workflow.txt

{
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      "notesInFlow": true
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      "parameters": {
        "promptType": "define",
        "text": "={{ $json.chat_input }}  acording to the query decide how much insurence the user is going to get and if he has qualified or failed for certain insurences from this data {{ $json.output }}  also give the output in proper format bullets with spaces between lines (no special symbols) and only mention necessary informations",
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      "name": "Extract from File"
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        "resource": "file",
        "fileId": "BQACAgUAAxkBAAMCaKbMV9pV3cSUvzynw55ABkg6HkkAAuEXAAJjwjlVin6s64JwCDo2BA",
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      "name": "Get a file",
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      "name": "Google Gemini Chat Model1",
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          "name": "Google Gemini(PaLM) Api account"
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      "type": "n8n-nodes-base.merge",
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      "notesInFlow": true,
      "alwaysOutputData": false
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    {
      "parameters": {
        "promptType": "define",
        "text": "=extract any relevant information from the text {{ $json.text }} on ref to {{ $json.chat_input }} and then pass the output and input query to next node",
        "options": {}
      },
      "type": "@n8n/n8n-nodes-langchain.agent",
      "typeVersion": 2.2,
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      "id": "db499987-9a1b-4301-8bd0-decfd86b592e",
      "name": "AI Agent1",
      "notesInFlow": true
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    {
      "parameters": {
        "jsCode": "// Get all input items from Merge node\nconst inputItems = $input.all();\n\n// Assume first item = Webhook, second item = Extract from File\nconst chatInput = inputItems[0]?.json?.body?.chat_input || \"\";\nconst pdfText   = inputItems[1]?.json?.text || \"\";\n\n// Return a single merged object\nreturn [\n  {\n    json: {\n      chat_input: chatInput,\n      text: pdfText\n    }\n  }\n];\n"
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        "jsCode": "// Get all input items from Merge node\nconst inputItems = $input.all();\n\n// Assume first item = Webhook, second item = Extract from File\nconst chatInput = inputItems[0]?.json?.body?.chat_input || \"\";\nconst outputref   = inputItems[1]?.json?.output || \"\";\n\n// Return a single merged object\nreturn [\n  {\n    json: {\n      chat_input: chatInput,\n      output: outputref\n    }\n  }\n];\n"
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    "Get a file": {
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    "Webhook": [
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          "accept": "*/*",
          "cache-control": "no-cache",
          "postman-token": "416ff2e9-ee40-46cf-bb81-17fe26b8182d",
          "host": "localhost:5678",
          "accept-encoding": "gzip, deflate, br",
          "connection": "keep-alive",
          "content-type": "multipart/form-data; boundary=--------------------------256920438755120176645587",
          "content-length": "415"
        },
        "params": {},
        "query": {},
        "body": {
          "chat_input": "accident - knee fracture ,  medicines - 5000 , surgery - 50000 , ",
          "session_id": "user123",
          "action": "sendMessage"
        },
        "webhookUrl": "http://localhost:5678/webhook/chat_09062005",
        "executionMode": "production"
      }
    ],
    "AI Agent": [
      {
        "output": "Based on the provided information for an accident resulting in a knee fracture, with `5,000 for medicines and `50,000 for surgery:\n\n**1. Total Claimed Amount:**\n`5,000 (Medicines) + `50,000 (Surgery) = **`55,000**\n\n**2. Initial Admissibility & Qualification Status:**\n\n*   **Covered Event:** An \"Accident\" and resulting \"Injury\" (knee fracture) are generally covered under the Golden Shield policy's inpatient treatment benefits. **(QUALIFIED)**\n*   **Waiting Periods:** The 30-day, 24-month specified disease/procedure, and Pre-existing Disease waiting periods are **not applicable for claims arising due to an accident.** This means the claim **(QUALIFIED)** on this front.\n*   **Sub-limits for Surgery:** The surgery cost of `50,000 for \"breakage of long bones/Joint replacements\" falls within all stated sub-limits (which start at `1,00,000 for an Annual Sum Insured of 3L/4L/5L). Therefore, the surgery cost itself **(QUALIFIED)** for coverage up to `50,000 within this category.\n*   **Inpatient Treatment:** Medicines and surgery are explicitly covered under Base Cover 1 (In Patient Treatment) if incurred during hospitalization. **(QUALIFIED)**\n\n**3. Factors Determining the Final Insurance Payout (Critical Missing Information & Potential Deductions):**\n\nTo provide an exact insurance payout, several crucial pieces of information are missing. These factors will determine how much of the `55,000 is actually paid out and whether the user \"failed\" to meet conditions for full reimbursement:\n\n*   **Annual Sum Insured (ASI):** This is essential. While the `50,000 surgery cost is within sub-limits, the overall ASI will determine the maximum an insured can claim.\n    *   **Impact:** If the total admissible claim (after all deductions) exceeds the ASI, the claim amount will be capped at the ASI.\n*   **Base Co-payment (d.12):**\n    *   **Missing Information:** Was a Base Co-payment (e.g., 50%) opted for at the time of policy purchase?\n    *   **Impact:** If yes, the user will **(FAIL)** to get full reimbursement and will bear that percentage of the admissible claim amount. For example, with a 50% co-payment, only 50% of the admissible amount would be paid by the insurer.\n*   **Voluntary Deductible (d.3):**\n    *   **Missing Information:** Was a Voluntary Deductible (a fixed amount) opted for?\n    *   **Impact:** If yes, the user will **(FAIL)** to get full reimbursement up to the deductible amount, as this amount must be paid by the insured first before the insurer pays. (Note: Cannot be opted with Base Co-payment).\n*   **Accident Type & Zone-based Co-payment (e.18):**\n    *   **Missing Information:** Was this a \"Road Traffic Accident\" (RTA)? What geographical zone was the premium paid for, and in which zone was the treatment received?\n    *   **Impact:**\n        *   If it was an **RTA**, the zone-based co-payment **shall not be applicable.** **(QUALIFIED)** on this.\n        *   If it was **not an RTA**, and treatment was taken in a higher geographical zone (e.g., Zone A) than the premium was paid for (e.g., Zone C), an additional zone-based co-payment (e.g., 25%) would apply. In this scenario, the user would **(FAIL)** to get full reimbursement of the claim due to the zone co-payment.\n*   **Room Rent Pro-rata Deduction (d.1.v):**\n    *   **Missing Information:** What room category was utilized during hospitalization, and what is the insured's entitlement based on their ASI?\n    *   **Impact:** If a room category higher than entitlement was used, a proportionate deduction would apply to \"Associated medical expenses\" (including nursing, OT charges, medical practitioner fees, etc.). If a higher room was used, the user would **(FAIL)** to get full reimbursement for associated expenses.\n*   **Non-Payable Items (f.30):**\n    *   **Missing Information:** Does the `55,000 expense include any explicitly non-payable items such as \"BELTS/ BRACES,\" \"SLINGS,\" \"WALKING AIDS CHARGES,\" \"KNEE BRACES,\" \"KNEE IMMOBILIZER,\" etc.?\n    *   **Impact:** If yes, these specific items will be deducted from the claim amount. The user would **(FAIL)** to get coverage for these particular items.\n*   **Claim Procedure Compliance (f.1.1):**\n    *   **Missing Information:** Was the claim notified within 10 days of hospitalization (for reimbursement) or pre-authorization sought within required timelines (for cashless)? Were all original documents submitted within 30 days of discharge?\n    *   **Impact:** Failure to adhere to these procedural requirements could lead to the claim being **(FAILED/REJECTED)** entirely.\n\n**4. Estimated Insurance Payout (Best Case Scenario):**\n\nAssuming:\n*   No Base Co-payment or Voluntary Deductible was opted for.\n*   The accident was an RTA, or the treatment zone matched the premium zone.\n*   The room category entitlement was met, or no pro-rata deduction applies.\n*   The `55,000 does not include any explicitly non-payable items.\n*   All claim procedures were followed correctly.\n*   The Annual Sum Insured is equal to or greater than `55,000.\n\nIn this **best-case scenario**, the user would likely receive **`55,000** as the insurance payout.\n\n**Conclusion on Qualification/Failure:**\n\nThe claim for a knee fracture due to an accident generally **qualifies** for coverage under the Golden Shield policy due to the nature of the event and the waiver of initial waiting periods. However, the final payout amount and whether the user \"fails\" to get full reimbursement hinges entirely on the specific policy options chosen (co-payment, deductible), the circumstances of the accident (RTA or not), the treatment specifics (room category, non-payable items), and adherence to claim procedures."
      }
    ],
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          "Author": "akshay",
          "Creator": "CorelDRAW 2022",
          "Title": "20220507001-Golden Shield-POLICY WORDING.cdr"
        },
        "text": "For Buy/ Renew/ Service/ Claim related queries Log on to www.icicilombard.com or call 1800 2666\n1UIN : ICIHLIP22012V012223\nGolden Shield\nPolicy Wording\nCIN: L67200MH2000PLC129408\ntheatre where surgical procedures are to be\ncarried out;\niv. Maintaining daily records of the patients and\nmaking them accessible to the insurance\ncompany’s authorized representative\nAYUSH Day Care Centre means and includes\nCommunity Health Centre (CHC), Primary Health\nCentre (PHC), Dispensary, Clinic, Polyclinic or any such\nhealth centre which is registered with the local\nauthorities, wherever applicable and having facilities\nfor carrying out treatment procedures and medical or\nsurgical/para-surgical interventions or both under the\nsupervision of registered AYUSH Medical Practitioner\n(s) on day care basis without in- patient services and\nmust comply with all the following criterion:\na. Having qualified registered AYUSH Medical\nPractitioner(s) in charge;\nb. Having dedicated AYUSH therapy sections as\nrequired and/or has equipped operation theatre\nwhere surgical procedures are to be carried out;\nc. Maintaining daily records of the patients and\nmaking them accessible to the insurance\ncompany’s authorized representative.\n(Explanation: Medical practitioner referred in the\ndefinition of “AYUSH Hospital” and “AYUSH day care\ncenter” shall carry the same meaning as defined in the\ndefinition of “Medical practitioner” under chapter I of\nGuidelines)\nCashless Facility means a facility extended by the\ninsurer to the insured where the payments, of the costs\nof treatment undergone by the insured in accordance\nwith the policy terms and conditions, are directly made\nto the network provider by the insurer to the extent pre-\nauthorization approved.\nCondition Precedent shall mean a policy term or\ncondition upon which the Insurer's liability under the\npolicy is conditional upon.\nCongenital Anomaly refers to a condition(s) which is\npresent since birth, and which is abnormal with\nreference to form, structure or position.\na. Internal Congenital Anomaly -Congenital anomaly\nwhich is not in the visible and accessible parts of\nthe body\nb. External Congenital Anomaly- Congenital\nanomaly which is in the visible and accessible\nparts of the body\nCo-payment means a cost sharing requirement under\na health insurance policy that provides that the\npolicyholder/insured/proposer will bear a specified\npercentage of the admissible claims amount. A co-\npayment does not reduce the Sum Insured.\nb. Preamble\nThis Policy has been issued on the basis of the Disclosure to\ninformation Norm, including the information provided by\nProposer in respect of the Insured Persons in the Proposal\nForm, any application for insurance cover in respect of any\nInsured Person and any other information or details\nsubmitted in relation to the Proposal Form. This Policy is a\ncontract of insurance between You and Us which is subject\nto the receipt of premium in full and accepted by Us in\nrespect of the Insured Persons and the terms, conditions\nand exclusions as specified in the Policy/ Policy Schedule /\nProduct Benefit Table of this Policy.\nc. Definitions\nFor the purposes of this Policy, the terms specified below\nshall have the meaning set forth wherever appearing/\nspecified in this Policy or related Extensions:\nWhere the context so requires, references to the singular\nshall also include references to the plural and references to\nany gender shall include references to all genders. Further\nany references to statutory enactment include subsequent\nchanges to the same.\ni. Standard definitions (Definitions whose wordings\nare specified by IRDAI)\nAccident means a sudden, unforeseen and involuntary\nevent caused by external, visible and violent means.\nAny one illness means continuous Period of illness and\nit includes relapse within 45 days from the date of last\nconsultation with the Hospital/Nursing Home where\ntreatment was taken.\nAyush Hospital is a healthcare facility wherein\nmedical/surgical/para-surgical treatment procedures\nand interventions are carried out by AYUSH Medical\npractitioner(s) comprising of any of the following:\na. Central or State government AYUSH hospital; or\nb. Teaching hospital attached to AYUSH college\nrecognized by the central government/Central\ncouncil of Indian medicine/ Central council for\nHomeopathy; or\nc. AYUSH Hospital, standalone or co-located with in-\npatient healthcare facility of any recognized\nsystem of medicine, registered with the local\nauthorities, wherever applicable, and is under the\nsupervision of a qualified registered AYUSH\nmedical practitioner and must comply with the\nfollowing criterion:\ni. Having at least 5 in-patient beds\nii. Having qualified AYUSH medical practitioner\nin charge round the clock\niii. Having dedicated AYUSH therapy sections as\nrequired and/or has equipped operation\n\n2 \nCIN: L67200MH2000PLC129408\nGrace Period means the specified period of time\nimmediately following the premium due date during\nwhich a payment can be made to renew or continue a\npolicy in force without loss of continuity benefits such\nas waiting periods and coverage of Pre Existing\nDiseases. Coverage is not available for the period for\nwhich no premium is received.\nHospital means any institution established for in-\npatient care and day care treatment of illness and / or\ninjuries and which has been registered as a hospital\nwith the local authorities under the Clinical\nEstablishments (Registration and Regulations) Act\n2010 or under enactments specified under the\nSchedule of Section 56(1) of the said Act Or comply\nwith all minimum criteria as under:\na. has qualified nursing staff under its employment\nround the clock;\nb. has at least 10 inpatient beds, in those towns\nhaving a population of less than 10,00,000 and 15\ninpatient beds in all other places\nc. has qualified medical practitioner(s) in charge\nround the clock;\nd. has a fully equipped operation theatre of its own\nwhere surgical procedures are carried out\ne. maintains daily records of patients and makes\nthese accessible to the Insurance company’s\nauthorized personnel.\nHospitalisation means admission in a Hospital for a\nminimum period of 24 consecutive in-patient care\nhours except for specified Procedures/Treatments,\nwhere such admission could be for a period of less than\n24 consecutive hours.\nInpatient care means treatment for which the insured\nperson has to stay in a Hospital for more than 24 hours\nfor a covered event.\nIllness means a sickness or disease or pathological\ncondition leading to the impairment of normal\nphysiological function and requires medical treatment.\na. Acute condition - Acute condition is a disease,\nillness or injury that is likely to respond quickly to\ntreatment which aims to return the person to his or\nher state of health immediately before suffering\nthe disease/illness/injury which leads to full\nrecovery.\nb. Chronic condition - A chronic condition is defined\nas a disease, illness, or injury that has one or more\nof the following characteristics:\ni. it needs ongoing or long-term monitoring\nthrough consultations, examinations, check-\nups, and / or tests\nii. it needs ongoing or long-term control or relief\nof symptoms\niii. it requires your rehabilitation for the patient or\nfor the patient to be specially trained to cope\nwith it\nCumulative Bonus shall mean any increase or addition\nin the Sum Insured granted by the insurer without an\nassociated increase in premium.\nDay care centre means any institution established for\nday care treatment of illness and/or injuries or a\nmedical setup with a hospital and which has been\nregistered with the local authorities, wherever\napplicable, and is under supervision of a registered and\nqualified medical practitioner AND must comply with\nall minimum criterion as under :-\na. has qualified nursing staff under its employment;\nb. has qualified medical practitioner/s in charge\nc. has fully equipped operation theatre of its own\nwhere surgical procedures are carried out;\nd. maintains daily records of patients and will make\nthese accessible to the insurance company’s\nauthorized personnel\nDay Care Treatment refers to medical treatment, and/\nor Surgical Procedure which is\ni. undertaken under General or Local Anesthesia in a\nHospital/ Day care centre in less than 24 hrs\nbecause of technological advancement, and\nii. which would have other wise required a\nhospitalisation of more than 24 hours.\nTreatment normally taken on an out-patient basis is\nnot included in the scope of this definition.\nDeductible is a cost sharing requirement under a\nhealth insurance policy that provides that provides\nthat the insurer will not be liable for specified rupee\namount in case of indemnity policies and for a specified\nnumber of days/hours in case of hospital cash policies,\nwhich will apply before any benefits are payable by the\ninsurer A deductible does not reduce the sum insured.\nDental treatment means a treatment related to teeth\nor structures supporting teeth including examinations,\nfillings (where appropriate), crowns, extractions and\nsurgery.\nDisclosure to information Norm means the policy shall\nbe void and all premium paid thereon shall be forfeited\nto the Company in the event of misrepresentation, mis-\ndescription or non-disclosure of any material fact.\nDomiciliary Hospitalisation means medical treatment\nfor an illness/disease/injury which in the normal course\nwould require care and treatment at a hospital but is\nactually taken while confined at home under any of the\nfollowing circumstances:\na. the condition of the patient is such that he/she is\nnot in a condition to be removed to a hospital, or\nb. the patient takes treatment at home on account of\nnon-availability of room in a hospital.\nEmergency Care means management for an illness or\ninjury which results in symptoms which occur suddenly\nand unexpectedly, and requires immediate care by a\nmedical practitioner to prevent death or serious long\nterm impairment of the insured person’s health\nGolden Shield\nUIN : ICIHLIP22012V012223\n\n3 CIN: L67200MH2000PLC129408\nHealth insurance policy), to transfer the credit gained\nfor pre-existing conditions and time bound exclusions,\nwith the same insurer.\nNetwork Provider means hospitals or health care\nproviders enlisted by an insurer, TPA or jointly by an\ninsurer and TPA to provide medical services to an\ninsured by a cashless facility.\nNon-Network Provider means any Hospital, day care\ncentre or other provider that is not part of the Network.\nNotification of claim means the process of intimating a\nclaim to the insurer or TPA through any of the\nrecognized modes of communication\nOPD treatment is one in which the Insured visits a\nclinic / hospital or associated facility like a consultation\nroom for diagnosis and treatment based on the advice\nof a Medical Practitioner. The Insured is not admitted as\na day care or in-patient.\nPortability means the right accorded to an individual\nhealth insurance policyholder/proposers (including all\nmembers under family cover), to transfer the credit\ngained for pre-existing conditions and time bound\nexclusions, from one insurer to another insurer\nPre-existing Disease means any condition, ailment,\ninjury or disease\na. That is/ are diagnosed by a physician within 48\nmonths prior to the effective date of the policy\nissued by the insurer or its reinstatement or\nb. For which medical advice or treatment was\nrecommended by, or received from, a physician\nwithin 48 months prior to the effective date of the\npolicy issued by the insurer or its reinstatement.\nPost-Hospitalisation Medical Expenses means\nmedical expenses incurred during predefined number\nof days immediately after the Insured Person is\ndischarged from the hospital, provided that :\na. Such Medical Expenses are for the same condition\nfor which the Insured Person’s Hospitalisation was\nrequired, and\nb. The In-patient Hospitalisation claim for such\nHospitalisation is admissible by the Insurance\nCompany.\nPre-Hospitalisation Medical Expenses means\nmedical expenses incurred during predefined number\nof days preceding the hospitalization of the insured\nperson, provided that:\na. Such Medical Expenses are incurred for the same\ncondition for which the Insured Person’s\nHospitalisation was required, and\nb. The In-patient Hospitalisation claim for such\nHospitalisation is admissible by the Insurance\nCompany.\nQualified Nurse is a person who holds a valid\nregistration from the Nursing Council of India or the\nNursing Council of any state in India.\niv. it continues indefinitely\nv. It recurs or is likely to recur\nInjury means any accidental physical bodily harm,\nexcluding illness or disease solely and directly caused\nby external, violent, visible and evident means which is\nverified and certified by a Medical Practitioner.\nIntensive Care Unit means an identified section, ward\nor wing of a hospital which is under the constant\nsupervision of a dedicated medical practitioner(s), and\nwhich is specially equipped for the continuous\nmonitoring and treatment of patients who are in a\ncritical condition, or require life support facilities and\nwhere the level of care and supervision is considerably\nmore sophisticated and intensive than in the ordinary\nand other wards\nICU (Intensive Care Unit) Charges means the amount\ncharged by a Hospital towards ICU expenses which\nshall include the expenses for ICU bed, general medical\nsupport services provided to any ICU patient including\nmonitoring devices, critical care nursing and intensivist\ncharges.\nMaternity expenses means;\na. medical treatment expenses traceable to childbirth\n(including complicated deliveries and caesarean\nsections incurred during Hospitalisation);\nb. expenses towards lawful medical termination of\npregnancy during the policy period.\nMedical Advice means any consultation or advice from\na Medical Practitioner including the issuance of any\nprescription or follow-up prescription.\nMedical Expenses means those expenses that an\nInsured Person has necessarily and actually incurred\nfor medical treatment on account of Illness or Accident\non the advice of a Medical Practitioner, as long as these\nare no more than would have been payable if the\nInsured Person had not been insured and no more than\nother hospitals or doctors in the same locality would\nhave charged for the same medical treatment.\nMedically Necessary Treatment is defined as any\ntreatment, tests medication or stay in hospital or part\nof a stay in Hospital which\n1. Is required for the medical management of the\nillness or Injury suffered by the insured\n2. Must not exceed the level of care necessary to\nprovide safe, adequate and appropriate medical\ncare in scope, duration or intensity\n3. Must have been prescribed by a Medical\npractitioner\n4. Must conform to the professional standard widely\naccepted in international medical practice or by the\nmedical community in India\nMigration means the right accorded to health\ninsurance policyholders/proposers (including all\nmembers under family cover and members of group\nUIN : ICIHLIP22012V012223\nGolden Shield\n\n4 CIN: L67200MH2000PLC129408\nthe Policy Schedule and is/are hereinafter referred as\n“You”/“Your”/ “Yours”/ “Yourself”\nMedical Practitioner is a person who holds a valid\nregistration from the Medical Council of any State or\nMedical Council of India or Council for Indian Medicine\nor for Homeopathy set up by the Government of India\nor a State Government and is thereby entitled to\npractice medicine within its jurisdiction; and is acting\nwithin the scope and jurisdiction of his license.\nThe term Medical Practitioner would include physician,\nspecialist, anaesthetist and surgeon but would exclude\nYou and Your spouse, Your children, Your brother(s),\nYour sister(s) and Your parent(s).\nPeriod of Insurance means the period as specifically\nappearing in the Policy Schedule and commencing\nfrom the Policy Period Start Date of the first Policy\ntaken by You from Us and then, running concurrent to\nYour current Policy subject to the Your continuous\nrenewal of such Policy with Us.\nPolicy means these Policy wordings, the Policy\nSchedule and any applicable endorsements or\nextensions attaching to or forming part thereof. The\nPolicy contains details of the extent of cover available\nto You, what is excluded from the cover and the terms &\nconditions on which the Policy is issued to You.\nProposer means the person(s) or the entity named in\nthe Policy Schedule who executed the Policy Schedule\nand is (are) responsible for payment of premium(s).\nPolicy Period means the period commencing from the\nPolicy Period Start Date, Time and ending at the Policy\nPeriod End Date, Time of the Policy and as specifically\nappearing in the Policy Schedule.\nPolicy Year means a period of twelve months\nbeginning from the Policy Period Start Date and ending\non the last day of such twelve-month period. For the\npurpose of subsequent years, “Policy Year” shall mean\na period of twelve months beginning from the end of\nthe previous Policy Year and lapsing on the last day of\nsuch twelve-month period, till the Policy Period End\nDate, as specified in the Policy Schedule\nService Provider means any person, organization,\ninstitution, or company that has been empanelled with\nUs to provide services specified under the Benefits\n(including add-ons) to The Insured person. These shall\nalso include all healthcare providers empanelled to\nform a part of network other than hospitals.\nThe list of the Service Providers is available at our\nwebsite (https://www.icicilombard.com/content/ilom-\nen/serviceprovider/search.asp) and is subject to\namendment from time to time.\nYou/Your/ Yours/ Yourself means the person(s) that\nWe insure and is/are specifically named as Insured /\nInsured Person(s) in the Policy Schedule.\nWe/ Our/ Ours/ Us means the ICICI Lombard General\nInsurance Company Limited\nReasonable and Customary Charges means the\ncharges for services or supplies, which are the\nstandard charges for the specific provider and\nconsistent with the prevailing charges in the\ngeographical area for identical or similar services,\ntaking into account the nature of Illness/injury involved.\nRenewal defines the terms on which the contract of\ninsurance can be renewed on mutual consent with a\nprovision of grace period for treating the renewal\ncontinuous for the purpose of gaining credit for pre-\nexisting diseases, time-bound exclusions and for all\nwaiting periods.\nRoom Rent means the amount charged by a hospital\ntowards Room and Boarding expenses and shall\ninclude associated medical expenses.\nSubrogation shall mean the right of the insurer to\nassume the rights of the insured person to recover\nexpenses paid out under the policy that may be\nrecovered from any other source.\nSurgery or Surgical Procedure means manual and/or\noperative procedure (s) required for treatment of an\nillness or injury, correction of deformities and defects,\ndiagnosis and cure of diseases, relief of suffering or\nprolongation of life, performed in a hospital or day care\ncentre by a Medical Practitioner\nUnproven/Experimental treatment means treatment\nincluding drug experimental therapy which is not\nbased on established medical practice in India, is\ntreatment experimental or unproven.\nii. Specific definitions (Definitions other than those\nmentioned under c. I. above)\nAdmission means Your admission in a Hospital as an\ninpatient for the purpose of medical treatment of an\nInjury and/or Illness.\nAYUSH treatments refers to the medical aid and / or\nhospitalisation treatments given under ‘Ayurveda,\nYo g a a n d N a t u r o p a t h y, U n a n i , S i d d h a a n d\nHomeopathy systems\nAnnual Sum Insured means and denotes the\nmaximum amount of cover available to You during\neach Policy Year of the Policy Period, as stated in the\nPolicy Schedule or any revisions thereof based on\nClaim settled under the Policy.\nBreak in Policy occurs at the end of the existing policy\nterm, when the premium due for renewal on a given\npolicy is not paid on or before the premium renewal\ndate or within 30 days thereof.\nClaim means a demand made by You or on Your behalf\nfor payment of Medical Expenses or any other\nexpenses or benefits, as covered under the Policy.\nImmediate Family means spouse, dependent children,\nbrother(s), sister(s) and dependent parent(s) of the\ninsured.\nInsured/Insured Person(s) means the individual(s)\nwhose name(s) is/are specifically appearing as such in\nUIN : ICIHLIP22012V012223\nGolden Shield\n\n5 CIN: L67200MH2000PLC129408\nd. Benefits covered under the policy\nThe Benefits listed in base cover are in-built benefits and\nshall be available to all Insured Persons in accordance with\nthe procedures set out in this Policy wording.\nThis Policy covers Allopathic and AYUSH treatments taken\nin India ONLY. Any expenses incurred outside the policy\nperiod will NOT be covered.\nAny claims made under any of the benefits mentioned\nbelow (except Care management program, Care\nmanagement plus program,) will impact eligibility for\nAdditional Sum Insured.\nAny unutilized annual sum insured/tele-consultations/e-\nconsultations/benefits cannot be carried forward to the\nnext policy year.\nBase Cover\n1. In Patient Treatment\nWe will cover the following Medical Expenses incurred in\nrespect of Hospitalization of the Insured Person during the\nPolicy Period, up to the Annual Sum Insured specified in the\nPolicy Schedule against this Benefit:\ni. Room Rent up to Twin sharing room (for Annual Sum\nInsured below ` 10 Lacs and Single private AC room for\nannual sum insured ` 10L and above);\nii. Intensive Care Unit Charges;\niii. Qualified Nurse charges;\niv. Medical Practitioner’s Fees ;\nv. Anaesthesia, blood, oxygen, operation theatre\ncharges, medicines, drugs and consumables (other\nthan those specified in the list of excluded expenses\n(non-medical) in Annexure I;\nvi. S u rg i c a l a p p l i a n ce s a n d p ro st h e t i c d ev i ce s\nrecommended in writing by the attending Medical\nPractitioner and that are used intra operatively during\na Surgical Procedure;\nvii. Cost of investigative tests or prescribed diagnostic\nprocedures directly related to the Injury/Illness for\nwhich the Insured Person is Hospitalized;\nWe will consider a claim under this Benefit, subject to the\nfollowing:\ni. The Hospitalization is for Medically Necessary\nTreatment.\nii. The hospitalization warrants inpatient admission in\nview of active line of treatment.\niii. The Hospitalization commences and continues on the\nwritten advice of a Medical Practitioner.\niv. The Medical Expenses incurred are Reasonable and\nCustomary Charges.\nv. If the Insured Person is admitted in a room category/\nlimit that is higher than the one that is specified in the\nPolicy Schedule/ Product benefit table of this policy,\nthen the Insured Person shall bear a rateable\nproportion of the total Associated medical expenses\n(including surcharges or taxes thereon) in the\nUIN : ICIHLIP22012V012223\nproportion of the difference between room rent of the\nentitled room category to the room rent actually\nincurred\na. For the purpose of this cover, “Associated medical\nexpenses” shall include room rent, nursing\ncharges, operation theatre charges, fees of\nm e d i c a l p r a c t i t i o n e r i n c l u d i n g s u r g e o n /\nanaesthetist / specialist within the same hospital\nwhere the insured person has been admitted and\nwill not include the cost of pharmacy and\nconsumables, cost of implants, medical devices\nand cost of diagnostics.\nb. Proportionate deductions are not applicable for\nICU charges\nc. Proportionate deductions shall not be applicable\nfor hospitals which do not follow differential billing\nor for those expenses in respect of which\ndifferential billing is not adopted based on the\nroom category.\nvi. Expenses associated with automation machine for\nperitoneal dialysis shall not be payable\nvii. Any Medical Expenses payable shall not in aggregate\nexceed the Annual Sum Insured and additional sum\ninsured / cumulative bonus (if any) as specified in the\nPolicy Schedule against this Benefit.\n2. Day Care Treatment\nWe will cover the Medical Expenses incurred in respect of\nthe Day Care Treatment of the Insured Person during the\nPolicy Period provided that:\ni. The Day Care Treatment is for Medically Necessary\nTreatment.\nii. The Day Care Treatment follows the written advice of a\nMedical Practitioner.\niii. The Medical Expenses incurred are Reasonable and\nCustomary Charges.\niv. We will also cover Medical Expenses incurred for\nprocedures including but not limited to intravenous\nchemotherapy, radiotherapy, hemodialysis or any\nother therapeutic procedure which requires a period of\nspecialized observation or medical care after\ncompletion of the procedure.\nv. We will not cover any Out Patient Treatment or\ndiagnostic services under this Benefit.\nvi. Expenses associated with automation machine for\nperitoneal dialysis shall not be payable\nvii. Any Medical Expenses payable shall not in aggregate\nexceed the Sum Insured and additional sum insured/\ncumulative bonus (if any) specified in the Policy\nSchedule against this Benefit.\n3. Coverage for Modern Treatments\nWe will cover the Medical Expenses incurred in respect of\nHospitalization of the Insured Person for the below\nmentioned modern treatments during the Policy Period, up\nto the Annual Sum Insured\nGolden Shield\n\n6 CIN: L67200MH2000PLC129408\nSr. No. Treatment/Procedure\n1 Uterine Artery Embolization and HIFU (High\nintensity focused ultrasound)\n2 Immunotherapy- Monoclonal Antibody to\nbe given as injection\n3 Vaporisation of the prostrate (Green laser\ntreatment or holmium laser treatment)\n4 Stem cell therapy: Hematopoietic stem cells\nfor bone marrow transplant for\nhaematological conditions\n5 Balloon Sinuplasty\n6 Oral Chemotherapy\n7 Robotic surgeries*\n8 Stereotactic radio Surgeries\n9 Deep Brain stimulation\n10 Intra vitreal injections\n11 Bronchical Thermoplasty\n12 IONM - (Intra Operative Neuro Monitoring)\nRobotic surgeries shall be subject to sub-limits as\nmentioned under d. benefits covered under the policy\nBase cover 15 Sub-limits applicable\n4. Pre Hospitalisation expenses\nWe will cover the Pre-hospitalization Medical Expenses\nincurred in respect of the Insured Person for up to 60days\nimmediately before the Insured Person’s Admission to\nHospital provided that:\ni. The Pre-hospitalization Medical Expenses incurred are\nReasonable and Customary Charges.\nii. We have accepted the claim under “d. Benefits covered\nunder the policy Base cover 1. Inpatient Treatment” in\nrespect of the Insured Person.\niii. We shall not be liable to make any payment in respect\nof any Pre-hospitalization Medical Expenses incurred\nprior to the Policy Period Start Date of the first policy\nwith Us in respect of the Insured Person.\niv. Expenses incurred on nursing care at home are\nexcluded from the scope of pre hospitalization\nexpenses.\nv. This Benefit will be provided on a reimbursement basis\nonly.\nvi. Any Pre-hospitalization Medical Expenses payable\nshall not in aggregate exceed the Annual Sum Insured\nand additional sum insured /cumulative bonus (if any)\nas specified in the Policy Schedule against this Benefit\n5. Post Hospitalisation expenses\nWe will cover the Post-hospitalization Medical Expenses\nincurred in respect of the Insured Person for up to 180 days\nimmediately following the Insured Person’s discharge from\nHospital provided that:\ni. The Post-hospitalization Medical Expenses incurred\nare Reasonable and Customary Charges.\nUIN : ICIHLIP22012V012223\nii. We have accepted the claim under “Inpatient\nTreatment” in respect of the Insured Person.\niii. We will also consider Post-hospitalization Medical\nExpenses incurred on Physiotherapy provided that\nsuch Physiotherapy is advised in writing by the\ntreating Medical Practitioner and is Medically\nNecessary Treatment. This service will be provided on\na reimbursement and/ or cashless basis where ever\napplicable.\niv. Expenses incurred on nursing care at home are\nexcluded from the scope of post hospitalization\nexpenses.\nv. Any Post-hospitalization Medical Expenses payable\nduring the Policy period shall not in aggregate exceed\nthe Annual Sum Insured and additional sum insured\n/cumulative bonus (if any) as specified in the Policy\nSchedule against this Benefit.\n6. Donor Expenses\nWe will cover the Medical Expenses incurred in respect of\nan organ donor’s Hospitalization during the Policy Period\nfor the harvesting of the organ donated to the Insured\nPerson provided that:\ni. The organ donation conforms to the Transplantation of\nHuman Organs Act 1994 and the organ is for the use of\nthe Insured Person;\nii. We will cover only those Medical Expenses incurred in\nrespect of an organ donor as an in-patient in the\nHospital.\niii. The Medical Expenses incurred are Reasonable and\nCustomary Charges.\niv. Any Medical Expenses payable during the Policy\nperiod shall not in aggregate exceed the Annual Sum\nInsured and additional sum insured /cumulative bonus\n(if any) as specified in the Policy Schedule against this\nBenefit subject to an overall limit of ` 10,00,000 only\nv. We have accepted a claim under Section “Inpatient\ntreatment” in respect of the Insured Person.