4128i HSRN 192700105 04 000

(a) Policy Schedule (Policy Certificate)
POLICYALL 3 3 2 2
Proposer Name PADMA B N Product name ICICI Lombard Complete Health Insurance
Address W/O GK,SHIVANANDA,SHIVANANDA Plan Name Health_Shield_R
BUILDING,RAMAIAH LAYOUT,BEHIND BES
SCHOOL,VINAYAKA
NAGAR,HEBBAGODI,ANEKAL TALUCK, Policy No. 4128i/HSRN/192700105/04/000
BANGALORE, KARNATAKA - 560099
Contact No. 99******69 Period of Insurance From 00:00 hrs 31-Jan-2024 To 23:59 hrs
30-Jan-2025
Email Address IC**********@GMAIL.COM Policy Tenure 1
Nominee Name Shivanand G K Alternate Policy No. 4128i/B-iHAR/192700105/04/000
LAN No. NA
Relationship With SPOUSE Policy Issuing Office Prabhadevi
Policyholder
Appointee Name Policy Issued On 30-Jan-2024
Nominee Age 45 Years 6 Month Previous Policy No. 4128i/B-iHA/192700105/03/000
GSTIN No. (Customer) Invoice No. 1001243276359
Servicing Branch Address 27, Third And Fourth Floor, Sjr Tower, Servicing Branch Name Bangalore
Bannerghatta Main Road, 3rd Phase, JP Nagar,
Bangalore, Bengaluru Urban, Karnataka-560078
Politically Exposed Person (PEP)/close relative of PEP: No
Insured's Name(s) Date of Birth Age Date of Joining Gender Relation With Proposer
1
Y M
PADMA B N 03-Oct-1983 40 3 31-Jan-2020 Female SELF
S NITHIN 24-Jul-2006 17 6 31-Jan-2020 Male SON
Insured's Pre-existing Illness/ Optional Add-on Cover* Pneumococcal vaccine Special nn
Annual Sum Insured
oo
Name(s) (`) Injury taken Condition
Befit_A,Convalescence_Benefit,Hospital_
PADMA B N None NO None
Daily_Cash
500000
Hospital_Daily_Cash,Convalescence_Ben 5
S NITHIN None NO None
efit,Befit_A
Plan Details
Plan Name Voluntary Co-payment Zone opted Guaranteed Cumulative Bonus [GCB]
HSRN_1Adult_1Child_1Year 0% Zone B 250000
Premium Details (`)
CGST SGST
Basic Premium Total Tax Payable Total Premium
% ` % `
14272.88 9 1284.56 9 1284.56 2569.12 16842
Signature Not Verified

Digitally signed by DS ICICI
LOMBARD GENERAL
INSURANCE CO LTD 1
Date: 2024.01.30 21:24:01
IST
109/20150914/284
ICICI Lombard General Insurance Company Limited

IRDA Reg. No. 115 CIN: L67200MH2000PLC129408 ICICI Lombard Complete Health Insurance UIN - ICIHLIP23144V072223
Mailing Address: Registered Office: Toll free no.: 1800 2666
ICICI Lombard General Insurance Company Limited, ICICI Lombard House, 414, P Balu Alternate No.: +918655 222 666 (chargeable)
Interface Building No.: 16, 601 / 602, 6th Floor, New Marg, Off Veer Savarkar Road, Near Email: [email protected]
Link Road, Malad (West), Mumbai - 400 064. Siddhi Vinayak Temple, Prabhadevi, Website: www.icicilombard.com 1 / 18
Mumbai -400025.
Table of Benefits
Covers Benefits
Upto Annual Sum Insured
In Patient Treatment
No room rent capping
Daycare procedures/treatment All procedures covered up to Annual Sum Insured
Coverage for modern treatments Upto Annual Sum Insured
Pre Hospitalisation Medical Expenses 30 days
Post Hospitalisation Medical Expenses 60 days
In Patient AYUSH hospitalisation Upto Annual Sum Insured
Reset Benefit Unlimited times for different illness and once for same illness
Cashless: Actuals; Reimbursement: 1% of Sum Insured ; maximum up to ₹ 10,000,
Domestic Road Ambulance Cover
within annual sum insured
Air Ambulance Cover Upto Annual Sum Insured
Donor expenses Upto Annual Sum Insured
Domicillary hospitalisation Upto Annual Sum Insured
Home Care Treatment 5% of Annual Sum Insured ; maximum upto ₹ 25,000
• Includes wellness program, health assistance, ambulance assistance and discounts
on services and products
Wellness Program
• Redemption of points will be through utilisation of services on our mobile application
20% for every claim free year maximum up to 100% of Annual Sum Insured ; no
Guaranteed Cumulative Bonus [GCB]
reduction in case of claims
Preventive Health check up As per annual sum insured package eligibility
Tele consultations Unlimited
2.5% discount on premium if all adults in the policy have been vaccinated with
Incentives associated with vaccination against Pneumococcal disease
pneumococcal vaccine
*Table of Benefits for BeFit Cover A
Sr. No Table of Benefit A

