ICICI Lombard General Insurance Company LTD

ICICI LOMBARD HOUSE, 414, Veer Savarkar Marg,

Near Siddhi Vinayak Temple, Prabhadevi, Mumbai 400 025

GROUP HEALTH (FLOATER) INSURANCE

CUSTOMER INFORMATION SHEET

DISCLAIMER NOTE: The information mentioned below is illustrative and not exhaustive. The information must be read in conjunction with the
policy wordings. In case of any conflict between the Customer Information Sheet and the policy wordings, the terms and conditions mentioned in the
policy wordings shall prevail.

POLICY CLAUSE
S. NO. TITLE DESCRIPTION
NUMBER
1. Product Name GROUP HEALTH (FLOATER) INSURANCE
The policy provides indemnification of medical expenses incurred by the
2. What am I Covered for? Insured during day care treatment,hospitalization, domiciliary a. Policy schedule
hospitalization, for any illness or injury suffered during the Policy Period.
Cover for Pre­Existing Diseases
Maternity Expenses
Out Patient Department (OPD) Expenses
HIV
Cost of Prescribed External Medical Aid
Baby Day One Cover
Critical Illnesses Cover
Travel Expenses For Medical Treatment
Dental Expenses
Cover for Alternate Methods Of Treatment
Donor Expenses
Ambulance Charges
d. Benefits covered under the
3. Optional Add On Covers Pre and Post Hospitalization
policy
Health Check­Up
Disease­Wise Sub­Limit
Domiciliary Hospitalization
Treatment Outside India
Convalescence Benefit
Loss of Wages/Salary Due To Hospitalization (Hospital Daily
Cash Allowance)
Cover for Allied Hospital Charges
Limit on Room Rent, Nursing Charges, Consultation Fees,
Diagnostic Charges, OT Charges etc.
Wellness & Preventive Care

Initial Waiting Period

Pre Existing Disease: 1 year
4. Waiting Period Specific Waiting Periods e.Exclusions
Maternity Expenses:9 months

Pre­Existing Diseases
Circumcision,plastic surgery
What are the major Cost of spectacles,contact lenses,hearing aids,etc.
5. Dental treatment or surgery of any kind unless requiring e.Exclusions
exclusions in the Policy
hospitalisation.
Convalescence, Sterility, general debility,

CIN : L67200MH2000PLC129408 UIN : ICIHLGP21381V052021

International self­injury and use of intoxicating drugs and/or

alcohol
Voluntary medical termination of pregnancy during the first
CIN : L67200MH2000PLC129408 UIN : ICIHLGP21381V052021

International self­injury and use of intoxicating drugs and/or

alcohol
Voluntary medical termination of pregnancy during the first
12 weeks from the date of conception
Naturopathy treatment
(Note: the above is the partial listing of the
policy exclusions,Please refer to the policy clauses for
the full listings)

Cashless or Reimbursement claims of covered medical

expenses up to specified Sum Insured as per the scope of g. Other terms &
6. Payment Basis
cover conditions

In case of a claim,this policy requires you to share the

following costs:
7. Loss Sharing Expences exceeding the sub limits a. Policy schedule
Room/ICU changes

The Policy can be renewed as a separate contract under the

then prevailing ICICI Lombard Group Health (Floater)
Insurance product or its nearest substitute (in case the
product ICICI Lombard Group Health (Floater) Insurance is
f. General Terms and
8. Renewal Conditions withdrawn by the Company) approved by IRDA. Clauses
The policy shall ordinarily be renewable except on grounds
of fraud, moral hazard or misrepresentation or non­
cooperation by the insured.

The Policy shall be void and all premium paid hereon shall
be forfeited to the Company, i n t h e e v e n t o f
misrepresentation, misdescription or non­disclosure of any
material fact.
Insured or the Company may cancel this Policy by giving
the Company or the insured, as the case may be, 15 days
f. General Terms and
9. Cancellation written notice for the cancellation of the Policy, and then the Clauses
Company shall refund premium on short term rates (if
initiated by the insured) or pro rata rates (if initiated by the
Company) for the unexpired Policy Period. The Company
shall follow the below short period scale unless otherwise
mutually agreed.