\nWe shall not be liable to pay for any claim under this Benefit\nwhich arises directly or indirectly for or in connection with\nany of the following:\ni. Pre-hospitalization Medical Expenses or Post-\nhospitalization Medical Expenses of the organ donor.\nii. Screening expenses of the organ donor.\niii. Any other Medical Expenses as a result of the\nharvesting from the organ donor.\niv. Costs directly or indirectly associated with the\nacquisition of the donor ’s organ (other than\nhospitalisation costs involved).\nv. Transplant of any organ/tissue where the transplant is\nexperimental or investigational.\nvi. Expenses related to organ transpor tation or\npreservation.\nvii. Expenses incurred by an Insured Person as a donor.\nGolden Shield\n\n7 CIN: L67200MH2000PLC129408UIN : ICIHLIP22012V012223\nviii. Any other medical treatment or complication in respect\nof the donor, consequent to harvesting.\n7. Domiciliary Hospitalization\nWe will cover the Medical Expenses incurred in respect of\nthe Domiciliary Hospitalization of the Insured Person\nduring the Policy Period provided that :\ni. The Domiciliary Hospitalization is for Medically\nNecessary Treatment.\nii. The Domiciliary Hospitalization commences and\ncontinues on the written advice of a Medical\nPractitioner.\niii. The Medical Expenses incurred are Reasonable and\nCustomary Charges.\niv. The Domiciliary Hospitalization continues for at least 3\nconsecutive days in which case We will make payment\nunder this Benefit in respect of Medical Expenses\ni n c u r r e d f r o m t h e f i r s t d a y o f D o m i c i l i a r y\nHospitalization.\nv. Any Medical Expenses payable shall not in aggregate\nexceed the Annual Sum Insured and additional sum\ninsured /cumulative bonus (if any) as specified in the\nPolicy Schedule against this Benefit.\nWe shall not be liable to pay for any claim under this Benefit\nwhich arises directly or indirectly from or in connection with\nany of the following:\na) Asthma, bronchitis, tonsillitis and upper respiratory\ntract infection including laryngitis and pharyngitis,\ncough and cold, influenza;\nb) Arthritis, gout and rheumatism;\nc) Ailments of spine/disc\nd) Chronic nephritis and nephritic syndrome;\ne) Any liver disease;\nf) Peptic ulcer\ng) Diarrhea and all type of dysenteries, including\ngastroenteritis;\nh) Diabetes mellitus and insipidus;\ni) Epilepsy;\nj) Hypertension;\nk) Pyrexia of any origin\n8. Home Care Treatment\nWe will cover the medical expenses incurred by the Insured\nperson on home care treatment maximum up to 5% of\nAnnual Sum Insured provided that :\na. The Medical Practitioner advices the Insured Person to\nundergo treatment at home\nb. There is a continuous active line of treatment with\nmonitoring of the health status by a medical\npractitioner for each day through the duration of the\nhome care treatment.\nc. Daily monitoring chart including records of the\ntreatment duly signed by the treating doctor is\nmaintained.\nGolden Shield\nd. The condition of the Insured Person is expected to\nimprove in a reasonable and foreseeable period of\ntime.\ne. Prior approval from Us has been taken. The Home care\ntreatment is availed only on a cashless basis, subject to\navailability of our empanelled service provider(s).\nKindly visit our website for cities/locations where such\nservices are available.\nf. Treatment availed is not categorized under “AYUSH” or\nany form of non- allopathic treatment\ng. Such treatment cannot be provided on outpatient basis\nHowever in case of unavailability of our empanelled service\nprovider in the insured person’s location, in case the insured\nperson intends to avail the services of non-network\nprovider and claims for reimbursement, a prior approval\nfrom Us needs to be taken before availing such services.\nIn case the insured person breaches the conditions of\napproval or fails to take the prior written approval from Us,\nwe are not liable to settle any claim under this section.\nFor the purpose of this benefit, Home care treatment shall\ninclude:\na. Diagnostic tests underwent at home as advised by\nmedical practitioner\nb. Medicines prescribed in writing by a medical\npractitioner\nc. Consultation charges of the medical practitioner\nd. Nursing charges if advised by the medical practitioner\nAny expenses payable during the Policy period shall not in\naggregate exceed the Annual Sum Insured and additional\nsum insured /cumulative bonus (if any) as specified in the.\n9. In Patient AYUSH Hospitalization\nWe will cover the Medical Expenses incurred in respect of\nthe Insured Person’s AYUSH Treatment during the Policy\nPeriod up to the Annual Sum Insured specified in the Policy\nSchedule provided that:\ni. The Medical Expenses incurred are Reasonable and\nCustomary Charges.\nii. The Insured Person is Hospitalized for AYUSH\nTreatment at a AYUSH hospital or an AYUSH Day-care\ncentre.\niii. The Insured Person’s Hospitalization commences and\ncontinues on the written advice of the treating Medical\nPractitioner.\niv. Any Medical Expenses payable during the Policy\nperiod shall not in aggregate exceed the Annual Sum\nInsured and additional sum insured /cumulative bonus\n(if any) as specified in the Policy Schedule against this\nBenefit.\nv. This Benefit will be provided on a reimbursement and/\nor on cashless basis where ever applicable.\nWe shall not be liable to pay for any claim under this Benefit\nwhich arises directly or indirectly for or in connection with\nany of the following:\n\n8 CIN: L67200MH2000PLC129408UIN : ICIHLIP22012V012223\nGolden Shield\ni. Pre-hospitalization Medical Expenses or Post-\nhospitalization Medical Expenses.\nii. Any expenses incurred for the purpose of evaluation or\ninvestigation.\n10. Domestic road ambulance cover\nWe will cover the expenses incurred on road ambulance\nservices which are offered by a healthcare or ambulance\nservice provider and which have been used during the\nPolicy Period to transfer the Insured Person to the nearest\nHospital with adequate emergency facilities for the\nprovision of Emergency Care, provided that:\n• Our maximum liability under this Benefit for every\nclaim arising during the Policy Year will be restricted to\n1% of the Annual Sum insured maximum up to\n`10,000;\n• We have accepted a claim under “Inpatient treatment”\nin respect of the Insured Person for the same\nAccident/Illness for which road ambulance services\nwere availed.\n• This Benefit includes and is limited to the cost of the\ntransportation of the Insured Person:\na) From the place of injury/illness to the nearest\nhospital\nb) To the nearest Hospital with higher medical\nfacilities which is prepared to admit the Insured\nPerson and provide the necessary medical\nser vices if such medical ser vices cannot\nsatisfactorily be provided at a Hospital where the\nInsured Person is situated, and only if that\ntransportation has been prescribed in writing by a\nMedical Practitioner and is for Medically\nNecessary Treatment.\nc) From a Hospital to the nearest diagnostic centre\nduring the course of Hospitalization for advanced\ndiagnostic treatment in circumstances where such\nfacility is not available in the existing Hospital.\n• The ambulance / service provider providing the\nservices be a registered provider with road traffic\nauthority.\nAny expenses in relation to transportation of the Insured\nPerson from Hospital to the Insured Person’s residence\nwhile transferring an Insured Person after he/she has been\ndischarged from the Hospital are not payable under this\nBenefit.\n11. Air Ambulance\nWe will cover the expenses up to the Annual sum insured\nincurred on air ambulance services in respect of an Insured\nPerson which are offered by a healthcare or an air\nambulance service provider and which have been used\nduring the Policy Period to transfer the Insured Person to\nthe nearest Hospital with adequate emergency facilities for\nthe provision of Emergency Care, provided that:\na. It is for a life threatening emergency health condition/s\nof the Insured Person which requires immediate and\nrapid ambulance transportation from the place where\nthe Insured Person is situated at the time of requiring\nEmergency Care to a hospital provided that the\ntransportation is for Medically Necessary Treatment, is\ncertified in writing by a Medical Practitioner, and road\nambulance services cannot be provided.\nb. Such air ambulance providing the services, should be\nduly licensed to operate as such by a competent\ngovernment Authority.\nc. This cover is limited to transportation from the area of\nemergency to the nearest Hospital only;\nd. We will not cover:\na. Any transportation from one Hospital to another;\nb. Any transportation of the Insured Person from\nHospital to the Insured Person’s residence after\nhe/she has been discharged from the Hospital\nc. Any transportation or air ambulance expenses\nincurred outside the geographical scope of India.\ne. We have accepted a claim under Inpatient treatment in\nrespect of the Insured Person for the same\nAccident/Illness for which air ambulance services were\navailed.\nf. We shall not be liable if Medically Necessary Treatment\ncan be provided at the Hospital where the Insured\nPerson is situated at the time of requiring Emergency\nCare.\n12. Base Co-payment\nThis policy will be subject to 50% base co-payment and\nHe/She shall be liable to pay 50% of admissible claim\namount of each and every claim. Base Co-payment once\nchosen cannot be changed mid-term. Modification of co-\npayment may happen only during renewal subject to\nunderwriting. In case, base co-payment is reduced during\nrenewal, fresh waiting periods shall be applicable on the\nmodified portion of base co-payment.\ni. Base Co-payment shall be applicable to all benefits\nunder the policy except any benefits availed under\nCare management program, Care management plus\nprogram, preventive health check-up,.\nii. Base Co-payment shall not be applicable in case\nvoluntary deductible has been opted for.\n13. Cumulative Bonus/ Additional Sum Insured\nWe will provide a Cumulative Bonus of 10% of the Annual\nSum insured at the end of each Policy Year if the expiring\nPolicy has been claim free and is continuously renewed\nwith Us. The Cumulative Bonus will not be accumulated for\nmore than 100% of the Annual Sum insured under any\ncircumstances.\ni. In case where the policy is on a floater basis the\ncumulative bonus will be on floater basis and for\nindividual policy the same will be on an individual\nbasis.\nii. In case where the policy is on a floater basis, the\ncumulative bonus will be accrued only if no claims have\n\nbeen made in respect of all Insured Person(s) in the\nexpiring policy period.\niii. In a floater policy as specified in the Policy Schedule,\nthe Cumulative Bonus so accrued during the previous\nPolicy Year(s) will only be available to those Insured\nPerson(s) who were insured in previous Policy Year(s)\nand continue to be insured with Us in the subsequent\nPolicy Year(s).\niv. Cumulative Bonus will not be added if the Policy is not\nrenewed with Us by the end of the Grace Period.\nv. Cumulative bonus can be utilised only when the\nAnnual Sum Insured is completely exhausted.\nvi. If the Policy Period is two or three years, any\nCumulative Bonus that has accrued for the first/second\nPolicy Year will be credited at the end of the first/second\nPolicy Year as the case may be and will be available for\nany claims made in the subsequent Policy Year.\nvii. If the Insured Persons in the expiring policy are covered\non an individual basis as specified in the Policy\nSchedule and there is an accumulated Cumulative\nBonus for each Insured Person under the expiring\npolicy, and such expiring policy has been Renewed\nwith Us on a floater policy basis as specified in the\nPolicy Schedule then the Cumulative Bonus to be\ncarried forward for credit in such Renewed Policy shall\nbe the lowest among all the Insured Persons.\nviii. In case of floater policies where Insured Persons\nRenew their expiring policy with Us by splitting the\nAnnual Sum Insured in to individual policies the\nCumulative Bonus of the expiring policy shall be\napportioned to such Renewed Policies in the\nproportion of the Annual Sum Insured of each\nRenewed Policy as detailed in table below.\n9 CIN: L67200MH2000PLC129408UIN : ICIHLIP22012V012223\nGolden Shield\nAnnual\nFloater Sum\nInsured\n20 Lac\nFloater\npolicy split\nto individual\npolicies with\nAnnual Sum\nInsured of\n10 Lacs each\nRevised\nAnnualSum\nInsuredof\neach\nindividual\npolicy\n10 Lac\nRevised\nAccumulated\nCumulative\nbonus/\nAdditional\nSumInsured\nofeach\nindividual\npolicy\n5 Lac\nAccumulate\ndCumulative\nbonus/\nAdditional\nSumInsured\n(after5claim\nfreeyears)\n10 Lac\nAnnual Sum\nInsured\n20 Lac\nAnnual Sum\nInsured\nreduced to\n` 10 Lacs\nRevised\nAnnual Sum\nInsured\n10 Lac\nRevised\nAccumulated\nCumulative\nbonus/\nAdditional\nSumInsured\n5 Lac\nAccumulated\nCumulative\nbonus/\nAdditional\nSumInsured\n(after5claim\nfreeyears)\n10 Lac\nix. If the Annual Sum Insured has been reduced at the time\nof Renewal, the applicable Cumulative Bonus shall be\nreduced in the same proportion to the Annual Sum\nInsured as detailed in table below\nx. If the Annual Sum Insured under the Policy has been\nincreased at the time of Renewal the Cumulative Bonus\nshall be calculated on the Annual Sum Insured of the\nlast completed Policy Year.\nxi. In the event of a Claim under the Policy during any\nsubsequent Policy Year, the accrued cumulative bonus\nshall not be reduced.\n14. Reset Benefit\nWe will reset the Annual Sum insured up to 100% of the\nAnnual Sum insured unlimited times, for all future claims\nwithin the same policy not related to the illness / disease /\ninjury for which a claim has been paid for the same insured\nperson in a Policy Year as stated in the Policy Schedule,\nprovided that:\ni. The Annual Sum insured including additional sum\ninsured /Cumulative Bonus (if any) in respect of the\nInsured Person is insufficient as a result of previous\nclaims paid in that Policy Year.\nii. The total amount of reset will not exceed the Annual\nSum Insured for that policy year.\niii. The Reset Benefit will be applied only if the claim is\nmade and admissible under “Inpatient Treatment” or\n“Daycare Procedure”.\niv. The Reset Benefit will not be triggered for the first claim\nmade during the Policy Year.\nv. The Reset benefit will be triggered only once and not\nunlimited times for all future claims within the same\npolicy which are related to the illness/disease/injury for\nwhich a claim has already been paid/registered for the\nsame insured person.\nvi. For individual policies, reset Sum Insured will be\navailable on individual basis whereas for floater\npolicies, it will be available on floater basis.\nvii. For any single claim during a Policy Year , the maximum\nclaim amount payable shall not exceed the sum of\n• The Annual Sum insured;\n• additional sum insured /Cumulative Bonus;\nviii. The Reset Benefit will not be available for an Illness /\nInjury or related complications including but not limited\nto any relapse within 45 days in respect of which a\nclaim has been paid in that Policy Year for the same\nInsured Person.\nix. Any unutilized Reset Benefit will not be carried forward\nto any subsequent Policy Years.\nx. During a Policy Year, the aggregate claim amount\npayable, shall not exceed the sum of:\n• The Annual Sum Insured\n• additional sum insured /Cumulative Bonus\n• Reset Sum Insured\n\n• The Network Provider /Health Service Provider shall be\nassigned by Us post receiving Insured Person’s request\nto avail a health check-up under this Benefit.\n• Utilisation of this preventive health check-up will not\nimpact the Annual Sum Insured or eligibility for\nadditional sum insured /cumulative Bonus.\n• Un-utilised health check-up package will not be carried\nforward to the next policy year and it will be the Insured\nPerson’s choice and responsibility to utilise the same\nwith in the designated policy period. We shall not be\nliable to provide any reminders or notifications for the\nsame.\n• In-case of long term policies (2 year or 3 years), the\npreventive health check-up package for all the policy\nyears shall be provided together in the first policy year\nitself. It shall be the responsibility of the Insured Person\nto preserve the same and undergo the check-ups\nduring the designated policy years.\nPlease Note:\n• We shall not hold any responsibility towards any loss\nor damage arising out of or in relation to any opinion,\nadvice, prescription, actual or alleged errors, omissions\nand representations made by the Medical Practitioner/\nHealthcare professional.\n• Choosing the services under this Benefit is purely upon\nthe customer’s own discretion and at own risk.\n• The Insured Person should seek assistance from a\nhealth care professional when interpreting and\napplying them to the Insured person’s individual\ncircumstances. If the Insured person has any concerns\nabout His/ her health, He/ She may consult His/ her\ngeneral practitioner.\n18. Incentives associated with Vaccination against\npneumococcal disease\nWe will provide an additional 2.5% discount on premium\n(fresh or renewal) for Insured Person(s) who have taken the\nPneumococcal vaccine or its equivalent vaccine which\n16. Enhanced Annual Sum insured for Road Traffic Accidents\nIf the insured person meets with a Road Traffic Accident\nresulting in in-patient hospitalization, then the Annual Sum\nInsured shall be doubled subject to the following:\n• It is declared and proven that the insured person was\ntaking due safety precautions such as use of seat-belt/\nhelmet/ following road traffic signals and was either\nriding as pillion rider in a two wheeler or travelling in a\nfour wheeler at the time of accident as evidenced by\nPolice record and Hospital record.\n• The enhanced(doubled) Sum Insured shall be available\nonly once during the policy period.\n• The enhanced (double) Sum Insured shall be available\nonly after exhaustion of the annual sum insured.\n• The enhanced Sum Insured can be utilized only for that\nparticular hospitalization following the Road Traffic\nAccident .\n• Reset benefit shall not trigger for claims under this\ncover.\n• This benefit shall not be applicable for day care\ntreatment.\n• The unutilized balance of enhanced (doubled) sum\ninsured for road traffic accidents cannot be carried\nforward for the remaining policy period or for renewal.\n• Claims under this benefit will reduce the Cumulative\nbonus/ additional sum insured\n17. Preventive health check-up\nInsured Persons can avail a preventive health check-up as\nper our pre- defined package only at our network providers\nor empanelled health service providers anytime during the\nPolicy period subject to the below conditions :\n• This benefit can be availed only on cashless basis and\nis limited to once a year per Insured Person.\n• This benefit can be availed through our mobile\napplication or via utilisation of health check-up\ncoupons provided with the policy kit\n10 CIN: L67200MH2000PLC129408UIN : ICIHLIP22012V012223\nGolden Shield\n15. Sub-limits applicable\nThe expenses payable during the entire policy period for treatment of the following diseases/ conditions (either as a day care or\nas an in-patient exceeding 24hrs of admission in the hospital) shall be maximum up to the amount mentioned in the table below;\nProcedures/Medical Conditions/Ailments/Diseases\nAnnual Sum Insured\n>20L\nTreatment of cataract \nUp to 25,000/ eye` Up to 50,000/ eye` Up to 75,000/ eye`\nTreatment of each and every ailment/procedure mentioned below\n10L/15L/20L3L/4L/5L\nTreatment of cerebrovascular and cardiovascular disorders\nTreatment/surgeries for cancer(including chemo/radio/oral)\nTreatment of other renal complications and disorders\nTreatment for breakage of long bones/Joint replacements\nRobotic surgeries for any ailment/condition/disease\n` 2,00,000 ` 3,50,000 ` 5,00,000\n` 1,00,000 ` 1,75,000 ` 2,50,000\nSub-limits will include the expenses incurred on pre hospitalisation and post hospitalisation expenses\n\nGolden Shield\n11 CIN: L67200MH2000PLC129408UIN : ICIHLIP22012V012223\nspecialist or a general physician will have to be\nborne by the Insured Person.\n• We shall not be liable for any discrepancy in the\ninformation provided under this Benefit.\n• Choosing the services under this Benefit is purely\nupon the customer’s own discretion and at own risk.\n• *The proposer should seek assistance from a\nhealth care professional when interpreting and\napplying them to the Insured person’s individual\ncircumstances. If the Insured person has any\nconcerns about His/ her health, He/ She may\nconsult His/ her general practitioner. We shall not\nhold any responsibility towards any loss or\ndamage arising out of or in relation to any opinion,\nadvice, prescription, actual or alleged errors,\nomissions and representations made by the\nMedical Practitioner/ Healthcare professional.\n2. Second E-opinion for Critical Illness\nWe shall arrange E-opinion on a cashless basis from\nour empanelled Medical Practitioners in case the\nInsured Person is diagnosed with any of the below\nlisted critical Illnesses during the Policy Period, and at\nhis/her sole discretion chooses to avail an E-opinion\nsubject to the below mentioned conditions.\n• The E-opinion will be arranged on cashless basis\nand the insured person will not have to bear any\nexpenses on the same.\n• The E-opinion will be based only on the\ninformation and documentation provided to Us\n( w h i c h w i l l b e s h a r e d w i t h t h e M e d i c a l\nPractitioner) and it should not be construed to\nconstitute medical advice and/or substitute the\nInsured Person's visit / consultation to an\nindependent Medical Practitioner/Healthcare\nprofessional.\n• This E-opinion can be availed only once during the\nPolicy Period for the same illness.\n• Appointments to avail this E-opinion may be\nrequested through Our Website or Our mobile\napplication or through calling Our call centre on\nOur toll free number.\n• The E-opinion provided under this Benefit shall be\nlimited to the listed critical Illnesses and will not be\nvalid for any medico legal purposes.\n• We do not assume any liability towards any loss or\ndamage arising out of or in relation to any opinion,\nadvice, prescription, actual or alleged errors,\nomissions and representations made by the\nMedical Practitioner.\nList of Critical Illness for which Second E-opinion may be\nrequested\nHeart and vascular conditions\n1. Myocardial Infarction\n2. Refractory heart failure\n3. Cardiomyopathy\nhelps prevent pneumococcal disease. All the members\ncovered under thepolicy should have be vaccinated in the\npast one year (1 year) from policy start date to avail this\ndiscount. i.e. if policy start date is 1st January 2022, all\ninsured persons under the policy should have been\nvaccinated against Pneumococcal disease in the period\nfrom 1st January 2021 to 31st December 2021. This\ndiscount shall be provided lifetime as long as the insured\nperson continues to renew this policy.\nMandatory Extension:\n19. Care Management Program\nIn consideration of payment of additional premium, the\ninsured person can avail benefits of the Care Management\nProgram. The Care Management Program aims to provide\nsolutions which will solve everyday challenges/issues\nfaced by You, promote holistic wellbeing and empower You\nto lead independent and enriching lives.\nOur Care management program focusses on providing You\nwith assistance and support in case of any challenge but at\nthe same time equipping you for the future. Our endeavour\nis to promote longevity, productivity and incentivise You for\nyour healthy behaviour which will enable dignified living.\nThe Insured Person shall have access to a host of benefits\nunder the Care management program on downloading and\nregistering on our mobile application. This activity is to\nensure adequate utilization of services offered and to\nredeem the wellbeing points awarded.\n1. Tele Consultation(s)\nWe will arrange consultations and recommendations\nfor routine health issues by a qualified Medical\nPractitioner or health care professional. For the\npurpose of this benefit Telephonic/Virtual consultation\nshall mean consultation provided by a qualified\nMedical Practitioner or Health care professional\nthrough various mode of communication like audio,\nvideo, online portal, chat or mobile application. The\nservices provided under this Benefit will be made\navailable subject to the terms and conditions, and in\nthe manner prescribed below:\n• T h e M e d i c a l Pr a c t i t i o n e r m a y s u g g e s t /\nrecommend / prescribe over the counter\nmedications based on the information provided, if\nrequired on a case to case basis. However, the\nservices under this Benefit should not be construed\nto constitute medical advice and/or substitute the\nInsured Person's visit / consultation to an\nindependent Medical Practitioner/Healthcare\nprofessional*.\n• There shall be no maximum limit on the count of\ntele-consultations that can be availed by the\nInsured Person in a policy year.\n• This service will be available 24 hours a day, and\n365 days in a year.\n• We/Medical Practitioner/Healthcare professional\nmay refer the Insured Person to another specialist\nor a general physician (outside of our empanelled\nnetwork), if required and the charges for such\n\nGolden Shield\n12 CIN: L67200MH2000PLC129408UIN : ICIHLIP22012V012223\n4. E-Counselling\nWe will offer e-counselling session(s) with a\nPsychologist via our mobile application for providing\nassistance in dealing with issues such as but not\nlimited to personal and lifestyle imbalance, anxiety,\ndepression, sleep disorders, stress and problems\nrelated to psychological/mental illness/ psychiatric and\npsychosomatic disorders.\nMaximum of 12 sessions will be provided per insured\nperson per policy period.\nThe e-counseling sessions shall be availed only\nthrough virtual modes of chat via our mobile\napplication.\n5. Health Management Program\nThe Health Management Program has been designed\nto ensure a regular monitoring of the Insured Person’s\nhealth and timely intervention and a concrete plan for\ncorrective measures in case of any decline in the health\nstatus of the Insured Person.\nThe Health Coach shall guide and motivate the Insured\nPerson to follow the customised Health management\nprogram designed for them to achieve their health and\nfitness goals.\nAs a part of the Health Management Program, the\ninsured person can avail the following benefits\na. Care Calls\nAll insured persons shall receive care calls to check\nup on their well-being and safety by our health\ncoach who understand the issues surrounding\nsenior individuals. The insured person(s) will be\nencouraged to express their concerns surrounding\ntheir well-being (if any) on these calls so that the\nhealth coach can address them later.\nb. Goal based incentives on outcome of Preventive\nhealth check-up\nMonitoring of one’s health status remains an\nimportant step towards becoming more self-\naware of one’s medical / health conditions.\nThe insured person shall be subjected to a mid-\nterm assessment via a Wellbeing Risk Assessment\n[WRA] which will include outcome of certain\nlaborator y tests and questionnaire based\nassessment covering aspects of lifestyle, current\nmedical history & family history.\nThe assessment will be carried out using a\ntelephonic/ digital connect with the Health Coach.\nThe health coach will encourage the insured\nperson to undergo certain laboratory tests (as\ndetailed in Table A) and we will incentivise the\nInsured Person in case of favourable findings of the\nlaboratory tests.\nThe insured person will have to undergo the below\nmentioned laboratory tests as a part of the mid-\nterm assessment from our empanelled diagnostic\nLung Conditions\n4. End stage lung Failure\n5. Primary(Idiopathic) pulmonary Hypertension\nLiver conditions\n6. End stage liver Failure\nNeuro/ spinal & psychiatric disease\n7. Multiple sclerosis with Persisting symptoms\n8. Motor neuron disease with Permanent symptoms\n9. Permanent paralysis of limbs\n10. Stroke resulting in permanent symptoms\n11. Coma of specified severity\n12. Alzheimer’s Disease before age of 50 years\n13. Parkinson’s disease before age of 50 years\n14. Apallic syndrome\n15. Benign brain tumour\n16. Creutzfeldt-Jakob disease (CJD)\n17. Major head trauma\nRenal diseases\n18. Kidney failure requiring regular dialysis\n19. Medullary cystic disease\nMusculoskeletal diseases\n20. Muscular dystrophy\n21. Poliomyelitis\nBleeding disorders\n22. Aplastic Anaemia\nAuto immune diseases\n23. Systemic Lupus Erythematous with renal involvement\n24. Myasthenia gravis\n25. Scleroderma\n26. Good pastures syndrome with lung or renal\ninvolvement\n27. Blindness\n28. Deafness\n29. Cancer of specified severity\n30. Third Degree Burns\n31. Loss of speech\n32. Loss of limbs\n33. Loss of Independent Existence\n3. Diet and Nutrition e-consultation\nWe will offer You diet and nutrition e-consultation on a\nvirtual platform via our mobile application to help you\nachieve your weight and health management goals.\nMaximum of 12 sessions will be provided per insured\nperson per policy period.\nThe e-consultation shall be availed only through virtual\nmodes of chat via our mobile application.\n\nGolden Shield\n13 CIN: L67200MH2000PLC129408UIN : ICIHLIP22012V012223\nperson 250 wellness points. Each yoga session/ meditation\nsession must last 30 minutes or more and the maximum\nwellness points that can be accrued under this task is 1500\nper insured person per policy year.\nPlease Note: The insured persons can join a virtual\nyoga/meditation class or visit an actual yoga/meditation\ncentre. The expenses associated with the class\nfees/membership fees/tutor or instructor fees etc. will\nhave to be borne by the insured person. Proof of payment\nof fees and certificate of completion of sessions will have\nto be provided to us in order for insured person to earn the\nwellness points.\nAlternately, in case the Insured Person is keen to achieve\ntargeted steps instead of par ticipation in yoga\nsessions/meditation sessions, we will award 250 wellness\npoints per month provided the insured person takes 4000+\nsteps per day for atleast 15 days in a month. The maximum\nwellness points that can be accrued by achieving targeted\nsteps is 1500 per insured person per policy year.\nOur mobile application will have to be downloaded within\n30 days of the policy start date to avail the benefit as the\naverage step count completed by an Insured person would\nbe monitored on this mobile application.\nEach wellness point will be valued at INR 0.20. Wellness\npoints so earned can be redeemed against any services\nunder discounts as mentioned in “discounts on services or\nproducts” on our mobile application.\nWellness points Maximum wellness Rupee Value\naccumulated points awarded per of Accumulated\nperson per policy year wellness points\nOutcome of 1500 300\nPreventive health\ncheck-ups\nParticipation in Yoga / 1500 300\nMeditation / Completion\nof Targeted steps\nTotal 3000 600\n7. Medical Vault\nThe insured person can upload His/Her health records in\nour mobile application so as to protect them from loss or\ntheft. These health records can then be viewed as per need\nand convenience of the insured person.\nBy availing this service, the Insured person agrees and has\nno objection to the health records being maintained with Us\nfor internal use only.\n8. Health Assistance (HAT)\nHAT shall assist the Insured Person in understanding their\nhealth condition better by providing answers to any queries\nrelated to health service providers\nThe services provided under this shall include:\n• Identifying a Physician/ Specialist\n• Availability of hospital beds/COVID hubs etc.\n• Providing guidance on engaging attendants or nurses\n• Facilitation with respect to arrangement of mobility\naids, daily living aids, medical equipment etc.\ncentres and will be guided by the health coach for\nthe same.\nIn case the insured person is desirous of\nundergoing laboratory tests at a diagnostic centre\nof their choice which is not empanelled with us, the\ninsured person will have to bear the charges\nassociated with the actual costs of the mid-term\nassessment diagnostic tests/ visit charges /\ncollection charges etc.\nThe insured person will also have to provide us\nwith the laborator y repor ts of the below\nmentioned medical tests/investigations conducted\nwithin the policy period for Us to award the\nwellness points.\nTable A\nMedical Tests Favorable Findings that need\nfindings improvement\nGlycosylated < 6% >6 and up to7%\nHaemoglobin (HbA1c)\nLow Density < 100 mg/dl >100 and < or\nLipoprotein (LDL) = 190 mg/dl\nHigh Density > or = 40 mg/dl > 20 mg/dl and\nLipoprotein (HDL) <40 mg/dl\nSerum cholesterol < or = 200mg/dl >200 and < or\n=300 mg/dl\nSerum Triglycerides <or = 150 mg/dl > 150 and <\n= 250mg/dl\nS. Creatinine < or = 1.3 mg/dl > 1.3 mg/dl\nThe insured person shall be awarded wellness points as per table\nB for each laboratory test mentioned below in case the findings of\nthe laboratory test are favourable as detailed in Table A.\nTable B\nMedical Tests Wellness points awarded in\ncase of favourable findings\nGlycosylated Haemoglobin (HbA1c) 500\nLow Density Lipoprotein (LDL) 200\nHigh Density Lipoprotein (HDL) 200\nSerum cholesterol 200\nSerum Triglycerides 200\nSerum Creatinine 200\nTotal 1500\nThe maximum wellness points that can be awarded under\nthis activity is restricted to 1500 wellness points per insured\nperson per policy year.\nEach wellness point will be valued at INR 0.20. Wellness\npoints so earned can be redeemed against deals and\ndiscounts on purchase of medicines from our empanelled\npharmacies or undergoing recommended diagnostic tests\nfrom our empanelled diagnostic centres etc. as listed on our\nmobile application.\n6. Participation in Yoga/Meditation Sessions/ Completion of\nTargeted Steps\nThe Insured Person can earn wellness points by\nparticipating in yoga sessions or meditation sessions\naimed at maintaining physical and mental Wellness.\nParticipation and successful completion of 10 yoga/\nmeditation sessions in a month will award the insured\n\n14 CIN: L67200MH2000PLC129408UIN : ICIHLIP22012V012223\nGolden Shield\n• Scheduling an appointment with any Medical\nPractitioner empanelled with Us\n• Scheduling appointments for a second opinion\n• Providing suitable options with respect to Hospitals as\nwell as providing assistance in Cashless facility,\nwherever applicable.\n• Scheduling appointments from diagnostic labs\nempanelled with us.\n• Providing information, assistance and facilitation on\ndoor step delivery of medicines\n• Providing preventive information on ailments\n• Providing guidance on post Hospitalization care, such\nas Physiotherapy/ Nursing at home.\nPlease note that services provided under this Benefit are\nsolely for assistance, and should not be construed to be a\nsubstitute for a visit/ consultation to an independent\nMedical Practitioner. Our role is limited to that of facilitation\nand Health Assistance services will not include the charges\nfor any independent Medical Practitioner/nutritionist/\ncharges incurred on diagnostics/ consulted on HAT’s\nrecommendation, and such charges are to be borne by the\nInsured Person.\nFor all facilitation services provided under this cover, our\nrole shall be limited to assistance only and the charges and\nexpenses associated with the actual service shall have to\nbe borne by the insured person.\nThis service is available on our mobile application or by\ncalling on 040-66274205 (please note that this number is\nsubject to change) from 8am to 8pm from Monday to\nSaturday except public holidays.\nBy availing this service, the Insured person agrees and has\nno objection to the health records being maintained with Us\nfor internal use only.\nWhile deciding to obtain the above services, the Insured\nperson(s) expressly notes and agrees that it is entirely for\nthem to decide whether to obtain these services and also to\ndecide the use (if any) to which these services are to be put\nfor.\n9. Ambulance Assistance\nWe will facilitate ground medical transportation by a\nService provider to transport the Insured Person to the\nnearest Hospital or any clinic or nursing home for medically\nnecessary treatment subject to availability of services in\nthat particular city/ location. Kindly visit our website for\nupdated list of cities/ locations where the services are\nprovided.\n1. The services under this Benefit are subject to the\nfollowing conditions:\n• The medical transportation is for a life threatening\nhealth condition of the Insured Person which\nrequires immediate and rapid transportation to the\nHospital; as certified in writing by the Medical\npractitioner\n• The Insured Person is in India and the treatment is\nin India only;\n• The ambulance service is availed within the same\ncity\n• This is an assistance service and the expenses for\nthe same will have to be borne by the insured\nperson or can be claimed under domestic road\nambulance cover( if inpatient treatment claim is\nfound to be admissible)\nProcess to avail Ambulance Assistance:\na) On calling Our helpline number provided below, Our\ntrained customer service executive (CSE) will ask the\nInsured person relevant questions to assess the\nsituation.\nb) The call may be redirected to a qualified Medical\nPractitioner in order to evaluate the requirement for an\nambulance with Advanced Life Support based on the\nInsured Person’s condition.\nc) The below mentioned details are to be made available\nfor availing the services:\n1. UHID of Insured Person, as provided on the Health\nCard.\n2. Contact number of the Insured Person\n3. Location of Insured Person\nHow to Call an Ambulance? (Via Call)\nCall 18001028136\nto reach the\nEmergency\nResponse Centre\nAn IVRS will ask\nyou to select option\n1or 2 depending on\nrequirement.\nDial 1 for Medical\nAmbulance\nServices\nCall will be\nanswered by an\nCSE & details like\nname, UHID, nature\nof emergency will\nbe asked\nEmergency\nAmbulance\nTransport\nwill arrive\nPatient will be\ntaken to the nearest\nhospital as per the\npredefined hospital\nnetwork chart\nDoctor may\naccompany patient\nin the ambulance\nif required\nClick on emergency\nicon & place request\nAmbulance\npick up & drop\nthe patient to\nhospital / health\nfacility\nCSE does\nfeedback Call\nCustomer service\nexecutive connects\nwith medical team\nThe medical team\nprovides with\ncontinued\nnecessary\nassistance on call\nDoctor understand\nsituation & advices\non emergency Care\n/ Selection of\nambulance\nCSE dispatch the\nambulance to\ndesired location &\nprovide necessary\ndetails\n\nGolden Shield\n15 CIN: L67200MH2000PLC129408UIN : ICIHLIP22012V012223\n10. Discounts on services / products\nWe shall only facilitate the Insured Person in availing\ndiscounts on services/ products including but not limited to\ninvestigations/ diagnostic tests/ laboratory tests / health\nsupplements/ medical equipment/ homecare services /\nvirtual health & wellness sessions/ AYUSH products /\nFitness & wellness related activities & products etc. at our\nempanelled diagnostic centres, drugs / medicines ordered\nfrom pharmacies etc. offered by our network providers/\nhealth service providers. These discounts can be viewed on\nour mobile application and one can redeem the wellness\npoints earned from Care Management Program (either\nthrough favourable findings on health check-up or\nparticipation in Yoga/ meditations sessions/ achieving\ntargeted steps per month) for availing discounts as per\nproduct terms and conditions and subject to availability.