Elevate

Customer Information Sheet/ Know Your Policy

This document provides key information about your policy. You are advised to go through your policy
document.
Sr. Description Policy Clause
No (Please refer to applicable Policy Clause Number in next column) Number
1. Name of Insurance Product/Policy
Elevate
2. Policy Number
3445546479
3. Type of Insurance Product/Policy
Both Indemnity and Benefit
4. Sum Insured
Basis-
- Floater Sum Insured – Rs. 10,00,000 - where all members under the policy have a single Sum
Insured limit which may be utilized by any or all members
5. Policy Coverage (What the policy covers?) d. Benefits
Expenses in respect of: covered under the
policy
i. Basic Covers:-
1. In-patient Treatment: Covers Hospitalization expenses for admission longer d. i. Basic cover.1
than 24 consecutive hours.
2. Day Care Procedures/Treatment - Covers Medical expenses for all Day Care d. i. Basic cover.2
procedures up to Annual Sum insured.
3. Modern Treatment Expenses - Covers medical expenses for listed modern d. i. Basic cover.3
treatments up to the Annual Sum Insured.
4. Pre Hospitalization Medical expenses - Covers Medical expenses incurred due d. i. Basic cover.4
to illness up to 90 days period immediately before an insured person's
admission to a hospital up to Annual Sum Insured.
5. Post Hospitalization Expenses - Covers Medical expenses incurred due to d. i. Basic cover. 5
illness up to 180 days immediately after an insured person's discharge from the
hospital up to Annual Sum Insured.
6. In Patient AYUSH Hospitalization - Covers expenses incurred on inpatient d. i. Basic cover. 6
AYUSH treatment up to Annual Sum Insured.
7. Domestic Road Ambulance Cover - Covers the expenses incurred on domestic d. i. Basic cover. 7
road ambulance up to Annual Sum Insured.
8. Donor Expenses - Covers Medical Expenses incurred for an organ donor's d. i. Basic cover. 8
Hospitalization for an organ donated to the Insured Person up to Annual Sum
Insured.
9. Domiciliary Hospitalization - Covers Medical expenses incurred in respect of d. i. Basic cover. 9
the Domiciliary Hospitalization up to the Annual Sum Insured.

ICICI Lombard General Insurance Company Limited

CIN: L67200MH2000PLC129408
IRDA Reg. No. 115 Registered Office Address: UIN: < ICIHLIP25031V012425 > Elevate
Mailing Address: ICICI Lomba rd Hous e, 414, P Ba lu Ma rg, Toll free no : 1800 2666
601 & 602, 6th Floor, Interfa ce 16, Off Veer Sa va rka r Roa d Ma rg Alternate no : 86552 22666 (cha rgea ble)
New Linking Roa d, Ma la d (Wes t) Nr Siddhi Vina ya k Temple, Pra bha devi, E-mail : cus tomers upport@icicilomba rd.com
Mumba i - 400 064 Mumba i 400 025 Website : www.icicilomba rd.com
 10. Guaranteed Cumulative bonus (GCB) - A Cumulative Bonus of 20% of the Sum d. i. Basic cover.
Insured for each completed and continuous claim free Policy Year subject to a 10
maximum of 100%. There will be no reduction in the event of a claim.

11. Reset Benefit - Available up to 100% of Annual Sum insured, unlimited times for d. i. Basic cover.
any illness/disease/injury. 11
12. Bariatric Surgery Cover - Covers medical expenses incurred on surgical d. i. Basic cover.
procedure/ treatment for obesity Up to Annual Sum Insured subject to a waiting 12
period of 2 years & 30 days in case Optional cover 3 Jumpstart has been opted.
13. In-Patient Hospitalization for Surrogate Mother: Covers Medical expenses d. i. Basic cover.
incurred for inpatient hospitalization of the surrogate mother appointed by the 13
intending couple/intending woman for complications arising out of pregnancy
and post-partum delivery complications during the policy period, up to a
maximum limit of Rs. 5 Lakhs. This cover will be available only if the policy
tenure is 3 years
14. In-Patient Hospitalization for Oocyte Donor: Covers Medical expenses d. i. Basic cover.
incurred for inpatient hospitalization of the Oocyte donor appointed by the 14
intending couple/ intending woman for complications arising due to oocyte
retrieval during the policy period, up to a maximum limit of Rs. 5 Lakhs.
15. Wellness Program - It intends to promote, incentivize and reward the insured d. i. Basic cover.
person for their healthy behavior through Wellness Points accumulation. The 15
total wellness points earned by the Insured person(s) will be redeemed towards
availing discount on renewal premium for the subsequent year.
Ways of earning wellness points is mentioned below.
I. Wellness Program
A. Health Assessment
B. Wellness Activities
C. Wellness Tasks
D. Fitness Challenge
E. Health Events
II. Health Assistance [HAT]: Available
III. Ambulance Assistance: Available
IV. Discounts on services and products: Available