For Cashless Service

Cashless treatment is only available at our Network
Providers Please refer www@icicilombard.com for updated
lis of our Network Providers
For Reimbursement of claim g. Other terms &
10. Claims Claims should be intimated 48 hours prior to
conditions
Hospitalization or within 24 hours post admission in case of
emergency
Document to be submited within 30 days from the date of
completion of treatment

Call the Company at the toll free number 1800 2666 or

email us at customersupport@icicilombard.com
In case of Insured is not satisfied,he/she may approach us at
the sub section "Grievance Redressal" on
Policy g. Other terms &
11. www@icicilombard.com Otherwise the Insured may use
Servicing/Grievances/Complaints conditions
IGMS
If the issue remains unresolved, Insured may approach
Ombudsman

Disclosure of Material Information during the Policy Period f. General Terms and
12. Insured's Obligations
Clauses
 Clauses

CIN : L67200MH2000PLC129408 UIN : ICIHLGP21381V052021

ICICI Lombard General Insurance Company LTD

ICICI LOMBARD HOUSE, 414, Veer Savarkar Marg,
Near Siddhi Vinayak Temple, Prabhadevi, Mumbai 400 025

4016/139264029/05/000
GROUP HEALTH (FLOATER) INSURANCE

UIN­ ICIHLGP21381V052021 Misc 12

a. Policy Schedule

> Insured Details

Policy Number : 4016/139264029/05/000

Issued At : MUMBAI
Name of the Insured : CAMERON MANUFACTURING INDIA PVT LTD
Mailing Address of the Insured : Iiird Floor Tidal Park Civil Aerodrome Post Coimbatore, Coimbatore, Tamil Nadu Pin 641014

Intermediary Details
Agency/Broker Code : DB49011

Agency/Broker Name : SECURE NOW INSURANCE BROKER PRIVATE LIMITED

Agent's/Broker's Mobile No. : 9696683999
Agent's/Broker's Email ID : support@securenow.in

> Policy Details

Period of Insurance : From : 00:00 Hours of November 01, 2022

To : Midnight of October 31, 2023
Product : GHI Floater

Total Lives Insured : 480

Sum Insured : Rs. 58,000,000.00
Details of Person Insured : As per Annexure

Premium Computation
Basic Premium : Rs. 6,468,591.00
Mailing Address of the Insured : Iiird Floor Tidal Park Civil Aerodrome Post Coimbatore, Coimbatore, Tamil Nadu Pin 641014

Intermediary Details
Agency/Broker Code : DB49011

Agency/Broker Name : SECURE NOW INSURANCE BROKER PRIVATE LIMITED

Agent's/Broker's Mobile No.
Agent's/Broker's Email ID
> Policy Details
: 9696683999
: support@securenow.in
ICICI Lombard General Insurance Company LTD
ICICI LOMBARD HOUSE, 414, Veer Savarkar Marg,
Near Siddhi Vinayak Temple, Prabhadevi, Mumbai 400 025

Period of Insurance : From : 00:00 Hours of November 01, 2022

To : Midnight of October 31, 2023
4016/139264029/05/000
Product : GHI Floater
GROUP HEALTH (FLOATER) INSURANCE
Total Lives Insured : 480
Sum Insured : Rs. 58,000,000.00
Details of Person Insured : As per Annexure

Premium Computation
Basic Premium : Rs. 6,468,591.00

Stamp Duty : (Rs.) 00.50

*Total Premium : (Rs.) 7,632,938.38
*Premium value mentioned above is inclusive of taxes applicable
Coverages

1 Policy type : Floater

2 Policy Construct : Employer Employee

3 Service Category : Both Cashless & Reimbursement

4 OPD/IPD : IPD

5 Third Party Administrator : ICICI Lombard Healthcare

6 OTC/Non OTC : Non­OTC

7 Physical Health Card : Yes

8 30 Days waiting period, 9 months : Waived Off

waiting period, 1st Year waiting
period

9 Age Band : 36 years ­ 90 yrs

10 Family Definition : Parents and Parents in law of the employees of Schlumberger

11 Sum Insured : Sum Insured Per family 200000 during the policy period as per annexure attached herewith.

12 Corporate Floater,Maternity Benefit : NA

for Normal & C­Section,AOY
Clause,Baby Day 1,Pre/Post Natal
Expenses,Home health care,OPD
Cover (Reimburement),Tele
Health,Emergency Support
Services,Claim Intimation & Network
clause,Last year claim details,Special
Condition 1,Special Condition 2

13 Room Rent : 7500 for Normal & 10000 for ICU. It is inclusive of nursing charges. Proportionate clause is
applicable. If Insured is admiited in higher category, insured will bear the difference in all medical
expenses as in final hospital bill in same propotion.