\nTerms and Conditions for Care Management Program\n• There shall be no minimum wellness points limit for\nredemption against health related deals and discounts\noffered on our mobile application.\n• The Insured Person(s) can choose to carry forward the\nwellness points for 3 years, in case they do not wish to\nredeem the same provided the policy is continuously\nrenewed without any break. The wellness points so\naccrued shall have to be redeemed at the end of the 3rd\nPolicy year.\n• The Insured Person shall notify Us and submit the\nrelevant documents, reports, receipts as and when\nrequired by us within 60 days of undertaking any\nactivity for us to reward appropriate wellness points.\n• In case of expiry of policy and the policy not being\nrenewed, the accrued wellness points may be carried\nforward for a period not exceeding three months.\n• There shall not be any cash reimbursement or\nredemption available against the wellness points\naccumulated by an Insured Person.\n• We or Our Health Service Providers or Our Network\nProviders do not warrant the validity, accuracy,\ncompleteness, safety, quality, or applicability of the\ncontent or anything said or written or any suggestions\nprovided in the course of providing the wellbeing\nservices.\n• We do not accept any liability towards quality of the\nservices made available by our network providers/\nhealth service providers and are not liable for any\ndefects or deficiencies on their part.\n• Availability of all Services under the care management\nprogram is subject to availability of Health Service\nprovider at the requested location.\n• We, Our group entities, or affiliates, their respective\ndirectors, officers, employees, agents, vendors, shall\nnot be responsible for or liable for, any actions, claims,\ndemands, losses, damages, costs, charges and\nexpenses which an Insured Person may claim to have\nsuffered, sustained or incurred, as a result of any\nadvice or information obtained by way of the wellness\nprogram or any actions chosen by the Insured Person\non the basis of such advice or information.\n• The care management program offered is subject to\nrevisions based on the insurance regulator y\nframework from time to time.\nOptional Covers\n1. Claim Protector\nIn consideration of payment of additional premium to Us,\nthe insured person can avail the benefit as mentioned\nunder claim protector. If a claim has been accepted under\nthe inpatient hospitalization cover, then the items which\nare not payable under the claim as per the List of Excluded\nitems released by IRDAI that is related to the particular\nclaim will become payable. The maximum claim pay-out\nunder this benefit shall be limited to Annual Sum Insured\nunder your policy.\nBase Co-payment as opted by the Insured Person in the\npolicy shall be applicable for this cover\n2. Modification of Base Co-payment\nIn consideration of payment of additional premium to Us,\nThe insured person will have the option to reduce his base\nco-payment from 50% to 40% or 30% or 20% and He/She\nshall be liable to pay the percentage (%) of admissible claim\namount of each and every claim.\nBase Co-payment once chosen cannot be changed mid-\nterm. Modification of co-payment may happen only\nduring renewal subject to underwriting. In case, base co-\npayment is reduced during renewal, fresh waiting periods\nshall be applicable on the modified portion of base co-\npayment.\n3. Voluntary Deductible\nIn case the Insured person has opted for a voluntary\ndeductible, as specified in the Policy Schedule, the\nDeductible will be applicable on aggregate basis for all\nHospitalization expenses during the Policy Year before it\nbecomes payable by Us, subject to terms, conditions and\nexclusions of the Policy. The voluntary deductible option\navailable will be 20% of Annual Sum Insured opted by\nYou.\ni. In case voluntary deductible has been opted for, base\nco-payment shall not be chosen. Zone based co-\npayment shall be applicable in case medically\nnecessary treatment (Except medically necessary\ntreatment for road traffic accidents) has been taken in\na zone higher (Zone A being the highest followed by\nZone B and then Zone C) than the zone for which\npremium has been paid on issuance of the policy.\nii. The deductible will apply on individual basis in case of\nindividual policy and on floater basis in case of floater\npolicy.\niii. Deductible once chosen cannot be changed mid-term.\nModification of deductible may happen only during\nrenewal subject to underwriting.\n\nGolden Shield\n16 CIN: L67200MH2000PLC129408UIN : ICIHLIP22012V012223\n4. Care management Plus Program\nIn consideration of payment of additional premium, Insured\nPerson can avail the benefits associated with care\nmanagement Plus Program as detailed below\n1. Health Care Professional\nAll insured persons shall be assigned a dedicated\nHealth Care Professional who will act as a first point of\ncontact for any service need. The Health Care\nprofessional will be a certified nutritionist who will\nassist the Insured person(s) with a personalised diet\ndepending on their health concerns. The Health Care\nProfessional shall encourage and promote optimal\nhealth and assist on matters pertaining to fitness, diet\nand nutrition and wellbeing concerns faced by the\ninsured persons. He/She will encourage two way\ncommunication, provide reminders on healthy habits\nand reassure the insured person in times of need.\nThe health care professional will also play a significant\nrole in being the primary point of contact to the Insured\nPerson. The Health Care professional will\n• On-board the Insured Person on to our mobile\napplication\n• Educate the Insured Person on the pertinent\nfeatures of our mobile application such as but not\nlimited to availing Tele-consultations, utilising the\npreventive health check-up, conducting the mid-\nterm assessment, educating about health\nassistance services, redemption of wellness points\netc.\n• Give care calls to the Insured Person to understand\ninsured person’s issues surrounding fitness, diet &\nnutrition and wellbeing issues if any and propose\nsolutions for the same\n2. Update to family members-\nAs a part of the enhanced wellness features, your\nfamily members will be regularly updated about your\nhealth and adherence to prescribed diet(as prescribed\nunder the diet and nutrition e-consultation benefit\nunder Care management program) via messaging\nplatform(s) so that they can motivate and encourage\nand participate in your efforts to achieve your\nhealthcare goals.\nThe above update shall be provided only on Your\nconsent and after You provide us with contact details of\nfamily member who wishes to receive timely updates\nabout your health and diet regime.\n3. Out-patient consultations\nWe shall cover the Medical Expenses incurred during\nthe Policy period for out-patient consultations from a\nGeneral Medical Practitioner or Specialist Medical\nPractitioner or Super Specialist Medical practitioner or\nAYUSH medical practitioner in relation to any Illness\ncontracted or Injury suffered by the Insured Person\nduring the Policy period subject to the overall\nmaximum number of 4 consultations in a Policy Year.\nThese services shall be provided through our\nEmpanelled Health Service Provider subject to\navailability at the time of appointment.\nThis benefit shall also include e-consultation given by a\nGeneral Medical Practitioner or Specialist or Super\nSpecialist Medical Practitioner or AYUSH medical\npractitioner through a virtual mode of communication\nsuch as but not limited to chat, email, video, online\nportal, or mobile application.\nPhysiotherapy sessions shall be excluded from the\nscope of this benefit.\nCounselling availed for psychiatric ailments or mental\nhealth issues shall be excluded from the scope of this\nbenefit but it shall be covered in E-Counseling (section\nd. Base Cover. 18.4) as per the section d. Benefits\ncovered under the policy.\n4. Routine Diagnostics and Minor Procedure cover\nWe shall cover medical expenses incurred for\noutpatient diagnostic tests recommended by Medical\nPractitioner under our cashless network available in\nthe mobile application in relation to any Illness\ncontracted or Injury suffered by the Insured Person\nduring the Policy Period and for listed minor procedures\nundergone at a general practitioner or specialist /\nsuper-specialist medical practitioner by the Insured\nPerson during the Policy period maximum up ` 2,000.\nThese services shall be provided through our\nEmpanelled Health Service Provider subject to\navailability at the time of appointment. The diagnostic\ntests shall include but will not be limited to\nh i s t o p a t h o l o g y, b i o c h e m i s t r y, h e m a t o l o g y,\nimmunology, microbiology, serology, pathology,\nradiology, ultrasound and TMT. Genetic studies shall be\nexcluded from the scope of this cover.\nWe may even arrange for diagnostic tests to be carried\nout at the location of the Insured Person provided such\nlocation is within the geographical reach of the Health\nService Provider on the date of the request. This service\nshall be subject to availability of Our empanelled\nHealth Service provider.\nList of Minor Procedures covered under this benefit #\nSr. No. Procedure\n1 Drainage of abscess\n2 Injection including Intramuscular\n(Per Injection cost)\n3 Intravenous injection(IV)\n4 Sprain Management\n(Joint movement/ exercise)\n5 Otoscopic examination\n(Magnifying otoscopy)\n6 Nasal packing for control of haemorrhage\n7 Nebulizer therapy\n8 Removal of foreign body\n\nGolden Shield\n17 CIN: L67200MH2000PLC129408UIN : ICIHLIP22012V012223\nList of Minor Procedures covered under this benefit #\nSr. No. Procedure\n9 Suturing (Staple under LA)\n10 Removal of suture\n11 Stabilization of joint\n12 Syringing ear to remove wax\n13 Application or removal of plaster cast\n14 Laryngoscopy\n15 Minor wound management\n#\nthis includes only the cost of administration. The\nactual cost of consumables shall be covered under the\npharmacy cover. However, the said cost will have to be\nborne by the insured person in case the annual sum\ninsured under the pharmacy cover has been exhausted\nor is out of scope of the Pharmacy cover or in case the\nconsumable is a non-payable item.\n5. Pharmacy cover\nWe shall cover medical expenses incurred on purchase\nof medicines, drugs, and medical consumables, as\nprescribed by a Medical Practitioner under our\ncashless network available in the mobile application\nfor any Illness contracted or Injury suffered by the\nInsured Person during the Policy Period, maximum up\nto ` 2,000 through our Empanelled Health Service\nProvider subject to availability on the date of the\nrequest.\nHealth supplements, Nutraceuticals, foods for special\ndietary use, foods for special medical purpose, foods\nwith added probiotics and/or foods with added\nprebiotics, vaccinations, vitamins, tonics or other\nrelated products are excluded from the scope of this\ncover.\n6. Nursing at Home\nWe shall cover the expenses incurred by You, up to\n` 2,000 for each day up to a maximum of 15 days post\nHospitalization for the medical services of a Qualified\nNurse at Your residence, provided that the nurse is\nemployed in a Hospital and the engagement of such\nQualified Nurse is certified as necessary by a Medical\nPractitioner and related directly to any Illness or Injury,\ncovered under the Policy. The payment under this cover\nis subject to admissibility of Your In-patient treatment\nClaim under the Policy.\nd. Exclusions\nWe will not be liable for any Voluntary Deductible\namount, if applicable and as specifically defined in the\nPolicy Schedule under the Policy.\nWe will not be liable to make any payment under this\nPolicy in connection with or in respect of any expenses\nwhatsoever incurred in connection with or in respect of:\ni. Standard exclusions (Exclusions for which\nstandard wordings are specified by IRDAI)\n1. Code- Excl01: Pre-Existing Diseases\na. Expenses related to the treatment of a\npre-existing Disease (PED) and its direct\ncomplications shall be excluded until the\nexpiry of 24 months of continuous\ncoverage after the date of inception of the\nfirst policy with insurer.\nb. In case of enhancement of sum insured the\nexclusion shall apply afresh to the extent\nof sum insured increase.\nc. If the Insured Person is continuously\ncovered without any break as defined\nunder the portability norms of the extant\nIRDAI (Health Insurance) Regulations,\nthen waiting period for the same would be\nreduced to the extent of prior coverage.\nd. Coverage under the policy after the expiry\nof 24 months for any pre-existing disease\nis subject to the same being declared at\nthe time of application and accepted by\nInsurer.\n2. Code- Excl02: Specified disease/procedure\nwaiting period\na. Expenses related to the treatment of the\nlisted Conditions, surgeries/treatments\nshall be excluded until the expiry of 24\nmonths of continuous coverage after the\ndate of inception of the first policy with us.\nThis exclusion shall not be applicable for\nclaims arising due to an accident.\nb. In case of enhancement of sum insured the\nexclusion shall apply afresh to the extent\nof sum insured increase.\nc. If any of the specified disease/procedure\nfalls under the waiting period specified for\npre-Existing diseases, then the longer of\nthe two waiting periods shall apply.\nd. The waiting period for listed conditions\nshall apply even if contracted after the\npolicy or declared and accepted without a\nspecific exclusion.\ne. If the Insured Person is continuously\ncovered without any break as defined\nunder the applicable norms on portability\nstipulated by IRDAI, then waiting period\nfor the same would be reduced to the\nextent of prior coverage.\n\nGolden Shield\n18 CIN: L67200MH2000PLC129408UIN : ICIHLIP22012V012223\nf. List of specific Illness and Surgical Procedures as mention below:\nSr.\nNo.\nOrgan /Organ\nSystem\nIllness/ diagnosis\n(irrespective of treatments medical or surgical)\nSurgeries/ Procedures (irrespective of any\nillness or diagnosis other than cancers)\n1 \nENT Deviated Nasal Septum Septoplasty\nCSOM-Chronic Suppurative Otitis Media Mastoidectomy\nTympanoplasty, Myringotomy &\nMyringoplasty\nAny treatment for conditions related to\ntonsils, adenoids, sinuses, Turbinates/\nconcha\n2 \nGynaecological Fibroids (fibromyoma)\nEndometriosis, Cervicitis\nUterine Prolapse\nDysfunctional uterine bleeding\nPolycystic Ovarian Syndrome (PCOS)\nDilatation and curettage (D&C)\nMyomectomy\nHysterectomy (unless due to malignancy\n3 \nOrthopaedic \nArthritis\nGout and Rheumatism\nSpinal and Vertebral Disorders including diagnosis as low back ache\nArthroscopy\nSurgeries for joint replacements\nRepairs/ reconstruction of ligaments/\nmeniscus/ tendons\nSpinal & Vertebral Surgeries\n4 Gastrointestinal \nStones in gall bladder & Biliary System, cholecystitis, acalculous\ncholecystitis\nFissure/fistula in anus, hemorrhoids, pilonidal sinus\nEsophageal Varices & Gastric Varices\nAll types Hernia\nGastrointestinal ulcers including Gastritis & Duodenitis/ Erosions\nof gastrointestinal tract\nCholecystectomy, Procedures for biliary\nstones\nAll forms of Liver cirrhosis\nEndoscopy\nProcedures for Esophageal Varices &\nGastric Varices\nEndoscopy\n5 Uro-genital \nStones in Urinary system Surgeries and procedures related to\nStones in Urinary system\nChronic Renal Failure or end stage Renal Failure or chronic\nkidney disease including dialysis\nHydrocele, varicocele/ rectocele/ Spermatocele\nDialysis but not limited to haemodialysis &\nperitoneal dialysis\n6 Eye \nCataract\nRetinal detachment\nGlaucoma\nUsage of intra vitreal injections including but not limited to avastin\n& lucentis\nBenign Hyperplasia of prostate Prostatic Surgeries\n\nGolden Shield\n19 CIN: L67200MH2000PLC129408UIN : ICIHLIP22012V012223\nf. List of specific Illness and Surgical Procedures as mention below: (Contd.)\nSr.\nNo.\nOrgan /Organ\nSystem\nIllness/ diagnosis\n(irrespective of treatments medical or surgical)\nSurgeries/ Procedures (irrespective of any\nillness or diagnosis other than cancers)\n7 Other General\nconditions\n(Applicable to\nall organ\nsystems/\norgans/\ndisciplines\nwhether or not\ndescribed\nabove)\nAll internal/ external tumors, cysts, nodules, polyps, sinus, fistula\nVaricose veins & Varicose ulcers\nParkinson’s disease/Alzheimer’s disease\nExpenses related to any admission primarily for\nenforced bed rest and not for receiving treatment. This\nalso includes:\na. Custodial care either at home or in a nursing facility\nfor personal care such as help with activities of\ndaily living such as bathing, dressing, moving\naround either by skilled nurses or assistant or non-\nskilled persons.\nb. Any services for people who are terminally ill to\naddress physical, social, emotional and spiritual\nneeds\niii. Code- Excl06: Obesity/ Weight Control\nExpenses related to the surgical treatment of\nobesity that does not fulfil all the below conditions:\n1. Surgery to be conducted is upon the advice of\nthe Doctor\n2. The surgery/Procedure conducted should be\nsupported by clinical protocols\n3. The member has to be 18 years of age or older\nand\n4. Body Mass Index (BMI);\na. greater than or equal to 40 or\nb. greater than or equal to 35 in conjunction\nwith any of the following severe co-\nmorbidities following failure of less\ninvasive methods of weight loss:\ni. Obesity-related cardiomyopathy\nii. Coronary heart disease\niii. Severe Sleep Apnea\niv. Uncontrolled Type2 Diabetes\niv. Code- Excl07: Change of Gender treatments\nExpenses related to any treatment, including surgical\nmanagement, to change characteristics of the body to\nthose of the opposite sex.\nv. Code- Excl08: Cosmetic or plastic Surgery\nExpenses for cosmetic or plastic surgery or any\ntreatment to change appearance unless for\nreconstruction following an Accident, Burn(s) or\n3. a. Expenses related to the treatment of the below\nmentioned illness within 90 days from the first policy\ncommencement date shall be excluded unless they\nare pre-existing and disclosed at the time of\nunderwriting\ni. Hypertension\nii. Diabetes\niii. Cardiac Conditions\nb. This exclusion shall not, however, apply if the Insured\nPerson has continuous coverage for more than twelve\nmonths.\nc. The within referred waiting period is made applicable\nto the enhanced sum insured in the event of granting\nhigher sum insured subsequently.\n4. Code- Excl03: 30-day waiting period\na. Expenses related to the treatment of any illness within\n30 days from the first policy commencement date shall\nbe excluded except claims arising due to an accident,\nprovided the same are covered.\nb. This exclusion shall not, however, apply if the Insured\nPerson has Continuous Coverage for more than twelve\nmonths.\nc. The within referred waiting period is made applicable\nto the enhanced sum insured in the event of granting\nhigher sum insured subsequently\nUnless covered by way of an appropriate extensions /\noptional covers, We shall not be liable to make any\npayment under this Policy in connection with or in\nrespect of\n5. Permanent Exclusions\ni. Code- Excl04: Investigation & Evaluation\na. Expenses related to any admission primarily for\ndiagnostics and evaluation purposes only are\nexcluded.\nb. Any diagnostic expenses which are not related or\nnot incidental to the current diagnosis and\ntreatment are excluded.\nii. Co d e - E xc l 0 5 : E xc l u s i o n N a m e : Re st Cu re ,\nrehabilitation and respite care-\n\nGolden Shield\n20 CIN: L67200MH2000PLC129408UIN : ICIHLIP22012V012223\nxv. Code- Excl18: Maternity: Medical treatment expenses\ntraceable to childbirth (including complicated\ndeliveries and caesarean sections incurred during\nhospitalization) except ectopic pregnancy. Expenses\ntowards miscarriage (unless due to an accident) and\nlawful medical termination of pregnancy during the\npolicy period\nii. Specific exclusions (Exclusions other than those\nmentioned under e.i. above)\n6. Any ailment/ illness/ injury/ condition or treatment\nor service that is specifically excluded in the Policy\nSchedule under Special Conditions\n7. Any expenses incurred on prosthesis, corrective\ndevices, external durable medical equipment of\nany kind, instruments used in treatment of sleep\napnoea syndrome or cost of cochlear implant(s)\nunless necessitated by an Accident or required\nintra-operatively.\n8. Multifocal Lens and ambulatory devices such as\nwalkers, crutches, splints, stockings of any kind\nand also any medical equipment which is\nsubsequently used at home.\n9. Expenses incurred on dental treatment unless\nnecessitated due to an Accident\n10. Personal comfort, cosmetics, convenience and\nhygiene related items and services\n11. Acupressure, acupuncture, magnetic and other\ntherapies\n12. Circumcision unless necessary for treatment of an\nIllness or necessitated due to an Accident.\n13. Expenses for venereal disease or any sexually\ntransmitted disease (except HIV/AIDS)\n14. Any Treatment or medical services taken outside\nthe geographical boundaries of India.\n15. Any expenses incurred on out-patient (OPD)\ntreatment. (This exclusion shall not be applicable\nin case care management plus program has been\nopted for by payment of additional premium)\n16. Intentional self-injury (whether arising from an\nattempt to commit suicide or otherwise)\n17. Any injury or illness caused by or arising from or\nattributed to war, invasion, acts of foreign\nenemies, hostilities (whether war be declared or\nnot ), civil war, commotion, unrest, rebellion,\nrevolution, militar y or usurped power or\nconfiscation or nationalisation or requisition of or\ndamage by or under the order of any government\nor public local authority\n18. Any Illness or Injury caused by or contributed to by\nnuclear weapons/materials or contributed to by or\narising from ionising radiation or contamination by\nradioactivity by any nuclear fuel or from any nuclear\nwaste or from the combustion of nuclear fuel\nCancer or as part of medically necessary treatment to\nremove a direct and immediate health risk to the\ninsured. For this to be considered a medical necessity, it\nmust be certified by the attending Medical Practitioner.\nvi. Code- Excl09: Hazardous or Adventure sports\nExpenses related to any treatment necessitated due to\nparticipation as a professional in hazardous or\nadventure sports, including but not limited to, para-\njumping, rock climbing, mountaineering, rafting, motor\nracing, horse racing or scuba diving, hand gliding, sky\ndiving, deep-sea diving.\nvii. Code- Excl10: Breach of law\nExpenses for treatment directly arising from or\nconsequent upon any Insured Person committing or\nattempting to commit a breach of law with criminal\nintent.\nviii. Code- Excl11: Excluded Providers\nExpenses incurred towards treatment in any hospital or\nby any Medical Practitioner or any other provider\nspecifically excluded by the Insurer and disclosed in its\nwebsite / notified to the policyholders are not admissible.\nHowever, in case of life threatening situations or\nfollowing an accident, expenses up to the stage of\nstabilization are payable but not the complete claim\nix. Code- Excl12: Treatment for, Alcoholism, drug or\nsubstance abuse or any addictive condition and\nconsequences thereof.\nx. Code- Excl13: Treatments received in heath\nhydros, nature cure clinics, spas or similar\nestablishments or private beds registered as a nursing\nhome attached to such establishments or where\nadmission is arranged wholly or partly for domestic\nreasons.\nxi. Code- Excl14: Dietary supplements and substances that\ncan be purchased without prescription, including but\nnot limited to Vitamins, minerals and organic\nsubstances unless prescribed by a medical practitioner\nas part of hospitalization claim or day care procedure.\nxii. Code- Excl15: Expenses related to the treatment for\ncorrection of eye sight due to refractive error less than\n7.5 dioptres\nxiii. Code- Excl16: Unproven Treatments: Expenses\nrelated to any unproven treatment, services and\nsupplies for or in connection with any treatment.\nUnproven treatments are treatments, procedures or\nsupplies that lack significant medical documentation\nto support their effectiveness.\nxiv. Code- Excl17: Sterility and Infertility: Expenses related\nto sterility and infertility. This includes:\ni. Any type of contraception, sterilization\nii. Assisted Reproduction services including artificial\ninsemination and advanced reproductive\ntechnologies such as IVF, ZIFT, GIFT, ICSI\niii. Gestational Surrogacy\niv. Reversal of sterilization\n\nGolden Shield\n21 CIN: L67200MH2000PLC129408UIN : ICIHLIP22012V012223\n(Explanation: \"Bank rate\" shall mean the rate\nfixed by the Reserve Bank of lndia (RBl) at the\nbeginning of the financial year in which claim\nhas fallen due)\n4. Complete Discharge\nAny payment to the policyholder, insured person or\nhis/ her nominees or his/ her legal representative or\nassignee or to the hospital as the case may be, for\nany benefit under the Policy shall be a valid\ndischarge towards payment of claim by the\nCompany to the extent of that amount for the\nparticular claim\n5. Multiple Policies\ni. In case of multiple policies taken by an insured\nperson during a period from one or more\ninsurers to indemnify treatment costs, the\ninsured person shall have the right to require a\nsettlement of his/her claim in terms of any of\nhis/her policies. In all such cases the insurer\nchosen by the insured person shall be obliged\nto settle the claim as long as the claim is within\nthe limits of and according to the terms of the\nchosen policy.\nii. Insured Person having multiple policies shall\nalso have the right to prefer claims under this\npolicy for the amounts disallowed under any\nother policy / policies, even if the sum insured is\nnot exhausted. Then the Insurer shall\nindependently settle the claim subject to the\nterms and conditions of this policy.\niii. If the amount to be claimed exceeds the sum\ninsured under a single policy, the insured\nperson shall have the right to choose insurers\nfrom whom he/she wants to claim the balance\namount.\niv. Where an insured person has policies from\nmore than one insurer to cover the same risk\non indemnity basis, the insured person shall\nonly be indemnified the treatment costs in\naccordance with the terms and conditions of\nthe chosen policy.\n6. Fraud\nIf any claim made by the insured person, is in any\nrespect fraudulent, or if any false statement, or\ndeclaration is made or used in support thereof, or if\nany fraudulent means or devices are used by the\ninsured person or anyone acting on his/her behalf to\nobtain any benefit under this policy, all benefits under\nthis policy and the premium paid shall be forfeited.\nAny amount already paid against claims made\nunder this policy but which are found fraudulent\nlater shall be repaid by all recipient(s) /\npolicyholder(s), who has made that particular\nclaim, who shall be jointly and severally liable for\nsuch repayment to the insurer.\n19. Treatment for any condition / illness which requires\nhormone replacement therapy.\n20. Artificial life maintenance for the Insured Person\nwho has been declared brain dead or in vegetative\nstate as demonstrated by:\na. Deep coma and unresponsiveness to all forms\nof stimulation; or\nb. Absent pupillary light reaction; or\nc. Absent oculo-vestibular and corneal reflexes;\nor\nd. Complete apnea.\ne. General Terms and Clauses\ni. Standard General Terms and Clauses (General Terms\nand clauses whose wordings are specified by IRDAI)\n1. Disclosure of Information\nThe Policy shall be void and all premium paid\nthereon shall be forfeited to the Company in the\nevent of misrepresentation, mis-description or\nnon-disclosure of any material fact by the\npolicyholder\n(Explanation: \"Material facts\" for the purpose of\nthis policy shall mean all relevant information\nsought by the company in the proposal form and\nother connected documents to enable it to take\ninformed decision in the context of underwriting\nthe risk)\n2. Condition Precedent to Admission of Liability\nThe terms and conditions of the policy must be fulfilled\nby the insured person for the Company to make any\npayment for claim(s) arising under the policy.\n3. Claim Settlement (provision for Penal lnterest)\nI. The Company shall settle or reject a claim, as\nthe case may be, within 30 days from the date\nof receipt of last necessary document.\nII. ln the case of delay in the payment of a claim,\nthe Company shall be liable to pay interest to\nthe policyholder from the date of receipt of last\nnecessary document to the date of payment of\nclaim at a rate 2% above the bank rate.\nIII. However, where the circumstances of a claim\nwarrant an investigation in the opinion of the\nCompany, it shall initiate and complete such\ninvestigation at the earliest, in any case not\nlater than 30 days from the date of receipt of\nlast necessary document. ln such cases, the\nCompany shall settle or reject the claim within\n45 days from the date of receipt of last\nnecessary document.\nIV. ln case of delay beyond stipulated 45 days, the\nCompany shall be liable to pay interest to the\npolicyholder at a rate 2% above the bank rate\nfrom the date of receipt of last necessary\ndocument to the date of payment of claim.\n\nGolden Shield\n22 CIN: L67200MH2000PLC129408UIN : ICIHLIP22012V012223\n8. Migration:\nThe insured person will have the option to migrate the\npolicy to other health insurance products/plans offered\nby the company by applying for migration of the policy\nat least 30 days before the policy renewal date as per\nIRDAI guidelines on Migration. lf such person is\npresently covered and has been continuously covered\nwithout any lapses under any health insurance\nproduct/ plan offered by the company, the insured\nperson will get the accrued continuity benefits in\nwaiting periods as per IRDAI guidelines on migration.\nFor Detailed Guidelines on migration, kindly refer the link\nhttps://www.irdai.gov.in/ADMINCMS/cms/frmGuidelines_Layo\nut.aspx?page=PageNo3987\n9. Portability\nThe insured person will have the option to port the\npolicy to other insurers by applying to such insurer to\nport the entire policy along with all the members of the\nfamily, if any, at least 45 days before, but not earlier\nthan 60 days from the policy renewal date as per IRDAI\nguidelines related to portability. lf such person is\npresently covered and has been continuously covered\nwithout any lapses under any health insurance policy\nwith an lndian General/Health insurer, the proposed\ninsured person will get the accrued continuity benefits\nin waiting periods as per IRDAI guidelines on\nportability.\nFor Detailed Guidelines on portability, kindly refer the link\nhttps://www.irdai.gov.in/ADMINCMS/cms/frmGuidelin\nes_Layout.aspx?page=PageNo3987\n10. Renewal of Policy\nThe policy shall ordinarily be renewable except on\ngrounds of fraud, misrepresentation by the insured\nperson\ni. The Company shall endeavor to give notice for\nrenewal. However, the Company is not under\nobligation to give any notice for renewal.\nii. Renewal shall not be denied on the ground that the\ninsured person had made a claim or claims in the\npreceding policy years.\niii. Request for renewal along with requisite premium\nshall be received by the Company before the end of\nthe policy period.\niv. At the end of the policy period, the policy shall\nterminate and can be renewed within the Grace\nPeriod of 30 days to maintain continuity of benefits\nwithout break in policy. Coverage is not available\nduring the grace period.\nv. No loading shall apply on renewals based on\nindividual claims experience.\n11. Withdrawal of Policy\ni. ln the likelihood of this product being withdrawn in\nfuture, the Company will intimate the insured\nperson about the same 90 days prior to expiry of\nthe policy.\nFor the purpose of this clause, the expression\n\"fraud\" means any of the following acts committed\nby the Insured Person or by his agent or the\nhospital/doctor/any other party acting on behalf of\nthe insured person, with intent to deceive the\ninsurer or to induce the insurer to issue an\ninsurance Policy :-\na) the suggestion, as a fact of that which is not\ntrue and which the Insured Person does not\nbelieve to be true;\nb) the active concealment of a fact by the Insured\nPerson having knowledge or belief of the fact;\nc) any other act fitted to deceive; and\nd) any such act or omission as the law specially\ndeclares to be fraudulent\nThe company shall not repudiate the claim and / or\nforfeit the policy benefits on the ground of fraud, if\nthe insured person / beneficiary can prove that the\nmisstatement was true to the best of his\nknowledge and there was no deliberate intention\nto suppress the fact or that such mis-statement of\nor suppression of material fact are within the\nknowledge of the insurer.\n7. Cancellation\na) The policyholder may cancel this Policy by giving\n15 days' written notice, and in such an event, the\nCompany shall refund premium for the unexpired\nPolicy Period as detailed below.\nCancellation Period Refund % Refund % Refund %\nfor 1 year for 2 years for 3 years\ntenure tenure tenure\npolicy policy policy\nFrom 16 days to 1 month 75% 80% 80%\nFrom 1 month to 3 months 60% 70% 75%\nFrom 3 months to 6 months 40% 60% 70%\nFrom 6 months to 9 months 20% 50% 60%\nFrom 9 months to 12 months 0% 40% 55%\nFrom 12 months to 15 months - 30% 45%\nFrom 15 months to 18 months - 20% 40%\nFrom 18 months to 21 months - 10% 35%\nFrom 21 months to 24 months - 0% 25%\nFrom 24 months to 27 months - - 20%\nFrom 27 months to 30 months - - 10%\nFrom 30 months to 33 months - - 5%\nFrom 33 months to 36 months - - 0%\nNotwithstanding anything contained herein or\notherwise, no refunds of premium shall be made in\nrespect of Cancellation where, any claim has been\nadmitted or has been lodged or any benefit has\nbeen availed by the Insured person under the\nPolicy.\nb) The Company may cancel the Policy at any time on\ngrounds of mis-representation, non-disclosure of\nmaterial facts, fraud by the Insured Person, by\ngiving 15 days' written notice. There would be no\nrefund of premium on cancellation on grounds of\nmis-representation, non-disclosure of material\nfacts or fraud.\n\nGolden Shield\n23 CIN: L67200MH2000PLC129408UIN : ICIHLIP22012V012223\n15. Free look period\nThe Free Look Period shall be applicable on new\nindividual health insurance policies and not on\nrenewals or at the time of porting/migrating the policy.\nThe insured person shall be allowed free look period of\nfifteen days from date of receipt of the Policy\ndocuments to review the terms and conditions of the\nPolicy, and to return the same if not acceptable.\nIf the insured has not made any claim during the Free\nLook Period, the insured shall be entitled to\na) a refund of the premium paid less any expenses\nincurred by the company on medical examination\nof the insured person and the stamp duty charges;\nor\nb) where the risk has already commenced and the\noption of return of the Policy is exercised by the\ninsured person, a deduction towards the\nproportionate risk premium for period of cover or\nc) where only a part of the insurance coverage has\ncommenced, such propor tionate premium\ncommensurate with the insurance coverage\nduring such period;\n16. Redressal of Grievances\nln case of any grievance the insured person may\ncontact the company through\nWebsite : www.icicilombard.com\nToll Free : 1800 2666\nE-Mail : customersupport@icicilombard.com\nCourier : ICICI Lombard General Insurance Company Ltd.\nICICI Lombard House,\n414, Veer Savarkar Marg,\nNear Siddhi Vinayak Temple,\nPrabhadevi, Mumbai- 400025\nlnsured person may also approach the grievance cell at\nany of the company's branches with the details of\ngrievance.\nlf lnsured person is not satisfied with the redressal of\ngrievance through one of the above methods, insured\nperson may contact the grievance officer at :\nManager- Service Quality,\nCorporate Manager- Service Quality,\nNational Manager- Operations &\nfinally Director-services and Business development at\nthe following address:\nICICI Lombard General Insurance Company Limited,\nICICI Lombard House,\n414, Veer Savarkar Marg,\nNear Siddhi Vinayak Temple,\nPrabhadevi, Mumbai - 400 025.\nFor updated details of grievance officer, kindly refer the link\nhttps://www.icicilombard.com/grievance-redressal\nlf lnsured person is not satisfied with the redressal of\ngrievance through above methods, the insured person\nii. lnsured Person will have the option to migrate to\nsimilar health insurance product available with the\nCompany at the time of renewal with all the\naccrued continuity benefits such as cumulative\nbonus, waiver of waiting period as per IRDAI\nguidelines, provided the policy has been\nmaintained without a break.\n12. Moratorium Period\nAfter completion of eight continuous years under this\npolicy no look back would be applied. This period of\neight years is called as moratorium period. The\nmoratorium would be applicable for the sums insured\nof the first policy and subsequently completion of 8\ncontinuous years would be applicable from date of\nenhancement of sum insured only on the enhanced\nlimits. After the expiry of Moratorium Period no health\ninsurance claim shall be contestable except for proven\nfraud and permanent exclusions specified in the policy\ncontract. The policies would however be subject to all\nlimits, sub limits, co-payments, deductibles as per the\npolicy contract\n13. Premium Payment in lnstalments (Wherever\napplicable)\nlf the insured person has opted for Payment of\nPremium on an instalment basis i.e. Half Yearly,\nQuarterly or Monthly, as mentioned in the policy\nSchedule/Certificate of lnsurance, the following\nConditions shall apply (notwithstanding any terms\ncontrary elsewhere in the policy)\ni. Grace Period of 15 days would be given to pay the\ninstalment premium due for the policy.\nii. During such grace period, coverage will not be\navailable from the due date of instalment premium\ntill the date of receipt of premium by Company.