The Coverage

The beneficiary can avail cashless hospitalization in a network Hospitals empanelled

under the scheme subject to the terms and conditions/limits of the policy.

Annual Limit (Per Family) Rs 5,00,000 (Sum Insured)

It is a purely Cashless Policy. Reimbursement of claims is allowed only in case of Pre &
Post Hospitalization

Benefit Plan under the Scheme

• It shall cover treatment of all medical/surgical diseases requiring minimum 24 hrs

hospitalizations up to an expenditure of Rs. 5 Lac per year per family on floater
basis subject to the terms and conditions of the Scheme.

• It shall also cover the treatment of the procedures listed below which do not
require 24 hrs hospitalization.

Dialysis, Chemotherapy, Radiotherapy, Eye Surgery, Lithotripsy (Kidney Stone

Removal) Tonsillectomy, Laparoscopy, Arthroscopy, Endoscopy, Coronary
Angiography, DNC, Coloscopy, Mammography, IVP, KUB, MBI Scanning,
Strontium -89 Therapy, Thulium Study.

Maternity is covered subject to the following conditions:-

• The benefit is available only for female employee or wife of the employee.
• The benefit is available for maximum first two children only.
• No waiting period required in the policy

Claim in respect of delivery for only first two children and or operation associated
therewith shall be considered in respect of any one insured person covered under
the policy or any renewal thereof.

Explanation 1:

Expenses incurred in connection with voluntary medical termination of pregnancy during

first 12(Twelve) weeks from the date of conception are not covered.

Explanation 2:
2

Pre-natal and post-natal expenses are not covered unless admitted in recognised
hospital/nursing home and treatment is taken there.
Exclusions

The following shall not be included in the Scheme:-

Scheme:-

Diseases, illness, accident or injuries directly or indirectly caused by or arising from or

attributable to war, invasion, act of foreign enemy, war like operations (whether war be
declared or not). However, injuries resulting from accidents arising out of acts of terrorism
shall be covered;

Circumcision or vaccination or cosmetic or aesthetic treatment of any description, plastic

surgery unless necessary for treatment of disease not excluded by the terms of the
policy;

The cost of spectacles, contact lenses and hearing aids;

Dental treatment or surgery of any kind unless it requires hospitalization;

Convalescence, general debility, run-down condition or rest cure, congenital external

disease or defects or anomalies, sterility, venereal disease, intentional self-injury (whether
arising from an attempt to suicide or otherwise and use of intoxicating drugs and/or
alcohol.

All expenses arising out of any condition directly or indirectly caused to or associated
with HIV and Acquired Immuno Deficiency Syndrome (AIDS).

Expenses on vitamins and tonics unless forming part of treatment for injury or disease as
certified by the attending Medical Practitioner; and

Diseases, illness, accident or injuries directly or indirectly caused by or contributed to by

nuclear weapons/materials or contributed to by or arising from ionizing radiation or
contamination by radioactivity by any nuclear fuel or from any nuclear waste or from the
combustion of nuclear fuel;

Naturopathy treatment; and

Cosmetic surgery, Contact lenses surgery for correction of refractive errors.

Hospitalization
Planned Hospitalization

• The insured persons will avail the cashless facility for treatment in any of the
network hospitals after showing his /her Health Insurance Card and the
concerned hospital will directly obtain authorisation from ICICI Lombard.
• Should our medical officer need any clarification he may contact your doctor
before he initiates action on your request.
• Any change in the date of hospitalization, hospital, nature of illness or surgeon
who is going to perform the procedure will make the authorization invalid. A
fresh authorization will have to be taken.
• The authorization is valid only for network hospitals.

Getting Admitted
• Contact the admission desk of the Hospital
• It is mandatory to provide valid ID card to the Network Hospital/nursing home at
its IPD reception at the time of admission.

Pre & Post Hospitalization Expenses

The Scheme allows reimbursement of medical expenses incurred towards the
ailment/disease for the hospitalization was necessitated 30 days prior to hospitalization
and upto 60 days after discharge.

Insured will meet cost of pre-post admission investigations and medicines which do not
fall during the course of hospitalisation. ICICI Lombard will reimburse the cost of
medicines and investigations, only to the extent to which the same is prescribed; by the
treating doctor and which have direct relation to the diagnosis for which the cashless
claim has been approved.

The insured to submit the following documents within 90 days at the address given
below:-

a. Original claim form duly filled and signed by the primary member
b. Part –C of the claim form with account details of primary member
supported with original cancelled cheque
c. Copy of discharge Summary
d. Original detailed Itemized Bill
e. Original payment receipts
f. Original investigation reports
g. Original medicine and pharmacy Bills
h. Original supporting prescriptions
i. Original implant Invoice

Address:-
Area Manager,
ICICI Lombard GIC Ltd.
Hall no 301 & 302
3rd floor North Block
Bahu Plaza, Jammu - 180001

Or

Area Manager
ICICI Lombard GIC Ltd.
4th Floor, Chinar Complex
Residency Road
Srinagar 190001