ii. Optional Covers (Applicable if opted by the Insured):-

1. Infinite Care - We will cover the Medical Expenses incurred in respect of d. ii. Optional
Hospitalisation under in-patient treatment / daycare procedures/treatment or in- cover.1
patient AYUSH Hospitalization of the Insured Person for any one claim during the
entire life of the Policy without any limits on the Annual Sum Insured subject to
the conditions specified in the Policy wordings.
2. Power Booster (Guaranteed Super Bonus) - If the Insured Person has opted for d. ii. Optional
this optional cover, We will provide a Cumulative Bonus of 100% of expiring or cover.2
renewed Annual Sum Insured (whichever is lower) at the end of each Policy Year
irrespective of a claim being initiated in the Policy Year.
10. Claim Protector - Expenses incurred on items that are not payable as per the d. ii. Optional
List I- Items for which coverage is not available in the Policy of Annexure II which cover.10
are not payable to the particular claim will become payable up to the Annual
sum insured, within overall basic annual sum insured.

ICICI Lombard General Insurance Company Limited

CIN: L67200MH2000PLC129408
IRDA Reg. No. 115 Registered Office Address: UIN: < ICIHLIP25031V012425 > Elevate
Mailing Address: ICICI Lomba rd Hous e, 414, P Ba lu Ma rg, Toll free no : 1800 2666
601 & 602, 6th Floor, Interfa ce 16, Off Veer Sa va rka r Roa d Ma rg Alternate no : 86552 22666 (cha rgea ble)
New Linking Roa d, Ma la d (Wes t) Nr Siddhi Vina ya k Temple, Pra bha devi, E-mail : cus tomers upport@icicilomba rd.com
Mumba i - 400 064 Mumba i 400 025 Website : www.icicilomba rd.com
 16. Health Check-up - Adult insured person(s) aged 18 years and above can avail a d. ii. Optional
pre- defined health check-up up to 0.5% of Annual Sum Insured subject to a cover.16
maximum of Rs. 5,000 on cashless basis
23. Tele Consultation(s) - If opted, the Insured Person can avail 24X7 unlimited tele d. ii. Optional
consultations through Our mobile application. cover.23
6. Exclusions (What does the policy not cover)
i. Standard Exclusions (Exclusions for which standard wordings are specified by e. i.
IRDAI):-

1. Pre-Existing Diseases - Code- Excl01 e.i.1

a. Expenses related to the treatment of a pre-existing Disease (PED) and its direct
complications shall be excluded until the expiry of 36 months of continuous
coverage after the date of inception of the first policy with insurer as selected by
the 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 under
the portability / migration norms of the extant IRDAI (Health Insurance)
Regulations, then waiting period for the same would be reduced to the extent of
prior coverage.
d. Coverage under the policy after the expiry of 36 months for any pre-existing
disease is subject to the same being declared at the time of application and
accepted by Insurer.

ICICI Lombard General Insurance Company Limited

CIN: L67200MH2000PLC129408
IRDA Reg. No. 115 Registered Office Address: UIN: < ICIHLIP25031V012425 > Elevate
Mailing Address: ICICI Lomba rd Hous e, 414, P Ba lu Ma rg, Toll free no : 1800 2666
601 & 602, 6th Floor, Interfa ce 16, Off Veer Sa va rka r Roa d Ma rg Alternate no : 86552 22666 (cha rgea ble)
New Linking Roa d, Ma la d (Wes t) Nr Siddhi Vina ya k Temple, Pra bha devi, E-mail : cus tomers upport@icicilomba rd.com
Mumba i - 400 064 Mumba i 400 025 Website : www.icicilomba rd.com
 2. Specified disease/procedure waiting period- Code- Excl02 e.i.2
a. Expenses related to the treatment of the listed Conditions, surgeries/treatments
shall be excluded until the expiry of 24 months of continuous coverage after the
date of inception of the first policy with us. This exclusion shall not be applicable
for claims arising due to an accident.
b. In case of enhancement of sum insured the exclusion shall apply afresh to the
extent of sum insured increase.
c. If any of the specified disease/procedure falls under the waiting period specified
for pre-Existing diseases, then the longer of the two waiting periods 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 under
the applicable norms on portability stipulated by IRDAI, then waiting period for
the same would be reduced to the extent of prior coverage.
f. List of specific diseases/procedures
1. Any types of gastric or duodenal ulcers
2. Benign prostatic hypertrophy
3. All types of sinuses
4. Hemorrhoids
5. Dysfunctional uterine bleeding
6. Endometriosis
7. Stones in the urinary and biliary systems
8. Surgery on ears/tonsils/adenoids/ paranasal sinuses
9. Cataracts
10. Hernia of all types and Hydrocele
11. Fistulae in anus
12. Fissure in anus
13. Fibromyoma
14. Hysterectomy
15. Surgery for any skin ailment
16. Surgery on all internal or external tumours/ cysts/ nodules/polyps of any kind
including breast lumps with exception of Malignancy
17. Dialysis required for Chronic Renal Failure.
18. Joint Replacement Surgeries unless necessitated by Accident happening after
the Policy risk inception date.
19. Dilatation and curettage
20. Varicose Veins and Varicose Ulcers
21. Non Infective Arthritis and other form arthritis
22. Gout and Rheumatism
23. Prolapse inter Vertebral Disc and Spinal Diseases including
spondylitis/spondylosis unless arising from Accident
3. a. Expenses related to the treatment of the below mentioned illness within 90 days e.i.3
from the first policy commencement date shall be excluded unless they are pre-
existing and disclosed at the time of underwriting
1. Hypertension
2. Diabetes
3. Cardiac Conditions
b. This exclusion shall not, however, apply if the Insured Person has continuous
coverage for more than twelve months
The within referred waiting period is made applicable to the enhanced Sum
Insured in the event of granting higher sum insured subsequently.