\niii. The insured person will get the accrued continuity\nbenefit in respect of the \"Waiting Periods\",\n\"Specific Waiting Periods\" in the event of payment\nof premium within the stipulated grace Period.\niv. No interest will be charged lf the instalment\npremium is not paid on due date.\nv. ln case of instalment premium due not received\nwithin the grace period, the policy will get\ncancelled.\nvi. ln the event of a claim, all subsequent premium\ninstalments shall immediately become due and\npayable.\nvii. The company has the right to recover and deduct\nall the pending instalments from the claim amount\ndue under the policy.\n14. Possibility of Revision of Terms of the Policy Including\nthe Premium Rates\nThe Company, with prior approval of IRDAI, may revise\nor modify the terms of the policy including the premium\nrates. The insured person shall be notified three\nmonths before the changes are effected.\n\nGolden Shield\n24 CIN: L67200MH2000PLC129408UIN : ICIHLIP22012V012223\nbased co-payment shall not be applicable in case of\nmedically necessary treatment taken for road traffic\naccidents.\nThe additional zone based co-payment that will be levied will\nbe as per tables mentioned below\nAdditional zone based Co-Payment Grid\nTreatment Zone opted at\ntaken in Zone policy issuance\nA B C\nA 0% 15.0% 25.0%\nB Nil additional 0% 12.0%\nco-payment\nC Nil additional Nil additional 0%\nco-payment co-payment\nPlease refer to the claim illustrations as detailed in g.\nother terms and conditions 1. Claim Administration for\nfurther understanding\n19. Conditional Underwriting\nRisk based loading:\nWe may apply a risk loading on the premium payable\n(based on the declarations made in the proposal form\nand the health status of the persons proposed for\ninsurance) at the Commencement Date or on any\nrenewal of the Policy with Us or on the receipt of a\nrequest for enhancing the Annual Sum Insured. The\nmaximum risk loading applicable for an individual will\nnot exceed 100% per diagnosis / medical condition and\nan overall risk loading of 200% per individual.\nWe will send You the applicable risk loading in writing\nvia a counter offer letter. You shall give Us Your consent\nand the additional premium (if any), within 15 days of\nthe issuance of Our Counter offer letter.\nIf You neither accept Our letter nor revert to Us within\n15 days, We will cancel Your application and refund the\npremium paid within the next 7 days.\n20. Material Change\nThe Insured shall notify the Company in writing of any\nmaterial change in the risk in relation to the declaration\nmade in the proposal form or medical examination\nreport at each Renewal and the Company may, adjust\nthe scope of cover and/or premium, if necessary,\naccordingly.\n21. Records to be Maintained\nThe Insured Person shall keep an accurate record\ncontaining all relevant medical records and shall allow\nthe Company or its representatives to inspect such\nrecords. The Proposer or Insured Person shall furnish\nsuch information as the Company may require for\nsettlement of any claim under the Policy, within\nreasonable time limit and within the time limit specified\nin the Policy.\n22. Notice & Communication\ni. Any notice, direction, instruction or any other\ncommunication related to the Policy should be\nmade in writing.\nm a y a l s o a p p r o a c h t h e o ff i ce o f l n s u r a n ce\nOmbudsman of the respective area/region for\nredressal of grievance as per lnsurance Ombudsman\nRules 2017. Grievance may also be lodged at IRDAI\nl n t e g r a t e d G r i e v a n c e M a n a g e m e n t S y s t e m\nhttps://igms.irda.gov.in/\n17. Nomination:\nThe policyholder is required at the inception of the\npolicy to make a nomination for the purpose of\npayment of claims under the policy in the event of\ndeath of the policyholder. Any change of nomination\nshall be communicated to the company in writing and\nsuch change shall be effective only when an\nendorsement on the policy is made. ln the event of\ndeath of the policyholder, the Company will pay the\nnominee {as named in the Policy Schedule/Policy\nCertificate/Endorsement (if any)} and in case there is no\nsubsisting nominee, to the legal heirs or legal\nrepresentatives of the policyholder whose discharge\nshall be treated as full and final discharge of its liability\nunder the policy.\nii. Specific terms and clauses (terms and other clauses\nother than those mentioned above under f. I. above)\n18. Zone based Premium\nThis Policy only covers medical treatment taken within\nIndia arising during the Policy Period. All payments\nunder this Policy will only be made in Indian Rupees\nwithin India.\nThe construction, interpretation and meaning of the\nprovisions of this Policy shall be determined in\naccordance with Indian law.\nFor the purpose of Policy issuance, the premium will be\ncomputed basis the zone chosen by the Insured Person\nin the proposal form. The premium that would be\napplicable zone wise and the cities defined in each\nzone are as under:\n• Zone A- NCR*, Mumbai, Thane District,, Navi\nMumbai, Gujarat, Kolkata\n• Zone B- Hyderabad, Secunderabad, Chhattisgarh,\nMadhya Pradesh, Daman & Diu, Dadar & Nagar\nHaveli, Goa, Maharashtra (excluding Mumbai,\nThane District, Navi Mumbai)\n• Zone C- Rest of India\nNCR* includes Includes Delhi and the following\ndistricts: Faridabad, Gurgaon/Gurugram, Mewat,\nRohtak, Sonipat, Panipat, Jhajjhar, Palwal, Karnal,\nGhaziabad, Noida/Gautam Budh Nagar, Bulandshahr,\nBaghpat, Hapur, Shamli, Muzaffarnagar\nAdditional zone based Co-Payment would be levied on\neach and every claim (over and above the base co-\npayment opted by the Insured person) in case\nmedically necessary treatment has been taken in a\nzone higher (Zone A being the highest followed by\nZone B and then Zone C) than the zone for which\npremium has been paid on issuance of the policy. Zone\n\nGolden Shield\n25 CIN: L67200MH2000PLC129408UIN : ICIHLIP22012V012223\nand Conciliation Act 1996, as amended by\nArbitration and Conciliation (Amendment ) Act,\n2015 (No. 3 of 2016).\nii. It is clearly agreed and understood that no difference\nor dispute shall be preferable to arbitration as herein\nbefore provided, if the Company has disputed or not\naccepted liability under or in respect of the policy, iii. It\nis hereby expressly stipulated and declared that it\nshall be a condition precedent to any right of action or\nsuit upon the policy that award by such arbitrator /\narbitrators of the amount of expenses shall be first\nobtained.\n27. Policy alignment\nPolicy Alignment option will be available in cases\nwherein insured(s) with two separate health indemnity\npolicies with Us, having different policy end dates but\nwant to align the policy start dates. We can align the\npolicies by extending the coverage of one policy till the\nend date of the other policy.\nSuch policies will be charged with premium on pro rata\nbasis though the sum insured under the policy shall\nremain constant.\n28. Endorsements (Changes in Policy)\ni. This policy constitutes the complete contract of\ninsurance. This Policy cannot be modified by\nanyone (including an insurance agent or broker)\nexcept the company. Any change made by the\ncompany shall be evidenced by a written\nendorsement signed and stamped.\nii. The proposer may be changed only at the time of\nrenewal. The new proposer must be the legal\nheir/immediate family member. Such change\nwould be subject to acceptance by the company\nand payment of premium (if any). The renewed\nPolicy shall be treated as having been renewed\nwithout break.\niii. The proposer may be changed during the Policy\nPeriod only in case of his/her demise or him/her\nmoving out of India.\niv. Mid- term endorsement of addition of members in\nthe policy shall not be permitted\n29. Change of Sum Insured\nSum insured can be changed (increased/ decreased)\nonly at the time of renewal subject to underwriting by\nthe Company. For any increase in SI, the waiting period\nshall start afresh only for the enhanced portion of the\nsum insured.\n30. Non Payables\nBelow are the non-payable items applicable in the\npolicy. The list may be updated as per the direction of\nAuthority, for updated list please visit our website:\nwww.iciciclombard.com\nii. Such communication shall be sent to the address\nof the Company or through any other electronic\nmodes specified in the Policy Schedule.\niii. The Company shall communicate to the Insured at\nthe address or through any other electronic mode\nmentioned in the schedule.\n23. Territorial Limit\nAll medical treatment for the purpose of this insurance\nwill have to be taken in India only.\n24. Automatic change in Coverage under the policy\nThe coverage for the Insured Person(s) shall\nautomatically terminate:\ni. In the case of his/ her (Insured Person) demise.\nHowever the cover shall continue for the remaining\nInsured Persons till the end of Policy Period. The\nother insured persons may also apply to renew the\npolicy. In case, the other insured person is minor,\nthe policy shall be renewed only through any one\nof his/her natural guardian or guardian appointed\nby court. All relevant particulars in respect of such\nperson (including his/her relationship with the\ninsured person) must be submitted to the company\nalong with the application. Provided no claim has\nbeen made, and termination takes place on\naccount of death of the insured person, pro-rata\nrefund of premium of the deceased insured person\nfor the balance period of the policy will be effective.\nii. Upon exhaustion of sum insured and additional\nsum insured (if any), for the policy year. However,\nthe policy is subject to renewal on the due date as\nper the applicable terms and conditions.\n25. Territorial Jurisdiction\nAll disputes or differences under or in relation to the\ninterpretation of the terms, conditions, validity,\nconstruct, limitations and/or exclusions contained in\nthe Policy shall be determined by the Indian court and\naccording to Indian law.\n26. Arbitration\ni. If any dispute or difference shall arise as to the\nquantum to be paid by the Policy, (liability being\nother wise admitted) such difference shall\nindependently of all other questions, be referred to\nthe decision of a sole arbitrator to be appointed in\nwriting by the parties here to or if they cannot\nagree upon a single arbitrator within thirty days of\nany party invoking arbitration, the same shall be\nreferred to a panel of three arbitrators, comprising\ntwo arbitrators, one to be appointed by each of the\nparties to the dispute/difference and the third\narbitrator to be appointed by such two arbitrators\nand arbitration shall be conducted under and in\naccordance with the provisions of the Arbitration\n\nGolden Shield\n26 CIN: L67200MH2000PLC129408UIN : ICIHLIP22012V012223\nList of Non Payable Items as per IRDAI (Contd.)\nSr. No. Items\n48 NIMBUS BED OR WATER OR AIR BED CHARGES\n49 AMBULANCE COLLAR\n50 AMBULANCE EQUIPMENT\n51 ABDOMINAL BINDER\n52 PRIVATE NURSES CHARGES- SPECIAL NURSING\nCHARGES\n53 SUGAR FREE Tablets\n54 CREAMS POWDERS LOTIONS (Toiletries are not\npayable, only prescribed medical pharmaceuticals\npayable)\n55 ECG ELECTRODES\n56 GLOVES\n57 NEBULISATION KIT\n58 RECOVERY KIT, ETC]ANY KIT WITH NO DETAILS\nMENTIONED [DELIVERY KIT, ORTHOKIT,\n59 KIDNEY TRAY\n60 MASK\n61 OUNCE GLASS\n62 OXYGEN MASK\n63 PELVIC TRACTION BELT\n64 PAN CAN\n65 TROLLY COVER\n66 UROMETER, URINE JUG\n67 AMBULANCE\n68 VASOFIX SAFETY\nf. Other Terms and Conditions\n1. Claim Administration\nThe fulfilment of the terms and conditions of this\nPolicy (including payment of premium by the due\ndates mentioned in the Policy Schedule) insofar as\nthey relate to anything to be done or complied with\nby each of You shall be conditions precedent to\nadmission of Our liability. You are requested to go\nthrough our list of de-listed/excluded providers\nwhich is available on our website. As the list is\ndynamic, please refer to the latest list.\nThe claim pay-out would be adjudicated in\nfollowing sequence:\ni. If a room/ICU accommodation has been opted\nfor where the room rent or category is higher\nthan the eligible limit as applicable for the\nInsured Person, then the associated medical\nexpenses payable shall be pro-rated as per\napplicable limits.\nii. Associated medical expenses means those\nexpenses as listed below which vary in\naccordance with the room rent or room\ncategory or ICU Charges in a hospital:\na. Room, boarding, nursing and operation\ntheatre expenses as charged by the\nHospital where the insured person availed\ntreatment\nb. Intensive care unit (ICU) Charges\nList of Non Payable Items as per IRDAI\nSr. No. Items\n1 BABY FOOD\n2 BABY UTILITIES CHARGES\n3 BEAUTY SERVICES\n4 BELTS/ BRACES\n5 BUDS\n6 COLD PACK/HOT PACK\n7 CARRY BAGS\n8 EMAIL / INTERNET CHARGES\n9 FOOD CHARGES (OTHER THAN PATIENT’s DIET\nPROVIDED BY HOSPITAL)\n10 LEGGINGS\n11 LAUNDRY CHARGES\n12 MINERAL WATER\n13 SANITARY PAD\n14 TELEPHONE CHARGES\n15 GUEST SERVICES\n16 CREPE BANDAGE\n17 DIAPER OF ANY TYPE\n18 EYELET COLLAR\n19 SLINGS\n20 BLOOD GROUPING AND CROSS MATCHING OF\nDONORS SAMPLES\n21 SERVICE CHARGES WHERE NURSING CHARGE\nALSO CHARGED\n22 Television Charges\n23 SURCHARGES\n24 ATTENDANT CHARGES\n25 EXTRA DIET OF PATIENT (OTHER THAN THAT\nWHICH FORMS PART OF BED\n26 BIRTH CERTIFICATE\n27 CERTIFICATE CHARGES\n28 COURIER CHARGES\n29 CONVEYANCE CHARGES\n30 MEDICAL CERTIFICATE\n31 MEDICAL RECORDS\n32 PHOTOCOPIES CHARGES\n33 MORTUARY CHARGES\n34 WALKING AIDS CHARGES\n35 OXYGEN CYLINDER (FOR USAGE OUTSIDE THE\nHOSPITAL)\n36 SPACER\n37 SPIROMETRE\n38 NEBULIZER KIT\n39 STEAM INHALER\n40 ARMSLING\n41 THERMOMETER\n42 CERVICAL COLLAR\n43 SPLINT\n44 DIABETIC FOOT WEAR\n45 KNEE BRACES (LONG/ SHORT/ HINGED)\n46 KNEE IMMOBILIZER/SHOULDER IMMOBILIZER\n47 LUMBO SACRAL BELT\n\nGolden Shield\n27 CIN: L67200MH2000PLC129408UIN : ICIHLIP22012V012223\napplied incase voluntary deductible has been\nopted for.\nv. Base Co-payment shall be applicable on the\namount payable by Us and our liability to\nmake payment shall than be arrived at.\nvi. In case, the claim is for a Procedure/Medical\nCondition/Ailment/Disease which is subject to\nsub-limits as per policy terms and conditions,\nthe claim will be settled to the extent of\namount which is lesser of the three amounts –\ni.e. claimed amount or maximum amount as\nper sub-limits applicable or ICICI Lombard\nLiability after deduction of base co-payment/\nvoluntary deductible.\nc. Fees charged by surgeon, anesthetist,\nmedical practitioner\nd. Investigation expenses\niii. Zone based co-payment shall be applicable in\nall cases (Except medically necessar y\ntreatment for road traffic accidents) where\ntreatment is taken in a zone higher than for\nwhich premium was paid for\niv. The voluntary deductible shall be applied to\naggregate of all claims that are either paid or\npayable (not excluded) under this policy. Our\nliability to make payment shall commence only\nonce the aggregate amount of all claims\npayable or paid exceed the voluntar y\ndeductible. Base Co-payment shall not be\nIllustration 2 - Insured person opted for voluntary deductible\nHeading Particulars\nA. Annual Sum Insured ` 20,00,000 ` 20,00,000\nB. Voluntary deductible opted at time of policy issuance\nScenario 1 Scenario 2\n` 4,00,000 ` 4,00,000\nC. Base Co-payment applicable \nNA NA\nZone opted \nB (Goa) B (Goa)\nHospitalization Diagnosis \nHeart Attack/\nPTCA done/\nCardiovascular\ndisease\nHeart Attack/\nPTCA done/\nCardiovascular\ndisease\nTreatment taken in \nGoa (Zone B) \nMumbai (Zone A)\n` 20,00,000\nScenario 3\n` 4,00,000\nNA\nB (Goa)\nGuwahati (Zone C)\nHeart Attack/\nPTCA done/\nCardiovascular\ndisease\nIllustrations for claim settlement\nIllustration 1 - Insured Person opted for base co-payment\nHeading \nParticulars\nA. Annual Sum Insured ` 10,00,000 ` 10,00,000 ` 10,00,000\nB. Base Co-payment opted at time of policy issuance\nScenario 1 Scenario 2 Scenario 3\n20% 20% 20%\nZone opted \nB (Goa) B (Goa) \nB (Goa)\nHospitalization Diagnosis \nHeart Attack/\nPTCA done/\nCardiovascular\ndisease\nHeart Attack/\nPTCA done/\nCardiovascular\ndisease\nHeart Attack/\nPTCA done/\nCardiovascular\ndisease\nTreatment taken in \nGoa (Zone B) \nMumbai (Zone A) Guwahati (Zone C)\nC. Hospitalisation expenses Amount ` 4,00,000 \n` 5,00,000 \n` 3,00,000\nD. Pre and Post hospitalisation expenses ` 35,000 ` 50,000 ` 20,000\nE. Total claimed Expenses*[C+D] \n` 4,35,000 \n` 5,50,000 \n` 3,20,000\nF. Zone based co-payment 0% 15% 0%\nG. Claimed amount after application of zone based co-payment\n[E*F]\n` 4,35,000 ` 4,67,500 ` 3,20,000\nH. Sub-limit for cardiovascular diseases ` 3,50,000 ` 3,50,000\nI. Insured Person liability after application of base co-payment\n[G*B]\n` 87,000 ` 93,500 ` 64,000\nJ. ICICI Lombard Liability after deduction of co-payment [G-I] ` 3,48,000 ` 3,74,000 ` 2,56,000\nFinal payable amount to Insured Person [lesser amount out of G, H, J] ` 3,48,000 ` 3,50,000 ` 2,56,000\nK.\nBalance Annual Sum Insured [A-K] ` 6,52,000 ` 6,50,000 ` 7,44,000\nL.\n*It has been assumed that total claimed expenses are same as total payable expenses. i.e. there are no deductions in the claimed amount.\n` 3,50,000\n\nGolden Shield\n28 CIN: L67200MH2000PLC129408UIN : ICIHLIP22012V012223\nIllustrations for claim settlement (Contd.)\nIllustration 2 - Insured person opted for voluntary deductible (Contd.)\nHeading Particulars Scenario 1 Scenario 2 Scenario 3\nJ. Sub-limit for cardiovascular diseases ` 3,50,000 ` 3,50,000 ` 3,50,000\nFinal payable amount to Insured Person [lesser amount out of I,J] ` 35,000 ` 67,500\nK.\nBalance Annual Sum Insured [A-K] ` 19,65,000 ` 19,32,500 ` 20,00,000\nL.\n*It has been assumed that total claimed expenses are same as total payable expenses. i.e. there are no deductions in the claimed amount.\nD. Hospitalisation expenses Amount ` 4,00,000 ` 5,00,000 ` 3,00,000\nE. Pre and Post hospitalisation expenses ` 35,000 ` 50,000 ` 20,000\nF. Total claimed Expenses*[D+E] ` 4,35,000 ` 5,50,000 ` 3,20,000\nG. Zone based co-payment 0% 15% 0%\nH. Claimed amount after application of zone based co-payment\n[F*G]\n` 4,35,000 ` 4,67,500 ` 3,20,000\nI. IL Liability after application of voluntary deductible [H-B] ` 35,000 ` 67,500\nThe claim amount assessed above would be deducted from the\nfollowing amounts in the following progressive order:\n1. Annual Sum Insured\n2. Additional Sum Insured/Cumulative Bonus (if accrued and\navailable)\n3. Reset Sum Insured (If applicable)\nFurther, upon the discovery or happening of any Illness or Injury\nthat may give rise to a Claim under this Policy, then as a\ncondition precedent to the admission of Our liability, You shall\nundertake the following:\n1.1 Claims Procedure\nA. For Cashless Settlement\nCashless treatment is only available at a Network\nProvider (List of Network Providers is available at our\nwebsite). In order to avail of cashless treatment, the\nfollowing procedure must be followed by You:\nPre-authorization\nPrior to taking treatment and/ or incurring Medical\nExpenses at a Network Provider, You must contact Us\nor Our in house claim processing team accompanied\nwith full particulars namely, Policy Number, Your name,\nYour relationship with Policy Holder, nature of Illness or\nInjury, name and address of the Medical Practitioner/\nHospital and any other information that may be\nrelevant to the Illness/ Injury/ Hospitalisation. You must\nrequest preauthorization at least 48 hours before a\nplanned Hospitalization and in case of an emergency\nsituation, within 24 hours of Hospitalization. To avail of\nCashless Hospitalization facility, you are required to\nproduce the health card, as provided to You with this\nPolicy, subject to the terms and conditions for the\nusage of the said health card Or You can seek pre\nauthorization by providing Your Policy number and ID\nproof to the hospital who can co-ordinate with Our\nclaim team to provide cashless facility. We will consider\nYour request after having obtained accurate and\ncomplete information for the Illness or Injury for which\ncashless Hospitalization facility is sought by You and\nWe will confirm Your request in writing.\nB. For Reimbursement Settlement\ni. You shall give notice to Us or Our in house claim\nprocessing team by calling the toll free number\n1 8 0 0 2 6 6 6 o r e m a i l i n g u s a t a s\ncustomersupport@icicilombard.com specified in\nthe Policy provided to You and also in writing at\nOur address with particulars as below:\nv Policy number;\nv Your Name;\nv Your relationship with the Policyholder;\nv Nature of Illness or Injury;\nv Name and address of the attending Medical\nPractitioner and the Hospital;\nv Any other information that may be relevant to\nthe Illness/ Injury/ Hospitalisation\nThe above information needs to be provided to Us\nor Our in house claim processing team immediately\nand in any event within 10 days of Hospitalization,\nfailing which We will have the right to treat the\nClaim as inadmissible, as We may deem fit at Our\nsole discretion.\nii. You must immediately consult a Medical\nPractitioner and follow the advice and treatment\nthat he recommends.\nNA as\nexpenses have\nnot crossed\nvoluntary\ndeductible\namount\n-\n\nGolden Shield\n29 CIN: L67200MH2000PLC129408UIN : ICIHLIP22012V012223\nof Policy) OR communicate non admissibility of claim\nwithin 14 days after You submit complete set of\ndocuments & information in respect of the claims. In\ncase We fail to make the payment of admissible claims\nor to communicate non admissibility of claim within the\ntime period, We shall pay 2% interest over and above\nthe rate defined as per IRDAI (Protection of\nPolicyholder's interest) Regulation 2017.\nB. For Cashless Claims: If You notify pre authorization\nrequest for cashless facility through any of Our\nempanelled network hospitals along with complete set\nof documents & information, We will respond within 4\nhours of the actual receipt of such pre authorization\nrequest with:\na. Approval, or\nb. Rejection, or\nc. Query seeking further information\nIn case the request is for enhancement, i.e. Request\nfor increase in the amount already authorized, We\nwill respond to it within 3 hours.\nIn case of delay in response by Us beyond the time\nperiod as stated above for cashless claims, We\nshall be liable to pay 1,000 to You. Our maximum`\nliability in respect of a single hospitalization shall,\nat no time exceed 1,000. We will not be liable to`\nmake any payments under this Claim Service\nGuarantee in case of any force majeure, natural\nevent or manmade disturbance which impedes\nOur inability to make a decision or to communicate\nsuch decisions to You.\nThe service guarantee shall not be applicable for\nany cases delayed on account of reasonable\napprehension of fraud or fraudulent claims or\ncases referred to/by any adjudicative forum for\nnecessary disposal.\nYo u m ay l o d g e c l a i m s e p a ra te l y fo r t h e\nhospitalization claim, Pre-Post hospitalization. In\nsuch scenario, if delay happens beyond the time\nperiod as specified above, the interest amount\ncalculated will be on the net sanctioned amount of\nrespective transaction and not the total amount\npaid for the entire claim.\nAny amount paid towards interest under Claim\nService Guarantee will not affect the Annual Sum\nInsured as specified in the Schedule.\nIf you are not eligible for 'Claim Service Guarantee'\nfor the reasons stated above, We will inform the\nsame to You, within 14 days in case of A. For\nReimbursement claims and within 4 hours in case\nof B. For Cashless claims above.\nYou or someone claiming on Your behalf must promptly\nand in any event within 30 days of Your discharge from\na Hospital (for post-hospitalization expenses, within\n30 days from the completion of post-hospitalization\nperiod) deliver to Us the documentation (written details\nof the quantum of any Claim along with all original\nsupporting documentation) as more particularly listed\nin Claim documents section. In case there is a delay\nbeyond 30 days in submission of claim documents, we\nmay condone the delay provided the insured person\nsubmits a valid reason justifying the delay to us in\nwriting. However, in both the above cases i.e.\ng.1.1.1(A) & (B), You must take reasonable steps or\nmeasure to minimise the quantum of any Claim that\nmay be covered under the Policy If so requested by Us\nor Our in house claim processing team, You will have to\nundergo a medical examination from Our nominated\nMedical Practitioner, as and when We or Our in house\nclaim processing team considers reasonable and\nnecessary. The cost of such examination will be borne\nby Us.\nClaim falling in two Policy periods\nIf the claim event falls within two Policy periods, the claims\nshall be paid taking into consideration the available Sum\nInsured in the two Policy periods, including the Deductions\nfor each Policy Period. Such eligible claim amount to be\npayable to the Insured shall be reduced to the extent of\npremium to be received for the Renewal/due date of\npremium of health insurance Policy, if not received earlier.\n1.2 CLAIM DOCUMENTS\nYou shall be required to furnish the following documents for\nor in support of a Claim:\ni. Duly completed Claim form signed by You and the\nMedical Practitioner. The claim form can be\ndownloaded from our website www.icicilombard.com.\nii. Original bills, receipts and discharge certificate/ card\nfrom the Hospital/ Medical Practitioner.\niii. Original bills from chemists supported by proper\nprescription.\niv. Original investigation test reports and payment\nreceipts.\nv. Indoor case papers\nvi. Medical Practitioner's referral letter advising\nHospitalization in non-Accident cases.\nvii. Any other document as required by Us or Our TPA to\ninvestigate the Claim or Our obligation to make\npayment for it\n1.3 Claim Service Guarantee\nWe provide You Claim Service Guarantee as follows\nA. For Reimbursement Claims: We shall make the\npayment of admissible claim (as per terms & conditions\n\nGolden Shield\n30 CIN: L67200MH2000PLC129408UIN : ICIHLIP22012V012223\nOffice Details\nJurisdiction of Office\nUnion Territory, District)\nBHOPAL\nOffice of the Insurance Ombudsman,\nJanak Vihar Complex, 2nd Floor, 6, Malviya\nNagar, Opp. Airtel Office, Near New Market,\nBhopal – 462 003.\nTel.: 0755 - 2769201 / 2769202\nFax: 0755 - 2769203\nEmail: bimalokpal.bhopal@cioins.co.in\nMadhya Pradesh\nChattisgarh.\nBHUBANESHWAR - Shri Suresh Chandra\nPanda\nOffice of the Insurance Ombudsman, 62,\nForest park, Bhubneshwar – 751 009.\nTel.: 0674 - 2596461 /2596455\nFax: 0674 - 2596429\nEmail: bimalokpal.bhubaneswar@cioins.co.in\nOrissa.\nCHANDIGARH\nOffice of the Insurance Ombudsman,\nS.C.O. No. 101, 102 & 103, 2nd Floor,\nBatra Building, Sector 17-D,\nChandigarh - 160 017.\nTel.: 0172 - 2706196 / 2706468\nFax: 0172 - 2708274\nEmail: bimalokpal.chandigarh@cioins.co.in\nPunjab, Haryana\n(excluding Gurugram,\nFaridabad, Sonepat\nand Bahadurgarh)\nHimachal Pradesh,\nUnion Territories of\nJammu & Kashmir,\nLadakh &\nChandigarh.\nCHENNAI\nOffice of the Insurance Ombudsman,\nFatima Akhtar Court, 4th Floor, 453,\nAnna Salai, Teynampet, Chennai - 600 018.\nTel.: 044 - 24333668 / 24335284\nFax: 044 - 24333664\nEmail: bimalokpal.chennai@cioins.co.in\nTamil Nadu, Tamil\nNadu Puducherry\nTown and Karaikal\n(which are part of\nPuducherry).\nAHMEDABAD - Shri Kuldip Singh\nOffice of the Insurance Ombudsman,\nJeevan Prakash Building, 6th Floor, Tilak\nMarg, Relief Road, Ahmedabad - 380 001.\nTel.: 079 - 25501201/02/05/06\nEmail: bimalokpal.ahmedabad@cioins.co.in\nGujarat, Dadra &\nNagar Haveli, Daman\nand Diu.\nBENGALURU\nOffice of the Insurance Ombudsman,\nJeevan Soudha Building, PID No. 57-27-N-19,\nGround Floor, 19/19, 24th Main Road,\nJP Nagar, Ist Phase, Bengaluru - 560 078.\nTel.: 080 - 26652048 / 26652049\nEmail: bimalokpal.bengaluru@cioins.co.in\nKarnataka.\nOffice Details\nJurisdiction of Office\nUnion Territory, District)\nDELHI - Shri Sudhir Krishna\nOffice of the Insurance Ombudsman,\n2/2 A, Universal Insurance Building,\nAsaf Ali Road, New Delhi - 110 002.\nTel.: 011 - 23232481/23213504\nEmail: bimalokpal.delhi@cioins.co.in\nDelhi & Following\nDistricts of Haryana\n- Gurugram,\nFaridabad, Sonepat\n& Bahadurgarh.\nGUWAHATI\nOffice of the Insurance Ombudsman,\nJeevan Nivesh, 5th Floor, Nr. Panbazar over\nBridge, S. S. Road, Guwahati -781001\n(ASSAM).\nTel.: 0361 - 2632204 / 2602205\nEmail: bimalokpal.guwahati@cioins.co.in\nAssam, Meghalaya,\nManipur, Mizoram,\nArunachal Pradesh,\nNagaland and\nTripura.\nHYDERABAD\nOffice of the Insurance Ombudsman,\n6-2-46, 1st floor, “Moin Court”, Lane Opp.\nSaleem Function Palace, A. C. Guards,\nLakdi-Ka-Pool, Hyderabad - 500 004.\nTel.: 040 - 23312122 Fax: 040 - 23376599\nEmail: bimalokpal.hyderabad@cioins.co.in\nAndhra Pradesh,\nTelangana, Yanam\nand part of Union\nTerritory of\nPuducherry.\nERNAKULAM - Ms. Poonam Bodra\nOffice of the Insurance Ombudsman,\n2nd Floor, Pulinat Bldg., Opp. Cochin\nShipyard, M. G. Road, Ernakulam - 682 015.\nTel.: 0484 - 2358759 / 2359338\nFax: 0484 - 2359336\nEmail: bimalokpal.ernakulam@cioins.co.in\nKerala, Lakshadweep,\nMahe-a part of Union\nTerritory of\nPuducherry.\nKOLKATA - Shri P. K. Rath\nOffice of the Insurance Ombudsman,\nHindustan Bldg. Annexe, 4th Floor,\n4, C.R. Avenue, KOLKATA - 700 072.\nTel.: 033 - 22124339 / 22124340\nFax : 033 - 22124341\nEmail: bimalokpal.kolkata@cioins.co.in\nWest Bengal, Sikkim,\nAndaman & Nicobar\nIslands.\nJAIPUR\nOffice of the Insurance Ombudsman,\nJeevan Nidhi - II Bldg., Gr. Floor, Bhawani\nSingh Marg, Jaipur - 302 005.\nTel.: 0141 - 2740363\nEmail: bimalokpal.jaipur@cioins.co.in\nRajasthan.\nAnnexure A\nLUCKNOW - Shri Justice Anil Kumar\nSrivastava\nOffice of the Insurance Ombudsman,\n6th Floor, Jeevan Bhawan, Phase-II,\nNawal Kishore Road, Hazratganj,\nLucknow - 226 001.\nTel.: 0522 - 2231330 / 2231331\nFax: 0522 - 2231310\nEmail: bimalokpal.lucknow@cioins.co.in\nDistricts of Uttar\nPradesh : Lalitpur,\nJhansi, Mahoba,\nHamirpur, Banda,\nChitrakoot,\nAllahabad, Mirzapur,\nSonbhabdra,\nFatehpur, Pratapgarh,\nJaunpur,Varanasi,\nGazipur, Jalaun,\nKanpur, Lucknow,\nUnnao, Sitapur,\nLakhimpur, Bahraich,\nBarabanki, Raebareli,\nSravasti, Gonda,\nFaizabad, Amethi,\nKaushambi,\nBalrampur, Basti,\nAmbedkarnagar,\nSultanpur,\nMaharajgang,\nSantkabirnagar,\nAzamgarh,\nKushinagar,\nGorkhpur, Deoria,\nMau, Ghazipur,\nChandauli, Ballia,\nSidharathnagar.\nMUMBAI\nOffice of the Insurance Ombudsman,\n3rd Floor, Jeevan Seva Annexe, S. V. Road,\nSantacruz (W), Mumbai - 400 054.\nTel.: 022 - 26106552 / 26106960\nFax: 022 - 26106052\nEmail: bimalokpal.mumbai@cioins.co.in\nGoa, Mumbai\nMetropolitan Region\nexcluding Navi\nMumbai & Thane.\n\nGolden Shield\n31 CIN: L67200MH2000PLC129408UIN : ICIHLIP22012V012223\nOffice Details\nJurisdiction of Office\nUnion Territory, District) \nOffice Details\nJurisdiction of Office\nUnion Territory, District)\nAnnexure A (Contd.)\nNOIDA - Shri Chandra Shekhar Prasad\nOffice of the Insurance Ombudsman,\nBhagwan Sahai Palace, 4th Floor, Main\nRoad, Naya Bans, Sector 15, Distt: Gautam\nBuddh Nagar, U.P-201301.\nTel.: 0120-2514252 / 2514253\nEmail: bimalokpal.noida@cioins.co.in\nState of Uttaranchal\nand the following\nDistricts of Uttar\nPradesh: Agra,\nAligarh, Bagpat,\nBareilly, Bijnor,\nBudaun,\nBulandshehar, Etah,\nKanooj, Mainpuri,\nMathura, Meerut,\nMoradabad,\nMuzaffarnagar,\nOraiyya, Pilibhit,\nEtawah, Farrukhabad,\nFirozbad,\nGautambodhanagar,\nGhaziabad, Hardoi,\nShahjahanpur, Hapur,\nShamli, Rampur,\nKashganj, Sambhal,\nAmroha, Hathras,\nKanshiramnagar,\nSaharanpur.\nPATNA - Shri N. K. Singh\nOffice of the Insurance Ombudsman,\n1st Floor, Kalpana Arcade Building,\nBazar Samiti Road, Bahadurpur,\nPatna 800 006. Tel.: 0612-2680952\nEmail: bimalokpal.patna@cioins.co.in\nBihar, Jharkhand.\nPUNE - Shri Vinay Sah\nOffice of the Insurance Ombudsman,\nJeevan Darshan Bldg., 3rd Floor,\nC.T.S. No.s. 195 to 198, N. C. Kelkar Road,\nNarayan Peth, Pune - 411 030.\nTel.: 020-41312555\nEmail: bimalokpal.pune@cioins.co.in\nMaharashtra, Area of\nNavi Mumbai and\nThane excluding\nMumbai Metropolitan\nRegion.\nMailing Address : 601 & 602, 6th Floor, Interface 16, New Linking Road, Malad (West), Mumbai - 400 064.\nCorporate Office : ICICI Lombard House, 414, Veer Savarkar Marg, Near Siddhi Vinayak Temple, Prabhadevi, Mumbai 400 025.\nVisit us at www.icicilombard.com • Mail us at customersupport@icicilombard.com • Toll Free No.: 1800 2666 (Toll Free also accessible from your mobile)\nInsurance is the subject matter of solicitation. IRDA Reg. No. 115 UIN: ICIHLIP22012V012223\nICICI Lombard General Insurance Company Limited",
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        "text": "For Buy/ Renew/ Service/ Claim related queries Log on to www.icicilombard.com or call 1800 2666\n1UIN : ICIHLIP22012V012223\nGolden Shield\nPolicy Wording\nCIN: L67200MH2000PLC129408\ntheatre where surgical procedures are to be\ncarried out;\niv. Maintaining daily records of the patients and\nmaking them accessible to the insurance\ncompany’s authorized representative\nAYUSH Day Care Centre means and includes\nCommunity Health Centre (CHC), Primary Health\nCentre (PHC), Dispensary, Clinic, Polyclinic or any such\nhealth centre which is registered with the local\nauthorities, wherever applicable and having facilities\nfor carrying out treatment procedures and medical or\nsurgical/para-surgical interventions or both under the\nsupervision of registered AYUSH Medical Practitioner\n(s) on day care basis without in- patient services and\nmust comply with all the following criterion:\na. Having qualified registered AYUSH Medical\nPractitioner(s) in charge;\nb. Having dedicated AYUSH therapy sections as\nrequired and/or has equipped operation theatre\nwhere surgical procedures are to be carried out;\nc. Maintaining daily records of the patients and\nmaking them accessible to the insurance\ncompany’s authorized representative.\n(Explanation: Medical practitioner referred in the\ndefinition of “AYUSH Hospital” and “AYUSH day care\ncenter” shall carry the same meaning as defined in the\ndefinition of “Medical practitioner” under chapter I of\nGuidelines)\nCashless Facility means a facility extended by the\ninsurer to the insured where the payments, of the costs\nof treatment undergone by the insured in accordance\nwith the policy terms and conditions, are directly made\nto the network provider by the insurer to the extent pre-\nauthorization approved.\nCondition Precedent shall mean a policy term or\ncondition upon which the Insurer's liability under the\npolicy is conditional upon.\nCongenital Anomaly refers to a condition(s) which is\npresent since birth, and which is abnormal with\nreference to form, structure or position.\na. Internal Congenital Anomaly -Congenital anomaly\nwhich is not in the visible and accessible parts of\nthe body\nb. External Congenital Anomaly- Congenital\nanomaly which is in the visible and accessible\nparts of the body\nCo-payment means a cost sharing requirement under\na health insurance policy that provides that the\npolicyholder/insured/proposer will bear a specified\npercentage of the admissible claims amount. A co-\npayment does not reduce the Sum Insured.\nb. Preamble\nThis Policy has been issued on the basis of the Disclosure to\ninformation Norm, including the information provided by\nProposer in respect of the Insured Persons in the Proposal\nForm, any application for insurance cover in respect of any\nInsured Person and any other information or details\nsubmitted in relation to the Proposal Form. This Policy is a\ncontract of insurance between You and Us which is subject\nto the receipt of premium in full and accepted by Us in\nrespect of the Insured Persons and the terms, conditions\nand exclusions as specified in the Policy/ Policy Schedule /\nProduct Benefit Table of this Policy.\nc. Definitions\nFor the purposes of this Policy, the terms specified below\nshall have the meaning set forth wherever appearing/\nspecified in this Policy or related Extensions:\nWhere the context so requires, references to the singular\nshall also include references to the plural and references to\nany gender shall include references to all genders. Further\nany references to statutory enactment include subsequent\nchanges to the same.\ni. Standard definitions (Definitions whose wordings\nare specified by IRDAI)\nAccident means a sudden, unforeseen and involuntary\nevent caused by external, visible and violent means.\nAny one illness means continuous Period of illness and\nit includes relapse within 45 days from the date of last\nconsultation with the Hospital/Nursing Home where\ntreatment was taken.\nAyush Hospital is a healthcare facility wherein\nmedical/surgical/para-surgical treatment procedures\nand interventions are carried out by AYUSH Medical\npractitioner(s) comprising of any of the following:\na. Central or State government AYUSH hospital; or\nb. Teaching hospital attached to AYUSH college\nrecognized by the central government/Central\ncouncil of Indian medicine/ Central council for\nHomeopathy; or\nc. AYUSH Hospital, standalone or co-located with in-\npatient healthcare facility of any recognized\nsystem of medicine, registered with the local\nauthorities, wherever applicable, and is under the\nsupervision of a qualified registered AYUSH\nmedical practitioner and must comply with the\nfollowing criterion:\ni. Having at least 5 in-patient beds\nii. Having qualified AYUSH medical practitioner\nin charge round the clock\niii. Having dedicated AYUSH therapy sections as\nrequired and/or has equipped operation\n\n2 \nCIN: L67200MH2000PLC129408\nGrace Period means the specified period of time\nimmediately following the premium due date during\nwhich a payment can be made to renew or continue a\npolicy in force without loss of continuity benefits such\nas waiting periods and coverage of Pre Existing\nDiseases. Coverage is not available for the period for\nwhich no premium is received.\nHospital means any institution established for in-\npatient care and day care treatment of illness and / or\ninjuries and which has been registered as a hospital\nwith the local authorities under the Clinical\nEstablishments (Registration and Regulations) Act\n2010 or under enactments specified under the\nSchedule of Section 56(1) of the said Act Or comply\nwith all minimum criteria as under:\na. has qualified nursing staff under its employment\nround the clock;\nb. has at least 10 inpatient beds, in those towns\nhaving a population of less than 10,00,000 and 15\ninpatient beds in all other places\nc. has qualified medical practitioner(s) in charge\nround the clock;\nd. has a fully equipped operation theatre of its own\nwhere surgical procedures are carried out\ne. maintains daily records of patients and makes\nthese accessible to the Insurance company’s\nauthorized personnel.\nHospitalisation means admission in a Hospital for a\nminimum period of 24 consecutive in-patient care\nhours except for specified Procedures/Treatments,\nwhere such admission could be for a period of less than\n24 consecutive hours.\nInpatient care means treatment for which the insured\nperson has to stay in a Hospital for more than 24 hours\nfor a covered event.