ICICI LOMBARD GIC LTD

GROUP HEALTH INSURANCE

Quote cum proposal format
Quote No.(4016/IP-03670413/003)

Proposer Details Policy Coverages

Name of the Proposer MONIKA ALCOBEV Policy Construct Employer - Employee
LIMITED OPD/IPD IPD
Location of Proposer MUMBAI Service Category Both(Cashless +
Industry Type IT/ITES/Software Reimbursement)
Intermediary Name TURTLEMINT INSURANCE IPD Claim Intimation Period 30 Days
BROKING SERVICES PVT 30 Days Waiting Period Waived Off
LTD First year exclusion Waived Off
Date 17/Oct/2023 9 months waiting period Waived Off
Policy Details Third party Administrator IL HEALTH CARE
Floater/Non-Floater Floater No of Employees 232
Transaction Market Rollover No. of Dependents 209
Family Definition Self+Spouse+4 Children Total SI 46,400,000
Premium Details
Gross Premium 1,624,485.42
Stamp Duty .50
Add: Goods & Service Tax 292,407.38
Total Premium Payable 1,916,893
*Premium value mentioned above is inclusive of taxes
applicable.
Basic 643693.44

Policy Conditions

Age Band 1 day to 80 years

Family Definition Employee, spouse , 4 dependent children upto 25 yrs. of Age covered under policy.

SI is restricted to Rs. 200000 per family during the policy period as per annexure attached
Sum Insured
herewith.

2% of SI(200000) maximum upto Rs.4000 for Normal and 4% of SI(200000) maximum upto
Room Rent Rs.7000 for ICU (inclusive of nursing charges) . If insured is admitted in a higher category, then
insured will bear difference of all medical expenses as in final hospital bill in same proportion.

Maternity Benefit
For Metro 25000-35000 for Normal and C-section respectively & for Non-Metro 20000-30000
for Normal & C-
for Normal and C-section respectively for First 2 children.
Section

Pre-Existing
Pre-Existing diseases are covered
Disease

Pre-Post
Pre Hospitalisation and Post Hospitalisation for 60-90 days respectively are covered.
Hospitalisation

Baby Day 1 Baby covered from day1 within maternity limit

Page 1 of 5
ICICI LOMBARD GIC LTD
GROUP HEALTH INSURANCE
Quote cum proposal format
Quote No.(4016/IP-03670413/003)

Pre/Post Natal
Pre-Post Natal Expenses to the limit of Rs 5000 is covered Within Maternity Limit
Expense

Ambulance
Ambulance Charges limited to Rs 2000 per person.
Service

Health Assistance is a dedicated medical care service that assists you in all your health related
Health queries for identifying Specialist/Hospital/fixing an appointment with Doctors/Nutritionist
Assistance /facilitating 2nd opinion, etc. To avail this facility please call our Helpline at 040 6627 4205 (9:30
Services am to 6 pm Mon to Sat, excluding public holidays) or write to
[email protected].

Domiciliary
Excluded
Hospitalisation

Septoplasty, Infertility and Related Ailments incl.'Male sterility'; Treatment on trial/experimental

basis; Admin/Registration/Service/Misc. Charges; Expenses on fitting of Prosthesis; Any
Exclusion
device/instrument/machine contributing/replacing the function of an organ; Holter Monitoring
are outside the scope of the policy.

Policy also covers hospitalization arising out of Psychiatric ailments within a limit of Rs.30000
Special Condition as well as treatment of Functional Endoscopic Sinus Surgery within a limit of Rs.35000 The
coverage for treatment of mental illness is also covered upto Rs 30000 within the sum insured.

Co-Payment For employee only 0% co-pay for all claims.

Co-Payment For spouse only 0% co-pay for all claims.

Co-Payment For children only 0% co-pay for all claims.

Day Care
Day Care Procedures are Covered as per the standard list
Procedures

Claim must be filed within 30 days from the date of completion of treatment. However, the
Company may at its discretion consider waiver based on merits of the claim, where there is
Claim submission delay in intimation or in submission of documents due to unavoidable circumstances and it is
clause proved that the delay was for reasons beyond the control of the insured and under the
circumstances in which the insured was placed it was not possible for him or any other person
to give such notice or file claim within the prescribed time-limit

Mid term inclusion of dependents will be possible only in case of:a) spouse (on account of
Mid-Term
marriage during the policy term) b) children (childbirth during the policy term but after the the
Inclusion
child has completed 91 days of age) subject to not more than four children

Reasonable and
Customary Waived Off
Charges

Claim Intimation
and Network Waived Off
clause

Premium to be charged on Pro Rata Basis for addition/deletion endorsement. No Refund for
Add-Del of Lives
deletion-if lives less than minimum required and if insured has claimed during policy

Page 2 of 5
ICICI LOMBARD GIC LTD
GROUP HEALTH INSURANCE
Quote cum proposal format
Quote No.(4016/IP-03670413/003)

Special Condition
Lasik Surgery is covered if correction index is +/-6.5
1

Special Condition
Terrorism is covered
2

Special Condition
Air Ambulance is covered upto Rs 100,000 or family sum insured whichever is less.
4

Attendant charges are cover upto Rs 5,000 (Per life incase case of Employee only policy or
else it's Per Family within Family sum insured) if length of stay for the patient is more than 5
Special Condition
days. Add on covers cost pertaining to boarding and lodging of the attendant in a
5
hospital/location prescribed by treating Medical Practitioner on reimbursement basis by
presenting original Bills for each cost incurred.

Special Condition
Lucentis is covered upto Rs 50,000 Per family within the Sum Insured
6

Special Condition Internal Congenital disease is covered and External congenital disease is covered in life
7 threatning situation.