ICICI Lombard General Insurance Company Limited

CIN: L67200MH2000PLC129408
IRDA Reg. No. 115 Registered Office Address: UIN: < ICIHLIP25031V012425 > Elevate
Mailing Address: ICICI Lomba rd Hous e, 414, P Ba lu Ma rg, Toll free no : 1800 2666
601 & 602, 6th Floor, Interfa ce 16, Off Veer Sa va rka r Roa d Ma rg Alternate no : 86552 22666 (cha rgea ble)
New Linking Roa d, Ma la d (Wes t) Nr Siddhi Vina ya k Temple, Pra bha devi, E-mail : cus tomers upport@icicilomba rd.com
Mumba i - 400 064 Mumba i 400 025 Website : www.icicilomba rd.com
 4. 30-day waiting period- Code- Excl03 e.i.4
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 within referred waiting period is made applicable to the enhanced sum
insured in the event of granting higher sum insured subsequently.
5. Investigation & Evaluation- Code- Excl04 e.i.5
a. Expenses related to any admission primarily for diagnostics and evaluation
purposes only are excluded.
b. Any diagnostic expenses which are not related or not incidental to the current
diagnosis and treatment are excluded.
6. Rest Cure, rehabilitation and respite care- Code- Excl05 e.i.6
a. Expenses related to any admission primarily for enforced bed rest and not for
receiving treatment. This also includes:
i. Custodial care either at home or in a nursing facility for personal care such as
help with activities of daily living such as bathing, dressing, moving around
either by skilled nurses or assistant or non-skilled persons.
ii. Any services for people who are terminally ill to address physical, social,
emotional and spiritual needs.
7. Obesity/ Weight Control: Code- Excl06 e.i.7
Expenses related to the surgical treatment of obesity that does not fulfil all the
below conditions:
1. Surgery to be conducted is upon the advice of the Doctor
2. The surgery/Procedure conducted should be supported by clinical protocols
3. The member has to be 18 years of age or older and
4. Body Mass Index (BMI);
a. greater than or equal to 40 or
b. greater than or equal to 35 in conjunction with any of the following severe
co-morbidities following failure of less invasive methods of weight loss:
i. Obesity-related cardiomyopathy
ii. Coronary heart disease
iii. Severe Sleep Apnea
iv. Uncontrolled Type2 Diabetes
8. Change-of-Gender treatments: Code- Excl07 e.i.8
Expenses related to any treatment, including surgical management, to change
characteristics of the body to those of the opposite sex.
9. Cosmetic or plastic Surgery: Code- Excl08 e.i.9
Expenses for cosmetic or plastic surgery or any treatment to change appearance
unless for reconstruction following an Accident, Burn(s) or Cancer or as part of
medically necessary treatment to remove a direct and immediate health risk to
the insured. For this to be considered a medical necessity, it must be certified by
the attending Medical Practitioner.
10. Hazardous or Adventure sports: Code- Excl09 e.i.10
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.

11. Breach of law: Code- Excl10 e.i.11

Expenses for treatment directly arising from or consequent upon any Insured
Person committing or attempting to commit a breach of law with criminal intent.

