ICICI Lombard General Insurance Company LTD
ICICI LOMBARD HOUSE, 414, Veer Savarkar Marg,
Near Siddhi Vinayak Temple, Prabhadevi, Mumbai 400 025
GROUP HEALTH (FLOATER) INSURANCE
CUSTOMER INFORMATION SHEET
DISCLAIMER NOTE: The information mentioned below is illustrative and not exhaustive. The information must be read in conjunction with the
policy wordings. In case of any conflict between the Customer Information Sheet and the policy wordings, the terms and conditions mentioned in the
policy wordings shall prevail.
POLICY CLAUSE
S. NO. TITLE DESCRIPTION
NUMBER
1. Product Name GROUP HEALTH (FLOATER) INSURANCE
The policy provides indemnification of medical expenses incurred by
the Insured during day care treatment,hospitalization, domiciliary
2. What am I Covered for? a. Policy schedule
hospitalization, for any illness or injury suffered during the Policy
Period.
l Cover for PreExisting Diseases
l Maternity Expenses
l Out Patient Department (OPD) Expenses
l HIV
l Cost of Prescribed External Medical Aid
l Baby Day One Cover
l Critical Illnesses Cover
l Travel Expenses For Medical Treatment
l Dental Expenses
l Cover for Alternate Methods Of Treatment
l Donor Expenses
l Ambulance Charges
Optional Add On l Pre and Post Hospitalization d. Benefits covered under
3.
Covers l Health CheckUp the policy
l DiseaseWise SubLimit
l Domiciliary Hospitalization
l Treatment Outside India
l Convalescence Benefit
l Loss of Wages/Salary Due To Hospitalization (Hospital Daily
Cash Allowance)
l Cover for Allied Hospital Charges
l Limit on Room Rent, Nursing Charges, Consultation Fees,
Diagnostic Charges, OT Charges etc.
l Wellness & Preventive Care
l Initial Waiting Period
l Pre Existing Disease: 1 year
4. Waiting Period l Specific Waiting Periods e.Exclusions
l Maternity Expenses:9 months
l PreExisting Diseases
l Circumcision,plastic surgery
l Cost of spectacles,contact lenses,hearing aids,etc.
What are the major l Dental treatment or surgery of any kind unless requiring
5. e.Exclusions
exclusions in the Policy hospitalisation.
l Convalescence, Sterility, general debility,
CIN : L67200MH2000PLC129408 UIN : ICIHLGP21381V052021
l International selfinjury and use of intoxicating drugs and/or
alcohol
l Voluntary medical termination of pregnancy during the first 12
weeks from the date of conception
l Naturopathy treatment
l (Note: the above is the partial listing of the
l policy exclusions,Please refer to the policy clauses for the
full listings)
l Cashless or Reimbursement claims of covered medical
expenses up to specified Sum Insured as per the scope of g. Other terms &
6. Payment Basis cover conditions
l In case of a claim,this policy requires you to share the
following costs:
7. Loss Sharing l Expences exceeding the sub limits a. Policy schedule
l Room/ICU changes
l The Policy can be renewed as a separate contract under the
then prevailing ICICI Lombard Group Health (Floater)
Insurance product or its nearest substitute (in case the product
ICICI Lombard Group Health (Floater) Insurance is
withdrawn by the Company) approved by IRDA. f. General Terms and
8. Renewal Conditions
l The policy shall ordinarily be renewable except on grounds of Clauses
fraud, moral hazard or misrepresentation or non cooperation
by the insured.
l The Policy shall be void and all premium paid hereon shall be
forfeited to the Company, in the event of misrepresentation,
misdescription or nondisclosure of any material fact.
l Insured or the Company may cancel this Policy by giving the
Company or the insured, as the case may be, 15 days written
notice for the cancellation of the Policy, and then the f. General Terms and
9. Cancellation Company shall refund premium on short term rates (if Clauses
initiated by the insured) or pro rata rates (if initiated by the
Company) for the unexpired Policy Period. The Company
shall follow the below short period scale unless otherwise
mutually agreed.
l For Cashless Service
l Cashless treatment is only available at our Network Providers
Please refer [email protected] for updated lis of our
Network Providers
l For Reimbursement of claim g. Other terms &
10. Claims l Claims should be intimated 48 hours prior to Hospitalization conditions
or within 24 hours post admission in case of emergency
l Document to be submited within 30 days from the date of
completion of treatment
l Call the Company at the toll free number 1800 2666 or email
us at [email protected]
l In case of Insured is not satisfied,he/she may approach us at
the sub section "Grievance Redressal" on
Policy [email protected] Otherwise the Insured may use g. Other terms &
11.
