have the right
written notice, and in such an event, the Company shall
to require a settlement of his/her claim in terms of any
refund premium on short term rates for the unexpired
of his/her policies. ln all such cases the insurer chosen
Policy Period as per the rates detailed below.
by the insured person shall be obliged to settle the claim
as long as the claim is within the limits of and according
Cancellation Refund Refund Refund Refund Refund
to the terms of the chosen policy.

ICICI Lombard General Insurance Company Limited

IRDA Reg. No. 115 CIN: L67200MH2000PLC129408 UIN : ICIHLGP22083V022122 Health Shield 360
Mailing Address: Registered Office Address: Toll free no : 1800 2666
601 & 602, 6th Floor, Interface 16, ICICI Lombard House, 414, Veer Savarkar Marg, Alternate no : 86552 22666 (chargeable)
New Linking Road, Malad (West) Near Siddhi Vinayak Temple, Prabhadevi, E-mail : [email protected]
Mumbai - 400 064 Mumbai 400 025 Website : www.icicilombard.com
Period % for 1 % for 2 % for 3 % for 4 % for 5 on Migration. lf such person is presently covered and has
year years years years years been continuously covered without any lapses under any
tenure tenure tenure tenure tenure health insurance product/ plan offered by the company, the
policy policy policy policy policy
insured person will get the accrued continuity benefits in
From 16
waiting periods as per IRDAI guidelines on migration.
days to 1 77.5% 80.0% 82.5% 82.5% 82.5%
month
From 1 For Detailed Guidelines on migration, kindly refer the link
month to 3 62.5% 72.5% 77.5% 77.5% 80.0% https://www.irdai.gov.in/ADMINCMS/cms/frmGuidelines_Lay
months out.aspx?page=PageNo3987
From 3
months to 6 42.5% 62.5% 70.0% 72.5% 75.0% 9. Portability
months The insured person will have the option to port the policy to
From 6 other insurers by applying to such insurer to port the entire
months to 9 20.0% 52.5% 62.5% 67.5% 70.0% policy along with all the members of the family, if any, at least
months 45 days before, but not earlier than 60 days from the policy
From 9 renewal date as per IRDAI guidelines related to portability. lf
months to 0.0% 42.5% 55.0% 62.5% 67.5% such person is presently covered and has been continuously
12 months covered without any lapses under any health insurance policy
From 12 with an lndian General/Health insurer, the proposed insured
months to 30.0% 47.5% 57.5% 62.5% person will get the accrued continuity benefits in waiting
15 months periods as per IRDAI guidelines on portability.
From 15 For Detailed Guidelines on portability, kindly refer the link
months to 20.0% 42.5% 52.5% 57.5% https://www.irdai.gov.in/ADMINCMS/cms/frmGuidelines_Lay
18 months out.aspx?page=PageNo3987
From 18
months to 10.0% 35.0% 47.5% 55.0% 10. Renewal of Policy
21 months The policy shall ordinarily be renewable except on
From 21 misrepresentation by the insured person.
months to 0.0% 27.5% 42.5% 50.0%
24 months i. The Company shall endeavor to give notice for
From 24 renewal. However, the Company is not under
months to 20.0% 35.0% 45.0%
27 months obligation to give any notice for renewal.
From 27 ii. Renewal shall not be denied on the ground that the
months to 12.5% 30.0% 42.5%
30 months insured person had made a claim or claims in the
From 30 preceding policy years.
months to 5.0% 25.0% 37.5%
33 months
iii. Request for renewal along with requisite premium
From 33 shall be received by the Company before the end of
months to 0.0% 20.0% 32.5%
the policy period.
36 months
Notwithstanding anything contained herein or iv. At the end of the policy period, the policy shall
otherwise, no refunds of premium shall be made in terminate and can be renewed within the Grace
respect of Cancellation where, any claim has been
Period of 30 days to maintain continuity of benefits
admitted or has been lodged or any benefit has been
availed by the Insured person under the Policy. without break in policy. Coverage is not available
during the grace period.
b) The Company may cancel the Policy at any time on v. No loading shall apply on renewals based on
grounds of mis-representation, non-disclosure of
material facts, fraud by the Insured Person, by giving 15 individual claims experience
days' written notice. There would be no refund of
premium on cancellation on grounds of mis- 11. Withdrawal of Policy
representation, non-disclosure of material facts or i. ln the likelihood of this product being withdrawn in
fraud. future, the Company will intimate the insured person
about the same 90 days prior to expiry of the policy.
ii. lnsured Person will have the option to migrate to similar
8. Migration:
health insurance product available with the Company at
The insured person will have the option to migrate the policy the time of renewal with all the accrued continuity
to other health insurance products/plans offered by the benefits such as cumulative bonus, waiver of waiting
company by applying for migration of the policy atleast 30 period. as per IRDAI guidelines, provided the policy has
days before the policy renewal date as per IRDAI guidelines been maintained without a break.