ICICI Lombard General Insurance Company Limited

CIN: L67200MH2000PLC129408
IRDA Reg. No. 115 Registered Office Address: UIN: < ICIHLIP25031V012425 > Elevate
Mailing Address: ICICI Lomba rd Hous e, 414, P Ba lu Ma rg, Toll free no : 1800 2666
601 & 602, 6th Floor, Interfa ce 16, Off Veer Sa va rka r Roa d Ma rg Alternate no : 86552 22666 (cha rgea ble)
New Linking Roa d, Ma la d (Wes t) Nr Siddhi Vina ya k Temple, Pra bha devi, E-mail : cus tomers upport@icicilomba rd.com
Mumba i - 400 064 Mumba i 400 025 Website : www.icicilomba rd.com
 12. Excluded providers: Code- Excl11 e.i.12
Expenses incurred towards treatment in any hospital or by any Medical
Practitioner or any other provider specifically excluded by the insurer and
disclosed in its website / notified to the policyholders are not admissible.
However, in case of life threatening situations or following an accident, expenses
up to the stage of stabilization are payable but not the complete claim.
(The list of excluded providers/delisted hospitals is available on our website
www.icicilombard.com and is timely updated.)
13. Treatment for, Alcoholism, drug or substance abuse or any addictive condition and e.i.13
consequences thereof. Code- Excl12
14. Treatments received in heath hydros, nature cure clinics, spas or similar e.i.14
establishments or private beds registered as a nursing home attached to such
establishments or where admission is arranged wholly or partly for domestic
reasons. Code- Excl13
15. Dietary supplements and substances that can be purchased without prescription, e.i.15
including but not limited to Vitamins, minerals and organic substances unless
prescribed by a medical practitioner as part of hospitalization claim or day care
procedure. Code- Excl14
16. Refractive Error: Code- Excl15 e.i.16
Expenses related to the treatment for correction of eye sight due to refractive
error less than 7. 5 dioptres.
17. Unproven Treatments: Code- Excl 16 e.i.17
Expenses related to any unproven treatment, 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.
18. Sterility and lnfertility: Code- Excl 17 e.i.18
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
The above exclusion part b. Assisted Reproduction services including artificial
insemination and advanced reproductive technologies such as IVF, ZIFT, GIFT, ICSI
shall not apply to claims which are otherwise admissible under d. i.14 "In-patient
Hospitalisation for Oocyte Donor" which pertains to Medical Expenses incurred in
respect of Hospitalization of the Oocyte donor for complications arising due to
oocyte retrieval process

The above exclusion part c. Gestational surrogacy shall not apply to claims which
are otherwise admissible under d. i.13 "In-patient Hospitalisation for Surrogate
Mother" which pertains to Medical Expenses incurred in respect of Hospitalization
of the Surrogate mother for complications arising out of pregnancy and post-
partum delivery complications

ICICI Lombard General Insurance Company Limited

CIN: L67200MH2000PLC129408
IRDA Reg. No. 115 Registered Office Address: UIN: < ICIHLIP25031V012425 > Elevate
Mailing Address: ICICI Lomba rd Hous e, 414, P Ba lu Ma rg, Toll free no : 1800 2666
601 & 602, 6th Floor, Interfa ce 16, Off Veer Sa va rka r Roa d Ma rg Alternate no : 86552 22666 (cha rgea ble)
New Linking Roa d, Ma la d (Wes t) Nr Siddhi Vina ya k Temple, Pra bha devi, E-mail : cus tomers upport@icicilomba rd.com
Mumba i - 400 064 Mumba i 400 025 Website : www.icicilomba rd.com
 19. Maternity: Code Excl18 e.i.19
Expenses related to sterility and infertility. This includes:
i. Medical treatment expenses traceable to childbirth (including complicated
deliveries and caesarean sections incurred during hospitalization) except ectopic
pregnancy;
ii. Expenses towards miscarriage (unless due to an accident) and lawful medical
termination of pregnancy during the policy period.
This exclusion will not be applicable in case optional cover 5 Maternity Benefit
has been opted

ii. Specific Exclusions (Exclusions other than those specified above): - e. ii. Specific
Exclusions
20. War (whether declared or not) and war like occurrence or invasion, acts of foreign e.ii.20
enemies, hostilities, civil war, rebellion, revolutions, insurrections, mutiny,
military or usurped power, seizure, capture, arrest, restraints and detainment of
all kinds.
21. Nuclear, chemical or biological attack or weapons, contributed to, caused by, e.ii.21
resulting from or from any other cause or event contributing concurrently or in any
other sequence to the loss, claim or expense.
22. Any expenses incurred on Out Patient treatment. This exclusion will not be e.ii.22
applicable in case optional cover 8. BeFit has been opted
23. Any expenses incurred on prosthesis, corrective devices, external durable medical e.ii.23
equipment of any kind, like wheelchairs, crutches, instruments used in treatment
of sleep apnoea syndrome or cost of cochlear implant(s) unless necessitated by
an Accident or required intra-operatively.
24. Treatment, procedures and preventive, diagnostic, restorative, cosmetic services e.ii.24
related to disease, disorder and conditions related to natural teeth and gingiva
except if required by an Insured Person while Hospitalized due to an Accident.
25. Treatment taken outside the geographical limits of India. This exclusion shall not e.ii.25
be applicable for policies where Optional cover 9. Worldwide cover has been
opted.
26. Personal comfort, cosmetics, convenience and hygiene related items and services e.ii.26
27. Acupressure, acupuncture, magnetic and other therapies e.ii.27
28. Circumcision unless necessary for treatment of an Illness or necessitated due to e.ii.28
an Accident.
29. Expenses for venereal disease or any sexually transmitted disease except HIV. e.ii.29
30. Screening, counselling or Treatment relating to external birth defects and external e.ii.30
congenital Illnesses or defects or anomalies
31. Intentional self-injury (whether arising from an attempt to commit suicide or e.ii.31
otherwise)
32. Any ailment/ illness/ injury/ condition or treatment or service that is specifically e.ii.32
excluded in the Policy Schedule under Special Conditions.
7. Waiting Period-
- Time period during which specified diseases/treatments are not covered
- It is counted from the beginning of the policy coverage
1. Initial waiting period: 30 days for all illnesses (except Hospitalization due to e.i.4
injury).