Servicing/Grievances/Complaints IGMS conditions
l If the issue remains unresolved, Insured may approach
Ombudsman
l Disclosure of Material Information during the Policy Period f. General Terms and
12. Insured's Obligations
Clauses
CIN : L67200MH2000PLC129408 UIN : ICIHLGP21381V052021
ICICI Lombard General Insurance Company LTD
ICICI LOMBARD HOUSE, 414, Veer Savarkar Marg,
Near Siddhi Vinayak Temple, Prabhadevi, Mumbai 400 025
4016/X/220414582/01/000
GROUP HEALTH (FLOATER) INSURANCE
UIN ICIHLGP21381V052021 Misc 12
a. Policy Schedule
> Insured Details
Policy Number : 4016 X 220414582 01 000
Issued At : MUMBAI
Name of the Insured : MOBIPRO INNOVATION PRIVATE LIMITED
Mailing Address of the Insured : 23, Bhai Veer Singh Marg, Gole Market, New Delhi, Delhi, New Delhi, Delhi Pin 110001
Intermediary Details
Agency/Broker Code : ILG44792
Agency/Broker Name : MEGHA CHAUDHRY
Agent's/Broker's Mobile No. : 9582871712
Agent's/Broker's Email ID : meghagupta161 gmail.com
> Policy Details
Period of Insurance : From : 00:00 Hours of April 29, 2022
To : Midnight of April 28, 2023
Product : GHI Floater
Total Lives Insured : 22
Sum Insured : Rs. 5,000,000.00
Details of Person Insured : As per Annexure
Premium Computation
Basic Premium : Rs. 311,678.00
Stamp Duty : (Rs.) 00.50
ICICI Lombard General Insurance Company LTD
ICICI LOMBARD HOUSE, 414, Veer Savarkar Marg,
Near Siddhi Vinayak Temple, Prabhadevi, Mumbai 400 025
4016/X/220414582/01/000
GROUP HEALTH (FLOATER) INSURANCE
*Total Premium : (Rs.) 367,781.04
*Premium value mentioned above is inclusive of taxes applicable
Coverages
1 Day Care Procedures : Day Care Procedures are Covered as per the standard list
2 Special Condition 7 : Internal Congenital disease is covered and External congenital disease is covered in life threatning
situation.
3 Claim Intimation and Network clause : Waived Off
4 Age Band : 1 day to 80 years
5 ID Cards : Physical Health Card to be issued
6 Claim submission clause : Claim must be filed within 30 days from the date of completion of treatment. However, the
Company may at its discretion consider waiver based on merits of the claim, where there is delay in
intimation or in submission of documents due to unavoidable circumstances and it is proved that
the delay was for reasons beyond the control of the insured and under the circumstances in which
the insured was placed it was not possible for him or any other person to give such notice or file
claim within the prescribed timelimit
7 Special Condition 8 : 50% CoPay for cyberknife treatment/Stem Cell Transplantation. Cochlear Implant treatment shall
be restricted to 50% of the SI.
8 Disease wise sublimits : No SubLimits
9 Family Definition : Employee, spouse , 4 dependent children upto 25 yrs. of Age covered under policy.
10 CoPayment : For children only 0% copay for all claims.
11 Health Assistance Services : Health Assistance is a dedicated medical care service that assists you in all your health related
queries for identifying Specialist/Hospital/fixing an appointment with
Doctors/Nutritionist /facilitating 2nd opinion, etc. To avail this facility please call our Helpline at
040 6627 4205 (9:30 am to 6 pm Mon to Sat, excluding public holidays) or write to
[email protected].
12 Special Condition 2 : Terrorism is covered
13 Termination : Policy will cease to be in effect from the date of termination of relationship with the organization.
14 Transaction : Renewal
15 Baby Day 1 : Baby covered from day1 within Family Sum Insured
16 CoPayment : For spouse only 0% copay for all claims.
17 Domiciliary Hospitalisation : Excluded
18 Special Condition 4 : Air Ambulance is covered upto Rs 100,000 or family sum insured whichever is less.
19 MidTerm Inclusion : Mid term inclusion of dependents will be possible only in case of:a) spouse (on account of marriage
during the policy term) b) children (childbirth during the policy term but after the the child has
completed 91 days of age) subject to not more than four children
20 PrePost Hospitalisation : Pre Hospitalisation and Post Hospitalisation for 6090 days respectively are covered.
21 Pre/Post Natal Expense : PrePost Natal Expenses to the limit of Rs 5000 is covered Above Maternity Limit
22 Policy Construct : Employer Employee
23 Exclusion : Septoplasty, Infertility and Related Ailments incl.'Male sterility'; Treatment on trial/experimental
basis; Admin/Registration/Service/Misc. Charges; Expenses on fitting of Prosthesis; Any
device/instrument/machine contributing/replacing the function of an organ; Holter Monitoring are
outside the scope of the policy.