ICICI Lombard General Insurance Company Limited

IRDA Reg. No. 115 CIN: L67200MH2000PLC129408 UIN : ICIHLGP22083V022122 Health Shield 360
Mailing Address: Registered Office Address: Toll free no : 1800 2666
601 & 602, 6th Floor, Interface 16, ICICI Lombard House, 414, Veer Savarkar Marg, Alternate no : 86552 22666 (chargeable)
New Linking Road, Malad (West) Near Siddhi Vinayak Temple, Prabhadevi, E-mail : [email protected]
Mumbai - 400 064 Mumbai 400 025 Website : www.icicilombard.com
15. Redressal of Grievances
12. Premium Payment in installments ln case of any grievance the insured person may contact the
lf the insured person has opted for Payment of Premium on company through
an instalment basis i.e. Half Yearly, Quarterly or Monthly, as Website: www.icicilombard.com
mentioned in the policy Schedule/Certificate of lnsurance, Toll Free: 1800 2666
the following Conditions shall apply (notwithstanding any E-Mail: [email protected]
terms contrary elsewhere in the policy) Courier: ICICI Lombard General Insurance Company
i. Grace Period of 15 days would be given to pay the Ltd.
instalment premium due for the policy ICICI Lombard House,
ii. During such grace period, coverage will not be 414, Veer Savarkar Marg,
available from the due date of instalment premium
Near Siddhi Vinayak Temple,
till the date of receipt of premium by Company.
iii. The insured person will get the accrued continuity Prabhadevi, Mumbai- 400025
benefit in respect of the "Waiting Periods", "Specific lnsured person may also approach the grievance cell at any
Waiting Periods" in the event of payment of
of the company's branches with the details of grievance
premium within the stipulated grace Period.
iv. No interest will be charged lf the instalment lf lnsured person is not satisfied with the redressal of
premium is not paid on due date. grievance through one of the above methods, insured
v. ln case of instalment premium due not received
person may contact the grievance officer at Manager-
within the grace period, the policy will get cancelled.
vi. ln the event of a claim, all subsequent premium Service Quality, Corporate Manager- Service Quality,
instalments shall immediately become due and National Manager- Operations & finally Director-services
payable. and Business development at the following address:
vii. The company has the right to recover and deduct all
the pending instalments from the claim amount due
under the policy. ICICI Lombard General Insurance Company Limited,
ICICI Lombard House,
13. Possibility of Revision of Terms of the Policy Including 414, Veer Savarkar Marg,
the Premium Rates Near Siddhi Vinayak Temple,
The Company, with prior approval of lRDAl, may revise or Prabhadevi, Mumbai 400025
modify the terms of the policy including the premium rates. For updated details of grievance officer, kindly refer the link..
The insured person shall be notified three months before .https://www.icicilombard.com/grievance-redressal...
the changes are effected. lf lnsured person is not satisfied with the redressal of
grievance through above methods, the insured person may
14. Free look period also approach the office of lnsurance Ombudsman of the
The Free Look Period shall be applicable on new individual respective area/region for redressal of grievance as per
lnsurance Ombudsman Rules 2017. Grievance may also be
health insurance policies and not on renewals or at the
lodged at IRDAI lntegrated Grievance Management System
time of porting/migrating the policy. - https:/ligms. irda.qov. in/
The insured person shall be allowed free look period of
fifteen days from date of receipt of the policy document to The Details of Insurance Ombudsman are Available Below:
review the terms and conditions of the policy, and to return
the same if not acceptable. Jurisdiction of
Office Details Office Union
lf the insured has not made any claim during the Free Look Territory, District)
Period, the insured shall be entitled to
AHMEDABAD
i. a refund of the premium paid less any expenses incurred
Office of the Insurance Ombudsman,
by the Company on medical examination of the insured Jeevan Prakash Building, 6th floor, Gujarat,
Tilak Marg, Relief Road, Dadra & Nagar
person and the stamp duty charges or
Ahmedabad – 380 001. Haveli,
ii. where the risk has already commenced and the option Tel.: 079 - 25501201/02/05/06 Daman and Diu.
Email:
of return of the policy is exercised by the insured person,
[email protected]
a deduction towards the proportionate risk premium for BENGALURU
period of cover or Office of the Insurance Ombudsman,
Jeevan Soudha Building, PID No. 57-
iii. Where only a part of the insurance coverage has 27-N-19
Karnataka.
commenced, such proportionate premium Ground Floor, 19/19, 24th Main Road,
JP Nagar, Ist Phase,
commensurate with the insurance coverage during such Bengaluru – 560 078.
period; Tel.: 080 - 26652048 / 26652049