1 Outpatient Consultation 1
2 Routine Diagnostics Cover and Minor Procedures Cover 500
3 Pharmacy Cover 500
4 Physiotherapy Session 0
5 e-Counselling 6
6 Diet and Nutrition e-Consultation 6
3 Agent Details
Agent Agent Agent
VASANTHA R 5596580 9243191941
Name Code contact No.
GSTIN Reg. No HSN/SAC code The stamp duty of ` 1 paid vide deface no. CSD1820234850 dated
997133 GENERAL INSURANCE 30-Nov-2023
29AAACI7904G1ZJ
SERVICES
We hereby declare that though our aggregate turnover in any preceding financial year from 2017-18 onwards is more than the aggregate turnover notified under
sub-rule (4) of rule 48, we are not required to prepare an invoice in terms of the provisions of the said sub-rule.
SYSESB00172313742
Important: Insurance benefit shall become voidable at the option of the company, in the event of any untrue or incorrect statement, misrepresentation
non-description of any material particular in the proposal form/ personal statement, declaration and connected documents, or any material information has been
withheld by beneficiary or anyone acting on beneficiary's behalf to obtain insurance benefit. Please note that any claims arising out of pre-existing illness/ injury/
symptoms i s excluded from the scope of this policy subject to applicable terms and conditions. Refer to policy wordings for the terms and conditions. All disputes
are subject to the jurisdiction of Mumbai High Court only. For claims, please call us at our toll free no. 1800 2666 or e-mail to us at [email protected] or
write to us at ICICI Lombard GIC, 1st, 4th (Half), 5th and 6th floors, Varun Towers- II, Opp. Hyderabad Public school, Begumpet, Hyderabad District Hyderabad,Pin
code -500016 Telangana.
This policy has been issued based on the details furnished by the policyholder. Please review the details furnished in the policy certificate and confirm that same
are in order. In case of any discrepancy/ variation, you are requested to call us immediately at our toll free no. 1800 2666 or write to us at
[email protected]. In the absence of any communication from you within the period of 15 days of receipt of this document, the policy would be
deemed to be in order and issued as per your proposal. All refunds and claim payment will be done through NEFT only. In case of addition of member/ increase in
sum insured, fresh waiting period will be applicable to new member/ increased sum insured. This policy certificate is to be read with the policy wordings, as one
contract or any word or expression to which a specific meaning has been attached in any part of this policy shall bear the same meaning wherever it may appear.
109/20150914/284

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Click or Scan QR Code for Policy Wordings
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Tax Certificate
3
To
PADMA B N
W/O GK,SHIVANANDA,SHIVANANDA BUILDING,RAMAIAH
LAYOUT,BEHIND BES SCHOOL,VINAYAKA
NAGAR,HEBBAGODI,ANEKAL TALUCK
BANGALORE
KARNATAKA - 560099
ANNUAL
Subject: Premium certificate for the purpose of deduction under section 80D of Income Tax
Act, 1961 and any amendments made thereafter.
Dear PADMA B N,
This is to certify that the Company has received the premium dated Jan 31, 2024 for Health
insurance coverage under "Health Insurance Policy" with the following details.
Policyholder's PADMA B N 4128i/HSRN/192700105/0 Policy Number

Name 4/000
Policy Start DateJan 31, 2024 Policy End Date Jan 30, 2025
Plan Name HSRN_1Adult_1Child_1Ye Total Premium Paid 16842
ar (`)
GSTIN Number GSTIN Reg.No (ICICI 29AAACI7904G1ZJ
(Customer) Lombard)
Servicing Branch Bangalore Servicing Branch 27, Third And Fourth
Name Address Floor, Sjr Tower,
Bannerghatta Main Road,
3rd Phase, JP Nagar,
Bangalore, Bengaluru
Urban, Karnataka-560078
Premium Details (`)