24 Special Condition 5 : Attendant charges are cover upto Rs 5,000 (Per life incase case of Employee only policy or else it's
Per Family within Family sum insured) if length of stay for the patient is more than 5 days. Add
on covers cost pertaining to boarding and lodging of the attendant in a hospital/location prescribed
ICICI Lombard General Insurance Company LTD
ICICI LOMBARD HOUSE, 414, Veer Savarkar Marg,
Near Siddhi Vinayak Temple, Prabhadevi, Mumbai 400 025
4016/X/220414582/01/000
GROUP HEALTH (FLOATER) INSURANCE
by treating Medical Practitioner on reimbursement basis by presenting original Bills for each cost
incurred.
25 Special Condition 9 : INR 48000 for Health check up
26 Sum Insured : SI is restricted to 'Rs.' 500000 per family during the policy period as per annexure attached
herewith.
27 AddDel of Lives : Premium to be charged on Pro Rata Basis for addition/deletion endorsement. No Refund for
deletionif lives less than minimum required and if insured has claimed during policy
28 Service Category : Both (Cashless + Reimbursement)
29 PreExisting Disease : PreExisting diseases are covered
30 Special Condition 1 : Lasik Surgery is covered if correction index is +/6.5
31 Portability : Portability is available on this product as per IRDA directive and product features
32 Last year claim details : Last year claim paid amount is 'Rs.' 60000 and outstanding amount is 'Rs.' 0 as on 19APR22 in
expiring policy
33 Maternity Benefit for Normal & C : For Metro 7500075000 for Normal and Csection respectively & for NonMetro 7500075000 for
Section Normal and Csection respectively for First 2 children.
34 CoPayment : For employee only 0% copay for all claims.
35 Special Condition : Policy also covers hospitalization arising out of Psychiatric ailments within a limit of 'Rs.' 30000 as
well as treatment of Functional Endoscopic Sinus Surgery within a limit of 'Rs.' 35000 The
coverage for treatment of mental illness is also covered upto Rs 30000 within the sum insured.
36 Special Condition 6 : Lucentis is covered upto Rs 50,000 Per family within the Sum Insured
37 Reasonable and Customary Charges : Waived Off
38 Room Rent : No room rent capping for Sum Insured 'Rs.' 500000
39 Ambulance Service : Ambulance Charges limited to Rs 1000 per person.
40 OPD/IPD : IPD
41 1st year Exclusion : Waive off
42 30 Days Waiting Period : Waive off
43 9 months waiting period : Waive off
44 Domiciliary Hospitalization : Excluded
45 PrePost Hospitalization : 6090days
Conditions
1. No. of Employees : 10
2. No. of Dependants : 12
3. Third Party Administrator (TPA)/ : IL Health Care
In house For TPA Address and Contact details please visit our website www.icicilombard.com (Download
Section)
ICICI Lombard General Insurance Company LTD
ICICI LOMBARD HOUSE, 414, Veer Savarkar Marg,
Near Siddhi Vinayak Temple, Prabhadevi, Mumbai 400 025
4016/X/220414582/01/000
GROUP HEALTH (FLOATER) INSURANCE
CIN : L67200MH2000PLC129408 UIN :ICIHLGP21381V052021
ICICI Lombard General Insurance Company LTD
ICICI LOMBARD HOUSE, 414, Veer Savarkar Marg,
Near Siddhi Vinayak Temple, Prabhadevi, Mumbai 400 025
4016 X 220414582 01 000
GROUP HEALTH (FLOATER) INSURANCE
Policy shall stand cancelled ab initio in the event of non realisation of the premium.
Disclaimer: This document to be read in conjunction with the Schedule II & Schedule III of the policy.
GSTIN Reg. No : 04AAACI7904G1ZV
IL GIC GSTIN Address : Plot no. 149 Fourth The statement Industrial area Chandigarh Chandigarh 160002
HSN SAC code : 997133 GENERAL INSURANCE SERVICES
Signed for and on behalf of the ICICI Lombard General Insurance Company Limited at Mumbai on April 29, 2022.
Authorised Signatory
ICICI Lombard General Insurance Company Ltd.
CIN : L67200MH2000PLC129408 UIN :ICIHLGP21381V052021