\nIllness means a sickness or disease or pathological\ncondition leading to the impairment of normal\nphysiological function and requires medical treatment.\na. Acute condition - Acute condition is a disease,\nillness or injury that is likely to respond quickly to\ntreatment which aims to return the person to his or\nher state of health immediately before suffering\nthe disease/illness/injury which leads to full\nrecovery.\nb. Chronic condition - A chronic condition is defined\nas a disease, illness, or injury that has one or more\nof the following characteristics:\ni. it needs ongoing or long-term monitoring\nthrough consultations, examinations, check-\nups, and / or tests\nii. it needs ongoing or long-term control or relief\nof symptoms\niii. it requires your rehabilitation for the patient or\nfor the patient to be specially trained to cope\nwith it\nCumulative Bonus shall mean any increase or addition\nin the Sum Insured granted by the insurer without an\nassociated increase in premium.\nDay care centre means any institution established for\nday care treatment of illness and/or injuries or a\nmedical setup with a hospital and which has been\nregistered with the local authorities, wherever\napplicable, and is under supervision of a registered and\nqualified medical practitioner AND must comply with\nall minimum criterion as under :-\na. has qualified nursing staff under its employment;\nb. has qualified medical practitioner/s in charge\nc. has fully equipped operation theatre of its own\nwhere surgical procedures are carried out;\nd. maintains daily records of patients and will make\nthese accessible to the insurance company’s\nauthorized personnel\nDay Care Treatment refers to medical treatment, and/\nor Surgical Procedure which is\ni. undertaken under General or Local Anesthesia in a\nHospital/ Day care centre in less than 24 hrs\nbecause of technological advancement, and\nii. which would have other wise required a\nhospitalisation of more than 24 hours.\nTreatment normally taken on an out-patient basis is\nnot included in the scope of this definition.\nDeductible is a cost sharing requirement under a\nhealth insurance policy that provides that provides\nthat the insurer will not be liable for specified rupee\namount in case of indemnity policies and for a specified\nnumber of days/hours in case of hospital cash policies,\nwhich will apply before any benefits are payable by the\ninsurer A deductible does not reduce the sum insured.\nDental treatment means a treatment related to teeth\nor structures supporting teeth including examinations,\nfillings (where appropriate), crowns, extractions and\nsurgery.\nDisclosure to information Norm means the policy shall\nbe void and all premium paid thereon shall be forfeited\nto the Company in the event of misrepresentation, mis-\ndescription or non-disclosure of any material fact.\nDomiciliary Hospitalisation means medical treatment\nfor an illness/disease/injury which in the normal course\nwould require care and treatment at a hospital but is\nactually taken while confined at home under any of the\nfollowing circumstances:\na. the condition of the patient is such that he/she is\nnot in a condition to be removed to a hospital, or\nb. the patient takes treatment at home on account of\nnon-availability of room in a hospital.\nEmergency Care means management for an illness or\ninjury which results in symptoms which occur suddenly\nand unexpectedly, and requires immediate care by a\nmedical practitioner to prevent death or serious long\nterm impairment of the insured person’s health\nGolden Shield\nUIN : ICIHLIP22012V012223\n\n3 CIN: L67200MH2000PLC129408\nHealth insurance policy), to transfer the credit gained\nfor pre-existing conditions and time bound exclusions,\nwith the same insurer.\nNetwork Provider means hospitals or health care\nproviders enlisted by an insurer, TPA or jointly by an\ninsurer and TPA to provide medical services to an\ninsured by a cashless facility.\nNon-Network Provider means any Hospital, day care\ncentre or other provider that is not part of the Network.\nNotification of claim means the process of intimating a\nclaim to the insurer or TPA through any of the\nrecognized modes of communication\nOPD treatment is one in which the Insured visits a\nclinic / hospital or associated facility like a consultation\nroom for diagnosis and treatment based on the advice\nof a Medical Practitioner. The Insured is not admitted as\na day care or in-patient.\nPortability means the right accorded to an individual\nhealth insurance policyholder/proposers (including all\nmembers under family cover), to transfer the credit\ngained for pre-existing conditions and time bound\nexclusions, from one insurer to another insurer\nPre-existing Disease means any condition, ailment,\ninjury or disease\na. That is/ are diagnosed by a physician within 48\nmonths prior to the effective date of the policy\nissued by the insurer or its reinstatement or\nb. For which medical advice or treatment was\nrecommended by, or received from, a physician\nwithin 48 months prior to the effective date of the\npolicy issued by the insurer or its reinstatement.\nPost-Hospitalisation Medical Expenses means\nmedical expenses incurred during predefined number\nof days immediately after the Insured Person is\ndischarged from the hospital, provided that :\na. Such Medical Expenses are for the same condition\nfor which the Insured Person’s Hospitalisation was\nrequired, and\nb. The In-patient Hospitalisation claim for such\nHospitalisation is admissible by the Insurance\nCompany.\nPre-Hospitalisation Medical Expenses means\nmedical expenses incurred during predefined number\nof days preceding the hospitalization of the insured\nperson, provided that:\na. Such Medical Expenses are incurred for the same\ncondition for which the Insured Person’s\nHospitalisation was required, and\nb. The In-patient Hospitalisation claim for such\nHospitalisation is admissible by the Insurance\nCompany.\nQualified Nurse is a person who holds a valid\nregistration from the Nursing Council of India or the\nNursing Council of any state in India.\niv. it continues indefinitely\nv. It recurs or is likely to recur\nInjury means any accidental physical bodily harm,\nexcluding illness or disease solely and directly caused\nby external, violent, visible and evident means which is\nverified and certified by a Medical Practitioner.\nIntensive Care Unit means an identified section, ward\nor wing of a hospital which is under the constant\nsupervision of a dedicated medical practitioner(s), and\nwhich is specially equipped for the continuous\nmonitoring and treatment of patients who are in a\ncritical condition, or require life support facilities and\nwhere the level of care and supervision is considerably\nmore sophisticated and intensive than in the ordinary\nand other wards\nICU (Intensive Care Unit) Charges means the amount\ncharged by a Hospital towards ICU expenses which\nshall include the expenses for ICU bed, general medical\nsupport services provided to any ICU patient including\nmonitoring devices, critical care nursing and intensivist\ncharges.\nMaternity expenses means;\na. medical treatment expenses traceable to childbirth\n(including complicated deliveries and caesarean\nsections incurred during Hospitalisation);\nb. expenses towards lawful medical termination of\npregnancy during the policy period.\nMedical Advice means any consultation or advice from\na Medical Practitioner including the issuance of any\nprescription or follow-up prescription.\nMedical Expenses means those expenses that an\nInsured Person has necessarily and actually incurred\nfor medical treatment on account of Illness or Accident\non the advice of a Medical Practitioner, as long as these\nare no more than would have been payable if the\nInsured Person had not been insured and no more than\nother hospitals or doctors in the same locality would\nhave charged for the same medical treatment.\nMedically Necessary Treatment is defined as any\ntreatment, tests medication or stay in hospital or part\nof a stay in Hospital which\n1. Is required for the medical management of the\nillness or Injury suffered by the insured\n2. Must not exceed the level of care necessary to\nprovide safe, adequate and appropriate medical\ncare in scope, duration or intensity\n3. Must have been prescribed by a Medical\npractitioner\n4. Must conform to the professional standard widely\naccepted in international medical practice or by the\nmedical community in India\nMigration means the right accorded to health\ninsurance policyholders/proposers (including all\nmembers under family cover and members of group\nUIN : ICIHLIP22012V012223\nGolden Shield\n\n4 CIN: L67200MH2000PLC129408\nthe Policy Schedule and is/are hereinafter referred as\n“You”/“Your”/ “Yours”/ “Yourself”\nMedical Practitioner is a person who holds a valid\nregistration from the Medical Council of any State or\nMedical Council of India or Council for Indian Medicine\nor for Homeopathy set up by the Government of India\nor a State Government and is thereby entitled to\npractice medicine within its jurisdiction; and is acting\nwithin the scope and jurisdiction of his license.\nThe term Medical Practitioner would include physician,\nspecialist, anaesthetist and surgeon but would exclude\nYou and Your spouse, Your children, Your brother(s),\nYour sister(s) and Your parent(s).\nPeriod of Insurance means the period as specifically\nappearing in the Policy Schedule and commencing\nfrom the Policy Period Start Date of the first Policy\ntaken by You from Us and then, running concurrent to\nYour current Policy subject to the Your continuous\nrenewal of such Policy with Us.\nPolicy means these Policy wordings, the Policy\nSchedule and any applicable endorsements or\nextensions attaching to or forming part thereof. The\nPolicy contains details of the extent of cover available\nto You, what is excluded from the cover and the terms &\nconditions on which the Policy is issued to You.\nProposer means the person(s) or the entity named in\nthe Policy Schedule who executed the Policy Schedule\nand is (are) responsible for payment of premium(s).\nPolicy Period means the period commencing from the\nPolicy Period Start Date, Time and ending at the Policy\nPeriod End Date, Time of the Policy and as specifically\nappearing in the Policy Schedule.\nPolicy Year means a period of twelve months\nbeginning from the Policy Period Start Date and ending\non the last day of such twelve-month period. For the\npurpose of subsequent years, “Policy Year” shall mean\na period of twelve months beginning from the end of\nthe previous Policy Year and lapsing on the last day of\nsuch twelve-month period, till the Policy Period End\nDate, as specified in the Policy Schedule\nService Provider means any person, organization,\ninstitution, or company that has been empanelled with\nUs to provide services specified under the Benefits\n(including add-ons) to The Insured person. These shall\nalso include all healthcare providers empanelled to\nform a part of network other than hospitals.\nThe list of the Service Providers is available at our\nwebsite (https://www.icicilombard.com/content/ilom-\nen/serviceprovider/search.asp) and is subject to\namendment from time to time.\nYou/Your/ Yours/ Yourself means the person(s) that\nWe insure and is/are specifically named as Insured /\nInsured Person(s) in the Policy Schedule.\nWe/ Our/ Ours/ Us means the ICICI Lombard General\nInsurance Company Limited\nReasonable and Customary Charges means the\ncharges for services or supplies, which are the\nstandard charges for the specific provider and\nconsistent with the prevailing charges in the\ngeographical area for identical or similar services,\ntaking into account the nature of Illness/injury involved.\nRenewal defines the terms on which the contract of\ninsurance can be renewed on mutual consent with a\nprovision of grace period for treating the renewal\ncontinuous for the purpose of gaining credit for pre-\nexisting diseases, time-bound exclusions and for all\nwaiting periods.\nRoom Rent means the amount charged by a hospital\ntowards Room and Boarding expenses and shall\ninclude associated medical expenses.\nSubrogation shall mean the right of the insurer to\nassume the rights of the insured person to recover\nexpenses paid out under the policy that may be\nrecovered from any other source.\nSurgery or Surgical Procedure means manual and/or\noperative procedure (s) required for treatment of an\nillness or injury, correction of deformities and defects,\ndiagnosis and cure of diseases, relief of suffering or\nprolongation of life, performed in a hospital or day care\ncentre by a Medical Practitioner\nUnproven/Experimental treatment means treatment\nincluding drug experimental therapy which is not\nbased on established medical practice in India, is\ntreatment experimental or unproven.\nii. Specific definitions (Definitions other than those\nmentioned under c. I. above)\nAdmission means Your admission in a Hospital as an\ninpatient for the purpose of medical treatment of an\nInjury and/or Illness.\nAYUSH treatments refers to the medical aid and / or\nhospitalisation treatments given under ‘Ayurveda,\nYo g a a n d N a t u r o p a t h y, U n a n i , S i d d h a a n d\nHomeopathy systems\nAnnual Sum Insured means and denotes the\nmaximum amount of cover available to You during\neach Policy Year of the Policy Period, as stated in the\nPolicy Schedule or any revisions thereof based on\nClaim settled under the Policy.\nBreak in Policy occurs at the end of the existing policy\nterm, when the premium due for renewal on a given\npolicy is not paid on or before the premium renewal\ndate or within 30 days thereof.\nClaim means a demand made by You or on Your behalf\nfor payment of Medical Expenses or any other\nexpenses or benefits, as covered under the Policy.\nImmediate Family means spouse, dependent children,\nbrother(s), sister(s) and dependent parent(s) of the\ninsured.\nInsured/Insured Person(s) means the individual(s)\nwhose name(s) is/are specifically appearing as such in\nUIN : ICIHLIP22012V012223\nGolden Shield\n\n5 CIN: L67200MH2000PLC129408\nd. Benefits covered under the policy\nThe Benefits listed in base cover are in-built benefits and\nshall be available to all Insured Persons in accordance with\nthe procedures set out in this Policy wording.\nThis Policy covers Allopathic and AYUSH treatments taken\nin India ONLY. Any expenses incurred outside the policy\nperiod will NOT be covered.\nAny claims made under any of the benefits mentioned\nbelow (except Care management program, Care\nmanagement plus program,) will impact eligibility for\nAdditional Sum Insured.\nAny unutilized annual sum insured/tele-consultations/e-\nconsultations/benefits cannot be carried forward to the\nnext policy year.\nBase Cover\n1. In Patient Treatment\nWe will cover the following Medical Expenses incurred in\nrespect of Hospitalization of the Insured Person during the\nPolicy Period, up to the Annual Sum Insured specified in the\nPolicy Schedule against this Benefit:\ni. Room Rent up to Twin sharing room (for Annual Sum\nInsured below ` 10 Lacs and Single private AC room for\nannual sum insured ` 10L and above);\nii. Intensive Care Unit Charges;\niii. Qualified Nurse charges;\niv. Medical Practitioner’s Fees ;\nv. Anaesthesia, blood, oxygen, operation theatre\ncharges, medicines, drugs and consumables (other\nthan those specified in the list of excluded expenses\n(non-medical) in Annexure I;\nvi. S u rg i c a l a p p l i a n ce s a n d p ro st h e t i c d ev i ce s\nrecommended in writing by the attending Medical\nPractitioner and that are used intra operatively during\na Surgical Procedure;\nvii. Cost of investigative tests or prescribed diagnostic\nprocedures directly related to the Injury/Illness for\nwhich the Insured Person is Hospitalized;\nWe will consider a claim under this Benefit, subject to the\nfollowing:\ni. The Hospitalization is for Medically Necessary\nTreatment.\nii. The hospitalization warrants inpatient admission in\nview of active line of treatment.\niii. The Hospitalization commences and continues on the\nwritten advice of a Medical Practitioner.\niv. The Medical Expenses incurred are Reasonable and\nCustomary Charges.\nv. If the Insured Person is admitted in a room category/\nlimit that is higher than the one that is specified in the\nPolicy Schedule/ Product benefit table of this policy,\nthen the Insured Person shall bear a rateable\nproportion of the total Associated medical expenses\n(including surcharges or taxes thereon) in the\nUIN : ICIHLIP22012V012223\nproportion of the difference between room rent of the\nentitled room category to the room rent actually\nincurred\na. For the purpose of this cover, “Associated medical\nexpenses” shall include room rent, nursing\ncharges, operation theatre charges, fees of\nm e d i c a l p r a c t i t i o n e r i n c l u d i n g s u r g e o n /\nanaesthetist / specialist within the same hospital\nwhere the insured person has been admitted and\nwill not include the cost of pharmacy and\nconsumables, cost of implants, medical devices\nand cost of diagnostics.\nb. Proportionate deductions are not applicable for\nICU charges\nc. Proportionate deductions shall not be applicable\nfor hospitals which do not follow differential billing\nor for those expenses in respect of which\ndifferential billing is not adopted based on the\nroom category.\nvi. Expenses associated with automation machine for\nperitoneal dialysis shall not be payable\nvii. Any Medical Expenses payable shall not in aggregate\nexceed the Annual Sum Insured and additional sum\ninsured / cumulative bonus (if any) as specified in the\nPolicy Schedule against this Benefit.\n2. Day Care Treatment\nWe will cover the Medical Expenses incurred in respect of\nthe Day Care Treatment of the Insured Person during the\nPolicy Period provided that:\ni. The Day Care Treatment is for Medically Necessary\nTreatment.\nii. The Day Care Treatment follows the written advice of a\nMedical Practitioner.\niii. The Medical Expenses incurred are Reasonable and\nCustomary Charges.\niv. We will also cover Medical Expenses incurred for\nprocedures including but not limited to intravenous\nchemotherapy, radiotherapy, hemodialysis or any\nother therapeutic procedure which requires a period of\nspecialized observation or medical care after\ncompletion of the procedure.\nv. We will not cover any Out Patient Treatment or\ndiagnostic services under this Benefit.\nvi. Expenses associated with automation machine for\nperitoneal dialysis shall not be payable\nvii. Any Medical Expenses payable shall not in aggregate\nexceed the Sum Insured and additional sum insured/\ncumulative bonus (if any) specified in the Policy\nSchedule against this Benefit.\n3. Coverage for Modern Treatments\nWe will cover the Medical Expenses incurred in respect of\nHospitalization of the Insured Person for the below\nmentioned modern treatments during the Policy Period, up\nto the Annual Sum Insured\nGolden Shield\n\n6 CIN: L67200MH2000PLC129408\nSr. No. Treatment/Procedure\n1 Uterine Artery Embolization and HIFU (High\nintensity focused ultrasound)\n2 Immunotherapy- Monoclonal Antibody to\nbe given as injection\n3 Vaporisation of the prostrate (Green laser\ntreatment or holmium laser treatment)\n4 Stem cell therapy: Hematopoietic stem cells\nfor bone marrow transplant for\nhaematological conditions\n5 Balloon Sinuplasty\n6 Oral Chemotherapy\n7 Robotic surgeries*\n8 Stereotactic radio Surgeries\n9 Deep Brain stimulation\n10 Intra vitreal injections\n11 Bronchical Thermoplasty\n12 IONM - (Intra Operative Neuro Monitoring)\nRobotic surgeries shall be subject to sub-limits as\nmentioned under d. benefits covered under the policy\nBase cover 15 Sub-limits applicable\n4. Pre Hospitalisation expenses\nWe will cover the Pre-hospitalization Medical Expenses\nincurred in respect of the Insured Person for up to 60days\nimmediately before the Insured Person’s Admission to\nHospital provided that:\ni. The Pre-hospitalization Medical Expenses incurred are\nReasonable and Customary Charges.\nii. We have accepted the claim under “d. Benefits covered\nunder the policy Base cover 1. Inpatient Treatment” in\nrespect of the Insured Person.\niii. We shall not be liable to make any payment in respect\nof any Pre-hospitalization Medical Expenses incurred\nprior to the Policy Period Start Date of the first policy\nwith Us in respect of the Insured Person.\niv. Expenses incurred on nursing care at home are\nexcluded from the scope of pre hospitalization\nexpenses.\nv. This Benefit will be provided on a reimbursement basis\nonly.\nvi. Any Pre-hospitalization Medical Expenses payable\nshall not in aggregate exceed the Annual Sum Insured\nand additional sum insured /cumulative bonus (if any)\nas specified in the Policy Schedule against this Benefit\n5. Post Hospitalisation expenses\nWe will cover the Post-hospitalization Medical Expenses\nincurred in respect of the Insured Person for up to 180 days\nimmediately following the Insured Person’s discharge from\nHospital provided that:\ni. The Post-hospitalization Medical Expenses incurred\nare Reasonable and Customary Charges.\nUIN : ICIHLIP22012V012223\nii. We have accepted the claim under “Inpatient\nTreatment” in respect of the Insured Person.\niii. We will also consider Post-hospitalization Medical\nExpenses incurred on Physiotherapy provided that\nsuch Physiotherapy is advised in writing by the\ntreating Medical Practitioner and is Medically\nNecessary Treatment. This service will be provided on\na reimbursement and/ or cashless basis where ever\napplicable.\niv. Expenses incurred on nursing care at home are\nexcluded from the scope of post hospitalization\nexpenses.\nv. Any Post-hospitalization Medical Expenses payable\nduring the Policy period shall not in aggregate exceed\nthe Annual Sum Insured and additional sum insured\n/cumulative bonus (if any) as specified in the Policy\nSchedule against this Benefit.\n6. Donor Expenses\nWe will cover the Medical Expenses incurred in respect of\nan organ donor’s Hospitalization during the Policy Period\nfor the harvesting of the organ donated to the Insured\nPerson provided that:\ni. The organ donation conforms to the Transplantation of\nHuman Organs Act 1994 and the organ is for the use of\nthe Insured Person;\nii. We will cover only those Medical Expenses incurred in\nrespect of an organ donor as an in-patient in the\nHospital.\niii. The Medical Expenses incurred are Reasonable and\nCustomary Charges.\niv. Any Medical Expenses payable during the Policy\nperiod shall not in aggregate exceed the Annual Sum\nInsured and additional sum insured /cumulative bonus\n(if any) as specified in the Policy Schedule against this\nBenefit subject to an overall limit of ` 10,00,000 only\nv. We have accepted a claim under Section “Inpatient\ntreatment” in respect of the Insured Person.\nWe shall not be liable to pay for any claim under this Benefit\nwhich arises directly or indirectly for or in connection with\nany of the following:\ni. Pre-hospitalization Medical Expenses or Post-\nhospitalization Medical Expenses of the organ donor.\nii. Screening expenses of the organ donor.\niii. Any other Medical Expenses as a result of the\nharvesting from the organ donor.\niv. Costs directly or indirectly associated with the\nacquisition of the donor ’s organ (other than\nhospitalisation costs involved).\nv. Transplant of any organ/tissue where the transplant is\nexperimental or investigational.\nvi. Expenses related to organ transpor tation or\npreservation.\nvii. Expenses incurred by an Insured Person as a donor.\nGolden Shield\n\n7 CIN: L67200MH2000PLC129408UIN : ICIHLIP22012V012223\nviii. Any other medical treatment or complication in respect\nof the donor, consequent to harvesting.\n7. Domiciliary Hospitalization\nWe will cover the Medical Expenses incurred in respect of\nthe Domiciliary Hospitalization of the Insured Person\nduring the Policy Period provided that :\ni. The Domiciliary Hospitalization is for Medically\nNecessary Treatment.\nii. The Domiciliary Hospitalization commences and\ncontinues on the written advice of a Medical\nPractitioner.\niii. The Medical Expenses incurred are Reasonable and\nCustomary Charges.\niv. The Domiciliary Hospitalization continues for at least 3\nconsecutive days in which case We will make payment\nunder this Benefit in respect of Medical Expenses\ni n c u r r e d f r o m t h e f i r s t d a y o f D o m i c i l i a r y\nHospitalization.\nv. Any Medical Expenses payable shall not in aggregate\nexceed the Annual Sum Insured and additional sum\ninsured /cumulative bonus (if any) as specified in the\nPolicy Schedule against this Benefit.\nWe shall not be liable to pay for any claim under this Benefit\nwhich arises directly or indirectly from or in connection with\nany of the following:\na) Asthma, bronchitis, tonsillitis and upper respiratory\ntract infection including laryngitis and pharyngitis,\ncough and cold, influenza;\nb) Arthritis, gout and rheumatism;\nc) Ailments of spine/disc\nd) Chronic nephritis and nephritic syndrome;\ne) Any liver disease;\nf) Peptic ulcer\ng) Diarrhea and all type of dysenteries, including\ngastroenteritis;\nh) Diabetes mellitus and insipidus;\ni) Epilepsy;\nj) Hypertension;\nk) Pyrexia of any origin\n8. Home Care Treatment\nWe will cover the medical expenses incurred by the Insured\nperson on home care treatment maximum up to 5% of\nAnnual Sum Insured provided that :\na. The Medical Practitioner advices the Insured Person to\nundergo treatment at home\nb. There is a continuous active line of treatment with\nmonitoring of the health status by a medical\npractitioner for each day through the duration of the\nhome care treatment.\nc. Daily monitoring chart including records of the\ntreatment duly signed by the treating doctor is\nmaintained.\nGolden Shield\nd. The condition of the Insured Person is expected to\nimprove in a reasonable and foreseeable period of\ntime.\ne. Prior approval from Us has been taken. The Home care\ntreatment is availed only on a cashless basis, subject to\navailability of our empanelled service provider(s).\nKindly visit our website for cities/locations where such\nservices are available.\nf. Treatment availed is not categorized under “AYUSH” or\nany form of non- allopathic treatment\ng. Such treatment cannot be provided on outpatient basis\nHowever in case of unavailability of our empanelled service\nprovider in the insured person’s location, in case the insured\nperson intends to avail the services of non-network\nprovider and claims for reimbursement, a prior approval\nfrom Us needs to be taken before availing such services.\nIn case the insured person breaches the conditions of\napproval or fails to take the prior written approval from Us,\nwe are not liable to settle any claim under this section.\nFor the purpose of this benefit, Home care treatment shall\ninclude:\na. Diagnostic tests underwent at home as advised by\nmedical practitioner\nb. Medicines prescribed in writing by a medical\npractitioner\nc. Consultation charges of the medical practitioner\nd. Nursing charges if advised by the medical practitioner\nAny expenses payable during the Policy period shall not in\naggregate exceed the Annual Sum Insured and additional\nsum insured /cumulative bonus (if any) as specified in the.\n9. In Patient AYUSH Hospitalization\nWe will cover the Medical Expenses incurred in respect of\nthe Insured Person’s AYUSH Treatment during the Policy\nPeriod up to the Annual Sum Insured specified in the Policy\nSchedule provided that:\ni. The Medical Expenses incurred are Reasonable and\nCustomary Charges.\nii. The Insured Person is Hospitalized for AYUSH\nTreatment at a AYUSH hospital or an AYUSH Day-care\ncentre.\niii. The Insured Person’s Hospitalization commences and\ncontinues on the written advice of the treating Medical\nPractitioner.\niv. Any Medical Expenses payable during the Policy\nperiod shall not in aggregate exceed the Annual Sum\nInsured and additional sum insured /cumulative bonus\n(if any) as specified in the Policy Schedule against this\nBenefit.\nv. This Benefit will be provided on a reimbursement and/\nor on cashless basis where ever applicable.\nWe shall not be liable to pay for any claim under this Benefit\nwhich arises directly or indirectly for or in connection with\nany of the following:\n\n8 CIN: L67200MH2000PLC129408UIN : ICIHLIP22012V012223\nGolden Shield\ni. Pre-hospitalization Medical Expenses or Post-\nhospitalization Medical Expenses.\nii. Any expenses incurred for the purpose of evaluation or\ninvestigation.\n10. Domestic road ambulance cover\nWe will cover the expenses incurred on road ambulance\nservices which are offered by a healthcare or ambulance\nservice provider and which have been used during the\nPolicy Period to transfer the Insured Person to the nearest\nHospital with adequate emergency facilities for the\nprovision of Emergency Care, provided that:\n• Our maximum liability under this Benefit for every\nclaim arising during the Policy Year will be restricted to\n1% of the Annual Sum insured maximum up to\n`10,000;\n• We have accepted a claim under “Inpatient treatment”\nin respect of the Insured Person for the same\nAccident/Illness for which road ambulance services\nwere availed.\n• This Benefit includes and is limited to the cost of the\ntransportation of the Insured Person:\na) From the place of injury/illness to the nearest\nhospital\nb) To the nearest Hospital with higher medical\nfacilities which is prepared to admit the Insured\nPerson and provide the necessary medical\nser vices if such medical ser vices cannot\nsatisfactorily be provided at a Hospital where the\nInsured Person is situated, and only if that\ntransportation has been prescribed in writing by a\nMedical Practitioner and is for Medically\nNecessary Treatment.\nc) From a Hospital to the nearest diagnostic centre\nduring the course of Hospitalization for advanced\ndiagnostic treatment in circumstances where such\nfacility is not available in the existing Hospital.\n• The ambulance / service provider providing the\nservices be a registered provider with road traffic\nauthority.\nAny expenses in relation to transportation of the Insured\nPerson from Hospital to the Insured Person’s residence\nwhile transferring an Insured Person after he/she has been\ndischarged from the Hospital are not payable under this\nBenefit.\n11. Air Ambulance\nWe will cover the expenses up to the Annual sum insured\nincurred on air ambulance services in respect of an Insured\nPerson which are offered by a healthcare or an air\nambulance service provider and which have been used\nduring the Policy Period to transfer the Insured Person to\nthe nearest Hospital with adequate emergency facilities for\nthe provision of Emergency Care, provided that:\na. It is for a life threatening emergency health condition/s\nof the Insured Person which requires immediate and\nrapid ambulance transportation from the place where\nthe Insured Person is situated at the time of requiring\nEmergency Care to a hospital provided that the\ntransportation is for Medically Necessary Treatment, is\ncertified in writing by a Medical Practitioner, and road\nambulance services cannot be provided.\nb. Such air ambulance providing the services, should be\nduly licensed to operate as such by a competent\ngovernment Authority.\nc. This cover is limited to transportation from the area of\nemergency to the nearest Hospital only;\nd. We will not cover:\na. Any transportation from one Hospital to another;\nb. Any transportation of the Insured Person from\nHospital to the Insured Person’s residence after\nhe/she has been discharged from the Hospital\nc. Any transportation or air ambulance expenses\nincurred outside the geographical scope of India.\ne. We have accepted a claim under Inpatient treatment in\nrespect of the Insured Person for the same\nAccident/Illness for which air ambulance services were\navailed.\nf. We shall not be liable if Medically Necessary Treatment\ncan be provided at the Hospital where the Insured\nPerson is situated at the time of requiring Emergency\nCare.\n12. Base Co-payment\nThis policy will be subject to 50% base co-payment and\nHe/She shall be liable to pay 50% of admissible claim\namount of each and every claim. Base Co-payment once\nchosen cannot be changed mid-term. Modification of co-\npayment may happen only during renewal subject to\nunderwriting. In case, base co-payment is reduced during\nrenewal, fresh waiting periods shall be applicable on the\nmodified portion of base co-payment.\ni. Base Co-payment shall be applicable to all benefits\nunder the policy except any benefits availed under\nCare management program, Care management plus\nprogram, preventive health check-up,.\nii. Base Co-payment shall not be applicable in case\nvoluntary deductible has been opted for.\n13. Cumulative Bonus/ Additional Sum Insured\nWe will provide a Cumulative Bonus of 10% of the Annual\nSum insured at the end of each Policy Year if the expiring\nPolicy has been claim free and is continuously renewed\nwith Us. The Cumulative Bonus will not be accumulated for\nmore than 100% of the Annual Sum insured under any\ncircumstances.\ni. In case where the policy is on a floater basis the\ncumulative bonus will be on floater basis and for\nindividual policy the same will be on an individual\nbasis.\nii. In case where the policy is on a floater basis, the\ncumulative bonus will be accrued only if no claims have\n\nbeen made in respect of all Insured Person(s) in the\nexpiring policy period.\niii. In a floater policy as specified in the Policy Schedule,\nthe Cumulative Bonus so accrued during the previous\nPolicy Year(s) will only be available to those Insured\nPerson(s) who were insured in previous Policy Year(s)\nand continue to be insured with Us in the subsequent\nPolicy Year(s).\niv. Cumulative Bonus will not be added if the Policy is not\nrenewed with Us by the end of the Grace Period.\nv. Cumulative bonus can be utilised only when the\nAnnual Sum Insured is completely exhausted.\nvi. If the Policy Period is two or three years, any\nCumulative Bonus that has accrued for the first/second\nPolicy Year will be credited at the end of the first/second\nPolicy Year as the case may be and will be available for\nany claims made in the subsequent Policy Year.\nvii. If the Insured Persons in the expiring policy are covered\non an individual basis as specified in the Policy\nSchedule and there is an accumulated Cumulative\nBonus for each Insured Person under the expiring\npolicy, and such expiring policy has been Renewed\nwith Us on a floater policy basis as specified in the\nPolicy Schedule then the Cumulative Bonus to be\ncarried forward for credit in such Renewed Policy shall\nbe the lowest among all the Insured Persons.\nviii. In case of floater policies where Insured Persons\nRenew their expiring policy with Us by splitting the\nAnnual Sum Insured in to individual policies the\nCumulative Bonus of the expiring policy shall be\napportioned to such Renewed Policies in the\nproportion of the Annual Sum Insured of each\nRenewed Policy as detailed in table below.\n9 CIN: L67200MH2000PLC129408UIN : ICIHLIP22012V012223\nGolden Shield\nAnnual\nFloater Sum\nInsured\n20 Lac\nFloater\npolicy split\nto individual\npolicies with\nAnnual Sum\nInsured of\n10 Lacs each\nRevised\nAnnualSum\nInsuredof\neach\nindividual\npolicy\n10 Lac\nRevised\nAccumulated\nCumulative\nbonus/\nAdditional\nSumInsured\nofeach\nindividual\npolicy\n5 Lac\nAccumulate\ndCumulative\nbonus/\nAdditional\nSumInsured\n(after5claim\nfreeyears)\n10 Lac\nAnnual Sum\nInsured\n20 Lac\nAnnual Sum\nInsured\nreduced to\n` 10 Lacs\nRevised\nAnnual Sum\nInsured\n10 Lac\nRevised\nAccumulated\nCumulative\nbonus/\nAdditional\nSumInsured\n5 Lac\nAccumulated\nCumulative\nbonus/\nAdditional\nSumInsured\n(after5claim\nfreeyears)\n10 Lac\nix. If the Annual Sum Insured has been reduced at the time\nof Renewal, the applicable Cumulative Bonus shall be\nreduced in the same proportion to the Annual Sum\nInsured as detailed in table below\nx. If the Annual Sum Insured under the Policy has been\nincreased at the time of Renewal the Cumulative Bonus\nshall be calculated on the Annual Sum Insured of the\nlast completed Policy Year.\nxi. In the event of a Claim under the Policy during any\nsubsequent Policy Year, the accrued cumulative bonus\nshall not be reduced.\n14. Reset Benefit\nWe will reset the Annual Sum insured up to 100% of the\nAnnual Sum insured unlimited times, for all future claims\nwithin the same policy not related to the illness / disease /\ninjury for which a claim has been paid for the same insured\nperson in a Policy Year as stated in the Policy Schedule,\nprovided that:\ni. The Annual Sum insured including additional sum\ninsured /Cumulative Bonus (if any) in respect of the\nInsured Person is insufficient as a result of previous\nclaims paid in that Policy Year.\nii. The total amount of reset will not exceed the Annual\nSum Insured for that policy year.\niii. The Reset Benefit will be applied only if the claim is\nmade and admissible under “Inpatient Treatment” or\n“Daycare Procedure”.\niv. The Reset Benefit will not be triggered for the first claim\nmade during the Policy Year.\nv. The Reset benefit will be triggered only once and not\nunlimited times for all future claims within the same\npolicy which are related to the illness/disease/injury for\nwhich a claim has already been paid/registered for the\nsame insured person.\nvi. For individual policies, reset Sum Insured will be\navailable on individual basis whereas for floater\npolicies, it will be available on floater basis.\nvii. For any single claim during a Policy Year , the maximum\nclaim amount payable shall not exceed the sum of\n• The Annual Sum insured;\n• additional sum insured /Cumulative Bonus;\nviii. The Reset Benefit will not be available for an Illness /\nInjury or related complications including but not limited\nto any relapse within 45 days in respect of which a\nclaim has been paid in that Policy Year for the same\nInsured Person.\nix. Any unutilized Reset Benefit will not be carried forward\nto any subsequent Policy Years.\nx. During a Policy Year, the aggregate claim amount\npayable, shall not exceed the sum of:\n• The Annual Sum Insured\n• additional sum insured /Cumulative Bonus\n• Reset Sum Insured\n\n• The Network Provider /Health Service Provider shall be\nassigned by Us post receiving Insured Person’s request\nto avail a health check-up under this Benefit.\n• Utilisation of this preventive health check-up will not\nimpact the Annual Sum Insured or eligibility for\nadditional sum insured /cumulative Bonus.\n• Un-utilised health check-up package will not be carried\nforward to the next policy year and it will be the Insured\nPerson’s choice and responsibility to utilise the same\nwith in the designated policy period. We shall not be\nliable to provide any reminders or notifications for the\nsame.