Special Condition 50% Co-Pay for cyberknife treatment/Stem Cell Transplantation. Cochlear Implant treatment
8 shall be restricted to 50% of the SI.

Portability Portability is available on this product as per IRDA directive and product features

Termination Policy will cease to be in effect from the date of termination of relationship with the organization.

ID Cards Physical cards will not be issued

Last year claim Last year claim paid amount is Rs. 751,755 and outstanding amount is Rs.201,643 as on 20-
details SEP-23 in expiring policy with372 inception lives

Transaction Market Rollover

Existing Insurer IFCO TOKYO GENERAL INSURANCE COMPANY LTD.

Disease wise
No SubLimits
sublimits

Demography

Sum 76-80
0-18 19-35 36-45 46-55 56-60 61-65 66-70 71-75 Total
Insured Above

200,000 94 228 75 37 3 0 1 0 3 441

Total 94 228 75 37 3 0 1 0 3 441

RATES FOR ENDORSEMENT (Per Life)

Sum 76-80
0-18 19-35 36-45 46-55 56-60 61-65 66-70 71-75
Insured Above

200,000 2041 3544 3914 6062 9877 12897 15170 17906 20632

Page 3 of 5
ICICI LOMBARD GIC LTD
GROUP HEALTH INSURANCE
Quote cum proposal format
Quote No.(4016/IP-03670413/003)

Grievances
For resolution of any query or grievance, Insured may contact the respective branch office of the Company or may
call toll free no.1800-2666 or may approach us at the sub section “Grievance Redressal” on our website
www.icicilombard.com (Customer Support section). However, if the resolution provided by us is not satisfactory you
may approach Insurance Regulatory and Development Authority (IRDA) through the Integrated Grievance
Management Section (IGMS) or IRDA Grievance Call Centre(IGCC) at their toll free no.155255.

Quote is valid for 45 days.Quote is liable to change with change in info.

Policy Details Contact Information

Period of Insurance From: 18/Oct/2023 HR Name

To: 17/Oct/2024
HR Contact No
Policy conditions as per quote format.
HR Email Id

Communication Details
Mailing Address
Address of Recipient
Address 1
Address 2
District/City
State
Country
Pincode

I/We, the undersigned hereby declare that the above statements and particulars are true, accurate and complete
and I/We declare and agree that this declaration and the answers given above shall be held to be promissory and
shall be the basis of contract between me/us and the company.
I/We, the undersigned have read and understood the Guidelines on Group Insurance Policies issued by the
Authority vide ref. no. 015/IRDA/Life/Circular/GI Guidelines 2005 dated July 14, 2005, as amended from time to
time, and shall adhere to its provisions at all times.
I/We hereby give my/our consent to the Company to verify and obtain my/our identity/address proof as well as the
identity /address proof of the insured through Central KYC Registry or UIDAI or through any other modes for the
purpose of undertaking KYC.
I/We hereby agree and ensure to maintain details of all the beneficiaries covered under the policy and shall share
the same with Company as and when required.

Are you or any of the proposed applicants a PEP* or a

NO
close relative of a PEP*?
*Politically Exposed Persons (PEPs) are individuals who are or have been entrusted with prominent public functions
in a foreign country, e.g., Heads of States/Governments, senior politicians, senior government/judicial/military
officers, senior executives of state-owned corporations, important political party officials, etc.

Page 4 of 5
ICICI LOMBARD GIC LTD
GROUP HEALTH INSURANCE
Quote cum proposal format
Quote No.(4016/IP-03670413/003)

Place:_________________ Proposer's Signature:______________

Name:___________________
Date:_____________

GUIDELINE FOR COMPLETION OF THE FORM

1.Insurance is a contract of utmost good faith requiring the Insured not only to disclose all material facts but also not
to suppress any material facts in response to the questions in the proposal form. If you think any fact is material,
please disclose it.
2. The Policy shall become voidable at the option of the Insurer, in the event of any untrue or incorrect statement,
misrepresentation, non-description or non-disclosure in any material particular in the proposal form/personal
statement, declaration and connected documents, or any material information has been withheld by the proposer or
any one acting on his behalf to obtain any benefit under this policy.
Note:
Coverage of risk is subject to realization of premium by the Company. Insurance coverage under the policy will
commence only on realization of full premium, receipt of complete reports (wherever applicable) and subject to
underwriting approval by the company. In case premiums not realized by the Company due to any reason, company
shall not be on cover and contract of insurance shall be treated as void ab-initio. Excess payment, if any, will be
refunded without any interest on receipt of required documents as necessary or will be utilized in future policy
issuance.

STATUTORY WARNING

PROHIBITION OF REBATES

Section 41 of the Insurance Act, 1938 as amended by the Insurance Laws (Amendment) Act, 2015

1 No person shall allow or offer to allow, either directly or indirectly as an inducement to any person to
) take out or renew or continue an insurance in respect of any kind of risk relating to lives or property,
in India, any rebate of the whole or part of the commission payable or any rebate of the premium
shown on the policy, nor shall any person taking out or renewing or continuing a Policy accept any
rebate, except such rebate as may be allowed in accordance with the published prospectuses or
tables of the Insurer.

2
Any person making default in complying with the provisions of this section shall be punishable with
)
fine which may extend to ten lac rupees.

ICICI Lombard General Insurance Company Limited

IRDA Regn. No. 115 CIN: U67200MH2000PLC129408
Mailing Address: Registered Office: Toll Free No: 1800-2666
401 & 402, 4th Floor, Interface 11, ICICI Lombard House, 414, Veer Savarkar Marg, Alternate No: +919223622666 (chargeable)
New Linking Road, Malad (West), Near Siddhi Vinayak Temple, Prabhadevi, Email:[email protected]
Mumbai - 400064 Mumbai - 400025 Website:www.icicilombard.com Page 5 of 5