CGST SGST
Basic Premium Total Tax Payable Total Premium
% ` % `
14272.88 9 1284.56 9 1284.56 2569.12 16842
Financial Year Amount (`)
2023-2024 16842.00
The product is eligible for deduction u/s 80D of the Income Tax, 1961 and any amendments
made there to.
Sincerely,
For ICICI Lombard General Insurance Company Ltd.
Authorised Signatory
Note: This certificate must be surrendered to the Insurance Company in case of Cancellation of
the Policy. In the event of incorrect representation of this declaration, the liability shall be upon
the policyholder.
In case You find any variations against Your proposal or any discrepancy in the Policy, please
contact Us immediately on the numbers available on our website www.icicilombard.com Or call
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Mumbai -400025.
contact Us immediately on the numbers available on our website www.icicilombard.com Or call
on our toll free no. 1800 2666
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Name : PADMA B N
Policy No. : 4128i/HSRN/192700105/04/000
Card No. : 122402250
Gender : Female Age : 40 DOB : 03-Oct-1983
Valid Upto : 30-Jan-2025
Name : S NITHIN
Policy No. : 4128i/HSRN/192700105/04/000
Card No. : 122402251
Gender : Male Age : 17 DOB : 24-Jul-2006
Valid Upto : 30-Jan-2025
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1447 no
ICICI Lombard Complete Health Insurance- Health Shield
Customer Information Sheet/ Know Your Policy
This document provides key information about your policy. You are advised to go through your policy document.
Sr. No Description Policy Clause Number

(Please refer to applicable Policy Clause Number in next column)
Name of Insurance Product/Policy
1.
ICICI Lombard Complete Health Insurance-Health Shield
Policy Number
2.
4128i/HSRN/192700105/04/000
Type of Insurance Product/Policy
3.
Both Indemnity and Benefit
Sum Insured
4. Basis-Floater Sum Insured- Rs. 500000 – where all members under the policy have a
single sum insured limit which maybe utilized by any or all members
Policy Coverage (What the policy covers?)
Expenses in respect of:
d. benefits covered under
5. the Policy
i. Basic Covers: -
Section d. A. 1
1. In-patient Treatment: Up to the Annual Sum Insured for admission longer than 24
consecutive hours. Room Rent charges “Single Private Room”
2. Day Care Procedures/Treatment – for a continuous period of less than 24 hours. Section d. A. 2
3. Modern Treatment Expenses – During policy period up to the annual Sum Insured. Section d. A. 3
4.Pre Hospitalization Medical expenses - 30 days before hospitalization up to the Section d. A. 4

Annual sum insured.
5. Post Hospitalization Expenses – 60 days after discharge from hospital up to the Section d. A. 5
Annual sum insured.
6. In Patient AYUSH Hospitalization- Up to Annual sum insured. Section d. A. 6
7. Reset Benefit – The Sum Insured will be reset up to 100% once a policy year for
same illness and Unlimited times for different illness , in case the Annual Sum insured Section d. A. 7
including any guaranteed cumulative bonus (if any), super no claim bonus (if any), sum
insured protector (if any) is insufficient as a result of previous claims
8. Domestic Road Ambulance – For transfer to the nearest Hospital. In case of Section d. A. 8
cashless claim; it will be covered as per actuals and limited to 1% of Annual Sum
Insured maximum up to ` 10,000 in case ambulance services are reimbursed.
9. Domestic Air Ambulance Cover - Covers expenses during emergencies up to the Section d. A. 9
annual Sum Insured.
10. Donor Expenses - Covers hospitalization expenses for an organ donor, donating Section d. A. 10
to the Insured Person up to Annual Sum Insured.
11. Domiciliary Hospitalization - Up to the Annual Sum Insured. Section d. A. 11
12. Home Care Treatment- Up to 5% of Annual Sum Insured subject to a maximum of Section d. A. 12
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` 25,000.
Section d. A. 13
13. Wellness Program: I. Wellness Program
II. Health Assistance
III. Ambulance Assistance
IV. Discounts on services and products
Wellness points earned by the Insured Person can be redeemed by availing services
such as out-patient consultations, purchase of pharmaceutical drugs/ medicines,
undergoing diagnostic tests, purchase of health supplements etc. through our mobile
application
14. Guaranteed Cumulative bonus(GCB) - A Get a 20% Cumulative Bonus of the Section d. A. 14
Annual Sum Insured each claim-free year, up to a max of 100% if the policy is
continuously renewed with us. No reduction to the cumulative bonus even in case of a
claim.
15. Preventive Health Check Up – Insured person(s) aged 21 years and above can
avail a preventive health check-up as per the plan eligibility. One coupon will be Section d. A. 15
provided per insured person subject to maximum of 2 coupons for floater policy
16. Teleconsultation(s) – Unlimited tele-consultations will be provided; 24 * 7 and 365 Section d. A. 16

days a year
17. Incentives associated with vaccination against Pneumococcal disease -

Discount of 2.5% on premium in case all adult members in the policy have been Section d. A. 17
vaccinated with the conjugate pneumococcal vaccine in the one year prior to policy
start date
Optional Benefits (As opted by the Insured):

1. Hospital Daily Cash- A daily cash allowance of Rs.1000 /day will be provided for
each completed day of Hospitalization for 3 consecutive days up to a maximum of 10
days in a policy year.
2. Convalescence Benefit - A lump sum allowance of Rs 10,000 will be provided once
every Policy year for a duration of minimum 10 consecutive days.
7. BeFit –Provides following benefits on cashless basis up to limits as specified in the
covers below
Sr. No Befit - Table of Benefit A 2