14 Pre­Existing Diseases : Pre­Existing Diseases Expenses Covered

15 Pre ­ Post Hospitalisation : Pre Hospitalisation and Post Hospitalisation for 30 days & 60 days respectively are covered.

16 Ambulance Service : Ambulance Charges limited to 'Rs.' 1000 per hospitalization

17 Group Quote : The policy is part of group quote of 3 entities of Schlumberger India, Schlumberger Asia and
Cameron.

18 Special Condition : This proposal is part of group proposal of dependent parents of Schlumberger Asia Pvt Ltd,
Schlumberger IndiaTechnology Centre Pvt Ltd and Cameron Manufacturing India Pvt Ltd
 Clause,Baby Day 1,Pre/Post Natal
Expenses,Home health care,OPD
Cover (Reimburement),Tele
Health,Emergency Support
Services,Claim Intimation & Network
clause,Last year claim details,Special
Condition 1,Special Condition 2

13 Room Rent : 7500 for Normal & 10000 for ICU. It is inclusive ICICI of nursing charges. Proportionate clause is
Lombard General Insurance Company LTD
applicable. If Insured is admiited in higher category, insured
ICICI will bear
LOMBARD the414,
HOUSE, difference in all
Veer Savarkar medical
Marg,
Near Siddhi Vinayak Temple, Prabhadevi, Mumbai 400 025
expenses as in final hospital bill in same propotion.

14 Pre­Existing Diseases : Pre­Existing Diseases Expenses Covered

15 Pre ­ Post Hospitalisation 4016/139264029/05/000

: Pre Hospitalisation and Post Hospitalisation for 30 days & 60 days respectively are covered.
GROUP HEALTH (FLOATER) INSURANCE
16 Ambulance Service : Ambulance Charges limited to 'Rs.' 1000 per hospitalization

17 Group Quote : The policy is part of group quote of 3 entities of Schlumberger India, Schlumberger Asia and
Cameron.

18 Special Condition : This proposal is part of group proposal of dependent parents of Schlumberger Asia Pvt Ltd,
Schlumberger IndiaTechnology Centre Pvt Ltd and Cameron Manufacturing India Pvt Ltd

19 Special Condition 1 : Opt In Opt out: The window of addition any parent is opened for only one time before policy
booking and no parents of the existing employees would be allowed to enroll in the policy in mid
term basis for the next 3 years

20 Domiciliary Hospitalisation : Excluded

21 Exclusion : Lasik Surgery, Septoplasty, Infertility & Related Ailments incl.'Male sterility';Treatment on
trial/experimental basis; Admin/Registration/Service/Misc. Charges; Expenses on fitting of
Prosthesis; Any device/instrument/machine contributing/replacing the function of an organ; Holter
Monitoring are outside the scope of the policy.

22 Policy construct : Employer­employee, service category­both cashless & reimbursement, OPD/IPD­IPD claim
Intimation period ­30 days

23 Special Condition : Policy also covers hospitalization arising out of Psychiatric ailments within a limit of 'Rs.' 30,000 as
well as treatment of Functional Endoscopic Sinus Surgery within a limit of 'Rs.' 35,000. The
coverage for treatment of mental illness is also covered upto Rs 30000 within the sum insured.

24 Co­Payment : 10% copay on all claims if the claimed amount is above 2 lac or full 2lac has to be paid

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

26 Claim submission clause : Claim must be filed within 30 days from the date of completion of treatment. However, the
Company may at its absolute discretion consider waiver, of this Condition in extreme cases of
hardship where it is proved to the satisfaction of the Company that 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 time­limit.