ICICI Lombard General Insurance Company Limited

IRDA Reg. No. 115 CIN: L67200MH2000PLC129408 UIN : ICIHLGP22083V022122 Health Shield 360
Mailing Address: Registered Office Address: Toll free no : 1800 2666
601 & 602, 6th Floor, Interface 16, ICICI Lombard House, 414, Veer Savarkar Marg, Alternate no : 86552 22666 (chargeable)
New Linking Road, Malad (West) Near Siddhi Vinayak Temple, Prabhadevi, E-mail : [email protected]
Mumbai - 400 064 Mumbai 400 025 Website : www.icicilombard.com
Chandauli, Ballia, of the Company
Sidharathnagar.
16. Nomination:
The policyholder is required at the inception of the policy to
make a nomination for the purpose of payment of claims under
the policy in the event of death of the policyholder. Any change
of nomination shall be communicated to the company in
writing and such change shall be effective only when an
MUMBAI
Office of the Insurance Ombudsman, endorsement on the policy is made. ln the event of death of
3rd Floor, Jeevan Seva Annexe, Goa, the policyholder, the Company will pay the nominee {as
S. V. Road, Santacruz (W), Mumbai named in the Policy Schedule/Policy Certificate/Endorsement
Mumbai - 400 054. Metropolitan Region (if any)} and in case there is no subsisting nominee, to the
Tel.: 022 - 26106552 / 26106960 excluding Navi legal heirs or legal representatives of the policyholder whose
Fax: 022 - 26106052 Mumbai & Thane. discharge shall be treated as full and final discharge of its
Email:
liability under the policy.
[email protected]
State of Uttaranchal
and the following ii. Specific Terms and Clauses
Districts of Uttar
Pradesh: 1. Records to be Maintained
Agra, Aligarh, The Insured Person shall keep an accurate record containing all
Bagpat, Bareilly, relevant medical records and shall allow the Company or its
Bijnor, Budaun, representatives to inspect such records. The Proposer or Insured
Bulandshehar, Etah, Person shall furnish such information as the Company may
Kanooj, Mainpuri, require for settlement of any claim under the Policy, within
NOIDA reasonable time limit and within the time limit specified in the
Mathura, Meerut,
Office of the Insurance Ombudsman, Policy.
Moradabad,
Bhagwan Sahai Palace
Muzaffarnagar,
4th Floor, Main Road, 2. Notice & Communication
Oraiyya, Pilibhit,
Naya Bans, Sector 15, i. Any notice, direction, instruction or any other
Etawah,
Distt: Gautam Buddh Nagar, communication related to the Policy should be made in writing.
Farrukhabad,
U.P-201301. ii. Such communication shall be sent to the address of the
Firozbad,
Tel.: 0120-2514252 / 2514253 Company or through any other electronic modes specified in the
Gautambodhanagar
Email: [email protected] Policy Schedule.
, Ghaziabad,
Hardoi, iii. The Company shall communicate to the Insured at the
Shahjahanpur, address or through any other electronic mode mentioned in the
Hapur, Shamli, schedule.
Rampur, Kashganj,
Sambhal, Amroha, 3. Territorial Limit
Hathras, All medical treatment for the purpose of this insurance will have
Kanshiramnagar, to be taken in India only unless worldwide cover has been opted
Saharanpur. for.
PATNA
Office of the Insurance Ombudsman, 4. Territorial Jurisdiction
1st Floor, Kalpana Arcade Building, All disputes or differences under or in relation to the interpretation
Bazar Samiti Road, Bihar, of the terms, conditions, validity, construct, limitations and/or
Bahadurpur, Jharkhand. exclusions contained in the Policy shall be determined by the
Patna 800 006. Indian court and according to Indian law.
Tel.: 0612-2680952
Email: [email protected] 5. Arbitration
PUNE i. If any dispute or difference shall arise as to the quantum
Office of the Insurance Ombudsman, Maharashtra, to be paid by the Policy, (liability being otherwise admitted) such
Jeevan Darshan Bldg., 3rd Floor, Area of Navi difference shall independently of all other questions, be referred
C.T.S. No.s. 195 to 198, Mumbai and Thane to the decision of a sole arbitrator to be appointed in writing by
N.C. Kelkar Road, Narayan Peth, excluding Mumbai the parties here to or if they cannot agree upon a single
Pune – 411 030. Metropolitan arbitrator within thirty days of any party invoking arbitration, the
Tel.: 020-41312555 Region. same shall be referred to a panel of three arbitrators, comprising
Email: [email protected] two arbitrators, one to be appointed by each of the parties to the
dispute/difference and the third arbitrator to be appointed by
such two arbitrators and arbitration shall be conducted under
The updated details of Insurance Ombudsman are also available
and in accordance with the provisions of the Arbitration and
on IRDA website: www.irda.gov.in on the website of General Conciliation Act 1996, as amended by Arbitration and
Insurance Council: www.generalinsurancecouncil.org.in, website Conciliation (Amendment) Act, 2015 (No. 3 of 2016).
of the company www.icicilombard.com or from any of the offices ii. It is clearly agreed and understood that no difference or