1 Outpatient Consultation 1
5 e-Counselling 6
8. Voluntary Co-payment - Of 0% for each and every claim as opted.
2
06. Exclusions (What does the policy not cover e. Exclusions under
i.Standard Exclusion the policy
1.Code- Excl01- Pre-Existing Diseases - i. Standard exclusions
a) Expenses related to the treatment of a pre-existing Disease (PED)
and its direct complications shall be excluded until the expiry of 24
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and its direct complications shall be excluded until the expiry of 24
months of continuous coverage after the date of inception of the
first policy with insurer.
b) In case of enhancement of sum insured the exclusion shall apply
afresh to the extent of sum insured increase.
c) If the Insured Person is continuously covered without any break
as defined by IRDAI (Health Insurance) Regulations, then waiting
period for the same would be reduced to the extent of prior
coverage
d) Coverage after the expiry of specified months for any
pre-existing disease is subject to the same being declared at the
time of application and accepted by Insurer.
. 2. Code- Excl02- Specified Disease/Procedure waiting period

a) Expenses for listed conditions, surgeries/treatments shall be
excluded until the expiry of 24 months of continuous coverage
post first policy inception. Not applicable for claims arising due
to an accident.
b) In case of enhancement of sum insured the exclusion reapplies
for increased sum insured.
c) If any of the specified disease/procedure falls under the waiting
period specified for pre-existing diseases, the longer waiting
period shall apply.
d) The waiting period for listed conditions shall apply even if
contracted after the policy or declared and accepted without a
specific exclusion.
e) If the Insured Person is continuously covered without any break
as defined by IRDAI, then waiting period for the same would be
reduced to the extent of prior coverage.
List of specific diseases/procedure:

1. Cataract
2. Benign prostatic hypertrophy
3. Myomectomy, Hysterectomy unless because of malignancy
4. All types of Hernia, Hydrocele
5. Fissures &/or Fistula in anus, haemorrhoids/piles
6. Arthritis, gout, rheumatism and spinal disorders
7. Joint replacements unless due to accident
8. Sinusitis and related disorders
9. Stones in the urinary and biliary systems
10. Dilatation and curettage , Endometriosis
11. All types of Skin and internal tumors/ cysts/nodules/ polyps of
any kind including breast lumps unless malignant
12. Dialysis required for chronic renal failure
13. Surgery on tonsils, adenoids and sinuses
14. Gastric and Duodenal erosions & ulcers
15. Deviated Nasal Septum
16. Varicose Veins/ Varicose Ulcers
* 2 years after policy inception, the maximum liability arising out of

any Claim from a cataract treatment claim shall be restricted
to up to 10% of the Annual Sum Insured subject to a maximum of
` 1 Lakh per eye.
3.For treatment of the below mentioned illness within 90 days from the first policy
commencement date unless they are pre-existing and disclosed at the time of
underwriting
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i.Hypertension
ii.Diabetes
iii.Cardiac Conditions
a) This exclusion does not apply if the Insured Person has continuous
coverage for more than twelve months.
b) The waiting period also applies to increased sum insured with higher
coverage subsequently.
4.Code- Excl03-30-day waiting period -

a) Expenses related to the treatment of any illness within 30 days from
the first policy commencement date shall be excluded except
claims arising due to an accident, provided the same are covered.
b) This exclusion shall not, however, apply if the Insured Person has
Continuous Coverage for more than twelve months.
c) The referred waiting period is made applicable to the enhanced sum
insured in the event of granting higher sum insured subsequently.
ii. Permanent Exclusions

i.Code- Excl04: - Investigation & Evaluation
a)Admission primarily for diagnostics and evaluation purposes only are
excluded.
b)Diagnostic expenses unrelated or not incidental to the current diagnosis
and treatment.
ii. Code- Excl05: Exclusion Name: Rest Cure, rehabilitation and respite care For
admission primarily for enforced bed rest and not for receiving treatment. This also
includes:
a)Custodial care at home or in a nursing facility for personal assistance

by skilled nurses or non-skilled persons.
b)Any services for people who are terminally ill to address their
physical, social, emotional and spiritual needs.
iii. Code- Excl06: Obesity/ Weight Control
Expenses related to the surgical treatment of obesity that does not fulfil
pall the below conditions:
a)Surgery to be conducted based on Doctor advice
b)The surgery/Procedure conducted should be supported by clinical
protocols
c)The member has to be 18 years of age or older and
d)Body Mass Index (BMI);
>= 40 or
>= 35 in conjunction with any of the following severe co-morbidities
following failure of less invasive methods of weight loss:
a)Obesity-related cardiomyopathy
b)Coronary heart disease
c)Severe Sleep Apnea
d)Uncontrolled Type2 Diabetes
iv. Code- Excl07: Change of Gender treatments