ICICI Lombard General Insurance Company Limited

CIN: L67200MH2000PLC129408
IRDA Reg. No. 115 Registered Office Address: UIN: < ICIHLIP25031V012425 > Elevate
Mailing Address: ICICI Lomba rd Hous e, 414, P Ba lu Ma rg, Toll free no : 1800 2666
601 & 602, 6th Floor, Interfa ce 16, Off Veer Sa va rka r Roa d Ma rg Alternate no : 86552 22666 (cha rgea ble)
New Linking Roa d, Ma la d (Wes t) Nr Siddhi Vina ya k Temple, Pra bha devi, E-mail : cus tomers upport@icicilomba rd.com
Mumba i - 400 064 Mumba i 400 025 Website : www.icicilomba rd.com
 2. Specific waiting period (Not applicable for claims arising due to an e.i.2
accident): First 24 months, for specific Illness and treatment. (Please refer to
the policy clauses for the full listing)
3. Pre-Existing Diseases: Declared & accepted Pre-existing diseases will be e.i.1
covered after 24 months of continuous coverage.
4. In case of hypertension, diabetes and cardiac conditions, the waiting period will e.i.3
be 90 days unless disclosed as pre-existing diseases.
5. Jumpstart - 30 days d. i. Basic cover. 3
6. Maternity waiting period: 24 months d. ii. Optional
Cover 5
7. World Wide Cover Waiting Period – 24 months d. ii. Optional
cover.8
8. BeFit – 30 days d. ii. Optional
Cover 9
9. Critical illness: waiting period of 90 days and survival period of 0 days will be d. ii. Optional
applicable Cover 17
10. Bariatric Surgery Waiting Period – 24 months d. i. Basic cover.
12
11 In patient Hospitalization for Surrogate Mother – 30 days d. i. Basic cover.
13
12 In patient Hospitalization for Oocyte Donor – 30 days d. i. Basic cover.
14
8. Financial Limits of coverage
i. 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.
1. In-Patient Treatment – Room rent charges up to Single Private Room d.i.1
2. In-Patient Treatment for Surrogate Mother – Up to Rs.5,00,000 d.i.13
3. In-Patient Treatment for Oocyte Donor – Up to Rs.5,00,000 d.i.14
Optional Covers (As opted by the customer): -
8. Health Check Up - Up to 0.5% of annual sum insured subject to a maximum of d.ii.16
Rs. 5,000 for pre-defined packages and on cashless basis
ii. Co-payment d. ii. Optional
(It is a specified amount /percentage of the admissible claim amount to be paid by Cover. 19
policyholder/insured)
Voluntary Co-payment if opted shall be applicable for each and every claim.
Voluntary Co-Payment opted-10%/20%/30%/40%/50%. Refer to the Policy Schedule for the
voluntary co-payment applicable on the Policy.

ICICI Lombard General Insurance Company Limited

CIN: L67200MH2000PLC129408
IRDA Reg. No. 115 Registered Office Address: UIN: < ICIHLIP25031V012425 > Elevate
Mailing Address: ICICI Lomba rd Hous e, 414, P Ba lu Ma rg, Toll free no : 1800 2666
601 & 602, 6th Floor, Interfa ce 16, Off Veer Sa va rka r Roa d Ma rg Alternate no : 86552 22666 (cha rgea ble)
New Linking Roa d, Ma la d (Wes t) Nr Siddhi Vina ya k Temple, Pra bha devi, E-mail : cus tomers upport@icicilomba rd.com
Mumba i - 400 064 Mumba i 400 025 Website : www.icicilomba rd.com
 iii. Deductible d. ii. Optional
(It is a specified amount:) Cover. 20
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)
Voluntary Deduc ble opted- Op ons available range from Rs. 10,000 to Rs.50,000. Refer to
the Policy Schedule for the voluntary deductible applicable on the Policy.
Voluntary Deduc ble if opted shall be applicable on an aggregate basis for all hospitalisa on
expenses during the policy year which fall under basic cover.