\n• In-case of long term policies (2 year or 3 years), the\npreventive health check-up package for all the policy\nyears shall be provided together in the first policy year\nitself. It shall be the responsibility of the Insured Person\nto preserve the same and undergo the check-ups\nduring the designated policy years.\nPlease Note:\n• We shall not hold any responsibility towards any loss\nor damage arising out of or in relation to any opinion,\nadvice, prescription, actual or alleged errors, omissions\nand representations made by the Medical Practitioner/\nHealthcare professional.\n• Choosing the services under this Benefit is purely upon\nthe customer’s own discretion and at own risk.\n• The Insured Person should seek assistance from a\nhealth care professional when interpreting and\napplying them to the Insured person’s individual\ncircumstances. If the Insured person has any concerns\nabout His/ her health, He/ She may consult His/ her\ngeneral practitioner.\n18. Incentives associated with Vaccination against\npneumococcal disease\nWe will provide an additional 2.5% discount on premium\n(fresh or renewal) for Insured Person(s) who have taken the\nPneumococcal vaccine or its equivalent vaccine which\n16. Enhanced Annual Sum insured for Road Traffic Accidents\nIf the insured person meets with a Road Traffic Accident\nresulting in in-patient hospitalization, then the Annual Sum\nInsured shall be doubled subject to the following:\n• It is declared and proven that the insured person was\ntaking due safety precautions such as use of seat-belt/\nhelmet/ following road traffic signals and was either\nriding as pillion rider in a two wheeler or travelling in a\nfour wheeler at the time of accident as evidenced by\nPolice record and Hospital record.\n• The enhanced(doubled) Sum Insured shall be available\nonly once during the policy period.\n• The enhanced (double) Sum Insured shall be available\nonly after exhaustion of the annual sum insured.\n• The enhanced Sum Insured can be utilized only for that\nparticular hospitalization following the Road Traffic\nAccident .\n• Reset benefit shall not trigger for claims under this\ncover.\n• This benefit shall not be applicable for day care\ntreatment.\n• The unutilized balance of enhanced (doubled) sum\ninsured for road traffic accidents cannot be carried\nforward for the remaining policy period or for renewal.\n• Claims under this benefit will reduce the Cumulative\nbonus/ additional sum insured\n17. Preventive health check-up\nInsured Persons can avail a preventive health check-up as\nper our pre- defined package only at our network providers\nor empanelled health service providers anytime during the\nPolicy period subject to the below conditions :\n• This benefit can be availed only on cashless basis and\nis limited to once a year per Insured Person.\n• This benefit can be availed through our mobile\napplication or via utilisation of health check-up\ncoupons provided with the policy kit\n10 CIN: L67200MH2000PLC129408UIN : ICIHLIP22012V012223\nGolden Shield\n15. Sub-limits applicable\nThe expenses payable during the entire policy period for treatment of the following diseases/ conditions (either as a day care or\nas an in-patient exceeding 24hrs of admission in the hospital) shall be maximum up to the amount mentioned in the table below;\nProcedures/Medical Conditions/Ailments/Diseases\nAnnual Sum Insured\n>20L\nTreatment of cataract \nUp to 25,000/ eye` Up to 50,000/ eye` Up to 75,000/ eye`\nTreatment of each and every ailment/procedure mentioned below\n10L/15L/20L3L/4L/5L\nTreatment of cerebrovascular and cardiovascular disorders\nTreatment/surgeries for cancer(including chemo/radio/oral)\nTreatment of other renal complications and disorders\nTreatment for breakage of long bones/Joint replacements\nRobotic surgeries for any ailment/condition/disease\n` 2,00,000 ` 3,50,000 ` 5,00,000\n` 1,00,000 ` 1,75,000 ` 2,50,000\nSub-limits will include the expenses incurred on pre hospitalisation and post hospitalisation expenses\n\nGolden Shield\n11 CIN: L67200MH2000PLC129408UIN : ICIHLIP22012V012223\nspecialist or a general physician will have to be\nborne by the Insured Person.\n• We shall not be liable for any discrepancy in the\ninformation provided under this Benefit.\n• Choosing the services under this Benefit is purely\nupon the customer’s own discretion and at own risk.\n• *The proposer should seek assistance from a\nhealth care professional when interpreting and\napplying them to the Insured person’s individual\ncircumstances. If the Insured person has any\nconcerns about His/ her health, He/ She may\nconsult His/ her general practitioner. We shall not\nhold any responsibility towards any loss or\ndamage arising out of or in relation to any opinion,\nadvice, prescription, actual or alleged errors,\nomissions and representations made by the\nMedical Practitioner/ Healthcare professional.\n2. Second E-opinion for Critical Illness\nWe shall arrange E-opinion on a cashless basis from\nour empanelled Medical Practitioners in case the\nInsured Person is diagnosed with any of the below\nlisted critical Illnesses during the Policy Period, and at\nhis/her sole discretion chooses to avail an E-opinion\nsubject to the below mentioned conditions.\n• The E-opinion will be arranged on cashless basis\nand the insured person will not have to bear any\nexpenses on the same.\n• The E-opinion will be based only on the\ninformation and documentation provided to Us\n( w h i c h w i l l b e s h a r e d w i t h t h e M e d i c a l\nPractitioner) and it should not be construed to\nconstitute medical advice and/or substitute the\nInsured Person's visit / consultation to an\nindependent Medical Practitioner/Healthcare\nprofessional.\n• This E-opinion can be availed only once during the\nPolicy Period for the same illness.\n• Appointments to avail this E-opinion may be\nrequested through Our Website or Our mobile\napplication or through calling Our call centre on\nOur toll free number.\n• The E-opinion provided under this Benefit shall be\nlimited to the listed critical Illnesses and will not be\nvalid for any medico legal purposes.\n• We do not assume any liability towards any loss or\ndamage arising out of or in relation to any opinion,\nadvice, prescription, actual or alleged errors,\nomissions and representations made by the\nMedical Practitioner.\nList of Critical Illness for which Second E-opinion may be\nrequested\nHeart and vascular conditions\n1. Myocardial Infarction\n2. Refractory heart failure\n3. Cardiomyopathy\nhelps prevent pneumococcal disease. All the members\ncovered under thepolicy should have be vaccinated in the\npast one year (1 year) from policy start date to avail this\ndiscount. i.e. if policy start date is 1st January 2022, all\ninsured persons under the policy should have been\nvaccinated against Pneumococcal disease in the period\nfrom 1st January 2021 to 31st December 2021. This\ndiscount shall be provided lifetime as long as the insured\nperson continues to renew this policy.\nMandatory Extension:\n19. Care Management Program\nIn consideration of payment of additional premium, the\ninsured person can avail benefits of the Care Management\nProgram. The Care Management Program aims to provide\nsolutions which will solve everyday challenges/issues\nfaced by You, promote holistic wellbeing and empower You\nto lead independent and enriching lives.\nOur Care management program focusses on providing You\nwith assistance and support in case of any challenge but at\nthe same time equipping you for the future. Our endeavour\nis to promote longevity, productivity and incentivise You for\nyour healthy behaviour which will enable dignified living.\nThe Insured Person shall have access to a host of benefits\nunder the Care management program on downloading and\nregistering on our mobile application. This activity is to\nensure adequate utilization of services offered and to\nredeem the wellbeing points awarded.\n1. Tele Consultation(s)\nWe will arrange consultations and recommendations\nfor routine health issues by a qualified Medical\nPractitioner or health care professional. For the\npurpose of this benefit Telephonic/Virtual consultation\nshall mean consultation provided by a qualified\nMedical Practitioner or Health care professional\nthrough various mode of communication like audio,\nvideo, online portal, chat or mobile application. The\nservices provided under this Benefit will be made\navailable subject to the terms and conditions, and in\nthe manner prescribed below:\n• T h e M e d i c a l Pr a c t i t i o n e r m a y s u g g e s t /\nrecommend / prescribe over the counter\nmedications based on the information provided, if\nrequired on a case to case basis. However, the\nservices under this Benefit should not be construed\nto constitute medical advice and/or substitute the\nInsured Person's visit / consultation to an\nindependent Medical Practitioner/Healthcare\nprofessional*.\n• There shall be no maximum limit on the count of\ntele-consultations that can be availed by the\nInsured Person in a policy year.\n• This service will be available 24 hours a day, and\n365 days in a year.\n• We/Medical Practitioner/Healthcare professional\nmay refer the Insured Person to another specialist\nor a general physician (outside of our empanelled\nnetwork), if required and the charges for such\n\nGolden Shield\n12 CIN: L67200MH2000PLC129408UIN : ICIHLIP22012V012223\n4. E-Counselling\nWe will offer e-counselling session(s) with a\nPsychologist via our mobile application for providing\nassistance in dealing with issues such as but not\nlimited to personal and lifestyle imbalance, anxiety,\ndepression, sleep disorders, stress and problems\nrelated to psychological/mental illness/ psychiatric and\npsychosomatic disorders.\nMaximum of 12 sessions will be provided per insured\nperson per policy period.\nThe e-counseling sessions shall be availed only\nthrough virtual modes of chat via our mobile\napplication.\n5. Health Management Program\nThe Health Management Program has been designed\nto ensure a regular monitoring of the Insured Person’s\nhealth and timely intervention and a concrete plan for\ncorrective measures in case of any decline in the health\nstatus of the Insured Person.\nThe Health Coach shall guide and motivate the Insured\nPerson to follow the customised Health management\nprogram designed for them to achieve their health and\nfitness goals.\nAs a part of the Health Management Program, the\ninsured person can avail the following benefits\na. Care Calls\nAll insured persons shall receive care calls to check\nup on their well-being and safety by our health\ncoach who understand the issues surrounding\nsenior individuals. The insured person(s) will be\nencouraged to express their concerns surrounding\ntheir well-being (if any) on these calls so that the\nhealth coach can address them later.\nb. Goal based incentives on outcome of Preventive\nhealth check-up\nMonitoring of one’s health status remains an\nimportant step towards becoming more self-\naware of one’s medical / health conditions.\nThe insured person shall be subjected to a mid-\nterm assessment via a Wellbeing Risk Assessment\n[WRA] which will include outcome of certain\nlaborator y tests and questionnaire based\nassessment covering aspects of lifestyle, current\nmedical history & family history.\nThe assessment will be carried out using a\ntelephonic/ digital connect with the Health Coach.\nThe health coach will encourage the insured\nperson to undergo certain laboratory tests (as\ndetailed in Table A) and we will incentivise the\nInsured Person in case of favourable findings of the\nlaboratory tests.\nThe insured person will have to undergo the below\nmentioned laboratory tests as a part of the mid-\nterm assessment from our empanelled diagnostic\nLung Conditions\n4. End stage lung Failure\n5. Primary(Idiopathic) pulmonary Hypertension\nLiver conditions\n6. End stage liver Failure\nNeuro/ spinal & psychiatric disease\n7. Multiple sclerosis with Persisting symptoms\n8. Motor neuron disease with Permanent symptoms\n9. Permanent paralysis of limbs\n10. Stroke resulting in permanent symptoms\n11. Coma of specified severity\n12. Alzheimer’s Disease before age of 50 years\n13. Parkinson’s disease before age of 50 years\n14. Apallic syndrome\n15. Benign brain tumour\n16. Creutzfeldt-Jakob disease (CJD)\n17. Major head trauma\nRenal diseases\n18. Kidney failure requiring regular dialysis\n19. Medullary cystic disease\nMusculoskeletal diseases\n20. Muscular dystrophy\n21. Poliomyelitis\nBleeding disorders\n22. Aplastic Anaemia\nAuto immune diseases\n23. Systemic Lupus Erythematous with renal involvement\n24. Myasthenia gravis\n25. Scleroderma\n26. Good pastures syndrome with lung or renal\ninvolvement\n27. Blindness\n28. Deafness\n29. Cancer of specified severity\n30. Third Degree Burns\n31. Loss of speech\n32. Loss of limbs\n33. Loss of Independent Existence\n3. Diet and Nutrition e-consultation\nWe will offer You diet and nutrition e-consultation on a\nvirtual platform via our mobile application to help you\nachieve your weight and health management goals.\nMaximum of 12 sessions will be provided per insured\nperson per policy period.\nThe e-consultation shall be availed only through virtual\nmodes of chat via our mobile application.\n\nGolden Shield\n13 CIN: L67200MH2000PLC129408UIN : ICIHLIP22012V012223\nperson 250 wellness points. Each yoga session/ meditation\nsession must last 30 minutes or more and the maximum\nwellness points that can be accrued under this task is 1500\nper insured person per policy year.\nPlease Note: The insured persons can join a virtual\nyoga/meditation class or visit an actual yoga/meditation\ncentre. The expenses associated with the class\nfees/membership fees/tutor or instructor fees etc. will\nhave to be borne by the insured person. Proof of payment\nof fees and certificate of completion of sessions will have\nto be provided to us in order for insured person to earn the\nwellness points.\nAlternately, in case the Insured Person is keen to achieve\ntargeted steps instead of par ticipation in yoga\nsessions/meditation sessions, we will award 250 wellness\npoints per month provided the insured person takes 4000+\nsteps per day for atleast 15 days in a month. The maximum\nwellness points that can be accrued by achieving targeted\nsteps is 1500 per insured person per policy year.\nOur mobile application will have to be downloaded within\n30 days of the policy start date to avail the benefit as the\naverage step count completed by an Insured person would\nbe monitored on this mobile application.\nEach wellness point will be valued at INR 0.20. Wellness\npoints so earned can be redeemed against any services\nunder discounts as mentioned in “discounts on services or\nproducts” on our mobile application.\nWellness points Maximum wellness Rupee Value\naccumulated points awarded per of Accumulated\nperson per policy year wellness points\nOutcome of 1500 300\nPreventive health\ncheck-ups\nParticipation in Yoga / 1500 300\nMeditation / Completion\nof Targeted steps\nTotal 3000 600\n7. Medical Vault\nThe insured person can upload His/Her health records in\nour mobile application so as to protect them from loss or\ntheft. These health records can then be viewed as per need\nand convenience of the insured person.\nBy availing this service, the Insured person agrees and has\nno objection to the health records being maintained with Us\nfor internal use only.\n8. Health Assistance (HAT)\nHAT shall assist the Insured Person in understanding their\nhealth condition better by providing answers to any queries\nrelated to health service providers\nThe services provided under this shall include:\n• Identifying a Physician/ Specialist\n• Availability of hospital beds/COVID hubs etc.\n• Providing guidance on engaging attendants or nurses\n• Facilitation with respect to arrangement of mobility\naids, daily living aids, medical equipment etc.\ncentres and will be guided by the health coach for\nthe same.\nIn case the insured person is desirous of\nundergoing laboratory tests at a diagnostic centre\nof their choice which is not empanelled with us, the\ninsured person will have to bear the charges\nassociated with the actual costs of the mid-term\nassessment diagnostic tests/ visit charges /\ncollection charges etc.\nThe insured person will also have to provide us\nwith the laborator y repor ts of the below\nmentioned medical tests/investigations conducted\nwithin the policy period for Us to award the\nwellness points.\nTable A\nMedical Tests Favorable Findings that need\nfindings improvement\nGlycosylated < 6% >6 and up to7%\nHaemoglobin (HbA1c)\nLow Density < 100 mg/dl >100 and < or\nLipoprotein (LDL) = 190 mg/dl\nHigh Density > or = 40 mg/dl > 20 mg/dl and\nLipoprotein (HDL) <40 mg/dl\nSerum cholesterol < or = 200mg/dl >200 and < or\n=300 mg/dl\nSerum Triglycerides <or = 150 mg/dl > 150 and <\n= 250mg/dl\nS. Creatinine < or = 1.3 mg/dl > 1.3 mg/dl\nThe insured person shall be awarded wellness points as per table\nB for each laboratory test mentioned below in case the findings of\nthe laboratory test are favourable as detailed in Table A.\nTable B\nMedical Tests Wellness points awarded in\ncase of favourable findings\nGlycosylated Haemoglobin (HbA1c) 500\nLow Density Lipoprotein (LDL) 200\nHigh Density Lipoprotein (HDL) 200\nSerum cholesterol 200\nSerum Triglycerides 200\nSerum Creatinine 200\nTotal 1500\nThe maximum wellness points that can be awarded under\nthis activity is restricted to 1500 wellness points per insured\nperson per policy year.\nEach wellness point will be valued at INR 0.20. Wellness\npoints so earned can be redeemed against deals and\ndiscounts on purchase of medicines from our empanelled\npharmacies or undergoing recommended diagnostic tests\nfrom our empanelled diagnostic centres etc. as listed on our\nmobile application.\n6. Participation in Yoga/Meditation Sessions/ Completion of\nTargeted Steps\nThe Insured Person can earn wellness points by\nparticipating in yoga sessions or meditation sessions\naimed at maintaining physical and mental Wellness.\nParticipation and successful completion of 10 yoga/\nmeditation sessions in a month will award the insured\n\n14 CIN: L67200MH2000PLC129408UIN : ICIHLIP22012V012223\nGolden Shield\n• Scheduling an appointment with any Medical\nPractitioner empanelled with Us\n• Scheduling appointments for a second opinion\n• Providing suitable options with respect to Hospitals as\nwell as providing assistance in Cashless facility,\nwherever applicable.\n• Scheduling appointments from diagnostic labs\nempanelled with us.\n• Providing information, assistance and facilitation on\ndoor step delivery of medicines\n• Providing preventive information on ailments\n• Providing guidance on post Hospitalization care, such\nas Physiotherapy/ Nursing at home.\nPlease note that services provided under this Benefit are\nsolely for assistance, and should not be construed to be a\nsubstitute for a visit/ consultation to an independent\nMedical Practitioner. Our role is limited to that of facilitation\nand Health Assistance services will not include the charges\nfor any independent Medical Practitioner/nutritionist/\ncharges incurred on diagnostics/ consulted on HAT’s\nrecommendation, and such charges are to be borne by the\nInsured Person.\nFor all facilitation services provided under this cover, our\nrole shall be limited to assistance only and the charges and\nexpenses associated with the actual service shall have to\nbe borne by the insured person.\nThis service is available on our mobile application or by\ncalling on 040-66274205 (please note that this number is\nsubject to change) from 8am to 8pm from Monday to\nSaturday except public holidays.\nBy availing this service, the Insured person agrees and has\nno objection to the health records being maintained with Us\nfor internal use only.\nWhile deciding to obtain the above services, the Insured\nperson(s) expressly notes and agrees that it is entirely for\nthem to decide whether to obtain these services and also to\ndecide the use (if any) to which these services are to be put\nfor.\n9. Ambulance Assistance\nWe will facilitate ground medical transportation by a\nService provider to transport the Insured Person to the\nnearest Hospital or any clinic or nursing home for medically\nnecessary treatment subject to availability of services in\nthat particular city/ location. Kindly visit our website for\nupdated list of cities/ locations where the services are\nprovided.\n1. The services under this Benefit are subject to the\nfollowing conditions:\n• The medical transportation is for a life threatening\nhealth condition of the Insured Person which\nrequires immediate and rapid transportation to the\nHospital; as certified in writing by the Medical\npractitioner\n• The Insured Person is in India and the treatment is\nin India only;\n• The ambulance service is availed within the same\ncity\n• This is an assistance service and the expenses for\nthe same will have to be borne by the insured\nperson or can be claimed under domestic road\nambulance cover( if inpatient treatment claim is\nfound to be admissible)\nProcess to avail Ambulance Assistance:\na) On calling Our helpline number provided below, Our\ntrained customer service executive (CSE) will ask the\nInsured person relevant questions to assess the\nsituation.\nb) The call may be redirected to a qualified Medical\nPractitioner in order to evaluate the requirement for an\nambulance with Advanced Life Support based on the\nInsured Person’s condition.\nc) The below mentioned details are to be made available\nfor availing the services:\n1. UHID of Insured Person, as provided on the Health\nCard.\n2. Contact number of the Insured Person\n3. Location of Insured Person\nHow to Call an Ambulance? (Via Call)\nCall 18001028136\nto reach the\nEmergency\nResponse Centre\nAn IVRS will ask\nyou to select option\n1or 2 depending on\nrequirement.\nDial 1 for Medical\nAmbulance\nServices\nCall will be\nanswered by an\nCSE & details like\nname, UHID, nature\nof emergency will\nbe asked\nEmergency\nAmbulance\nTransport\nwill arrive\nPatient will be\ntaken to the nearest\nhospital as per the\npredefined hospital\nnetwork chart\nDoctor may\naccompany patient\nin the ambulance\nif required\nClick on emergency\nicon & place request\nAmbulance\npick up & drop\nthe patient to\nhospital / health\nfacility\nCSE does\nfeedback Call\nCustomer service\nexecutive connects\nwith medical team\nThe medical team\nprovides with\ncontinued\nnecessary\nassistance on call\nDoctor understand\nsituation & advices\non emergency Care\n/ Selection of\nambulance\nCSE dispatch the\nambulance to\ndesired location &\nprovide necessary\ndetails\n\nGolden Shield\n15 CIN: L67200MH2000PLC129408UIN : ICIHLIP22012V012223\n10. Discounts on services / products\nWe shall only facilitate the Insured Person in availing\ndiscounts on services/ products including but not limited to\ninvestigations/ diagnostic tests/ laboratory tests / health\nsupplements/ medical equipment/ homecare services /\nvirtual health & wellness sessions/ AYUSH products /\nFitness & wellness related activities & products etc. at our\nempanelled diagnostic centres, drugs / medicines ordered\nfrom pharmacies etc. offered by our network providers/\nhealth service providers. These discounts can be viewed on\nour mobile application and one can redeem the wellness\npoints earned from Care Management Program (either\nthrough favourable findings on health check-up or\nparticipation in Yoga/ meditations sessions/ achieving\ntargeted steps per month) for availing discounts as per\nproduct terms and conditions and subject to availability.\nTerms and Conditions for Care Management Program\n• There shall be no minimum wellness points limit for\nredemption against health related deals and discounts\noffered on our mobile application.\n• The Insured Person(s) can choose to carry forward the\nwellness points for 3 years, in case they do not wish to\nredeem the same provided the policy is continuously\nrenewed without any break. The wellness points so\naccrued shall have to be redeemed at the end of the 3rd\nPolicy year.\n• The Insured Person shall notify Us and submit the\nrelevant documents, reports, receipts as and when\nrequired by us within 60 days of undertaking any\nactivity for us to reward appropriate wellness points.\n• In case of expiry of policy and the policy not being\nrenewed, the accrued wellness points may be carried\nforward for a period not exceeding three months.\n• There shall not be any cash reimbursement or\nredemption available against the wellness points\naccumulated by an Insured Person.\n• We or Our Health Service Providers or Our Network\nProviders do not warrant the validity, accuracy,\ncompleteness, safety, quality, or applicability of the\ncontent or anything said or written or any suggestions\nprovided in the course of providing the wellbeing\nservices.\n• We do not accept any liability towards quality of the\nservices made available by our network providers/\nhealth service providers and are not liable for any\ndefects or deficiencies on their part.\n• Availability of all Services under the care management\nprogram is subject to availability of Health Service\nprovider at the requested location.\n• We, Our group entities, or affiliates, their respective\ndirectors, officers, employees, agents, vendors, shall\nnot be responsible for or liable for, any actions, claims,\ndemands, losses, damages, costs, charges and\nexpenses which an Insured Person may claim to have\nsuffered, sustained or incurred, as a result of any\nadvice or information obtained by way of the wellness\nprogram or any actions chosen by the Insured Person\non the basis of such advice or information.\n• The care management program offered is subject to\nrevisions based on the insurance regulator y\nframework from time to time.\nOptional Covers\n1. Claim Protector\nIn consideration of payment of additional premium to Us,\nthe insured person can avail the benefit as mentioned\nunder claim protector. If a claim has been accepted under\nthe inpatient hospitalization cover, then the items which\nare not payable under the claim as per the List of Excluded\nitems released by IRDAI that is related to the particular\nclaim will become payable. The maximum claim pay-out\nunder this benefit shall be limited to Annual Sum Insured\nunder your policy.\nBase Co-payment as opted by the Insured Person in the\npolicy shall be applicable for this cover\n2. Modification of Base Co-payment\nIn consideration of payment of additional premium to Us,\nThe insured person will have the option to reduce his base\nco-payment from 50% to 40% or 30% or 20% and He/She\nshall be liable to pay the percentage (%) of admissible claim\namount of each and every claim.\nBase Co-payment once chosen cannot be changed mid-\nterm. Modification of co-payment may happen only\nduring renewal subject to underwriting. In case, base co-\npayment is reduced during renewal, fresh waiting periods\nshall be applicable on the modified portion of base co-\npayment.\n3. Voluntary Deductible\nIn case the Insured person has opted for a voluntary\ndeductible, as specified in the Policy Schedule, the\nDeductible will be applicable on aggregate basis for all\nHospitalization expenses during the Policy Year before it\nbecomes payable by Us, subject to terms, conditions and\nexclusions of the Policy. The voluntary deductible option\navailable will be 20% of Annual Sum Insured opted by\nYou.\ni. In case voluntary deductible has been opted for, base\nco-payment shall not be chosen. Zone based co-\npayment shall be applicable in case medically\nnecessary treatment (Except medically necessary\ntreatment for road traffic accidents) has been taken in\na zone higher (Zone A being the highest followed by\nZone B and then Zone C) than the zone for which\npremium has been paid on issuance of the policy.\nii. The deductible will apply on individual basis in case of\nindividual policy and on floater basis in case of floater\npolicy.\niii. Deductible once chosen cannot be changed mid-term.\nModification of deductible may happen only during\nrenewal subject to underwriting.\n\nGolden Shield\n16 CIN: L67200MH2000PLC129408UIN : ICIHLIP22012V012223\n4. Care management Plus Program\nIn consideration of payment of additional premium, Insured\nPerson can avail the benefits associated with care\nmanagement Plus Program as detailed below\n1. Health Care Professional\nAll insured persons shall be assigned a dedicated\nHealth Care Professional who will act as a first point of\ncontact for any service need. The Health Care\nprofessional will be a certified nutritionist who will\nassist the Insured person(s) with a personalised diet\ndepending on their health concerns. The Health Care\nProfessional shall encourage and promote optimal\nhealth and assist on matters pertaining to fitness, diet\nand nutrition and wellbeing concerns faced by the\ninsured persons. He/She will encourage two way\ncommunication, provide reminders on healthy habits\nand reassure the insured person in times of need.\nThe health care professional will also play a significant\nrole in being the primary point of contact to the Insured\nPerson. The Health Care professional will\n• On-board the Insured Person on to our mobile\napplication\n• Educate the Insured Person on the pertinent\nfeatures of our mobile application such as but not\nlimited to availing Tele-consultations, utilising the\npreventive health check-up, conducting the mid-\nterm assessment, educating about health\nassistance services, redemption of wellness points\netc.\n• Give care calls to the Insured Person to understand\ninsured person’s issues surrounding fitness, diet &\nnutrition and wellbeing issues if any and propose\nsolutions for the same\n2. Update to family members-\nAs a part of the enhanced wellness features, your\nfamily members will be regularly updated about your\nhealth and adherence to prescribed diet(as prescribed\nunder the diet and nutrition e-consultation benefit\nunder Care management program) via messaging\nplatform(s) so that they can motivate and encourage\nand participate in your efforts to achieve your\nhealthcare goals.\nThe above update shall be provided only on Your\nconsent and after You provide us with contact details of\nfamily member who wishes to receive timely updates\nabout your health and diet regime.\n3. Out-patient consultations\nWe shall cover the Medical Expenses incurred during\nthe Policy period for out-patient consultations from a\nGeneral Medical Practitioner or Specialist Medical\nPractitioner or Super Specialist Medical practitioner or\nAYUSH medical practitioner in relation to any Illness\ncontracted or Injury suffered by the Insured Person\nduring the Policy period subject to the overall\nmaximum number of 4 consultations in a Policy Year.\nThese services shall be provided through our\nEmpanelled Health Service Provider subject to\navailability at the time of appointment.\nThis benefit shall also include e-consultation given by a\nGeneral Medical Practitioner or Specialist or Super\nSpecialist Medical Practitioner or AYUSH medical\npractitioner through a virtual mode of communication\nsuch as but not limited to chat, email, video, online\nportal, or mobile application.\nPhysiotherapy sessions shall be excluded from the\nscope of this benefit.\nCounselling availed for psychiatric ailments or mental\nhealth issues shall be excluded from the scope of this\nbenefit but it shall be covered in E-Counseling (section\nd. Base Cover. 18.4) as per the section d. Benefits\ncovered under the policy.\n4. Routine Diagnostics and Minor Procedure cover\nWe shall cover medical expenses incurred for\noutpatient diagnostic tests recommended by Medical\nPractitioner under our cashless network available in\nthe mobile application in relation to any Illness\ncontracted or Injury suffered by the Insured Person\nduring the Policy Period and for listed minor procedures\nundergone at a general practitioner or specialist /\nsuper-specialist medical practitioner by the Insured\nPerson during the Policy period maximum up ` 2,000.\nThese services shall be provided through our\nEmpanelled Health Service Provider subject to\navailability at the time of appointment. The diagnostic\ntests shall include but will not be limited to\nh i s t o p a t h o l o g y, b i o c h e m i s t r y, h e m a t o l o g y,\nimmunology, microbiology, serology, pathology,\nradiology, ultrasound and TMT. Genetic studies shall be\nexcluded from the scope of this cover.\nWe may even arrange for diagnostic tests to be carried\nout at the location of the Insured Person provided such\nlocation is within the geographical reach of the Health\nService Provider on the date of the request. This service\nshall be subject to availability of Our empanelled\nHealth Service provider.\nList of Minor Procedures covered under this benefit #\nSr. No. Procedure\n1 Drainage of abscess\n2 Injection including Intramuscular\n(Per Injection cost)\n3 Intravenous injection(IV)\n4 Sprain Management\n(Joint movement/ exercise)\n5 Otoscopic examination\n(Magnifying otoscopy)\n6 Nasal packing for control of haemorrhage\n7 Nebulizer therapy\n8 Removal of foreign body\n\nGolden Shield\n17 CIN: L67200MH2000PLC129408UIN : ICIHLIP22012V012223\nList of Minor Procedures covered under this benefit #\nSr. No. Procedure\n9 Suturing (Staple under LA)\n10 Removal of suture\n11 Stabilization of joint\n12 Syringing ear to remove wax\n13 Application or removal of plaster cast\n14 Laryngoscopy\n15 Minor wound management\n#\nthis includes only the cost of administration. The\nactual cost of consumables shall be covered under the\npharmacy cover. However, the said cost will have to be\nborne by the insured person in case the annual sum\ninsured under the pharmacy cover has been exhausted\nor is out of scope of the Pharmacy cover or in case the\nconsumable is a non-payable item.\n5. Pharmacy cover\nWe shall cover medical expenses incurred on purchase\nof medicines, drugs, and medical consumables, as\nprescribed by a Medical Practitioner under our\ncashless network available in the mobile application\nfor any Illness contracted or Injury suffered by the\nInsured Person during the Policy Period, maximum up\nto ` 2,000 through our Empanelled Health Service\nProvider subject to availability on the date of the\nrequest.\nHealth supplements, Nutraceuticals, foods for special\ndietary use, foods for special medical purpose, foods\nwith added probiotics and/or foods with added\nprebiotics, vaccinations, vitamins, tonics or other\nrelated products are excluded from the scope of this\ncover.\n6. Nursing at Home\nWe shall cover the expenses incurred by You, up to\n` 2,000 for each day up to a maximum of 15 days post\nHospitalization for the medical services of a Qualified\nNurse at Your residence, provided that the nurse is\nemployed in a Hospital and the engagement of such\nQualified Nurse is certified as necessary by a Medical\nPractitioner and related directly to any Illness or Injury,\ncovered under the Policy. The payment under this cover\nis subject to admissibility of Your In-patient treatment\nClaim under the Policy.\nd. Exclusions\nWe will not be liable for any Voluntary Deductible\namount, if applicable and as specifically defined in the\nPolicy Schedule under the Policy.\nWe will not be liable to make any payment under this\nPolicy in connection with or in respect of any expenses\nwhatsoever incurred in connection with or in respect of:\ni. Standard exclusions (Exclusions for which\nstandard wordings are specified by IRDAI)\n1. Code- Excl01: Pre-Existing Diseases\na. Expenses related to the treatment of a\npre-existing Disease (PED) and its direct\ncomplications shall be excluded until the\nexpiry of 24 months of continuous\ncoverage after the date of inception of the\nfirst policy with insurer.\nb. In case of enhancement of sum insured the\nexclusion shall apply afresh to the extent\nof sum insured increase.\nc. If the Insured Person is continuously\ncovered without any break as defined\nunder the portability norms of the extant\nIRDAI (Health Insurance) Regulations,\nthen waiting period for the same would be\nreduced to the extent of prior coverage.\nd. Coverage under the policy after the expiry\nof 24 months for any pre-existing disease\nis subject to the same being declared at\nthe time of application and accepted by\nInsurer.\n2. Code- Excl02: Specified disease/procedure\nwaiting period\na. Expenses related to the treatment of the\nlisted Conditions, surgeries/treatments\nshall be excluded until the expiry of 24\nmonths of continuous coverage after the\ndate of inception of the first policy with us.\nThis exclusion shall not be applicable for\nclaims arising due to an accident.\nb. In case of enhancement of sum insured the\nexclusion shall apply afresh to the extent\nof sum insured increase.\nc. If any of the specified disease/procedure\nfalls under the waiting period specified for\npre-Existing diseases, then the longer of\nthe two waiting periods shall apply.\nd. The waiting period for listed conditions\nshall apply even if contracted after the\npolicy or declared and accepted without a\nspecific exclusion.\ne. If the Insured Person is continuously\ncovered without any break as defined\nunder the applicable norms on portability\nstipulated by IRDAI, then waiting period\nfor the same would be reduced to the\nextent of prior coverage.\n\nGolden Shield\n18 CIN: L67200MH2000PLC129408UIN : ICIHLIP22012V012223\nf. List of specific Illness and Surgical Procedures as mention below:\nSr.\nNo.\nOrgan /Organ\nSystem\nIllness/ diagnosis\n(irrespective of treatments medical or surgical)\nSurgeries/ Procedures (irrespective of any\nillness or diagnosis other than cancers)\n1 \nENT Deviated Nasal Septum Septoplasty\nCSOM-Chronic Suppurative Otitis Media Mastoidectomy\nTympanoplasty, Myringotomy &\nMyringoplasty\nAny treatment for conditions related to\ntonsils, adenoids, sinuses, Turbinates/\nconcha\n2 \nGynaecological Fibroids (fibromyoma)\nEndometriosis, Cervicitis\nUterine Prolapse\nDysfunctional uterine bleeding\nPolycystic Ovarian Syndrome (PCOS)\nDilatation and curettage (D&C)\nMyomectomy\nHysterectomy (unless due to malignancy\n3 \nOrthopaedic \nArthritis\nGout and Rheumatism\nSpinal and Vertebral Disorders including diagnosis as low back ache\nArthroscopy\nSurgeries for joint replacements\nRepairs/ reconstruction of ligaments/\nmeniscus/ tendons\nSpinal & Vertebral Surgeries\n4 Gastrointestinal \nStones in gall bladder & Biliary System, cholecystitis, acalculous\ncholecystitis\nFissure/fistula in anus, hemorrhoids, pilonidal sinus\nEsophageal Varices & Gastric Varices\nAll types Hernia\nGastrointestinal ulcers including Gastritis & Duodenitis/ Erosions\nof gastrointestinal tract\nCholecystectomy, Procedures for biliary\nstones\nAll forms of Liver cirrhosis\nEndoscopy\nProcedures for Esophageal Varices &\nGastric Varices\nEndoscopy\n5 Uro-genital \nStones in Urinary system Surgeries and procedures related to\nStones in Urinary system\nChronic Renal Failure or end stage Renal Failure or chronic\nkidney disease including dialysis\nHydrocele, varicocele/ rectocele/ Spermatocele\nDialysis but not limited to haemodialysis &\nperitoneal dialysis\n6 Eye \nCataract\nRetinal detachment\nGlaucoma\nUsage of intra vitreal injections including but not limited to avastin\n& lucentis\nBenign Hyperplasia of prostate Prostatic Surgeries\n\nGolden Shield\n19 CIN: L67200MH2000PLC129408UIN : ICIHLIP22012V012223\nf. List of specific Illness and Surgical Procedures as mention below: (Contd.)