Including surgery, to change body characteristics to the opposite sex.
v. Code- Excl08: Cosmetic or plastic Surgery

Excluded unless for reconstruction due to an accident, burn(s), cancer, or
as part of medically necessary treatment. It must be certified by the
attending medical practitioner to remove a direct health risk
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attending medical practitioner to remove a direct health risk
vi. Code- Excl09: Hazardous or Adventure sports

Expenses related to any treatment necessitated due to participation as a
professional in hazardous or adventure sports, including but not
limited to, para-jumping, rock climbing, mountaineering, rafting, motor
racing,horse racing or scuba diving, hand gliding, sky diving,
deep-sea diving.
vii. Code- Excl10: Breach of law

Expenses for or consequent to committing or attempting to commit a
breach of law with criminal intent.
viii. Code- Excl11: Excluded Providers
Expenses incurred towards treatment in any hospital / by any Medical

Practitioner / other provider specifically excluded by the
Insurer, disclosed on the website notified to the policyholders
are not admissible. However, in case of life threatening situations or an
accident, expenses up to the stage of stabilization are payable but not
the complete claim.
Click here for the list of delisted hospital as on the website
https://www.icicilombard.com/docs/default-
source/apps/healthclaims/assets/files/delisted-hospital-list.pdf
ix. Code- Excl12: Treatment for, alcoholism, drug or substance abuse or any
addictive condition and consequences thereof.
x. Code- Excl13: Treatments received in heath hydros, nature cure clinics, spas or
similar establishments or private beds registered as a nursing home attached to such
establishments or where admission is arranged wholly or partly for domestic reasons.
xi. Code- Excl14: Dietary supplements and substances that can be purchased
without prescription, not limited to vitamins, minerals and organic substances unless
prescribed by a medical practitioner as part of hospitalisation claim or day care
procedure.
xii. Code- Excl15: Refractive Error: For correction of eye sight due to refractive
error less than 7.5 dioptres
xiii. Code- Excl16: Unproven Treatments: Services and supplies for or in

connection with any treatment. Unproven treatments are treatments, procedures or
supplies that lack significant medical documentation to support their effectiveness.
xiv. Code- Excl17: Sterility and Infertility: Expenses related to, sterility
and infertility. This includes:
a) Any type of contraception, sterilization
b) Assisted Reproduction services including artificial insemination and
advanced reproductive technologies such as IVF, ZIFT, GIFT, ICSI
c) Gestational Surrogacy
d) Reversal of sterilization
xv. Code- Excl18: Maternity:

a) Medical treatment expenses traceable to childbirth (including
complicated deliveries and caesarean sections incurred during
hospitalisation) except ectopic pregnancy.
b) Expenses towards miscarriage (unless due to an accidents and lawful
medical termination of pregnancy during the policy period
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iii. Specific Exclusion
a) Any ailment/ illness/ injury/ condition or treatment or service that is

ii. Specific Exclusions
specifically excluded in the Policy Schedule under Special Conditions
(Other than those as
b) Any expenses incurred on prosthesis, corrective devices, external
specified under
durable medical equipment of any kind, like wheelchairs,
e.i. above
crutches, instruments used in treatment of sleep apnoea syndrome or
cost of cochlear implant(s) unless necessitated by an accident or
required intra-operatively.
c) Treatment, procedures and preventive, diagnostic, restorative,
cosmetic services related to disease, disorder and conditions
related to natural teeth and gingiva except if required due to an Accident.
d) Personal comfort, cosmetics, convenience and hygiene related items
and services
e) Acupressure, acupuncture, magnetic and other therapies
f)Circumcision unless necessary for treatment of an Illness or
necessitated due to an Accident.
g) Expenses for venereal disease or any sexually transmitted disease
except HIV.
h) Screening, counselling or treatment relating to external birth defects
and external congenital Illnesses or defects or anomalies.
i) Treatment taken outside the country, unless Worldwide Cover has been
opted for.
j) Intentional self-injury (whether arising from an attempt to commit
suicide or otherwise)
k) Any injury or illness arising from/attributed to war, invasion, acts of
foreign enemies, hostilities (whether war be declared or not), civil
war, commotion, unrest, rebellion, revolution, military or usurped power or
confiscation or nationalisation or requisition of or damage by or
under the order of any government or public local authority
l) For illness or injury not limited to the likes of nuclear weapons/materials
or ionizing radiation, contamination by radioactivity or similar events.
7. Waiting period
- Time period during which specified diseases/treatments are not covered
- It is counted from the beginning of the policy coverage
• Initial waiting period: 30 days for all illnesses (except hospitalization due to injury) e.i.4 Standard exclusions
• Specific waiting periods: First 24 months, for specific Illness and treatment.
(please refer to the policy wordings for the complete list) e.i.2
• Pre-Existing Diseases: Declared & accepted pre-existing diseases will be covered
after 24 months of continuous coverage. e.i.1
• Expense related to hypertension, diabetes and cardiac conditions within 90days
from the policy commencement date unless they are PED e.i.3
(Below waiting periods are applicable only if these covers are opted for)
• Critical Illness : 90 days Section d.B.15