iv. Any other limit (as applicable)

Not Applicable
9. Claims/claims procedures g. (Other terms
and conditions)

ICICI Lombard General Insurance Company Limited

CIN: L67200MH2000PLC129408
IRDA Reg. No. 115 Registered Office Address: UIN: < ICIHLIP25031V012425 > Elevate
Mailing Address: ICICI Lomba rd Hous e, 414, P Ba lu Ma rg, Toll free no : 1800 2666
601 & 602, 6th Floor, Interfa ce 16, Off Veer Sa va rka r Roa d Ma rg Alternate no : 86552 22666 (cha rgea ble)
New Linking Roa d, Ma la d (Wes t) Nr Siddhi Vina ya k Temple, Pra bha devi, E-mail : cus tomers upport@icicilomba rd.com
Mumba i - 400 064 Mumba i 400 025 Website : www.icicilomba rd.com
 Pre-authorization g.I.1. (Other terms
Prior to taking treatment and/ or incurring Medical Expenses at a Network Provider, You must and conditions)
contact Us or Our in house claim processing team accompanied with full par culars namely,
Policy Number, Your name, Your rela onship with Policy Holder, nature of Illness or Injury,
name and address of the Medical Prac oner/ Hospital and any other informa on that may
be relevant to the Illness/ Injury/ Hospitalisa on. You must request preauthoriza on at least
48 hours before a planned Hospitaliza on and in case of an emergency situa on, within 24
hours of Hospitalization.
To avail of Cashless Hospitaliza on facility, you are required to produce the health card, as
provided to You with this Policy, subject to the terms and condi ons for the usage of the said
health card Or You can seek pre authoriza on by providing Your Policy number and ID proof
to the hospital who can co-ordinate with Our claim team to provide cashless facility. We will
consider Your request a er having obtained accurate and complete informa on for the
Illness or Injury for which cashless Hospitaliza on facility is sought by You and We will
confirm Your request in writing.

A. For Reimbursement Settlement

i. You shall give notice to Us or Our in house claim processing team by calling the toll free
number 1800 2666 or emailing us at customersupport@icicilombard.com as specified in
the Policy provided to You and also in writing at Our address with particulars as below:
Policy number;
Your Name;
Your relationship with the Policyholder;
Nature of Illness or Injury;
Name and address of the attending Medical Practitioner and the Hospital;
Any other information that may be relevant to the Illness/ Injury/ Hospitalisation
The above information needs to be provided to Us or Our in house claim processing team
immediately and in any event within 10 days of Hospitalization, failing which We will
have the right to treat the Claim as inadmissible, as We may deem fit at Our sole
discretion.
ii. You must immediately consult a Medical Practitioner and follow the advice and
treatment that he recommends.
iii. You or someone claiming on Your behalf must promptly and in any event within 30 days
of Your discharge from a Hospital (for post-hospitalization expenses, within 30 days from
the completion of post-hospitalization period) deliver to Us the documentation (written
details of the quantum of any Claim along with all original supporting documentation) as
more particularly listed in Claim documents section. In case there is a delay beyond 30
days in submission of claim documents, we may condone the delay provided the insured
person submits a valid reason justifying the delay to us in writing.

However, in both the above cases i.e. g. Claim Administration I. 1. (A) & (B), You must
take reasonable steps or measure to minimize the quantum of any Claim that may be
covered under the Policy.
If so requested by Us, You will have to undergo a medical examination from Our
nominated Medical Practitioner, as and when We or Our in house claim processing team
considers reasonable and necessary. The cost of such examination will be borne by Us.

Claim falling in two Policy periods

If the claim event falls within two Policy periods, the claims shall be paid taking into
considera on the available Sum Insured in the two Policy periods, including the Deduc bles
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.
Claim Documents g.I.3. Claims
You shall be required to furnish the following documents for or in support of a Claim: Service Guarantee
1. Duly completed Claim form signed by You and the Medical Practitioner. The claim form (Other terms and
can be downloaded from our website www.icicilombard.com conditions)