\nSr.\nNo.\nOrgan /Organ\nSystem\nIllness/ diagnosis\n(irrespective of treatments medical or surgical)\nSurgeries/ Procedures (irrespective of any\nillness or diagnosis other than cancers)\n7 Other General\nconditions\n(Applicable to\nall organ\nsystems/\norgans/\ndisciplines\nwhether or not\ndescribed\nabove)\nAll internal/ external tumors, cysts, nodules, polyps, sinus, fistula\nVaricose veins & Varicose ulcers\nParkinson’s disease/Alzheimer’s disease\nExpenses related to any admission primarily for\nenforced bed rest and not for receiving treatment. This\nalso includes:\na. Custodial care either at home or in a nursing facility\nfor personal care such as help with activities of\ndaily living such as bathing, dressing, moving\naround either by skilled nurses or assistant or non-\nskilled persons.\nb. Any services for people who are terminally ill to\naddress physical, social, emotional and spiritual\nneeds\niii. Code- Excl06: Obesity/ Weight Control\nExpenses related to the surgical treatment of\nobesity that does not fulfil all the below conditions:\n1. Surgery to be conducted is upon the advice of\nthe Doctor\n2. The surgery/Procedure conducted should be\nsupported by clinical protocols\n3. The member has to be 18 years of age or older\nand\n4. Body Mass Index (BMI);\na. greater than or equal to 40 or\nb. greater than or equal to 35 in conjunction\nwith any of the following severe co-\nmorbidities following failure of less\ninvasive methods of weight loss:\ni. Obesity-related cardiomyopathy\nii. Coronary heart disease\niii. Severe Sleep Apnea\niv. Uncontrolled Type2 Diabetes\niv. Code- Excl07: Change of Gender treatments\nExpenses related to any treatment, including surgical\nmanagement, to change characteristics of the body to\nthose of the opposite sex.\nv. Code- Excl08: Cosmetic or plastic Surgery\nExpenses for cosmetic or plastic surgery or any\ntreatment to change appearance unless for\nreconstruction following an Accident, Burn(s) or\n3. a. Expenses related to the treatment of the below\nmentioned illness within 90 days from the first policy\ncommencement date shall be excluded unless they\nare pre-existing and disclosed at the time of\nunderwriting\ni. Hypertension\nii. Diabetes\niii. Cardiac Conditions\nb. This exclusion shall not, however, apply if the Insured\nPerson has continuous coverage for more than twelve\nmonths.\nc. The within referred waiting period is made applicable\nto the enhanced sum insured in the event of granting\nhigher sum insured subsequently.\n4. Code- Excl03: 30-day waiting period\na. Expenses related to the treatment of any illness within\n30 days from the first policy commencement date shall\nbe excluded except claims arising due to an accident,\nprovided the same are covered.\nb. This exclusion shall not, however, apply if the Insured\nPerson has Continuous Coverage for more than twelve\nmonths.\nc. The within referred waiting period is made applicable\nto the enhanced sum insured in the event of granting\nhigher sum insured subsequently\nUnless covered by way of an appropriate extensions /\noptional covers, We shall not be liable to make any\npayment under this Policy in connection with or in\nrespect of\n5. Permanent Exclusions\ni. Code- Excl04: Investigation & Evaluation\na. Expenses related to any admission primarily for\ndiagnostics and evaluation purposes only are\nexcluded.\nb. Any diagnostic expenses which are not related or\nnot incidental to the current diagnosis and\ntreatment are excluded.\nii. Co d e - E xc l 0 5 : E xc l u s i o n N a m e : Re st Cu re ,\nrehabilitation and respite care-\n\nGolden Shield\n20 CIN: L67200MH2000PLC129408UIN : ICIHLIP22012V012223\nxv. Code- Excl18: Maternity: Medical treatment expenses\ntraceable to childbirth (including complicated\ndeliveries and caesarean sections incurred during\nhospitalization) except ectopic pregnancy. Expenses\ntowards miscarriage (unless due to an accident) and\nlawful medical termination of pregnancy during the\npolicy period\nii. Specific exclusions (Exclusions other than those\nmentioned under e.i. above)\n6. Any ailment/ illness/ injury/ condition or treatment\nor service that is specifically excluded in the Policy\nSchedule under Special Conditions\n7. Any expenses incurred on prosthesis, corrective\ndevices, external durable medical equipment of\nany kind, instruments used in treatment of sleep\napnoea syndrome or cost of cochlear implant(s)\nunless necessitated by an Accident or required\nintra-operatively.\n8. Multifocal Lens and ambulatory devices such as\nwalkers, crutches, splints, stockings of any kind\nand also any medical equipment which is\nsubsequently used at home.\n9. Expenses incurred on dental treatment unless\nnecessitated due to an Accident\n10. Personal comfort, cosmetics, convenience and\nhygiene related items and services\n11. Acupressure, acupuncture, magnetic and other\ntherapies\n12. Circumcision unless necessary for treatment of an\nIllness or necessitated due to an Accident.\n13. Expenses for venereal disease or any sexually\ntransmitted disease (except HIV/AIDS)\n14. Any Treatment or medical services taken outside\nthe geographical boundaries of India.\n15. Any expenses incurred on out-patient (OPD)\ntreatment. (This exclusion shall not be applicable\nin case care management plus program has been\nopted for by payment of additional premium)\n16. Intentional self-injury (whether arising from an\nattempt to commit suicide or otherwise)\n17. Any injury or illness caused by or arising from or\nattributed to war, invasion, acts of foreign\nenemies, hostilities (whether war be declared or\nnot ), civil war, commotion, unrest, rebellion,\nrevolution, militar y or usurped power or\nconfiscation or nationalisation or requisition of or\ndamage by or under the order of any government\nor public local authority\n18. Any Illness or Injury caused by or contributed to by\nnuclear weapons/materials or contributed to by or\narising from ionising radiation or contamination by\nradioactivity by any nuclear fuel or from any nuclear\nwaste or from the combustion of nuclear fuel\nCancer or as part of medically necessary treatment to\nremove a direct and immediate health risk to the\ninsured. For this to be considered a medical necessity, it\nmust be certified by the attending Medical Practitioner.\nvi. Code- Excl09: Hazardous or Adventure sports\nExpenses related to any treatment necessitated due to\nparticipation as a professional in hazardous or\nadventure sports, including but not limited to, para-\njumping, rock climbing, mountaineering, rafting, motor\nracing, horse racing or scuba diving, hand gliding, sky\ndiving, deep-sea diving.\nvii. Code- Excl10: Breach of law\nExpenses for treatment directly arising from or\nconsequent upon any Insured Person committing or\nattempting to commit a breach of law with criminal\nintent.\nviii. Code- Excl11: Excluded Providers\nExpenses incurred towards treatment in any hospital or\nby any Medical Practitioner or any other provider\nspecifically excluded by the Insurer and disclosed in its\nwebsite / notified to the policyholders are not admissible.\nHowever, in case of life threatening situations or\nfollowing an accident, expenses up to the stage of\nstabilization are payable but not the complete claim\nix. Code- Excl12: Treatment for, Alcoholism, drug or\nsubstance abuse or any addictive condition and\nconsequences thereof.\nx. Code- Excl13: Treatments received in heath\nhydros, nature cure clinics, spas or similar\nestablishments or private beds registered as a nursing\nhome attached to such establishments or where\nadmission is arranged wholly or partly for domestic\nreasons.\nxi. Code- Excl14: Dietary supplements and substances that\ncan be purchased without prescription, including but\nnot limited to Vitamins, minerals and organic\nsubstances unless prescribed by a medical practitioner\nas part of hospitalization claim or day care procedure.\nxii. Code- Excl15: Expenses related to the treatment for\ncorrection of eye sight due to refractive error less than\n7.5 dioptres\nxiii. Code- Excl16: Unproven Treatments: Expenses\nrelated to any unproven treatment, services and\nsupplies for or in connection with any treatment.\nUnproven treatments are treatments, procedures or\nsupplies that lack significant medical documentation\nto support their effectiveness.\nxiv. Code- Excl17: Sterility and Infertility: Expenses related\nto sterility and infertility. This includes:\ni. Any type of contraception, sterilization\nii. Assisted Reproduction services including artificial\ninsemination and advanced reproductive\ntechnologies such as IVF, ZIFT, GIFT, ICSI\niii. Gestational Surrogacy\niv. Reversal of sterilization\n\nGolden Shield\n21 CIN: L67200MH2000PLC129408UIN : ICIHLIP22012V012223\n(Explanation: \"Bank rate\" shall mean the rate\nfixed by the Reserve Bank of lndia (RBl) at the\nbeginning of the financial year in which claim\nhas fallen due)\n4. Complete Discharge\nAny payment to the policyholder, insured person or\nhis/ her nominees or his/ her legal representative or\nassignee or to the hospital as the case may be, for\nany benefit under the Policy shall be a valid\ndischarge towards payment of claim by the\nCompany to the extent of that amount for the\nparticular claim\n5. Multiple Policies\ni. In case of multiple policies taken by an insured\nperson during a period from one or more\ninsurers to indemnify treatment costs, the\ninsured person shall have the right to require a\nsettlement of his/her claim in terms of any of\nhis/her policies. In all such cases the insurer\nchosen by the insured person shall be obliged\nto settle the claim as long as the claim is within\nthe limits of and according to the terms of the\nchosen policy.\nii. Insured Person having multiple policies shall\nalso have the right to prefer claims under this\npolicy for the amounts disallowed under any\nother policy / policies, even if the sum insured is\nnot exhausted. Then the Insurer shall\nindependently settle the claim subject to the\nterms and conditions of this policy.\niii. If the amount to be claimed exceeds the sum\ninsured under a single policy, the insured\nperson shall have the right to choose insurers\nfrom whom he/she wants to claim the balance\namount.\niv. Where an insured person has policies from\nmore than one insurer to cover the same risk\non indemnity basis, the insured person shall\nonly be indemnified the treatment costs in\naccordance with the terms and conditions of\nthe chosen policy.\n6. Fraud\nIf any claim made by the insured person, is in any\nrespect fraudulent, or if any false statement, or\ndeclaration is made or used in support thereof, or if\nany fraudulent means or devices are used by the\ninsured person or anyone acting on his/her behalf to\nobtain any benefit under this policy, all benefits under\nthis policy and the premium paid shall be forfeited.\nAny amount already paid against claims made\nunder this policy but which are found fraudulent\nlater shall be repaid by all recipient(s) /\npolicyholder(s), who has made that particular\nclaim, who shall be jointly and severally liable for\nsuch repayment to the insurer.\n19. Treatment for any condition / illness which requires\nhormone replacement therapy.\n20. Artificial life maintenance for the Insured Person\nwho has been declared brain dead or in vegetative\nstate as demonstrated by:\na. Deep coma and unresponsiveness to all forms\nof stimulation; or\nb. Absent pupillary light reaction; or\nc. Absent oculo-vestibular and corneal reflexes;\nor\nd. Complete apnea.\ne. General Terms and Clauses\ni. Standard General Terms and Clauses (General Terms\nand clauses whose wordings are specified by IRDAI)\n1. Disclosure of Information\nThe Policy shall be void and all premium paid\nthereon shall be forfeited to the Company in the\nevent of misrepresentation, mis-description or\nnon-disclosure of any material fact by the\npolicyholder\n(Explanation: \"Material facts\" for the purpose of\nthis policy shall mean all relevant information\nsought by the company in the proposal form and\nother connected documents to enable it to take\ninformed decision in the context of underwriting\nthe risk)\n2. Condition Precedent to Admission of Liability\nThe terms and conditions of the policy must be fulfilled\nby the insured person for the Company to make any\npayment for claim(s) arising under the policy.\n3. Claim Settlement (provision for Penal lnterest)\nI. The Company shall settle or reject a claim, as\nthe case may be, within 30 days from the date\nof receipt of last necessary document.\nII. ln the case of delay in the payment of a claim,\nthe Company shall be liable to pay interest to\nthe policyholder from the date of receipt of last\nnecessary document to the date of payment of\nclaim at a rate 2% above the bank rate.\nIII. However, where the circumstances of a claim\nwarrant an investigation in the opinion of the\nCompany, it shall initiate and complete such\ninvestigation at the earliest, in any case not\nlater than 30 days from the date of receipt of\nlast necessary document. ln such cases, the\nCompany shall settle or reject the claim within\n45 days from the date of receipt of last\nnecessary document.\nIV. ln case of delay beyond stipulated 45 days, the\nCompany shall be liable to pay interest to the\npolicyholder at a rate 2% above the bank rate\nfrom the date of receipt of last necessary\ndocument to the date of payment of claim.\n\nGolden Shield\n22 CIN: L67200MH2000PLC129408UIN : ICIHLIP22012V012223\n8. Migration:\nThe insured person will have the option to migrate the\npolicy to other health insurance products/plans offered\nby the company by applying for migration of the policy\nat least 30 days before the policy renewal date as per\nIRDAI guidelines on Migration. lf such person is\npresently covered and has been continuously covered\nwithout any lapses under any health insurance\nproduct/ plan offered by the company, the insured\nperson will get the accrued continuity benefits in\nwaiting periods as per IRDAI guidelines on migration.\nFor Detailed Guidelines on migration, kindly refer the link\nhttps://www.irdai.gov.in/ADMINCMS/cms/frmGuidelines_Layo\nut.aspx?page=PageNo3987\n9. Portability\nThe insured person will have the option to port the\npolicy to other insurers by applying to such insurer to\nport the entire policy along with all the members of the\nfamily, if any, at least 45 days before, but not earlier\nthan 60 days from the policy renewal date as per IRDAI\nguidelines related to portability. lf such person is\npresently covered and has been continuously covered\nwithout any lapses under any health insurance policy\nwith an lndian General/Health insurer, the proposed\ninsured person will get the accrued continuity benefits\nin waiting periods as per IRDAI guidelines on\nportability.\nFor Detailed Guidelines on portability, kindly refer the link\nhttps://www.irdai.gov.in/ADMINCMS/cms/frmGuidelin\nes_Layout.aspx?page=PageNo3987\n10. Renewal of Policy\nThe policy shall ordinarily be renewable except on\ngrounds of fraud, misrepresentation by the insured\nperson\ni. The Company shall endeavor to give notice for\nrenewal. However, the Company is not under\nobligation to give any notice for renewal.\nii. Renewal shall not be denied on the ground that the\ninsured person had made a claim or claims in the\npreceding policy years.\niii. Request for renewal along with requisite premium\nshall be received by the Company before the end of\nthe policy period.\niv. At the end of the policy period, the policy shall\nterminate and can be renewed within the Grace\nPeriod of 30 days to maintain continuity of benefits\nwithout break in policy. Coverage is not available\nduring the grace period.\nv. No loading shall apply on renewals based on\nindividual claims experience.\n11. Withdrawal of Policy\ni. ln the likelihood of this product being withdrawn in\nfuture, the Company will intimate the insured\nperson about the same 90 days prior to expiry of\nthe policy.\nFor the purpose of this clause, the expression\n\"fraud\" means any of the following acts committed\nby the Insured Person or by his agent or the\nhospital/doctor/any other party acting on behalf of\nthe insured person, with intent to deceive the\ninsurer or to induce the insurer to issue an\ninsurance Policy :-\na) the suggestion, as a fact of that which is not\ntrue and which the Insured Person does not\nbelieve to be true;\nb) the active concealment of a fact by the Insured\nPerson having knowledge or belief of the fact;\nc) any other act fitted to deceive; and\nd) any such act or omission as the law specially\ndeclares to be fraudulent\nThe company shall not repudiate the claim and / or\nforfeit the policy benefits on the ground of fraud, if\nthe insured person / beneficiary can prove that the\nmisstatement was true to the best of his\nknowledge and there was no deliberate intention\nto suppress the fact or that such mis-statement of\nor suppression of material fact are within the\nknowledge of the insurer.\n7. Cancellation\na) The policyholder may cancel this Policy by giving\n15 days' written notice, and in such an event, the\nCompany shall refund premium for the unexpired\nPolicy Period as detailed below.\nCancellation Period Refund % Refund % Refund %\nfor 1 year for 2 years for 3 years\ntenure tenure tenure\npolicy policy policy\nFrom 16 days to 1 month 75% 80% 80%\nFrom 1 month to 3 months 60% 70% 75%\nFrom 3 months to 6 months 40% 60% 70%\nFrom 6 months to 9 months 20% 50% 60%\nFrom 9 months to 12 months 0% 40% 55%\nFrom 12 months to 15 months - 30% 45%\nFrom 15 months to 18 months - 20% 40%\nFrom 18 months to 21 months - 10% 35%\nFrom 21 months to 24 months - 0% 25%\nFrom 24 months to 27 months - - 20%\nFrom 27 months to 30 months - - 10%\nFrom 30 months to 33 months - - 5%\nFrom 33 months to 36 months - - 0%\nNotwithstanding anything contained herein or\notherwise, no refunds of premium shall be made in\nrespect of Cancellation where, any claim has been\nadmitted or has been lodged or any benefit has\nbeen availed by the Insured person under the\nPolicy.\nb) The Company may cancel the Policy at any time on\ngrounds of mis-representation, non-disclosure of\nmaterial facts, fraud by the Insured Person, by\ngiving 15 days' written notice. There would be no\nrefund of premium on cancellation on grounds of\nmis-representation, non-disclosure of material\nfacts or fraud.\n\nGolden Shield\n23 CIN: L67200MH2000PLC129408UIN : ICIHLIP22012V012223\n15. Free look period\nThe Free Look Period shall be applicable on new\nindividual health insurance policies and not on\nrenewals or at the time of porting/migrating the policy.\nThe insured person shall be allowed free look period of\nfifteen days from date of receipt of the Policy\ndocuments to review the terms and conditions of the\nPolicy, and to return the same if not acceptable.\nIf the insured has not made any claim during the Free\nLook Period, the insured shall be entitled to\na) a refund of the premium paid less any expenses\nincurred by the company on medical examination\nof the insured person and the stamp duty charges;\nor\nb) where the risk has already commenced and the\noption of return of the Policy is exercised by the\ninsured person, a deduction towards the\nproportionate risk premium for period of cover or\nc) where only a part of the insurance coverage has\ncommenced, such propor tionate premium\ncommensurate with the insurance coverage\nduring such period;\n16. Redressal of Grievances\nln case of any grievance the insured person may\ncontact the company through\nWebsite : www.icicilombard.com\nToll Free : 1800 2666\nE-Mail : customersupport@icicilombard.com\nCourier : ICICI Lombard General Insurance Company Ltd.\nICICI Lombard House,\n414, Veer Savarkar Marg,\nNear Siddhi Vinayak Temple,\nPrabhadevi, Mumbai- 400025\nlnsured person may also approach the grievance cell at\nany of the company's branches with the details of\ngrievance.\nlf lnsured person is not satisfied with the redressal of\ngrievance through one of the above methods, insured\nperson may contact the grievance officer at :\nManager- Service Quality,\nCorporate Manager- Service Quality,\nNational Manager- Operations &\nfinally Director-services and Business development at\nthe following address:\nICICI Lombard General Insurance Company Limited,\nICICI Lombard House,\n414, Veer Savarkar Marg,\nNear Siddhi Vinayak Temple,\nPrabhadevi, Mumbai - 400 025.\nFor updated details of grievance officer, kindly refer the link\nhttps://www.icicilombard.com/grievance-redressal\nlf lnsured person is not satisfied with the redressal of\ngrievance through above methods, the insured person\nii. lnsured Person will have the option to migrate to\nsimilar health insurance product available with the\nCompany at the time of renewal with all the\naccrued continuity benefits such as cumulative\nbonus, waiver of waiting period as per IRDAI\nguidelines, provided the policy has been\nmaintained without a break.\n12. Moratorium Period\nAfter completion of eight continuous years under this\npolicy no look back would be applied. This period of\neight years is called as moratorium period. The\nmoratorium would be applicable for the sums insured\nof the first policy and subsequently completion of 8\ncontinuous years would be applicable from date of\nenhancement of sum insured only on the enhanced\nlimits. After the expiry of Moratorium Period no health\ninsurance claim shall be contestable except for proven\nfraud and permanent exclusions specified in the policy\ncontract. The policies would however be subject to all\nlimits, sub limits, co-payments, deductibles as per the\npolicy contract\n13. Premium Payment in lnstalments (Wherever\napplicable)\nlf the insured person has opted for Payment of\nPremium on an instalment basis i.e. Half Yearly,\nQuarterly or Monthly, as mentioned in the policy\nSchedule/Certificate of lnsurance, the following\nConditions shall apply (notwithstanding any terms\ncontrary elsewhere in the policy)\ni. Grace Period of 15 days would be given to pay the\ninstalment premium due for the policy.\nii. During such grace period, coverage will not be\navailable from the due date of instalment premium\ntill the date of receipt of premium by Company.\niii. The insured person will get the accrued continuity\nbenefit in respect of the \"Waiting Periods\",\n\"Specific Waiting Periods\" in the event of payment\nof premium within the stipulated grace Period.\niv. No interest will be charged lf the instalment\npremium is not paid on due date.\nv. ln case of instalment premium due not received\nwithin the grace period, the policy will get\ncancelled.\nvi. ln the event of a claim, all subsequent premium\ninstalments shall immediately become due and\npayable.\nvii. The company has the right to recover and deduct\nall the pending instalments from the claim amount\ndue under the policy.\n14. Possibility of Revision of Terms of the Policy Including\nthe Premium Rates\nThe Company, with prior approval of IRDAI, may revise\nor modify the terms of the policy including the premium\nrates. The insured person shall be notified three\nmonths before the changes are effected.\n\nGolden Shield\n24 CIN: L67200MH2000PLC129408UIN : ICIHLIP22012V012223\nbased co-payment shall not be applicable in case of\nmedically necessary treatment taken for road traffic\naccidents.\nThe additional zone based co-payment that will be levied will\nbe as per tables mentioned below\nAdditional zone based Co-Payment Grid\nTreatment Zone opted at\ntaken in Zone policy issuance\nA B C\nA 0% 15.0% 25.0%\nB Nil additional 0% 12.0%\nco-payment\nC Nil additional Nil additional 0%\nco-payment co-payment\nPlease refer to the claim illustrations as detailed in g.\nother terms and conditions 1. Claim Administration for\nfurther understanding\n19. Conditional Underwriting\nRisk based loading:\nWe may apply a risk loading on the premium payable\n(based on the declarations made in the proposal form\nand the health status of the persons proposed for\ninsurance) at the Commencement Date or on any\nrenewal of the Policy with Us or on the receipt of a\nrequest for enhancing the Annual Sum Insured. The\nmaximum risk loading applicable for an individual will\nnot exceed 100% per diagnosis / medical condition and\nan overall risk loading of 200% per individual.\nWe will send You the applicable risk loading in writing\nvia a counter offer letter. You shall give Us Your consent\nand the additional premium (if any), within 15 days of\nthe issuance of Our Counter offer letter.\nIf You neither accept Our letter nor revert to Us within\n15 days, We will cancel Your application and refund the\npremium paid within the next 7 days.\n20. Material Change\nThe Insured shall notify the Company in writing of any\nmaterial change in the risk in relation to the declaration\nmade in the proposal form or medical examination\nreport at each Renewal and the Company may, adjust\nthe scope of cover and/or premium, if necessary,\naccordingly.\n21. Records to be Maintained\nThe Insured Person shall keep an accurate record\ncontaining all relevant medical records and shall allow\nthe Company or its representatives to inspect such\nrecords. The Proposer or Insured Person shall furnish\nsuch information as the Company may require for\nsettlement of any claim under the Policy, within\nreasonable time limit and within the time limit specified\nin the Policy.\n22. Notice & Communication\ni. Any notice, direction, instruction or any other\ncommunication related to the Policy should be\nmade in writing.\nm a y a l s o a p p r o a c h t h e o ff i ce o f l n s u r a n ce\nOmbudsman of the respective area/region for\nredressal of grievance as per lnsurance Ombudsman\nRules 2017. Grievance may also be lodged at IRDAI\nl n t e g r a t e d G r i e v a n c e M a n a g e m e n t S y s t e m\nhttps://igms.irda.gov.in/\n17. Nomination:\nThe policyholder is required at the inception of the\npolicy to make a nomination for the purpose of\npayment of claims under the policy in the event of\ndeath of the policyholder. Any change of nomination\nshall be communicated to the company in writing and\nsuch change shall be effective only when an\nendorsement on the policy is made. ln the event of\ndeath of the policyholder, the Company will pay the\nnominee {as named in the Policy Schedule/Policy\nCertificate/Endorsement (if any)} and in case there is no\nsubsisting nominee, to the legal heirs or legal\nrepresentatives of the policyholder whose discharge\nshall be treated as full and final discharge of its liability\nunder the policy.\nii. Specific terms and clauses (terms and other clauses\nother than those mentioned above under f. I. above)\n18. Zone based Premium\nThis Policy only covers medical treatment taken within\nIndia arising during the Policy Period. All payments\nunder this Policy will only be made in Indian Rupees\nwithin India.\nThe construction, interpretation and meaning of the\nprovisions of this Policy shall be determined in\naccordance with Indian law.\nFor the purpose of Policy issuance, the premium will be\ncomputed basis the zone chosen by the Insured Person\nin the proposal form. The premium that would be\napplicable zone wise and the cities defined in each\nzone are as under:\n• Zone A- NCR*, Mumbai, Thane District,, Navi\nMumbai, Gujarat, Kolkata\n• Zone B- Hyderabad, Secunderabad, Chhattisgarh,\nMadhya Pradesh, Daman & Diu, Dadar & Nagar\nHaveli, Goa, Maharashtra (excluding Mumbai,\nThane District, Navi Mumbai)\n• Zone C- Rest of India\nNCR* includes Includes Delhi and the following\ndistricts: Faridabad, Gurgaon/Gurugram, Mewat,\nRohtak, Sonipat, Panipat, Jhajjhar, Palwal, Karnal,\nGhaziabad, Noida/Gautam Budh Nagar, Bulandshahr,\nBaghpat, Hapur, Shamli, Muzaffarnagar\nAdditional zone based Co-Payment would be levied on\neach and every claim (over and above the base co-\npayment opted by the Insured person) in case\nmedically necessary treatment has been taken in a\nzone higher (Zone A being the highest followed by\nZone B and then Zone C) than the zone for which\npremium has been paid on issuance of the policy. Zone\n\nGolden Shield\n25 CIN: L67200MH2000PLC129408UIN : ICIHLIP22012V012223\nand Conciliation Act 1996, as amended by\nArbitration and Conciliation (Amendment ) Act,\n2015 (No. 3 of 2016).\nii. It is clearly agreed and understood that no difference\nor dispute shall be preferable to arbitration as herein\nbefore provided, if the Company has disputed or not\naccepted liability under or in respect of the policy, iii. It\nis hereby expressly stipulated and declared that it\nshall be a condition precedent to any right of action or\nsuit upon the policy that award by such arbitrator /\narbitrators of the amount of expenses shall be first\nobtained.\n27. Policy alignment\nPolicy Alignment option will be available in cases\nwherein insured(s) with two separate health indemnity\npolicies with Us, having different policy end dates but\nwant to align the policy start dates. We can align the\npolicies by extending the coverage of one policy till the\nend date of the other policy.\nSuch policies will be charged with premium on pro rata\nbasis though the sum insured under the policy shall\nremain constant.\n28. Endorsements (Changes in Policy)\ni. This policy constitutes the complete contract of\ninsurance. This Policy cannot be modified by\nanyone (including an insurance agent or broker)\nexcept the company. Any change made by the\ncompany shall be evidenced by a written\nendorsement signed and stamped.\nii. The proposer may be changed only at the time of\nrenewal. The new proposer must be the legal\nheir/immediate family member. Such change\nwould be subject to acceptance by the company\nand payment of premium (if any). The renewed\nPolicy shall be treated as having been renewed\nwithout break.\niii. The proposer may be changed during the Policy\nPeriod only in case of his/her demise or him/her\nmoving out of India.\niv. Mid- term endorsement of addition of members in\nthe policy shall not be permitted\n29. Change of Sum Insured\nSum insured can be changed (increased/ decreased)\nonly at the time of renewal subject to underwriting by\nthe Company. For any increase in SI, the waiting period\nshall start afresh only for the enhanced portion of the\nsum insured.\n30. Non Payables\nBelow are the non-payable items applicable in the\npolicy. The list may be updated as per the direction of\nAuthority, for updated list please visit our website:\nwww.iciciclombard.com\nii. Such communication shall be sent to the address\nof the Company or through any other electronic\nmodes specified in the Policy Schedule.\niii. The Company shall communicate to the Insured at\nthe address or through any other electronic mode\nmentioned in the schedule.\n23. Territorial Limit\nAll medical treatment for the purpose of this insurance\nwill have to be taken in India only.\n24. Automatic change in Coverage under the policy\nThe coverage for the Insured Person(s) shall\nautomatically terminate:\ni. In the case of his/ her (Insured Person) demise.\nHowever the cover shall continue for the remaining\nInsured Persons till the end of Policy Period. The\nother insured persons may also apply to renew the\npolicy. In case, the other insured person is minor,\nthe policy shall be renewed only through any one\nof his/her natural guardian or guardian appointed\nby court. All relevant particulars in respect of such\nperson (including his/her relationship with the\ninsured person) must be submitted to the company\nalong with the application. Provided no claim has\nbeen made, and termination takes place on\naccount of death of the insured person, pro-rata\nrefund of premium of the deceased insured person\nfor the balance period of the policy will be effective.\nii. Upon exhaustion of sum insured and additional\nsum insured (if any), for the policy year. However,\nthe policy is subject to renewal on the due date as\nper the applicable terms and conditions.\n25. Territorial Jurisdiction\nAll disputes or differences under or in relation to the\ninterpretation of the terms, conditions, validity,\nconstruct, limitations and/or exclusions contained in\nthe Policy shall be determined by the Indian court and\naccording to Indian law.\n26. Arbitration\ni. If any dispute or difference shall arise as to the\nquantum to be paid by the Policy, (liability being\nother wise admitted) such difference shall\nindependently of all other questions, be referred to\nthe decision of a sole arbitrator to be appointed in\nwriting by the parties here to or if they cannot\nagree upon a single arbitrator within thirty days of\nany party invoking arbitration, the same shall be\nreferred to a panel of three arbitrators, comprising\ntwo arbitrators, one to be appointed by each of the\nparties to the dispute/difference and the third\narbitrator to be appointed by such two arbitrators\nand arbitration shall be conducted under and in\naccordance with the provisions of the Arbitration\n\nGolden Shield\n26 CIN: L67200MH2000PLC129408UIN : ICIHLIP22012V012223\nList of Non Payable Items as per IRDAI (Contd.)\nSr. No. Items\n48 NIMBUS BED OR WATER OR AIR BED CHARGES\n49 AMBULANCE COLLAR\n50 AMBULANCE EQUIPMENT\n51 ABDOMINAL BINDER\n52 PRIVATE NURSES CHARGES- SPECIAL NURSING\nCHARGES\n53 SUGAR FREE Tablets\n54 CREAMS POWDERS LOTIONS (Toiletries are not\npayable, only prescribed medical pharmaceuticals\npayable)\n55 ECG ELECTRODES\n56 GLOVES\n57 NEBULISATION KIT\n58 RECOVERY KIT, ETC]ANY KIT WITH NO DETAILS\nMENTIONED [DELIVERY KIT, ORTHOKIT,\n59 KIDNEY TRAY\n60 MASK\n61 OUNCE GLASS\n62 OXYGEN MASK\n63 PELVIC TRACTION BELT\n64 PAN CAN\n65 TROLLY COVER\n66 UROMETER, URINE JUG\n67 AMBULANCE\n68 VASOFIX SAFETY\nf. Other Terms and Conditions\n1. Claim Administration\nThe fulfilment of the terms and conditions of this\nPolicy (including payment of premium by the due\ndates mentioned in the Policy Schedule) insofar as\nthey relate to anything to be done or complied with\nby each of You shall be conditions precedent to\nadmission of Our liability. You are requested to go\nthrough our list of de-listed/excluded providers\nwhich is available on our website. As the list is\ndynamic, please refer to the latest list.\nThe claim pay-out would be adjudicated in\nfollowing sequence:\ni. If a room/ICU accommodation has been opted\nfor where the room rent or category is higher\nthan the eligible limit as applicable for the\nInsured Person, then the associated medical\nexpenses payable shall be pro-rated as per\napplicable limits.\nii. Associated medical expenses means those\nexpenses as listed below which vary in\naccordance with the room rent or room\ncategory or ICU Charges in a hospital:\na. Room, boarding, nursing and operation\ntheatre expenses as charged by the\nHospital where the insured person availed\ntreatment\nb. Intensive care unit (ICU) Charges\nList of Non Payable Items as per IRDAI\nSr. No. Items\n1 BABY FOOD\n2 BABY UTILITIES CHARGES\n3 BEAUTY SERVICES\n4 BELTS/ BRACES\n5 BUDS\n6 COLD PACK/HOT PACK\n7 CARRY BAGS\n8 EMAIL / INTERNET CHARGES\n9 FOOD CHARGES (OTHER THAN PATIENT’s DIET\nPROVIDED BY HOSPITAL)\n10 LEGGINGS\n11 LAUNDRY CHARGES\n12 MINERAL WATER\n13 SANITARY PAD\n14 TELEPHONE CHARGES\n15 GUEST SERVICES\n16 CREPE BANDAGE\n17 DIAPER OF ANY TYPE\n18 EYELET COLLAR\n19 SLINGS\n20 BLOOD GROUPING AND CROSS MATCHING OF\nDONORS SAMPLES\n21 SERVICE CHARGES WHERE NURSING CHARGE\nALSO CHARGED\n22 Television Charges\n23 SURCHARGES\n24 ATTENDANT CHARGES\n25 EXTRA DIET OF PATIENT (OTHER THAN THAT\nWHICH FORMS PART OF BED\n26 BIRTH CERTIFICATE\n27 CERTIFICATE CHARGES\n28 COURIER CHARGES\n29 CONVEYANCE CHARGES\n30 MEDICAL CERTIFICATE\n31 MEDICAL RECORDS\n32 PHOTOCOPIES CHARGES\n33 MORTUARY CHARGES\n34 WALKING AIDS CHARGES\n35 OXYGEN CYLINDER (FOR USAGE OUTSIDE THE\nHOSPITAL)\n36 SPACER\n37 SPIROMETRE\n38 NEBULIZER KIT\n39 STEAM INHALER\n40 ARMSLING\n41 THERMOMETER\n42 CERVICAL COLLAR\n43 SPLINT\n44 DIABETIC FOOT WEAR\n45 KNEE BRACES (LONG/ SHORT/ HINGED)\n46 KNEE IMMOBILIZER/SHOULDER IMMOBILIZER\n47 LUMBO SACRAL BELT\n\nGolden Shield\n27 CIN: L67200MH2000PLC129408UIN : ICIHLIP22012V012223\napplied incase voluntary deductible has been\nopted for.\nv. Base Co-payment shall be applicable on the\namount payable by Us and our liability to\nmake payment shall than be arrived at.\nvi. In case, the claim is for a Procedure/Medical\nCondition/Ailment/Disease which is subject to\nsub-limits as per policy terms and conditions,\nthe claim will be settled to the extent of\namount which is lesser of the three amounts –\ni.e. claimed amount or maximum amount as\nper sub-limits applicable or ICICI Lombard\nLiability after deduction of base co-payment/\nvoluntary deductible.\nc. Fees charged by surgeon, anesthetist,\nmedical practitioner\nd. Investigation expenses\niii. Zone based co-payment shall be applicable in\nall cases (Except medically necessar y\ntreatment for road traffic accidents) where\ntreatment is taken in a zone higher than for\nwhich premium was paid for\niv. The voluntary deductible shall be applied to\naggregate of all claims that are either paid or\npayable (not excluded) under this policy. Our\nliability to make payment shall commence only\nonce the aggregate amount of all claims\npayable or paid exceed the voluntar y\ndeductible. Base Co-payment shall not be\nIllustration 2 - Insured person opted for voluntary deductible\nHeading Particulars\nA. Annual Sum Insured ` 20,00,000 ` 20,00,000\nB. Voluntary deductible opted at time of policy issuance\nScenario 1 Scenario 2\n` 4,00,000 ` 4,00,000\nC. Base Co-payment applicable \nNA NA\nZone opted \nB (Goa) B (Goa)\nHospitalization Diagnosis \nHeart Attack/\nPTCA done/\nCardiovascular\ndisease\nHeart Attack/\nPTCA done/\nCardiovascular\ndisease\nTreatment taken in \nGoa (Zone B) \nMumbai (Zone A)\n` 20,00,000\nScenario 3\n` 4,00,000\nNA\nB (Goa)\nGuwahati (Zone C)\nHeart Attack/\nPTCA done/\nCardiovascular\ndisease\nIllustrations for claim settlement\nIllustration 1 - Insured Person opted for base co-payment\nHeading \nParticulars\nA. Annual Sum Insured ` 10,00,000 ` 10,00,000 ` 10,00,000\nB. Base Co-payment opted at time of policy issuance\nScenario 1 Scenario 2 Scenario 3\n20% 20% 20%\nZone opted \nB (Goa) B (Goa) \nB (Goa)\nHospitalization Diagnosis \nHeart Attack/\nPTCA done/\nCardiovascular\ndisease\nHeart Attack/\nPTCA done/\nCardiovascular\ndisease\nHeart Attack/\nPTCA done/\nCardiovascular\ndisease\nTreatment taken in \nGoa (Zone B) \nMumbai (Zone A) Guwahati (Zone C)\nC. Hospitalisation expenses Amount ` 4,00,000 \n` 5,00,000 \n` 3,00,000\nD. Pre and Post hospitalisation expenses ` 35,000 ` 50,000 ` 20,000\nE. Total claimed Expenses*[C+D] \n` 4,35,000 \n` 5,50,000 \n` 3,20,000\nF. Zone based co-payment 0% 15% 0%\nG. Claimed amount after application of zone based co-payment\n[E*F]\n` 4,35,000 ` 4,67,500 ` 3,20,000\nH. Sub-limit for cardiovascular diseases ` 3,50,000 ` 3,50,000\nI. Insured Person liability after application of base co-payment\n[G*B]\n` 87,000 ` 93,500 ` 64,000\nJ. ICICI Lombard Liability after deduction of co-payment [G-I] ` 3,48,000 ` 3,74,000 ` 2,56,000\nFinal payable amount to Insured Person [lesser amount out of G, H, J] ` 3,48,000 ` 3,50,000 ` 2,56,000\nK.