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• Critical Illness : 90 days Section d.B.15
• Worldwide Cover : 24 months Section d.B.7
• BeFit : 30 days
Financial limits of coverage

Sub-limit (It is a pre- defined limit and the insurance company will not pay any
amount in excess of this limit)
The policy will pay only up to the limits specified hereunder for the following
diseases/procedures:
• For Cataract Treatment, a sub-limit of 10% of the Annual Sum insured subject to a
maximum of ₹ 1 Lakh per eye is applicable
Basic Covers
• Domestic Road Ambulance Cover- limited to 1% of Annual Sum Insured
8. maximum up to ₹ 10,000.
• Home Care Treatment- up to 5% of Annual Sum Insured subject to a
maximum of ₹ 25,000.
• Guaranteed Cumulative bonus (GCB)- 20% of the Annual Sum Insured subject
to a maximum of 100% of annual sum insured.
• Incentives associated with vaccination against Pneumococcal disease-
Discount of 2.5% will be provided on premium.
Optional Covers
• Hospital Daily Cash- A daily cash allowance of Rs.1000 /- will be provided.
• Convalescence Benefit- lump sum allowance of Rs 10,000
• BeFit – up to the limits as mentioned below:
Sr. No Befit - Table of Benefits A

1 Outpatient Consultation 1 2
5 e-Counselling 6
Co-payment (It is a specified amount /percentage of the admissible claim
amount to be paid by policyholder/insured)
Voluntary co-payment opted- 0% will be applicable for each and every claim
Zone Based Pricing –

Premium depends on your chosen zone. If treatment is conducted in a higher zone,
co-payment applies. There will be no zone based co-payment for Zone A and Zone D
Treatment
Zone Zone based
taken in zone
Zone A 8%
Zone B Nil
Zone B
Zone C Nil
Zone D 8%
Zone A 16%
Zone B 8%
Zone C
Zone C Nil
Zone D 16%
Deductible (It is a specified amount:

- Up to which an insurance company will not pay any claim, and
- Which will be deducted from total claim amount (if claim amount is more
than the specified amount)
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Not Applicable
Any other limit (as applicable)
Not Applicable
9. Claims/claims procedures g.3. Claims Service
Guarantee
Turn Around Time(TAT) for claim settlements- (Other terms and and
For reimbursements claims- TAT shall be 14 days (on receiving complete request) for conditions
a claim to be paid or to be deemed inadmissible.
For cashless claims- TAT for response to the pre authorization request will be within 2
hours of receiving the complete request.
Claims Procedure- g.1. Claims Service

Guarantee
(Other terms and
Cashless (Pre-Authorization) Procedure; conditions)
Step 1 – Get your treatment at our network hospital, submit a copy of health card and
photo ID proof at Hospital Insurance desk during admission.
Step 2 – The hospital sends an approval request for your cashless admission along
with relevant documents (cashless pre-authorization form, investigation reports, past
consultation papers (as applicable),copy of health card and photo ID
proof, etc.)
Step 3 – Request will be processed as per policy terms and conditions
Step 4 – While you avail treatment the claim payment is settled directly to the
Provider/Hospital
Step 5 – You can check and track your claim status live on IL TakeCare app or
WhatsApp
Find our extensive list of hospitals providing cashless services on our website
https://www.icicilombard.com/health-insurance/health-claim/partner-hospital or on the IL
TakeCare App.
List of excluded providers/delisted hospitals is available on our website

https://www.icicilombard.com/docs/default-source/apps/healthclaims/assets/files/
delisted-hospital-list.pdf
Notify us 48 hours before planned admission or within 24 hours for emergencies when
using cashless services.
Non-medical and non-payable expenses are your responsibility.
Reimbursement Procedure;
Step 1 – Get treatment at a non-network hospital by self-paying all the treatment costs.
Collect all treatment and expenses related documents.
Step 2 – Send us the claim documents along with the claim form. You can also
emboss the original documents and submit an e-claim on the ILTakecare app. if
an e-claim is submitted please retain all the original documents and produce if asked by
Insurance to submit in original hard copy.
Step 3 – The claim will be processed as per policy terms and conditions
Step 4 – The approved amount in the claim would be reimbursed to you Insurer needs
to be notified of any planned Hospitalization at least 48 hours before admission and 24
hours after admission in the case of emergency hospitilisation.
We are to be provided with a duly completed ‘Claim Form’ and the requisite claim
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documents, as soon as practicable, latest within 30 days from the date of discharge
from the Hospital, failing which we will have the right to treat the claim
as inadmissible.
The relevant documents can be sent to

