Claims and Exclusion

Claims

• Cashless Claims
  • Get admitted in any one of our network hospital
  • Fax the pre-authorization along with relevant documents (investigation reports, Previous consultation papers if any, Cashless ID, Photo ID)
  • ICICI Lombard Health Care reviews your claim requested and accordingly will approve query or reject the same (as per policy terms and conditions).
  • ICICI Lombard Health Care settles the claim (as per policy terms and conditions) with the hospital after completion of all formalities
• Reimbursement Claims
  • Upon discharge, pay all hospital bills and collect all original documents of treatments and expenses underdone
  • Send the duly filled (and signed by insured and treating doctor) claim form and required claim documents.
  • ICICI Lombard Health Care reviews your claim requested and accordingly will approve, query or reject the same (as per policy terms and conditions)
  • ICICI Lombard Health Care Settles the claim (as per policy terms and conditions) and reimburses the approved amount
• Standard List Of Documents
  • Duly completed claim form signed by you and the medical practitioner.
  • Original bills, receipts and discharge certificate / card from the hospital / medical practitioner.
  • Original bills from chemists supported by proper prescription.
  • Original investigation test reports and payment receipts.
  • Indoor case papers.
  • Medical Practitioner’s referral letter advising hospitalisation in non-accident cases.
  • Any other document as required by ICICI Lombard Health Care to investigate the claim or our obligation to make payment for the same.

Exclusions¹⁰

Your policy does not cover:

Deductibles:We are not liable for the deductible amount as specified against the plan opted. We are not liable for any payment unless the hospitalisation medical expenses exceed the deductible. No deductible shall be applicable for optional covers.

Co-payment: We are not liable to pay 20% of admissible claim amount above the deductible applicable under the policy, for insured above 60 years of age. Not be applicable if aged 45 years or below during policy purchase with continuous renewal thereafter. No co-pay will be applicable for optional covers, if any.

First 30 days waiting period: Any illness that you contract within 30 days of the starting date of your policy, except those that are incurred because of an accident. This clause is not applicable on the subsequent renewals.

Pre-existing disease waiting period: Any Pre-Existing condition(s) until 24 months of Your continuous coverage has elapsed, since Period of Insurance Start Date

First 2 year exclusions

For medical diseases/ conditions and treatment/procedure mentioned below, a waiting period of 2 years will be applicable unless required due to occurrence of cancer.

• ENT: Sinusitis, deviated nasal septum
• Gynaecological: Fibroids (fibromyoma), endometriosis, prolapsed uterus, polycystic ovarian disorder (PCOD)
• Orthopaedic: Arthritis, gout and rheumatism, osteoarthritis and osteoporosis, spinal or vertebral disorders
• Gastrointestinal: Calculus diseases of gall bladder including cholecystitis, esophageal varices, pancreatitis, fissure/fistula in anus, hemorrhoids, pilonidal sinus, piles, ulcer and erosion, gastro esophageal reflux disorder (GERD), perineal abscesses, perianal abscesses
• Uro-genital: Calculus diseases of Urogenital system, for example: kidney stone, urinary bladder stone etc., benign enlargement of prostate, chronic kidney disease
• Eye: Cataract
• Other general conditions (Applicable to all organ systems/ organs/ disciplines whether or not described above): Internal tumors, cysts, nodules, polyps, skin tumors, lumps, all types of internal congenital anomalies/illnesses/defects

Permanent exclusions

• Acupressure, acupuncture, magnetic and such other therapies
• Unproven experimental treatment
• Cosmetic surgery
• Dental treatment unless due to accident
• Any case directly or indirectly related to criminal acts

Disclaimer

¹Tax deductions under Section 80D is as per applicable provision of the Act (including any amendments thereto) and are subject to changes in the tax laws.
²Factors determining the renewal premium are (i) age slab of the senior most insured member at the time of renewal (ii) any change in the renewing policy.
³Only when it has been undergone in an AYUSH hospital or in AYUSH Day Care Center on Re - imbursement basis.
⁶This cover can be availed only once during your lifetime. Once a claim becomes payable under this cover, no benefit will be provided under the same thereafter.
⁷Critical Illness and Personal Accident available only for adults, subject to maximum of 2 Adults only up to 60 years of age.
⁸Disclaimer: Cashless approval is subject to pre-authorisation by the company. Only expenses relating to hospitalisation will be reimbursed as per the policy coverage. Non-medical expenses will not be reimbursed.
¹⁰Following is an indicative list of the policy exclusions. Please refer to the policy clause for the complete list. #as on 31st July 2020

Metra Trust ("Bank") with registered office at KRM Tower, 8th Floor, No.1, Harrington Road, Chetpet, Chennai- 600031 is licensed as a corporate agent of ICICI Lombard General Insurance Company Limited under license no.CA0106 issued by Insurance Regulatory & Development Authority of India and does not underwrite the risk or acts as an insurer. This policy is issued to you by ICICI Lombard and is subject to the terms and conditions governing such policy. The contract of insurance is between ICICI Lombard and the insured only, and not between Metra Trust and the insured. Bank’s customer participation in the policy is entirely voluntary.

This is only an indication of the cover offered. For complete details on risk factors, terms, conditions, coverages and exclusions, please read the sales brochure carefully before concluding a sale. ICICI trade logo displayed above belongs to ICICI Bank and is used by ICICI Lombard GIC Ltd. under license and Lombard logo belongs to ICICI Lombard GIC Ltd. ICICI Lombard General Insurance Company Limited, ICICI Lombard House, 414, Veer Savarkar Marg, Prabhadevi, Mumbai – 400025. . IRDA Reg.No.115. Toll Free 1800 2666. Fax No – 022 61961323. CIN (L67200MH2000PLC129408). customersupport@iciclombard.com. www.icicilombard.com. Health Booster. Misc 140. UIN ICIHLIP22100V032122