ICICI Lombard General Insurance Company Limited

CIN: L67200MH2000PLC129408
IRDA Reg. No. 115 Registered Office Address: UIN: < ICIHLIP25031V012425 > Elevate
Mailing Address: ICICI Lomba rd Hous e, 414, P Ba lu Ma rg, Toll free no : 1800 2666
601 & 602, 6th Floor, Interfa ce 16, Off Veer Sa va rka r Roa d Ma rg Alternate no : 86552 22666 (cha rgea ble)
New Linking Roa d, Ma la d (Wes t) Nr Siddhi Vina ya k Temple, Pra bha devi, E-mail : cus tomers upport@icicilomba rd.com
Mumba i - 400 064 Mumba i 400 025 Website : www.icicilomba rd.com
 2. Original bills, receipts and discharge certificate/ card from the Hospital/ Medical
Practitioner
3. Original bills from chemists supported by proper prescription.
4. Original investigation test reports and payment receipts.
5. Indoor case papers
6. Medical Practitioner's referral letter advising Hospitalization in non-Accident cases.
7. Any other document as required by Us or to investigate the Claim or Our obligation to
make payment for it

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
Note : To claim or check your claim status, use the IL TakeCare App or contact us on WhatsApp
at +91 7738282666.

For cashless hospitaliza on in a non-network hospital, contact health assistance at least 48

hours before admission. Use "Anywhere Cashless" through IL TakeCare App's > Services We
Offer > Health Assistance. Available from 8am to 8pm, Mon to Sat (except public holidays).
You can also reach them via email at healthassistance@icicilombard.com or through this web
link: https://ilhc.icicilombard.com/Home/healthassistance.

For customer support during claims, call our toll-free number 18002666 or email us at
customersupport@icicilombard.com.

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

No fy 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.

If sending hard copies of claim documents, mail them to: ICICI Lombard GIC LTD, 1st, 4th, 5th
& 6th Floor Varun Towers-II, Opp Hyderabad Public School, Begumpet Hyderabad-500016
Telangana.

In the event of a payable claim, we shall make such payment in a lump sum through cashless
facility or provide reimbursement of benefits, up to an amount as specified for said cover.

Turn Around Time(TAT) for claim settlements-

For reimbursements claims- TAT will be 14 days for payment of claim or communica on of
non-admissibility of claim
For cashless claims- TAT for response to the pre authoriza on request will be within 2 hours
of receiving the request.

Claim Service Guarantee available under the Policy. (Please refer to the policy wordings for
Our full service guarantee.)

Download Claim Form-

https://echannel-wf.icicilombard.com/docs/default-
source/apps/healthclaims/assets/files/claim-form-greater-then-1-lac.pdf

ICICI Lombard General Insurance Company Limited

CIN: L67200MH2000PLC129408
IRDA Reg. No. 115 Registered Office Address: UIN: < ICIHLIP25031V012425 > Elevate
Mailing Address: ICICI Lomba rd Hous e, 414, P Ba lu Ma rg, Toll free no : 1800 2666
601 & 602, 6th Floor, Interfa ce 16, Off Veer Sa va rka r Roa d Ma rg Alternate no : 86552 22666 (cha rgea ble)
New Linking Roa d, Ma la d (Wes t) Nr Siddhi Vina ya k Temple, Pra bha devi, E-mail : cus tomers upport@icicilomba rd.com
Mumba i - 400 064 Mumba i 400 025 Website : www.icicilomba rd.com
10. Policy Servicing
You may contact us on our Toll Free no: 1800 2666, or email us at
customersupport@icicilombard.com 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
In case the insured is aggrieved in any way, the insured person should do the and conditions
following:
Call us on our toll free no. 1800 2666 or email us at
customersupport@icicilombard.com
There is an interactive voice response (IVR) facility for senior citizen's 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/
(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, Veer
Savarkar Marg, 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.
If the issue still remains unresolved, you may approach the grievance officer and/or
Insurance Ombudsman officer. kindly refer the link
https://www.icicilombard.com/grievance-redressal.

12. Things to remember

Free Look cancella on: You can cancel the policy within 30 days of receiving the Policy f.6. General terms
Documents whether received electronically or otherwise by wri en no ce via registered and conditions
post. We refund short-term premium rates. Refer to Policy Wordings and Prospectus for
details.
If you wish to cancel the Policy, contact us through our website www.icicilombard.com
(Customer Support sec on), call us toll Free at 1800 2666, or email
customersupport@icicilombard.com.
Policy renewal: Except on grounds of established fraud, or misrepresenta on or non- f.8. General terms
disclosure, renewal of your policy shall not be denied, provided the policy is not withdrawn. and conditions
Migra on and Portability - When your policy is due for renewal, you may migrate to another f. 10. & 11.
policy with us or port your policy to another insurer. General terms
and conditions
In case You are desirous of migra ng or outward por ng Your Policy, kindly contact us at
customersupport@icicilombard.com.
Change in Sum Insured:The sum insured can be modified (increase/decrease) only at f.27. General
renewal or any me, subject to company underwri ng. Wai ng period restarts for increased terms and
sum insured. conditions