ICICI Lombard Health Care,
1st, 4th (Half), 5th and 6th floors,
Varun Towers- II, Opp. Hyderabad Public school, Begumpet, Hyderabad, District
Hyderabad, Telangana Pin code -500016
documents, as soon as practicable, latest within 30 days from the date of discharge
from the Hospital, failing which we will have the right to treat the claim
as inadmissible.
The relevant documents can be sent to
ICICI Lombard Health Care,
1st, 4th (Half), 5th and 6th floors,
Varun Towers- II, Opp. Hyderabad Public school,
Begumpet, Hyderabad, District Hyderabad, Telangana Pin code -500016
Download the Claim Form here -

https://echannel-wf.icicilombard.com/docs/default-source/apps/healthclaims/assets/
files/claim-form-greater-then-1-lac.pdf
10. Policy Servicing f.General terms and

- You may contact us on our Toll Free no: 1800 2666, or email to conditions
[email protected] or use our IL TakeCare App or send a Hi to RIA,
our Responsive Intelligent Assistant on WhatsApp (7738282666) for policy services.
- For details of Company officials kindly visit our website
https://www.icicilombard.com/customer-support.
11. Grievances/Complaints f.16. General terms and
• In case the insured is aggrieved in any way, the insured person should do the conditions
following:
• Call us on our toll free no. 1800 2666 or email us at
[email protected]
• There is an interactive voice response (IVR) facility for senior citizens’ grievance
redressal for easy and faster resolution,
• If you are not satisfied with the resolution provided, you may approach us at the
subsection “Grievance Redressal “on our website
https://www.icicilombard.com/grievance-redressal (Customer Support section).
• If you are not satisfied with the resolution then You may successively write to
Manager- Service Quality, Corporate Manager- Service Quality, National Manager-
Operations & finally Director-services and Business development at the following
address:
ICICI Lombard General Insurance Company Limited, ICICI Lombard House, 414, P
Balu Marg, Off Veer Savarkar Road, Near Siddhi Vinayak Temple, Prabhadevi, Mumbai
400025.
• In case your complaint is not fully addressed, you may use the Integrated
Grievance Management System (IGMS) for escalating the complaint to IRDAI.
www.irda.gov.in.
12. Things to remember f. General terms
Free Look cancellation: and conditions-15
109/20150914/284

Mumbai -400025.
Free Look cancellation: and conditions-15
You may cancel the insurance within 15 days from the beginning of the policy by
giving Us 15 days’ written notice for the cancellation by registered post, and then We
shall refund premium on short term rates for the unexpired Policy Period. The free look
period shall be 30 days in case of electronic policies and policies sourced through
distance mode (if the Policy Tenure is 3 years or more). (Please refer to the Policy
Wordings and the Prospectus for more details) If you wish to cancel the Policy, You
may contact us through Our website www.icicilombard.com (Customer Support section)
or call us at toll Free no: 1800 2666, or email to [email protected].
Policy Renewal - We shall ordinarily renew the Policy except on grounds of moral f.General terms and
hazard, misrepresentation or fraud or non-cooperation by the Insured. conditions-10
Migration and Portability – f.General terms and

The insured person will have the option to port the policy to other insurers by applying conditions-8 and 9
to such insurer to port the entire policy along with all the members of the family, if
any, at least 45 days before, but not earlier than 60 days from the policy renewal date
as per IRDAI guidelines related to portability. lf such person is presently covered and
has
been continuously covered without any lapses under any health insurance policy with
an lndian General/Health insurer, the proposed insured person will get the accrued
continuity benefits in waiting periods as per IRDAI guidelines on portability.
For Detailed Guidelines on portability, kindly refer the link

https://www.irdai.gov.in/ADMINCMS/cms/frmGuidelines_Layout.aspx?page=PageNo
3987
• In case you are keen on migrating or outward porting kindly contact us at
[email protected]
Change in Sum Insured- Sum Insured can be changed (increased/decreased) only at f.General terms and
the time of renewal or at any time, subject to underwriting by the company. For conditions-28
increase in SI, the waiting period if any shall start afresh only for the enhanced portion
of the sum insured.
Zone Based Pricing - Premium will be computed basis zone chosen by Insured f.ii.Specific Terms and
Person. Zone based co-payment will be applicable in case treatment is taken in a Clauses-18
higher zone
Moratorium Period- After completion of eight continuous years under the policy no f.General terms and
look back to be applied. This period of eight years is called as moratorium period. The conditions-12
moratorium would be applicable for the sums insured of the first policy and
subsequently completion of eight continuous years would be applicable from date of
enhancement of sums insured only on the enhanced limits.
After the expiry of Moratorium Period, no health Insurance policy shall be contestable
except for prover fraud and permanent exclusions specified in the policy contract.
13. Your Obligations f. General terms and

