Astikan Healthcare Insurance Quotation

ICICI LOMBARD GIC LTD: GROUP MEDICLAIM INSURANCE QUO

PROPOSER DETAILS POLICY SUMMARY

Name of the Client Applied informatics Policy Start Date
Location of the Proposer Chandigarh Policy End Date
Industry Type It/Ites/Software Policy type
Previous Insurer 0 Policy Construct
IM ID 678076 Service Category
Floater/Non-Floater Non-Floater OPD/IPD
Employee, Spouse and 4 Third Party Administrator
Family Definition dependent children upto 25
yrs of age OTC/Non OTC
No.of Lives 400 Physical Health Card
PREMIUM DETAILS 30 Days waiting period
Gross Premium 1753692 IPD Claim Intimation Period
Add : GST 315665 Total SI (in Rs.)
Total Premium 2069357 No. of Employees
No. of Dependents

POLICY CONDITIONS
Age Band 0
Family Definition Employee, Spouse and 4 dependent children upto 25 yrs of age
Sum Insured Sum Insured Per Employee Rs.---------500000----- during the policy period as per annexure attach

Corporate Floater -
1% of SI maximum upto 3500 for Normal & 2% of SI maximum upto 5000 for ICU (inclusive of
Room Rent
insured will bear difference of all medical expenses as in final hospital bill in same proportion.

Maternity Benefit for Normal & C-

For Metro 35000-40000 & For Non-Metro 30000-35000 for First 2 children
Section

9 months waiting period Applicable

Pre-Existing Diseases Pre-Existing Diseases Expenses Covered
Pre - Post Hospitalisation Pre Hospitalisation and Post Hospitalisation for 60 days & 90 days respectively are covered.
AOY Clause Not Applicable
Baby Day 1 NA
Pre/Post Natal Expenses Not covered
Ambulance Service Ambulance Charges limited to Rs.1000 per hospitalization

OPD Cover (Reimburement) Not covered

Home Healthcare on cashless (IL empanelled provider) basis is covered, if the treating doctor advi
Home Healthcare a hospital. Services are available in 9 major cities only i.e. Bangalore, Chandigarh, Chennai, Delhi
please call ICICI Lombard, Health Assistance Team.
Health Check Up NA
 Health Assistance is a dedicated medical care service that assists you in all your health related que
Health Assistance Services Doctors/Nutritionist /facilitating 2nd opinion, etc. To avail this facility please call our Helpline at
holidays) or write to healthassistance@icicilombard.com.

Tele Health Not Applicable

Emergency Support Services Not applicable

1st Year waiting period Waived Off

Domiciliary Hospitalisation Excluded
Lasik Surgery, Septoplasty, Infertility & Related Ailments incl.'Male sterility';Treatment on trial/e
Exclusion Expenses on fitting of Prosthesis; Any device/instrument/machine contributing/replacing the funct
Policy
policy. also covers hospitalization arising out of Psychiatric ailments within a limit of Rs. 30,000 a
Special Condition
a limit of Rs. 35,000. The coverage for treatment of mental illness is also covered upto Rs 30000 w
Co-Payment Overall Co-Payment:No Copay ,Parental Co-Payment: Nil Copay but If overall co-pay is opted th
Day Care Procedures Day Care Procedures are Covered as per the standard list
claim, where there is delay in intimation or in submission of documents due to unavoidable circum
Claim submission clause
control of the insured and under the circumstances in which the insured was placed it was not poss
Mid term inclusion of dependents will be possible only in case of:a) spouse (on account of marriag
Mid-Term Inclusion
term but after the the child has completed 91 days of age) subject to not more than four children

Reasonable and Customary Charges Not Applicable

Claim Intimation & Network clause Not Applicable

Premium to be charged on Pro-Rata for addition/deletion endorsement. , No Refund for deletion-if