\nBalance Annual Sum Insured [A-K] ` 6,52,000 ` 6,50,000 ` 7,44,000\nL.\n*It has been assumed that total claimed expenses are same as total payable expenses. i.e. there are no deductions in the claimed amount.\n` 3,50,000\n\nGolden Shield\n28 CIN: L67200MH2000PLC129408UIN : ICIHLIP22012V012223\nIllustrations for claim settlement (Contd.)\nIllustration 2 - Insured person opted for voluntary deductible (Contd.)\nHeading Particulars Scenario 1 Scenario 2 Scenario 3\nJ. Sub-limit for cardiovascular diseases ` 3,50,000 ` 3,50,000 ` 3,50,000\nFinal payable amount to Insured Person [lesser amount out of I,J] ` 35,000 ` 67,500\nK.\nBalance Annual Sum Insured [A-K] ` 19,65,000 ` 19,32,500 ` 20,00,000\nL.\n*It has been assumed that total claimed expenses are same as total payable expenses. i.e. there are no deductions in the claimed amount.\nD. Hospitalisation expenses Amount ` 4,00,000 ` 5,00,000 ` 3,00,000\nE. Pre and Post hospitalisation expenses ` 35,000 ` 50,000 ` 20,000\nF. Total claimed Expenses*[D+E] ` 4,35,000 ` 5,50,000 ` 3,20,000\nG. Zone based co-payment 0% 15% 0%\nH. Claimed amount after application of zone based co-payment\n[F*G]\n` 4,35,000 ` 4,67,500 ` 3,20,000\nI. IL Liability after application of voluntary deductible [H-B] ` 35,000 ` 67,500\nThe claim amount assessed above would be deducted from the\nfollowing amounts in the following progressive order:\n1. Annual Sum Insured\n2. Additional Sum Insured/Cumulative Bonus (if accrued and\navailable)\n3. Reset Sum Insured (If applicable)\nFurther, upon the discovery or happening of any Illness or Injury\nthat may give rise to a Claim under this Policy, then as a\ncondition precedent to the admission of Our liability, You shall\nundertake the following:\n1.1 Claims Procedure\nA. For Cashless Settlement\nCashless treatment is only available at a Network\nProvider (List of Network Providers is available at our\nwebsite). In order to avail of cashless treatment, the\nfollowing procedure must be followed by You:\nPre-authorization\nPrior to taking treatment and/ or incurring Medical\nExpenses at a Network Provider, You must contact Us\nor Our in house claim processing team accompanied\nwith full particulars namely, Policy Number, Your name,\nYour relationship with Policy Holder, nature of Illness or\nInjury, name and address of the Medical Practitioner/\nHospital and any other information that may be\nrelevant to the Illness/ Injury/ Hospitalisation. You must\nrequest preauthorization at least 48 hours before a\nplanned Hospitalization and in case of an emergency\nsituation, within 24 hours of Hospitalization. To avail of\nCashless Hospitalization facility, you are required to\nproduce the health card, as provided to You with this\nPolicy, subject to the terms and conditions for the\nusage of the said health card Or You can seek pre\nauthorization by providing Your Policy number and ID\nproof to the hospital who can co-ordinate with Our\nclaim team to provide cashless facility. We will consider\nYour request after having obtained accurate and\ncomplete information for the Illness or Injury for which\ncashless Hospitalization facility is sought by You and\nWe will confirm Your request in writing.\nB. For Reimbursement Settlement\ni. You shall give notice to Us or Our in house claim\nprocessing team by calling the toll free number\n1 8 0 0 2 6 6 6 o r e m a i l i n g u s a t a s\ncustomersupport@icicilombard.com specified in\nthe Policy provided to You and also in writing at\nOur address with particulars as below:\nv Policy number;\nv Your Name;\nv Your relationship with the Policyholder;\nv Nature of Illness or Injury;\nv Name and address of the attending Medical\nPractitioner and the Hospital;\nv Any other information that may be relevant to\nthe Illness/ Injury/ Hospitalisation\nThe above information needs to be provided to Us\nor Our in house claim processing team immediately\nand in any event within 10 days of Hospitalization,\nfailing which We will have the right to treat the\nClaim as inadmissible, as We may deem fit at Our\nsole discretion.\nii. You must immediately consult a Medical\nPractitioner and follow the advice and treatment\nthat he recommends.\nNA as\nexpenses have\nnot crossed\nvoluntary\ndeductible\namount\n-\n\nGolden Shield\n29 CIN: L67200MH2000PLC129408UIN : ICIHLIP22012V012223\nof Policy) OR communicate non admissibility of claim\nwithin 14 days after You submit complete set of\ndocuments & information in respect of the claims. In\ncase We fail to make the payment of admissible claims\nor to communicate non admissibility of claim within the\ntime period, We shall pay 2% interest over and above\nthe rate defined as per IRDAI (Protection of\nPolicyholder's interest) Regulation 2017.\nB. For Cashless Claims: If You notify pre authorization\nrequest for cashless facility through any of Our\nempanelled network hospitals along with complete set\nof documents & information, We will respond within 4\nhours of the actual receipt of such pre authorization\nrequest with:\na. Approval, or\nb. Rejection, or\nc. Query seeking further information\nIn case the request is for enhancement, i.e. Request\nfor increase in the amount already authorized, We\nwill respond to it within 3 hours.\nIn case of delay in response by Us beyond the time\nperiod as stated above for cashless claims, We\nshall be liable to pay 1,000 to You. Our maximum`\nliability in respect of a single hospitalization shall,\nat no time exceed 1,000. We will not be liable to`\nmake any payments under this Claim Service\nGuarantee in case of any force majeure, natural\nevent or manmade disturbance which impedes\nOur inability to make a decision or to communicate\nsuch decisions to You.\nThe service guarantee shall not be applicable for\nany cases delayed on account of reasonable\napprehension of fraud or fraudulent claims or\ncases referred to/by any adjudicative forum for\nnecessary disposal.\nYo u m ay l o d g e c l a i m s e p a ra te l y fo r t h e\nhospitalization claim, Pre-Post hospitalization. In\nsuch scenario, if delay happens beyond the time\nperiod as specified above, the interest amount\ncalculated will be on the net sanctioned amount of\nrespective transaction and not the total amount\npaid for the entire claim.\nAny amount paid towards interest under Claim\nService Guarantee will not affect the Annual Sum\nInsured as specified in the Schedule.\nIf you are not eligible for 'Claim Service Guarantee'\nfor the reasons stated above, We will inform the\nsame to You, within 14 days in case of A. For\nReimbursement claims and within 4 hours in case\nof B. For Cashless claims above.\nYou or someone claiming on Your behalf must promptly\nand in any event within 30 days of Your discharge from\na Hospital (for post-hospitalization expenses, within\n30 days from the completion of post-hospitalization\nperiod) deliver to Us the documentation (written details\nof the quantum of any Claim along with all original\nsupporting documentation) as more particularly listed\nin Claim documents section. In case there is a delay\nbeyond 30 days in submission of claim documents, we\nmay condone the delay provided the insured person\nsubmits a valid reason justifying the delay to us in\nwriting. However, in both the above cases i.e.\ng.1.1.1(A) & (B), You must take reasonable steps or\nmeasure to minimise the quantum of any Claim that\nmay be covered under the Policy If so requested by Us\nor Our in house claim processing team, You will have to\nundergo a medical examination from Our nominated\nMedical Practitioner, as and when We or Our in house\nclaim processing team considers reasonable and\nnecessary. The cost of such examination will be borne\nby Us.\nClaim falling in two Policy periods\nIf the claim event falls within two Policy periods, the claims\nshall be paid taking into consideration the available Sum\nInsured in the two Policy periods, including the Deductions\nfor each Policy Period. Such eligible claim amount to be\npayable to the Insured shall be reduced to the extent of\npremium to be received for the Renewal/due date of\npremium of health insurance Policy, if not received earlier.\n1.2 CLAIM DOCUMENTS\nYou shall be required to furnish the following documents for\nor in support of a Claim:\ni. Duly completed Claim form signed by You and the\nMedical Practitioner. The claim form can be\ndownloaded from our website www.icicilombard.com.\nii. Original bills, receipts and discharge certificate/ card\nfrom the Hospital/ Medical Practitioner.\niii. Original bills from chemists supported by proper\nprescription.\niv. Original investigation test reports and payment\nreceipts.\nv. Indoor case papers\nvi. Medical Practitioner's referral letter advising\nHospitalization in non-Accident cases.\nvii. Any other document as required by Us or Our TPA to\ninvestigate the Claim or Our obligation to make\npayment for it\n1.3 Claim Service Guarantee\nWe provide You Claim Service Guarantee as follows\nA. For Reimbursement Claims: We shall make the\npayment of admissible claim (as per terms & conditions\n\nGolden Shield\n30 CIN: L67200MH2000PLC129408UIN : ICIHLIP22012V012223\nOffice Details\nJurisdiction of Office\nUnion Territory, District)\nBHOPAL\nOffice of the Insurance Ombudsman,\nJanak Vihar Complex, 2nd Floor, 6, Malviya\nNagar, Opp. Airtel Office, Near New Market,\nBhopal – 462 003.\nTel.: 0755 - 2769201 / 2769202\nFax: 0755 - 2769203\nEmail: bimalokpal.bhopal@cioins.co.in\nMadhya Pradesh\nChattisgarh.\nBHUBANESHWAR - Shri Suresh Chandra\nPanda\nOffice of the Insurance Ombudsman, 62,\nForest park, Bhubneshwar – 751 009.\nTel.: 0674 - 2596461 /2596455\nFax: 0674 - 2596429\nEmail: bimalokpal.bhubaneswar@cioins.co.in\nOrissa.\nCHANDIGARH\nOffice of the Insurance Ombudsman,\nS.C.O. No. 101, 102 & 103, 2nd Floor,\nBatra Building, Sector 17-D,\nChandigarh - 160 017.\nTel.: 0172 - 2706196 / 2706468\nFax: 0172 - 2708274\nEmail: bimalokpal.chandigarh@cioins.co.in\nPunjab, Haryana\n(excluding Gurugram,\nFaridabad, Sonepat\nand Bahadurgarh)\nHimachal Pradesh,\nUnion Territories of\nJammu & Kashmir,\nLadakh &\nChandigarh.\nCHENNAI\nOffice of the Insurance Ombudsman,\nFatima Akhtar Court, 4th Floor, 453,\nAnna Salai, Teynampet, Chennai - 600 018.\nTel.: 044 - 24333668 / 24335284\nFax: 044 - 24333664\nEmail: bimalokpal.chennai@cioins.co.in\nTamil Nadu, Tamil\nNadu Puducherry\nTown and Karaikal\n(which are part of\nPuducherry).\nAHMEDABAD - Shri Kuldip Singh\nOffice of the Insurance Ombudsman,\nJeevan Prakash Building, 6th Floor, Tilak\nMarg, Relief Road, Ahmedabad - 380 001.\nTel.: 079 - 25501201/02/05/06\nEmail: bimalokpal.ahmedabad@cioins.co.in\nGujarat, Dadra &\nNagar Haveli, Daman\nand Diu.\nBENGALURU\nOffice of the Insurance Ombudsman,\nJeevan Soudha Building, PID No. 57-27-N-19,\nGround Floor, 19/19, 24th Main Road,\nJP Nagar, Ist Phase, Bengaluru - 560 078.\nTel.: 080 - 26652048 / 26652049\nEmail: bimalokpal.bengaluru@cioins.co.in\nKarnataka.\nOffice Details\nJurisdiction of Office\nUnion Territory, District)\nDELHI - Shri Sudhir Krishna\nOffice of the Insurance Ombudsman,\n2/2 A, Universal Insurance Building,\nAsaf Ali Road, New Delhi - 110 002.\nTel.: 011 - 23232481/23213504\nEmail: bimalokpal.delhi@cioins.co.in\nDelhi & Following\nDistricts of Haryana\n- Gurugram,\nFaridabad, Sonepat\n& Bahadurgarh.\nGUWAHATI\nOffice of the Insurance Ombudsman,\nJeevan Nivesh, 5th Floor, Nr. Panbazar over\nBridge, S. S. Road, Guwahati -781001\n(ASSAM).\nTel.: 0361 - 2632204 / 2602205\nEmail: bimalokpal.guwahati@cioins.co.in\nAssam, Meghalaya,\nManipur, Mizoram,\nArunachal Pradesh,\nNagaland and\nTripura.\nHYDERABAD\nOffice of the Insurance Ombudsman,\n6-2-46, 1st floor, “Moin Court”, Lane Opp.\nSaleem Function Palace, A. C. Guards,\nLakdi-Ka-Pool, Hyderabad - 500 004.\nTel.: 040 - 23312122 Fax: 040 - 23376599\nEmail: bimalokpal.hyderabad@cioins.co.in\nAndhra Pradesh,\nTelangana, Yanam\nand part of Union\nTerritory of\nPuducherry.\nERNAKULAM - Ms. Poonam Bodra\nOffice of the Insurance Ombudsman,\n2nd Floor, Pulinat Bldg., Opp. Cochin\nShipyard, M. G. Road, Ernakulam - 682 015.\nTel.: 0484 - 2358759 / 2359338\nFax: 0484 - 2359336\nEmail: bimalokpal.ernakulam@cioins.co.in\nKerala, Lakshadweep,\nMahe-a part of Union\nTerritory of\nPuducherry.\nKOLKATA - Shri P. K. Rath\nOffice of the Insurance Ombudsman,\nHindustan Bldg. Annexe, 4th Floor,\n4, C.R. Avenue, KOLKATA - 700 072.\nTel.: 033 - 22124339 / 22124340\nFax : 033 - 22124341\nEmail: bimalokpal.kolkata@cioins.co.in\nWest Bengal, Sikkim,\nAndaman & Nicobar\nIslands.\nJAIPUR\nOffice of the Insurance Ombudsman,\nJeevan Nidhi - II Bldg., Gr. Floor, Bhawani\nSingh Marg, Jaipur - 302 005.\nTel.: 0141 - 2740363\nEmail: bimalokpal.jaipur@cioins.co.in\nRajasthan.\nAnnexure A\nLUCKNOW - Shri Justice Anil Kumar\nSrivastava\nOffice of the Insurance Ombudsman,\n6th Floor, Jeevan Bhawan, Phase-II,\nNawal Kishore Road, Hazratganj,\nLucknow - 226 001.\nTel.: 0522 - 2231330 / 2231331\nFax: 0522 - 2231310\nEmail: bimalokpal.lucknow@cioins.co.in\nDistricts of Uttar\nPradesh : Lalitpur,\nJhansi, Mahoba,\nHamirpur, Banda,\nChitrakoot,\nAllahabad, Mirzapur,\nSonbhabdra,\nFatehpur, Pratapgarh,\nJaunpur,Varanasi,\nGazipur, Jalaun,\nKanpur, Lucknow,\nUnnao, Sitapur,\nLakhimpur, Bahraich,\nBarabanki, Raebareli,\nSravasti, Gonda,\nFaizabad, Amethi,\nKaushambi,\nBalrampur, Basti,\nAmbedkarnagar,\nSultanpur,\nMaharajgang,\nSantkabirnagar,\nAzamgarh,\nKushinagar,\nGorkhpur, Deoria,\nMau, Ghazipur,\nChandauli, Ballia,\nSidharathnagar.\nMUMBAI\nOffice of the Insurance Ombudsman,\n3rd Floor, Jeevan Seva Annexe, S. V. Road,\nSantacruz (W), Mumbai - 400 054.\nTel.: 022 - 26106552 / 26106960\nFax: 022 - 26106052\nEmail: bimalokpal.mumbai@cioins.co.in\nGoa, Mumbai\nMetropolitan Region\nexcluding Navi\nMumbai & Thane.\n\nGolden Shield\n31 CIN: L67200MH2000PLC129408UIN : ICIHLIP22012V012223\nOffice Details\nJurisdiction of Office\nUnion Territory, District) \nOffice Details\nJurisdiction of Office\nUnion Territory, District)\nAnnexure A (Contd.)\nNOIDA - Shri Chandra Shekhar Prasad\nOffice of the Insurance Ombudsman,\nBhagwan Sahai Palace, 4th Floor, Main\nRoad, Naya Bans, Sector 15, Distt: Gautam\nBuddh Nagar, U.P-201301.\nTel.: 0120-2514252 / 2514253\nEmail: bimalokpal.noida@cioins.co.in\nState of Uttaranchal\nand the following\nDistricts of Uttar\nPradesh: Agra,\nAligarh, Bagpat,\nBareilly, Bijnor,\nBudaun,\nBulandshehar, Etah,\nKanooj, Mainpuri,\nMathura, Meerut,\nMoradabad,\nMuzaffarnagar,\nOraiyya, Pilibhit,\nEtawah, Farrukhabad,\nFirozbad,\nGautambodhanagar,\nGhaziabad, Hardoi,\nShahjahanpur, Hapur,\nShamli, Rampur,\nKashganj, Sambhal,\nAmroha, Hathras,\nKanshiramnagar,\nSaharanpur.\nPATNA - Shri N. K. Singh\nOffice of the Insurance Ombudsman,\n1st Floor, Kalpana Arcade Building,\nBazar Samiti Road, Bahadurpur,\nPatna 800 006. Tel.: 0612-2680952\nEmail: bimalokpal.patna@cioins.co.in\nBihar, Jharkhand.\nPUNE - Shri Vinay Sah\nOffice of the Insurance Ombudsman,\nJeevan Darshan Bldg., 3rd Floor,\nC.T.S. No.s. 195 to 198, N. C. Kelkar Road,\nNarayan Peth, Pune - 411 030.\nTel.: 020-41312555\nEmail: bimalokpal.pune@cioins.co.in\nMaharashtra, Area of\nNavi Mumbai and\nThane excluding\nMumbai Metropolitan\nRegion.\nMailing Address : 601 & 602, 6th Floor, Interface 16, New Linking Road, Malad (West), Mumbai - 400 064.\nCorporate Office : ICICI Lombard House, 414, Veer Savarkar Marg, Near Siddhi Vinayak Temple, Prabhadevi, Mumbai 400 025.\nVisit us at www.icicilombard.com • Mail us at customersupport@icicilombard.com • Toll Free No.: 1800 2666 (Toll Free also accessible from your mobile)\nInsurance is the subject matter of solicitation. IRDA Reg. No. 115 UIN: ICIHLIP22012V012223\nICICI Lombard General Insurance Company Limited",
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        "output": "Here's the extracted relevant information:\n\n---\n\n### General Queries (Buy/Renew/Service/Claim)\n\n*   **Website:** www.icicilombard.com\n*   **Toll-Free Number:** 1800 2666\n*   **Email for Customer Support:** customersupport@icicilombard.com\n*   **Grievance Redressal (if initial contact is insufficient):**\n    *   **Website:** www.icicilombard.com (Grievance Redressal section)\n    *   **Toll Free:** 1800 2666\n    *   **Email:** customersupport@icicilombard.com\n    *   **Courier:** ICICI Lombard General Insurance Company Ltd., ICICI Lombard House, 414, Veer Savarkar Marg, Near Siddhi Vinayak Temple, Prabhadevi, Mumbai- 400025\n    *   **Insurance Ombudsman:** If not satisfied with company's redressal, you can approach the office of the Insurance Ombudsman for your respective area/region (Annexure A in the policy wording lists contact details and jurisdictions).\n    *   **IRDAI Integrated Grievance Management System:** https://igms.irda.gov.in/\n\n---\n\n### Claim Scenario Analysis: Accident - Knee Fracture, Medicines (`5000), Surgery (`50000)\n\n**Policy:** Golden Shield (UIN: ICIHLIP22012V012223)\n\n**Total Claimed Amount:** `55,000 (`5,000 for medicines + `50,000 for surgery)\n\n**Admissibility & Coverage:**\n\n1.  **Covered Event:** An \"Accident\" and resulting \"Injury\" (like a knee fracture) are generally covered under the policy's base inpatient treatment benefits.\n2.  **Waiting Periods:**\n    *   **30-day waiting period (Excl03):** Not applicable for claims arising due to an accident.\n    *   **24-month specified disease/procedure waiting period (Excl02):** Not applicable for claims arising due to an accident.\n    *   **Pre-existing Diseases (Excl01):** If the knee fracture is directly due to an accident, the PED exclusion typically wouldn't apply, provided the accident is the sole cause.\n3.  **In Patient Treatment:**\n    *   **Surgery and Medical Practitioner's Fees:** Covered under Base Cover 1 (In Patient Treatment) for Medical Practitioner’s Fees (iv) and Anaesthesia, operation theatre charges, medicines, drugs and consumables (v).\n    *   **Medicines:** The `5,000 for medicines would be covered as \"medicines, drugs and consumables\" (d.1.v) if incurred during hospitalization.\n4.  **Sub-limits (d.15):** Surgery for \"breakage of long bones/Joint replacements\" has sub-limits based on the Annual Sum Insured (ASI):\n    *   ASI 3L/4L/5L: `1,00,000\n    *   ASI 10L/15L/20L: `1,75,000\n    *   ASI >20L: `2,50,000\n    *   Since the surgery cost is `50,000, it falls within all these sub-limits and would likely be covered up to this amount, subject to other deductions.\n5.  **Ambulance Cover (d.10, d.11):** If road or air ambulance was used to transport the insured person to the hospital for Emergency Care related to this accident, those expenses might also be covered (road ambulance up to 1% of ASI, max `10,000; air ambulance up to ASI). The prompt doesn't mention ambulance use, but it's a potential benefit for accident claims.\n\n**Potential Deductions and Conditions:**\n\n1.  **Base Co-payment (d.12):** If the insured person has opted for a Base Co-payment (e.g., 50%), then that percentage of the admissible claim amount will be borne by the insured.\n2.  **Voluntary Deductible (d.3):** If a Voluntary Deductible was opted for, that amount must be paid first by the insured before the insurer's liability commences. (Note: Base Co-payment and Voluntary Deductible are mutually exclusive; you cannot opt for both).\n3.  **Zone-based Co-payment (e.18):**\n    *   If the \"accident\" is **not** a \"Road Traffic Accident,\" and the treatment is taken in a higher geographical zone (e.g., Zone A) than the zone for which premium was paid (e.g., Zone C), an additional zone-based co-payment (e.g., 25% for A from C) would apply *in addition to any base co-payment*.\n    *   **Crucially:** \"Zone based co-payment shall not be applicable in case of medically necessary treatment taken for road traffic accidents.\" So, if this was specifically a Road Traffic Accident, this deduction would not apply.\n4.  **Room Rent Pro-rata Deduction (d.1.v):** If the insured person is admitted to a room category higher than their entitlement (based on Annual Sum Insured), a proportionate deduction on \"Associated medical expenses\" (including nursing, OT charges, medical practitioner fees) will apply. ICU charges are exempt from this.\n5.  **Non-Payable Items (f.30):** Certain items commonly used for fractures, such as \"BELTS/ BRACES,\" \"SLINGS,\" \"WALKING AIDS CHARGES,\" \"KNEE BRACES,\" \"KNEE IMMOBILIZER,\" \"LUMBO SACRAL BELT\" are explicitly listed as non-payable and would be deducted from the claim if included in the `55,000.\n6.  **Claim Procedure (f.1.1):**\n    *   **Notification:** Must be given to ICICI Lombard within 10 days of hospitalization for reimbursement, or a pre-authorization request made at least 48 hours before planned hospitalization (within 24 hours for emergency) for cashless.\n    *   **Document Submission:** All required original documents must be submitted within 30 days of discharge (or completion of post-hospitalization period).\n\n---\n\n### Input Query to Next Node\n\n**Claim Type:** Medical Expense (Hospitalization - Accident/Injury)\n**Policy Holder:** [Assumed, not specified in input]\n**Policy Name:** Golden Shield\n**UIN:** ICIHLIP22012V012223\n**Claim Event:** Accident resulting in Knee Fracture\n**Claimed Costs:**\n    *   Medicines: `5,000\n    *   Surgery: `50,000\n    *   **Total Initial Claim:** `55,000\n\n**Assessment Details:**\n*   **Admissibility:** High probability of coverage, as accident claims generally bypass initial waiting periods. Surgery and inpatient medicines are covered benefits.\n*   **Sub-limits Check:** `50,000 for surgery is within the policy's sub-limits for \"breakage of long bones/Joint replacements\" across all Sum Insured tiers.\n*   **Critical Missing Information / Conditions for Final Payout:**\n    1.  **Annual Sum Insured (ASI):** Required for room rent entitlement and to confirm overall coverage limits.\n    2.  **Co-payment/Deductible Choice:** Was a Base Co-payment (e.g., 50%) or Voluntary Deductible opted for? This significantly impacts the net payable amount.\n    3.  **Accident Type:** Was it a \"Road Traffic Accident\" (RTA)? If yes, zone-based co-payment is waived. If not an RTA, further check on Zone-based premium paid vs. treatment zone is needed.\n    4.  **Treatment Zone:** Which geographical zone (A, B, or C) was the treatment received in? Which zone was the premium paid for? (Relevant if not an RTA).\n    5.  **Room Category:** What room category was utilized during hospitalization, and what is the insured's entitlement based on their ASI? (To check for potential pro-rata deductions).\n    6.  **Non-Payable Items Check:** Are the `55,000 expenses net of any \"Non-Payable Items\" (e.g., braces, splints, walking aids) relevant to a knee fracture? If not, further deductions will apply.\n    7.  **Network Provider Status:** Was the treatment taken at a Network Provider (for cashless) or Non-Network Provider (for reimbursement)?\n    8.  **Claim Process Compliance:** Was pre-authorization obtained for cashless, or notification and documents submitted within stipulated timelines for reimbursement?\n\n**Initial Estimated Payout (Best Case - No Co-pay/Deductible, No Room Rent Deduction, Zone Match, Covered Items):** `55,000 (subject to above conditions and actual bill itemization).`"
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        "output": "Here's the extracted relevant information:\n\n---\n\n### General Queries (Buy/Renew/Service/Claim)\n\n*   **Website:** www.icicilombard.com\n*   **Toll-Free Number:** 1800 2666\n*   **Email for Customer Support:** customersupport@icicilombard.com\n*   **Grievance Redressal (if initial contact is insufficient):**\n    *   **Website:** www.icicilombard.com (Grievance Redressal section)\n    *   **Toll Free:** 1800 2666\n    *   **Email:** customersupport@icicilombard.com\n    *   **Courier:** ICICI Lombard General Insurance Company Ltd., ICICI Lombard House, 414, Veer Savarkar Marg, Near Siddhi Vinayak Temple, Prabhadevi, Mumbai- 400025\n    *   **Insurance Ombudsman:** If not satisfied with company's redressal, you can approach the office of the Insurance Ombudsman for your respective area/region (Annexure A in the policy wording lists contact details and jurisdictions).\n    *   **IRDAI Integrated Grievance Management System:** https://igms.irda.gov.in/\n\n---\n\n### Claim Scenario Analysis: Accident - Knee Fracture, Medicines (`5000), Surgery (`50000)\n\n**Policy:** Golden Shield (UIN: ICIHLIP22012V012223)\n\n**Total Claimed Amount:** `55,000 (`5,000 for medicines + `50,000 for surgery)\n\n**Admissibility & Coverage:**\n\n1.  **Covered Event:** An \"Accident\" and resulting \"Injury\" (like a knee fracture) are generally covered under the policy's base inpatient treatment benefits.\n2.  **Waiting Periods:**\n    *   **30-day waiting period (Excl03):** Not applicable for claims arising due to an accident.\n    *   **24-month specified disease/procedure waiting period (Excl02):** Not applicable for claims arising due to an accident.\n    *   **Pre-existing Diseases (Excl01):** If the knee fracture is directly due to an accident, the PED exclusion typically wouldn't apply, provided the accident is the sole cause.\n3.  **In Patient Treatment:**\n    *   **Surgery and Medical Practitioner's Fees:** Covered under Base Cover 1 (In Patient Treatment) for Medical Practitioner’s Fees (iv) and Anaesthesia, operation theatre charges, medicines, drugs and consumables (v).\n    *   **Medicines:** The `5,000 for medicines would be covered as \"medicines, drugs and consumables\" (d.1.v) if incurred during hospitalization.\n4.  **Sub-limits (d.15):** Surgery for \"breakage of long bones/Joint replacements\" has sub-limits based on the Annual Sum Insured (ASI):\n    *   ASI 3L/4L/5L: `1,00,000\n    *   ASI 10L/15L/20L: `1,75,000\n    *   ASI >20L: `2,50,000\n    *   Since the surgery cost is `50,000, it falls within all these sub-limits and would likely be covered up to this amount, subject to other deductions.\n5.  **Ambulance Cover (d.10, d.11):** If road or air ambulance was used to transport the insured person to the hospital for Emergency Care related to this accident, those expenses might also be covered (road ambulance up to 1% of ASI, max `10,000; air ambulance up to ASI). The prompt doesn't mention ambulance use, but it's a potential benefit for accident claims.\n\n**Potential Deductions and Conditions:**\n\n1.  **Base Co-payment (d.12):** If the insured person has opted for a Base Co-payment (e.g., 50%), then that percentage of the admissible claim amount will be borne by the insured.\n2.  **Voluntary Deductible (d.3):** If a Voluntary Deductible was opted for, that amount must be paid first by the insured before the insurer's liability commences. (Note: Base Co-payment and Voluntary Deductible are mutually exclusive; you cannot opt for both).\n3.  **Zone-based Co-payment (e.18):**\n    *   If the \"accident\" is **not** a \"Road Traffic Accident,\" and the treatment is taken in a higher geographical zone (e.g., Zone A) than the zone for which premium was paid (e.g., Zone C), an additional zone-based co-payment (e.g., 25% for A from C) would apply *in addition to any base co-payment*.\n    *   **Crucially:** \"Zone based co-payment shall not be applicable in case of medically necessary treatment taken for road traffic accidents.\" So, if this was specifically a Road Traffic Accident, this deduction would not apply.\n4.  **Room Rent Pro-rata Deduction (d.1.v):** If the insured person is admitted to a room category higher than their entitlement (based on Annual Sum Insured), a proportionate deduction on \"Associated medical expenses\" (including nursing, OT charges, medical practitioner fees) will apply. ICU charges are exempt from this.\n5.  **Non-Payable Items (f.30):** Certain items commonly used for fractures, such as \"BELTS/ BRACES,\" \"SLINGS,\" \"WALKING AIDS CHARGES,\" \"KNEE BRACES,\" \"KNEE IMMOBILIZER,\" \"LUMBO SACRAL BELT\" are explicitly listed as non-payable and would be deducted from the claim if included in the `55,000.\n6.  **Claim Procedure (f.1.1):**\n    *   **Notification:** Must be given to ICICI Lombard within 10 days of hospitalization for reimbursement, or a pre-authorization request made at least 48 hours before planned hospitalization (within 24 hours for emergency) for cashless.\n    *   **Document Submission:** All required original documents must be submitted within 30 days of discharge (or completion of post-hospitalization period).\n\n---\n\n### Input Query to Next Node\n\n**Claim Type:** Medical Expense (Hospitalization - Accident/Injury)\n**Policy Holder:** [Assumed, not specified in input]\n**Policy Name:** Golden Shield\n**UIN:** ICIHLIP22012V012223\n**Claim Event:** Accident resulting in Knee Fracture\n**Claimed Costs:**\n    *   Medicines: `5,000\n    *   Surgery: `50,000\n    *   **Total Initial Claim:** `55,000\n\n**Assessment Details:**\n*   **Admissibility:** High probability of coverage, as accident claims generally bypass initial waiting periods. Surgery and inpatient medicines are covered benefits.\n*   **Sub-limits Check:** `50,000 for surgery is within the policy's sub-limits for \"breakage of long bones/Joint replacements\" across all Sum Insured tiers.\n*   **Critical Missing Information / Conditions for Final Payout:**\n    1.  **Annual Sum Insured (ASI):** Required for room rent entitlement and to confirm overall coverage limits.\n    2.  **Co-payment/Deductible Choice:** Was a Base Co-payment (e.g., 50%) or Voluntary Deductible opted for? This significantly impacts the net payable amount.\n    3.  **Accident Type:** Was it a \"Road Traffic Accident\" (RTA)? If yes, zone-based co-payment is waived. If not an RTA, further check on Zone-based premium paid vs. treatment zone is needed.\n    4.  **Treatment Zone:** Which geographical zone (A, B, or C) was the treatment received in? Which zone was the premium paid for? (Relevant if not an RTA).\n    5.  **Room Category:** What room category was utilized during hospitalization, and what is the insured's entitlement based on their ASI? (To check for potential pro-rata deductions).\n    6.  **Non-Payable Items Check:** Are the `55,000 expenses net of any \"Non-Payable Items\" (e.g., braces, splints, walking aids) relevant to a knee fracture? If not, further deductions will apply.\n    7.  **Network Provider Status:** Was the treatment taken at a Network Provider (for cashless) or Non-Network Provider (for reimbursement)?\n    8.  **Claim Process Compliance:** Was pre-authorization obtained for cashless, or notification and documents submitted within stipulated timelines for reimbursement?\n\n**Initial Estimated Payout (Best Case - No Co-pay/Deductible, No Room Rent Deduction, Zone Match, Covered Items):** `55,000 (subject to above conditions and actual bill itemization).`"
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      {
        "chat_input": "accident - knee fracture ,  medicines - 5000 , surgery - 50000 , ",
        "output": "Here's the extracted relevant information:\n\n---\n\n### General Queries (Buy/Renew/Service/Claim)\n\n*   **Website:** www.icicilombard.com\n*   **Toll-Free Number:** 1800 2666\n*   **Email for Customer Support:** customersupport@icicilombard.com\n*   **Grievance Redressal (if initial contact is insufficient):**\n    *   **Website:** www.icicilombard.com (Grievance Redressal section)\n    *   **Toll Free:** 1800 2666\n    *   **Email:** customersupport@icicilombard.com\n    *   **Courier:** ICICI Lombard General Insurance Company Ltd., ICICI Lombard House, 414, Veer Savarkar Marg, Near Siddhi Vinayak Temple, Prabhadevi, Mumbai- 400025\n    *   **Insurance Ombudsman:** If not satisfied with company's redressal, you can approach the office of the Insurance Ombudsman for your respective area/region (Annexure A in the policy wording lists contact details and jurisdictions).\n    *   **IRDAI Integrated Grievance Management System:** https://igms.irda.gov.in/\n\n---\n\n### Claim Scenario Analysis: Accident - Knee Fracture, Medicines (`5000), Surgery (`50000)\n\n**Policy:** Golden Shield (UIN: ICIHLIP22012V012223)\n\n**Total Claimed Amount:** `55,000 (`5,000 for medicines + `50,000 for surgery)\n\n**Admissibility & Coverage:**\n\n1.  **Covered Event:** An \"Accident\" and resulting \"Injury\" (like a knee fracture) are generally covered under the policy's base inpatient treatment benefits.\n2.  **Waiting Periods:**\n    *   **30-day waiting period (Excl03):** Not applicable for claims arising due to an accident.\n    *   **24-month specified disease/procedure waiting period (Excl02):** Not applicable for claims arising due to an accident.\n    *   **Pre-existing Diseases (Excl01):** If the knee fracture is directly due to an accident, the PED exclusion typically wouldn't apply, provided the accident is the sole cause.\n3.  **In Patient Treatment:**\n    *   **Surgery and Medical Practitioner's Fees:** Covered under Base Cover 1 (In Patient Treatment) for Medical Practitioner’s Fees (iv) and Anaesthesia, operation theatre charges, medicines, drugs and consumables (v).\n    *   **Medicines:** The `5,000 for medicines would be covered as \"medicines, drugs and consumables\" (d.1.v) if incurred during hospitalization.\n4.  **Sub-limits (d.15):** Surgery for \"breakage of long bones/Joint replacements\" has sub-limits based on the Annual Sum Insured (ASI):\n    *   ASI 3L/4L/5L: `1,00,000\n    *   ASI 10L/15L/20L: `1,75,000\n    *   ASI >20L: `2,50,000\n    *   Since the surgery cost is `50,000, it falls within all these sub-limits and would likely be covered up to this amount, subject to other deductions.\n5.  **Ambulance Cover (d.10, d.11):** If road or air ambulance was used to transport the insured person to the hospital for Emergency Care related to this accident, those expenses might also be covered (road ambulance up to 1% of ASI, max `10,000; air ambulance up to ASI). The prompt doesn't mention ambulance use, but it's a potential benefit for accident claims.\n\n**Potential Deductions and Conditions:**\n\n1.  **Base Co-payment (d.12):** If the insured person has opted for a Base Co-payment (e.g., 50%), then that percentage of the admissible claim amount will be borne by the insured.\n2.  **Voluntary Deductible (d.3):** If a Voluntary Deductible was opted for, that amount must be paid first by the insured before the insurer's liability commences. (Note: Base Co-payment and Voluntary Deductible are mutually exclusive; you cannot opt for both).\n3.  **Zone-based Co-payment (e.18):**\n    *   If the \"accident\" is **not** a \"Road Traffic Accident,\" and the treatment is taken in a higher geographical zone (e.g., Zone A) than the zone for which premium was paid (e.g., Zone C), an additional zone-based co-payment (e.g., 25% for A from C) would apply *in addition to any base co-payment*.\n    *   **Crucially:** \"Zone based co-payment shall not be applicable in case of medically necessary treatment taken for road traffic accidents.\" So, if this was specifically a Road Traffic Accident, this deduction would not apply.\n4.  **Room Rent Pro-rata Deduction (d.1.v):** If the insured person is admitted to a room category higher than their entitlement (based on Annual Sum Insured), a proportionate deduction on \"Associated medical expenses\" (including nursing, OT charges, medical practitioner fees) will apply. ICU charges are exempt from this.\n5.  **Non-Payable Items (f.30):** Certain items commonly used for fractures, such as \"BELTS/ BRACES,\" \"SLINGS,\" \"WALKING AIDS CHARGES,\" \"KNEE BRACES,\" \"KNEE IMMOBILIZER,\" \"LUMBO SACRAL BELT\" are explicitly listed as non-payable and would be deducted from the claim if included in the `55,000.\n6.  **Claim Procedure (f.1.1):**\n    *   **Notification:** Must be given to ICICI Lombard within 10 days of hospitalization for reimbursement, or a pre-authorization request made at least 48 hours before planned hospitalization (within 24 hours for emergency) for cashless.\n    *   **Document Submission:** All required original documents must be submitted within 30 days of discharge (or completion of post-hospitalization period).\n\n---\n\n### Input Query to Next Node\n\n**Claim Type:** Medical Expense (Hospitalization - Accident/Injury)\n**Policy Holder:** [Assumed, not specified in input]\n**Policy Name:** Golden Shield\n**UIN:** ICIHLIP22012V012223\n**Claim Event:** Accident resulting in Knee Fracture\n**Claimed Costs:**\n    *   Medicines: `5,000\n    *   Surgery: `50,000\n    *   **Total Initial Claim:** `55,000\n\n**Assessment Details:**\n*   **Admissibility:** High probability of coverage, as accident claims generally bypass initial waiting periods. Surgery and inpatient medicines are covered benefits.\n*   **Sub-limits Check:** `50,000 for surgery is within the policy's sub-limits for \"breakage of long bones/Joint replacements\" across all Sum Insured tiers.\n*   **Critical Missing Information / Conditions for Final Payout:**\n    1.  **Annual Sum Insured (ASI):** Required for room rent entitlement and to confirm overall coverage limits.\n    2.  **Co-payment/Deductible Choice:** Was a Base Co-payment (e.g., 50%) or Voluntary Deductible opted for? This significantly impacts the net payable amount.\n    3.  **Accident Type:** Was it a \"Road Traffic Accident\" (RTA)? If yes, zone-based co-payment is waived. If not an RTA, further check on Zone-based premium paid vs. treatment zone is needed.\n    4.  **Treatment Zone:** Which geographical zone (A, B, or C) was the treatment received in? Which zone was the premium paid for? (Relevant if not an RTA).\n    5.  **Room Category:** What room category was utilized during hospitalization, and what is the insured's entitlement based on their ASI? (To check for potential pro-rata deductions).\n    6.  **Non-Payable Items Check:** Are the `55,000 expenses net of any \"Non-Payable Items\" (e.g., braces, splints, walking aids) relevant to a knee fracture? If not, further deductions will apply.\n    7.  **Network Provider Status:** Was the treatment taken at a Network Provider (for cashless) or Non-Network Provider (for reimbursement)?\n    8.  **Claim Process Compliance:** Was pre-authorization obtained for cashless, or notification and documents submitted within stipulated timelines for reimbursement?\n\n**Initial Estimated Payout (Best Case - No Co-pay/Deductible, No Room Rent Deduction, Zone Match, Covered Items):** `55,000 (subject to above conditions and actual bill itemization).`"
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