ICICI Lombard General Insurance Company Limited

6. Policy alignment 6 COLD PACK/HOT PACK

Policy Alignment option will be available in cases wherein 7 CARRY BAGS
insured(s) with two separate health indemnity policies with Us,
having different policy end dates but want to align the policy start 8 EMAIL / INTERNET CHARGES
dates. We can align the policies by extending the coverage of one FOOD CHARGES (OTHER THAN PATIENT's DIET
9
policy till the end date of the other policy. PROVIDED BY HOSPITAL)
Such policies will be charged with premium on pro rata basis 10 LEGGINGS
though the sum insured under the policy shall remain constant.
11 LAUNDRY CHARGES
7. Endorsements (Changes in Policy) 12 MINERAL WATER
i. This policy constitutes the complete contract of
insurance. This Policy cannot be modified by anyone (including 13 SANITARY PAD
an insurance agent or broker) except the company. Any change 14 TELEPHONE CHARGES
made by the company shall be evidenced by a written
endorsement signed and stamped. 15 GUEST SERVICES
ii. The proposer may be changed only at the time of 16 CREPE BANDAGE
renewal. The new proposer must be the legal heir/immediate
family member. Such change would be subject to acceptance 17 DIAPER OF ANY TYPE
by the company and payment of premium (if any). The renewed 18 EYELET COLLAR
Policy shall be treated as having been renewed without break.
iii. The proposer may be changed during the Policy Period 19 SLINGS
only in case of his/her demise or him/her moving out of India. BLOOD GROUPING AND CROSS MATCHING OF
iv. Mid- term endorsement of addition of member in the 20
DONORS SAMPLES
policy shall only be allowed for newly wedded spouse by
SERVICE CHARGES WHERE NURSING CHARGE
marriage and new born baby with relevant documentation 21
ALSO CHARGED
8. Change of Sum Insured 22 Television Charges
Sum insured can be changed (increased/ decreased) only at the
23 SURCHARGES
time of renewal or at any time, subject to underwriting by the
Company. For any increase in SI, the waiting period shall start 24 ATTENDANT CHARGES
afresh only for the enhanced portion of the sum insured. EXTRA DIET OF PATIENT (OTHER THAN THAT
25
WHICH FORMS PART OF BED
9. Notices
Any notice, direction or instruction given under this Policy shall be 26 BIRTH CERTIFICATE
in writing and delivered by hand, post, or facsimile to: 27 CERTIFICATE CHARGES
In Your case, at Your last known address.
28 COURIER CHARGES
In Our case: 29 CONVEYANCE CHARGES
ICICI Lombard General Insurance Company Limited
ICICI Lombard House 30 MEDICAL CERTIFICATE
414, Veer Savarkar Marg, 31 MEDICAL RECORDS
Near Siddhi Vinayak Temple,
Prabhadevi, Mumbai 400025 32 PHOTOCOPIES CHARGES
33 MORTUARY CHARGES
Notice and instructions will be deemed served 7 days after posting
or immediately upon receipt in the case of hand delivery, facsimile 34 WALKING AIDS CHARGES
or e-mail. OXYGEN CYLINDER (FOR USAGE OUTSIDE THE
35
HOSPITAL)
10. Non Payables
36 SPACER
Below are the non-payable items applicable in the policy. The list
may be updated as per the direction of Authority, For updated list 37 SPIROMETRE
please visit Our website: www.iciciclombard.com 38 NEBULIZER KIT
39 STEAM INHALER
List of Non Payable Items 40 ARMSLING
Sr.
41 THERMOMETER
No Items