Add-Del of Lives
policy
Last year claim details -
Special Condition 1 Lasik Surgery is covered if correction index is +/- 6.5 D
Special Condition 2 Terrorism is covered
Special Condition 3 Ayurvedic treatment will be covered in a Government Hospital,on the prescription of a registered
Special Condition 4 Air Ambulance
Attendant is covered
charges are coverupto
uptoRsRs100,000 or family
5,000 (Per sum insured
life incase whicheveronly
case of Employee is less.
policy or else it'
Special Condition 5 patient is more than 5 days. Add on covers cost pertaining to boarding and lodging of the attendan
Special Condition 6 on reimbursement
Lucentis is coveredbasis
uptoby
Rspresenting
50,000 Peroriginal
family Bills
withinforthe
each
Sumcost incurred.
Insured
Special Condition 7 Internal Congenital disease is covered and External congenital disease is covered in life threatning
Special Condition 8 50% Co-Pay for cyberknife treatment/Stem Cell Transplantation.Cochlear Implant treatment shall
Portability Portability is available on this product as per IRDA directive and product features.
Termination Policy will cease to be in effect from the date of termination of relationship with the organization
Discalimer This policy is underwritten as a assumption of a fresh policy
Special Condition 9 -
Special Condition 10 -
Special Condition 11 -
Special Condition 12 -
Special Condition 13 -
Special Condition 14 -
Special Condition 15 -
Special Condition 16 -
Special Condition 17 -
Special Condition 18 -
Special Condition 19 -
Special Condition 20 -
Special Condition 21 -
Special Condition 22 -
Special Condition 23 -

DISEASE-WISE SUBLIMITS METRO

Appendix No Limit
Eye related No Limit
Gall Bladder No Limit
Hernia No Limit
Hydrocele No Limit
Hysterectomy No Limit
Piles No Limit
Urinary Stone (incl DJ stent removal for same stone) No Limit
Joint Replacement including Vertebral joints (Per knee) No Limit

DEMOGRAPHY: Age band wise - Sum Insured wise no of lives

3
Months 19 yrs. - 36 yrs. - 46 yrs. -
Age Band
.- 35 yrs. 45 yrs. 55 yrs.
18 yrs.
50000 0 0 0 0
100000 0 0 0 0
150000 0 0 0 0
200000 0 0 0 0
250000 0 0 0 0
300000 0 0 0 0
350000 0 0 0 0
400000 0 0 0 0
450000 0 0 0 0
500000 0 250 100 50
600000 0 0 0 0
700000 0 0 0 0
800000 0 0 0 0
900000 0 0 0 0
1000000 0 0 0 0
Total Lives 0 250 100 50

RATE FOR ADDITION/DELETION OF LIVES

3
Months 19 yrs. - 36 yrs. - 46 yrs. -
Age Band
.- 35 yrs. 45 yrs. 55 yrs.
18 yrs.
50000 1107 1382 1613 2247
100000 1204 1964 2165 3193
150000 1303 2197 2424 3673
200000 1350 2344 2588 4009
250000 1616 2663 2939 4548
300000 1819 2878 3175 4908
 350000 2230 3206 3535 5467
400000 2554 3408 3755 5812
450000 2980 3746 4127 6390
500000 3290 3936 4337 6717
600000 3553 4251 4684 7254
700000 4145 4960 5465 8463
800000 4737 5669 6246 9672
900000 5329 6377 7027 10881
1000000 5922 7086 7807 12090
Above rates are exclusive of 18% GST

ADDITIONAL DETAILS
Vertical SME-Agency

Mailing address 0

Contact no 0

Email Id 0

Risk address 0

GRIEVANCES

Grievance: For resolution of any query or grievance, Insured may contact the respective branch office of the company or may call the to
“Grievance Redressal” on our website www.icicilombard.com (Customer Support Section). However, if the resolution provided by us is
Development Authority (IRDA) through the integrated Grievance Management System (IGMS) or IRDA Grievance Call Centre (IGCC)
re Insurance Quotation

