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

• Any Pre-Existing condition(s) until 24 months of Your continuous coverage has elapsed, since Period of Insurance Start Date
• Any Expenses related to the treatment of Hypertension, Diabetes, cardiac conditions within 90 days from the first policy start date.
• 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.
• Any Medical Expenses incurred by You on treatment of following Illnesses within the first two (2) consecutive years of Period of Insurance Start Date:
  • Cataract⁹
  • All types of Hernia, Hydrocele
  • Arthritis, gout, rheumatism and spinal disorders
  • Surgery on tonsils, adenoids and sinuses • Dilatation and curettage, Endometriosis
  • Gastric and Duodenal erosions and ulcers
  • Varicose Veins / Varicose Ulcers
  • Benign Prostatic Hypertrophy
  • Joint replacements unless due to accident
  • Sinusitis and related disorders
  • Stones in the urinary and billiary systems
  • Dialysis required for chronic renal failure
  • Deviated Nasal Septum
  • Fissures / Fistula in anus, hemorrhoids / piles
  • All types of internal congenital anomalies / illness / defects
  • Myomectomy, Hysterectomy unless because of malignancy
  • All types of Skin and internal tumors / cysts / nodules / polyps of any kind including breast lumps unless malignant
• Permanent exclusions
  • Any illness / disease / injury pre-existing before the inception of the policy for the first 2 years. Such waiting period shall reduce if the insured has been covered under a similar policy before opting for this policy, subject however to portability regulations.
  • Medical expenses incurred during the first 30 days of inception of the policy, except those arising out of accidents. This exclusion doesn’t apply for subsequent renewals without a break.
  • Expenses attributable to self-inflicted injury (resulting from suicide, attempted suicide).
  • Expenses arising out of or attributable to alcohol or drug use / misuse / abuse
  • Cost of spectacles / contact lenses, dental treatment
  • Medical treatment expenses traceable to childbirth (including complicated deliveries and caesarean sections incurred during Hospitalisation) except ectopic pregnancy.

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 a AYUSH hospital or in AYUSH Day Care Center on Re - imbursement basis.
⁴Please note that reset will not trigger for first claim and reset cannot be used by same person and/or for same illness for which a claim has been paid in the policy year
⁵The waiting period for maternity cover is 3 years. The cover shall be limited to 2 deliveries / terminations during the period of insurance. Pre - natal and Post - natal expenses shall be covered under this benefit. This cover is applicable only for floater plan having Self and Spouse in the same policy. (Inbuilt under Health Elite and Health Elite Plus plans only)
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.
⁹After two years from the Period of Insurance Start Date, Our maximum liability arising out of any Claim for a cataract treatment shall not exceeds Rs. 20,000 per eye, during each Policy Year of the Policy Period for plans with Sum Insured up to Rs 5Lacs. Sub limit of Rs 1,00,000 per eye per Policy year will be applicable for Cataract surgery for plans with Sum Insured above Rs 5Lacs.
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. Insurance is underwritten by 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. ICICI Lombard Complete health Insurance. Misc128. UIN ICIHLIP21383V052021.