27 Mid­Term Inclusion : Mid term inclusion of dependents will be possible in case of new joinee only

28 Reasonable and Customary Charges : The Policy covers Reasonable and Customary Charges incurred towards the medical treatment
taken by the Insured Person during the Policy Period following an Illness or Injury that occurs
during the Policy Period, subject to availability of the Sum Insured and any specific limits specified
in the Schedule of Benefits and the terms, conditions and exclusions specified in the Policy
document.

29 Add­Del of Lives : Premium to be charged on Short­period scale for addition/deletion endorsement.

30 Disease wise sublimits : No limit

31 Co­share : Lead share of 51% with ICICI Lombard and co­share of 49% with IFFCO Tokio

32 Special Condition 8 : 50% Co­Pay for cyberknife treatment/Stem Cell Transplantation.Cochlear Implant treatment shall
be restricted to 50% of the SI.

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

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

35 1st year Exclusion : Not Applicable

36 30 Days Waiting Period : Not Applicable

37 9 months waiting period : Not Applicable

 taken by the Insured Person during the Policy Period following an Illness or Injury that occurs
during the Policy Period, subject to availability of the Sum Insured and any specific limits specified
in the Schedule of Benefits and the terms, conditions and exclusions specified in the Policy
document.

29 Add­Del of Lives : Premium to be charged on Short­period scale for addition/deletion endorsement.

30 Disease wise sublimits : No limit

ICICI Lombard General Insurance Company LTD
31 Co­share : Lead share of 51% with ICICI Lombard and co­share of 49%
ICICI with HOUSE,
LOMBARD IFFCO 414,
Tokio
Veer Savarkar Marg,
Near Siddhi Vinayak Temple, Prabhadevi, Mumbai 400 025

32 Special Condition 8 : 50% Co­Pay for cyberknife treatment/Stem Cell Transplantation.Cochlear Implant treatment shall
be restricted to 50% of the SI.

33 Portability 4016/139264029/05/000
: Portability is available on this product as per IRDA directive and product features.
GROUP HEALTH (FLOATER) INSURANCE
34 Termination : Policy will cease to be in effect from the date of termination of relationship with the organization.

35 1st year Exclusion : Not Applicable

36 30 Days Waiting Period : Not Applicable

37 9 months waiting period : Not Applicable

38 Domiciliary Hospitalization : Excluded

Conditions
1. No. of Employees : 00
2. No. of Dependants : 480
3. Third Party Administrator (TPA)/ : I­HealthCare
In house For TPA Address and Contact details please visit our website www.icicilombard.com (Download
Section)

Co­Insurance Details

S No. Name of the Co­insurer Share in % Type

1 ICICI LOMBARD GENERAL INSURANCE COMPANY LTD. 51 Leader
2 IFFCO TOKIO GENERAL INSURANCE COMPANY LIMITED 49 Follower

CIN : L67200MH2000PLC129408 UIN :ICIHLGP21381V052021

ICICI Lombard General Insurance Company LTD

ICICI LOMBARD HOUSE, 414, Veer Savarkar Marg,
Near Siddhi Vinayak Temple, Prabhadevi, Mumbai 400 025

4016 139264029 05 000

 CIN : L67200MH2000PLC129408 UIN :ICIHLGP21381V052021

ICICI Lombard General Insurance Company LTD

ICICI LOMBARD HOUSE, 414, Veer Savarkar Marg,
Near Siddhi Vinayak Temple, Prabhadevi, Mumbai 400 025

4016 139264029 05 000

GROUP HEALTH (FLOATER) INSURANCE

Policy shall stand cancelled ab initio in the event of non realisation of the premium.
Disclaimer: This document to be read in conjunction with the Schedule II & Schedule III of the policy.
GSTIN Reg. No : 06AAACI7904G1ZR
IL GIC GSTIN Address : Tower D, Twelth Global Business Park Mehrauli Gurgaon Road Gurgaon Haryana 122002
HSN SAC code : 997133 GENERAL INSURANCE SERVICES

Signed for and on behalf of the ICICI Lombard General Insurance Company Limited at Mumbai on November 02, 2022.

Authorised Signatory
ICICI Lombard General Insurance Company Ltd.

CIN : L67200MH2000PLC129408 UIN :ICIHLGP21381V052021