ICICI Lombard General Insurance Company Limited

IRDA Reg. No. 115 CIN: L67200MH2000PLC129408 UIN : ICIHLGP22083V022122 Health Shield 360
Mailing Address: Registered Office Address: Toll free no : 1800 2666
601 & 602, 6th Floor, Interface 16, ICICI Lombard House, 414, Veer Savarkar Marg, Alternate no : 86552 22666 (chargeable)
New Linking Road, Malad (West) Near Siddhi Vinayak Temple, Prabhadevi, E-mail : [email protected]
Mumbai - 400 064 Mumbai 400 025 Website : www.icicilombard.com
42 CERVICAL COLLAR Cashless treatment is only available at a Network Provider
(List of Network Providers is available at our website). In
43 SPLINT
order to avail of cashless treatment, the following procedure
44 DIABETIC FOOT WEAR must be followed by You:
45 KNEE BRACES (LONG/ SHORT/ HINGED)
46 KNEE IMMOBILIZER/SHOULDER IMMOBILIZER Pre-authorization
Prior to taking treatment and/or incurring Medical Expenses at
47 LUMBO SACRAL BELT a Network Provider, You must contact Us or Our in house
48 NIMBUS BED OR WATER OR AIR BED CHARGES claim processing team accompanied with full particulars
49 AMBULANCE COLLAR namely, Policy Number, Your name, Your relationship with
Proposer, nature of Illness or Injury, name and address of the
50 AMBULANCE EQUIPMENT
Medical Practitioner/ Hospital and any other information that
51 ABDOMINAL BINDER may be relevant to the Illness/ Injury/ Hospitalisation. You
PRIVATE NURSES CHARGES- SPECIAL NURSING must request pre-authorisation at least 48 hours before a
52
CHARGES planned Hospitalisation and in case of an emergency
53 SUGAR FREE Tablets situation, within 24 hours of Hospitalisation. To avail of
CREAMS POWDERS LOTIONS (Toiletries are not Cashless Hospitalisation facility, you are required to produce
54 payable, only prescribed medical pharmaceuticals the health card, as provided to You with this Policy, subject to
payable) the terms and conditions for the usage of the said health card
Or You can seek pre authorization by providing Your Policy
55 ECG ELECTRODES
number and ID proof to the hospital who can co-ordinate with
56 GLOVES Our claim team to provide cashless facility. We will consider
57 NEBULISATION KIT your request after having obtained accurate and complete
RECOVERY KIT, ETC]ANY KIT WITH NO DETAILS information for the Illness or Injury for which cashless
58 Hospitalisation facility is sought by You and We will confirm
MENTIONED [DELIVERY KIT, ORTHOKIT,
Your request in writing.
59 KIDNEY TRAY
60 MASK (B)For Reimbursement Settlement
61 OUNCE GLASS i. You shall give notice to Us or Our In house claim
processing team by calling the toll free number 1800 2666
62 OXYGEN MASK
or emailing us at [email protected] as
63 PELVIC TRACTION BELT specified in the Policy provided to You and also in writing
64 PAN CAN at Our address with particulars as below:
65 TROLLY COVER  Policy number;
 Your Name;
66 UROMETER, URINE JUG
 Your relationship with the Proposer;
67 AMBULANCE  Nature of Illness or Injury;
68 VASOFIX SAFETY  Name and address of the attending Medical
Practitioner and the Hospital;
 Any other information that may be relevant to the
g) Other Terms and Conditions Illness/ Injury/ Hospitalisation
The above information needs to be provided to Us or Our
CLAIM ADMINISTRATION In house claim processing team immediately and in any
