Coverage

The beneficiary can avail cashless hospitalisation in network hospitals empanelled under the scheme subject to the terms and conditions/limits of the policy. It is a purely cashless policy. Reimbursement of claims is allowed only in case of pre and post hospitalisation.

The annual Limit (per family) `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 hours hospitalisations up to an expenditure of `5 lakhs 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 hours hospitalisation:

• Dialysis
• Chemotherapy
• Radiotherapy
• Eye Surgery
• Lithotripsy (Kidney Stone Removal)
• Tonsillectomy
• Laparoscopy
• Arthroscopy
• Endoscopy
• Coronary Angiography
• DNC
• Colonoscopy
• 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 twelve weeks from the date of conception are not covered.

Explanation 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:-

• 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 hospitalisation
• 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
• Diseases, illness, accident or injuries directly or indirectly caused by or contributed to by nuclear weapons/materials, or contributed 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

Hospitalisation

Planned Hospitalisation

• 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 hospitalisation, hospital, nature of illness, or surgeon who is going to perform the procedure will make the authorisation invalid. A fresh authorisation will have to be obtained.
• The authorisation 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 Hospitalisation Expenses

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

Insured will meet cost of pre-post admission investigations and medicines that 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 is to submit the following documents within 90 days at the below-mentioned address:

• Original claim form duly filled and signed by the primary member
• Part - C of the claim form with account details of primary member supported with original cancelled cheque
• Copy of discharge summary
• Original detailed Itemized bill
• Original payment receipts
• Original investigation reports
• Original medicine and pharmacy bills
• Original supporting prescriptions
• Original implant invoice