ICICI Lombard General Insurance Company Limited

CIN: L67200MH2000PLC129408
IRDA Reg. No. 115 Registered Office Address: UIN: < ICIHLIP25031V012425 > Elevate
Mailing Address: ICICI Lomba rd Hous e, 414, P Ba lu Ma rg, Toll free no : 1800 2666
601 & 602, 6th Floor, Interfa ce 16, Off Veer Sa va rka r Roa d Ma rg Alternate no : 86552 22666 (cha rgea ble)
New Linking Roa d, Ma la d (Wes t) Nr Siddhi Vina ya k Temple, Pra bha devi, E-mail : cus tomers upport@icicilomba rd.com
Mumba i - 400 064 Mumba i 400 025 Website : www.icicilomba rd.com
 Zone Based Pricing - Premium depends on the insured person's residen al city and pin code. f.18. General
No fy us of any changes immediately to avoid impac ng claim admissibility. (Refer to policy terms and
wordings and prospectus for zone definition.) conditions
Moratorium Period - A er five con nuous years, no look-back is applied. The moratorium f.13. General
covers the sums insured for the first policy. A er enhancing sums insured, the five-year rule terms and
starts anew from the enhancement date. A er the Moratorium Period ends, the policy is conditions
indisputable, except for proven fraud and permanent exclusions stated in the policy contract.
13. Your Obligations f. General terms
Please disclose all pre-existing disease/s or condition/s before buying a policy. Non- and conditions.
disclosure may affect the claim settlement.
In the event of misrepresentation, mis-description, 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 are used by You or any one acting on Your behalf
to obtain any Benefit under this Policy, the Policy shall stand void and all premium
paid hereon shall be forfeited to the company.

Declaration by the Policy Holder:

I have read the above and confirm having noted the details.
Place: LUDHIANA

Date: 13/11/2024 Signature of the Policy Holder

NOTE: The informa on must be read in conjunc on with the product brochure and policy document. In case of any
conflict, the terms and conditions mentioned in the policy document shall prevail.

ICICI Lombard General Insurance Company Limited

CIN: L67200MH2000PLC129408
IRDA Reg. No. 115 Registered Office Address: UIN: < ICIHLIP25031V012425 > Elevate
Mailing Address: ICICI Lomba rd Hous e, 414, P Ba lu Ma rg, Toll free no : 1800 2666
601 & 602, 6th Floor, Interfa ce 16, Off Veer Sa va rka r Roa d Ma rg Alternate no : 86552 22666 (cha rgea ble)
New Linking Roa d, Ma la d (Wes t) Nr Siddhi Vina ya k Temple, Pra bha devi, E-mail : cus tomers upport@icicilomba rd.com
Mumba i - 400 064 Mumba i 400 025 Website : www.icicilomba rd.com
 Benefit Illustration
Annexure – A
Benefit Illustration in respect of policies offered on individual and family floater basis (Elevate)
Coverage opted on Coverage opted on individual basis
individual basis covering multiple members of the Coverage opted on family floater basis with overall
covering each member family under a single policy (Sum Sum insured (Only one sum insured is available for
of the family separately insured is available for each member the entire family)
Age of (at a single point in of the family)
the time)
members
insured Premium Premium or Premium
Premium Sum after Sum consolidated Floater after Sum
(₹) insured (₹) Discount discount insured premium for discount, discount insured
(₹) (₹) all members if any (₹) (₹)
of family (₹)
44 11,873 10,00,000 11,873 10,00,000
0.00% 19,667 - 19,667 10,00,000
48 15,129 10,00,000 15,129 10,00,000
Total Premium for all members Total Premium for all members
of the family is ₹ 27,002 when of the family is ₹ 27,002 when Total Premium when policy is opted on floater
each member is covered they are covered under a single basis is ₹ 19,667
separately. policy.
Sum insured available for each Sum insured available for each Sum insured of ₹ 10,00,000 is available for the
individual is ₹ 10,00,000. family member is ₹ 10,00,000. entire family.
Note: Premium rates specified in the above illustration shall be standard premium rates without considering any
loading. Also the premium rates shall be exclusive of taxes applicable.

ICICI Lombard General Insurance Company Limited

CIN: L67200MH2000PLC129408
IRDA Reg. No. 115 Registered Office Address: UIN: < ICIHLIP25031V012425 > Elevate
Mailing Address: ICICI Lomba rd Hous e, 414, P Ba lu Ma rg, Toll free no : 1800 2666
601 & 602, 6th Floor, Interfa ce 16, Off Veer Sa va rka r Roa d Ma rg Alternate no : 86552 22666 (cha rgea ble)
New Linking Roa d, Ma la d (Wes t) Nr Siddhi Vina ya k Temple, Pra bha devi, E-mail : cus tomers upport@icicilomba rd.com
Mumba i - 400 064 Mumba i 400 025 Website : www.icicilomba rd.com