The fulfillment of the terms and conditions of this Policy event within 10 days of Hospitalisation, failing which We
(including payment of premium by the due dates mentioned in will have the right to treat the Claim as inadmissible, as We
the Policy Schedule) insofar as they relate to anything to be may deem fit at Our sole discretion.
done or complied with by each of You shall be conditions ii. You must immediately consult a Medical Practitioner and
precedent to admission of Our liability. You are requested to go follow the advice and treatment that he recommends.
through our list of de-listed/excluded providers which is iii. You or someone claiming on Your behalf must promptly
available on our website and in any event within 30 days of Your discharge from a
Further, upon the discovery or happening of any Illness or Injury Hospital (for post-hospitalisation expenses, within 30 days
that may give rise to a Claim under this Policy, then as a from the completion of post-hospitalisation period) deliver
condition precedent to the admission of Our liability, You shall to Us the documentation (written details of the quantum of
undertake the following any Claim along with all original supporting documentation)
as more particularly listed in CLAIM DOCUMENTS
4.1 CLAIMS PROCEDURE section. In case there is a delay beyond 30 days in
(A) For Cashless Settlement submission of claim documents, we may condone the

ICICI Lombard General Insurance Company Limited

Settlement/Rejection of Claim
The settlement of claims would be done by Us within 30
days, after the receipt of last necessary document, any
rejections if done, would be provided with proper reasons
by Us.
Penal interest provision shall be as per Regulation 15(10)
of (Protection of Policyholders’ Interests) Regulations 2017

Claim falling in two Policy Periods

If the claim event falls within two Policy periods, the claims
shall be paid taking into consideration the available Sum
Insured in the two Policy Periods, including the Deductibles
for each Policy Period. Such eligible claim amount to be
payable to the Insured shall be reduced to the extent of
premium to be received for the Renewal/due date of
premium of health insurance Policy, if not received earlier.
Claims settlement will follow the below mentioned order in
case you have opted for super no claim bonus and sum
insured protector
1) Sum Insured
2) Additional Sum insured
3) Super No Claim Bonus (if opted and accrued)
4) Sum Insured Protector (if opted and accrued)

4.2 CLAIM DOCUMENTS

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

a) Duly completed Claim form signed by You and the

Medical Practitioner. The claim form can be downloaded
from Our website www.icicilombard.com
b) Original bills, receipts and discharge certificate/card from
the Hospital/Medical Practitioner
c) Original bills from chemists supported by proper
prescription.
d) Original investigation test reports and payment receipts.
e) Indoor case papers
f) Medical Practitioner’s referral letter advising
Hospitalisation in non-Accident cases.
g) Any other document as required by Us or Our In house
claim processing team to investigate the Claim or Our
obligation to make payment for it

ICICI Lombard General Insurance Company Limited

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Santosh

Uploaded by

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iii.