• Please disclose all pre-existing disease/s or condition/s before buying a policy. conditions
Non-disclosure may affect the claim settlement.
• The Policy shall be null and void and no benefit shall be payable if any information
shared by you in any form is untrue or incorrect/suppressed, or if there is any
mis-representation, non-disclosure of material facts, fraud or non-cooperation by You
in the proposal form, personal statement, medical history, declaration, and connected
documents, or a claim is found to be fraudulent or any fraudulent means or devices
109/20150914/284

Mumbai -400025.
documents, or a claim is found to be fraudulent or any fraudulent means or devices
are used by You or any one acting on Your behalf to obtain any Benefit under this
Policy.
• Please disclose all material information (Including Pre-Existing Diseases) before
buying the Policy.
• For us to fulfill any claims, it's crucial for you to comply with the policy terms, pay
premiums on time, and follow the specified claims procedures.
• Please inform us immediately of any change in the address, occupation, state of
health, or of any other changes affecting the Insured Person (or his Nominee/ legal
heir, as the case may be) Cooperation from the Insured/claimant is solicited in
providing all or sufficient documents as per the claims procedure in support of claim.
Declaration by the Policy Holder:

I have read the above and confirm having noted the details.
Place: Signature of the Policy Holder
Date:
NOTE: In case of any conflict, the terms and conditions mentioned in the policy document shall prevail.
109/20150914/284

Mumbai -400025.
109/20150914/284

Mumbai -400025.

4128i HSRN 192700105 04 000

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(a) Policy Schedule (Policy Certificate)

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

Signature Not Verified

ICICI Lombard General Insurance Company Limited

Sr. No Table of Benefit A

ICICI Lombard General Insurance Company Limited

ICICI Lombard General Insurance Company Limited

Policyholder's PADMA B N 4128i/HSRN/192700105/0 Policy Number

Premium Details (`)

ICICI Lombard General Insurance Company Limited

ICICI Lombard General Insurance Company Limited

ICICI Lombard General Insurance Company Limited

ICICI Lombard Complete Health Insurance- Health Shield

Customer Information Sheet/ Know Your Policy

Sr. No Description Policy Clause Number

4.Pre Hospitalization Medical expenses - 30 days before hospitalization up to the Section d. A. 4

6. In Patient AYUSH Hospitalization- Up to Annual sum insured. Section d. A. 6

11. Domiciliary Hospitalization - Up to the Annual Sum Insured. Section d. A. 11

ICICI Lombard General Insurance Company Limited

16. Teleconsultation(s) – Unlimited tele-consultations will be provided; 24 * 7 and 365 Section d. A. 16

17. Incentives associated with vaccination against Pneumococcal disease -

Optional Benefits (As opted by the Insured):

Sr. No Befit - Table of Benefit A 2

ICICI Lombard General Insurance Company Limited

. 2. Code- Excl02- Specified Disease/Procedure waiting period

List of specific diseases/procedure:

* 2 years after policy inception, the maximum liability arising out of

ICICI Lombard General Insurance Company Limited

4.Code- Excl03-30-day waiting period -

ii. Permanent Exclusions

a)Custodial care at home or in a nursing facility for personal assistance

iv. Code- Excl07: Change of Gender treatments

v. Code- Excl08: Cosmetic or plastic Surgery

ICICI Lombard General Insurance Company Limited

vi. Code- Excl09: Hazardous or Adventure sports

vii. Code- Excl10: Breach of law

viii. Code- Excl11: Excluded Providers

Expenses incurred towards treatment in any hospital / by any Medical

xiii. Code- Excl16: Unproven Treatments: Services and supplies for or in

xv. Code- Excl18: Maternity:

ICICI Lombard General Insurance Company Limited

a) Any ailment/ illness/ injury/ condition or treatment or service that is

• Critical Illness : 90 days Section d.B.15

ICICI Lombard General Insurance Company Limited

Financial limits of coverage

• BeFit – up to the limits as mentioned below:

Sr. No Befit - Table of Benefits A

Zone Based Pricing –

Deductible (It is a specified amount:

ICICI Lombard General Insurance Company Limited

Claims Procedure- g.1. Claims Service

List of excluded providers/delisted hospitals is available on our website

Non-medical and non-payable expenses are your responsibility.

ICICI Lombard General Insurance Company Limited

The relevant documents can be sent to

Download the Claim Form here -

10. Policy Servicing f.General terms and

ICICI Lombard General Insurance Company Limited