P MEDICLAIM INSURANCE QUOTATION

POLICY SUMMARY
16/Aug/21
15/Aug/22
Non-Floater
Employer Employee
Both Cashless & Reimbursement GST DETAILS (MANDATOY)
IPD Vertical Banca
ICICI Lombard Healthcare GST Registered Yes
Constitution of
OTC 0
business
Y Address 0
Waived Off GST In Number 0
30 Days Customer Type General
200000000 This is a first time
First time GHI policy GHI policy taken by
400
Declaration the Insured from any
0 Insurer

Y CONDITIONS

age
e policy period as per annexure attached herewith.

mum upto 5000 for ICU (inclusive of nursing charges). If insured is admitted in a higher category, then
al hospital bill in same proportion.

First 2 children

0 days respectively are covered.

s is covered, if the treating doctor advises an active line of treatment at home instead of being admitted in
Bangalore, Chandigarh, Chennai, Delhi (NCR), Hyderabad, Jaipur, Kolkata, Mumbai, Pune. To avail
sists you in all your health related queries for identifying Specialist/Hospital/fixing an appointment with
his facility please call our Helpline at 040 – 6627 4205 (9:30 am to 6 pm Mon to Sat, excluding public

ncl.'Male sterility';Treatment on trial/experimental basis; Admin/Registration/Service/Misc. Charges;

achine contributing/replacing the function of an organ; Holter Monitoring are outside the scope of the
ailments within a limit of Rs. 30,000 as well as treatment of Functional Endoscopic Sinus Surgery within
llness is also covered upto Rs 30000 within the sum insured.
Copay but If overall co-pay is opted then overall copay will be applicable on parents as well.

documents due to unavoidable circumstances and it is proved that the delay was for reasons beyond the
the insured was placed it was not possible for him or any other person to give such notice or file claim
ase of:a) spouse (on account of marriage during the policy term)b) children (childbirth during the policy
bject to not more than four children

dorsement. , No Refund for deletion-if lives less than minimum required & if insured has claimed during

ital,on the prescription of a registered medical practitioner only but to Sum Insured
nsured whicheveronly
ase of Employee is less.
policy or else it's Per Family within Family sum insured) if length of stay for the
o boarding and lodging of the attendant in a hospital/location prescribed by treating Medical Practitioner
mcost incurred.
Insured
tal disease is covered in life threatning situation.
ation.Cochlear Implant treatment shall be restricted to 50% of the SI.
e and product features.
n of relationship with the organization.
 NON-METRO

No Limit
No Limit
No Limit
No Limit
No Limit
No Limit
No Limit
No Limit
No Limit

d wise - Sum Insured wise no of lives

56 yrs. - 61 yrs. - 66 yrs. - 71 yrs. - 76 yrs. -

Total
60 yrs. 65 yrs. 70 yrs. 75 yrs. 80 yrs.

0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 400
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 400

DELETION OF LIVES

56 yrs. - 61 yrs. - 66 yrs. - 71 yrs. - 76 yrs. -

60 yrs. 65 yrs. 70 yrs. 75 yrs. 80 yrs.

3491 4368 5234 6177 7118

4969 6204 7444 8785 10125
5866 7514 8913 10520 12123
6532 8529 10032 11842 13645
7412 9682 11388 13442 15489
8002 10456 12296 14515 16725
 8914 11629 13686 16155 18615
9477 12346 14538 17162 19775
10166 13557 15972 18855 21725
10456 14236 16779 19808 22823
12548 17084 20135 23770 27388
14639 19931 23491 27731 31953
16730 22778 26847 31693 36517
18821 25625 30202 35655 41082
20913 28473 33558 39616 45647

ffice of the company or may call the toll free no. 1800-2666 or may approach us at the sub-section
ver, if the resolution provided by us is not satisfactory you may approach Insurance & Regulatory
IRDA Grievance Call Centre (IGCC) at their toll free no. 155255.