Having dedicated AYUSH therapy sections as required

ICICI Lombard General Insurance Company Limited

ICICI Lombard General Insurance Company Limited

ICICI Lombard General Insurance Company Limited

ICICI Lombard General Insurance Company Limited

A. Base Covers (Mandatory) 3 Pre-Hospitalisation and Post-Hospitalisation Expenses

1 Hospitalization Expenses We hereby agree subject to the terms, conditions and

ICICI Lombard General Insurance Company Limited

ICICI Lombard General Insurance Company Limited

ICICI Lombard General Insurance Company Limited

ICICI Lombard General Insurance Company Limited

ICICI Lombard General Insurance Company Limited

In consideration of payment of additional premium to Us, you can 12 Maternity Cover

ICICI Lombard General Insurance Company Limited

Provided always that; b) Diagnostics test as recommended/prescribed by the medical

ICICI Lombard General Insurance Company Limited

You will be required to furnish the following documents in 17 Compassionate Visit

This Benefit shall be payable subject to the following: 18 Convalescence Benefit

ICICI Lombard General Insurance Company Limited

20 Nursing at Home 22 Dependent Accommodation

ICICI Lombard General Insurance Company Limited

b. Zone 2: Hyderabad, Secunderabad, Chhattisgarh, Madhya

ICICI Lombard General Insurance Company Limited

2. Diabetes Table A: Classification during on-boarding

4. Obesity Glycosylated < 6% >6 and up to7%

i. Myocardial Infarction Blood Pressure Systolic Up to Systolic

ICICI Lombard General Insurance Company Limited

Systolic Up Systolic Green Category Amber category

ICICI Lombard General Insurance Company Limited

110-  The Be-Healthy points earned by you can be redeemed for

The Stay-healthy program has been structured to reward You for

ICICI Lombard General Insurance Company Limited

ICICI Lombard General Insurance Company Limited

Table G: Increase in Rupee Value of Wellbeing Points

ICICI Lombard General Insurance Company Limited

 For health risk assessment [HRA] services availed

ICICI Lombard General Insurance Company Limited

ICICI Lombard General Insurance Company Limited

iii. Elevation of infarction specific enzymes, I. An unequivocal diagnosis of Primary (Idiopathic)

ICICI Lombard General Insurance Company Limited

1. Class III: Marked limitation of physical activity.

12. ALZHEIMER’S DISEASE

ICICI Lombard General Insurance Company Limited

ICICI Lombard General Insurance Company Limited

I. End stage renal disease presenting as chronic irreversible 21. POLIOMYELITIS

ICICI Lombard General Insurance Company Limited

ICICI Lombard General Insurance Company Limited

vii. Non-invasive papillary cancer of the bladder Exclusions

6. Any Critical Illness traceable to pregnancy, childbirth,

ICICI Lombard General Insurance Company Limited

ICICI Lombard General Insurance Company Limited

ICICI Lombard General Insurance Company Limited

i. If the Insured Person dies before a claim has been % OF SUM

This Benefit shall be payable subject to the following:

ICICI Lombard General Insurance Company Limited

ICICI Lombard General Insurance Company Limited

3.2 Code- Excl02: Specified disease/procedure waiting

g) The modification is carried out within three months • Cataract

ICICI Lombard General Insurance Company Limited

ICICI Lombard General Insurance Company Limited

ICICI Lombard General Insurance Company Limited

ICICI Lombard General Insurance Company Limited

ICICI Lombard General Insurance Company Limited

ICICI Lombard General Insurance Company Limited

ICICI Lombard General Insurance Company Limited

ICICI Lombard General Insurance Company Limited

6. Policy alignment 6 COLD PACK/HOT PACK

ICICI Lombard General Insurance Company Limited

ICICI Lombard General Insurance Company Limited

Claim falling in two Policy Periods

4.2 CLAIM DOCUMENTS

a) Duly completed Claim form signed by You and the

ICICI Lombard General Insurance Company Limited

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