4154_369754690_00_000

RISK ASSUMPTION LETTER
Ref. No.: W372151419

Date: 19-11-2024
Dear Sir / Madam,
We thank you for placing your confidence with ICICI Lombard for your Insurance needs.
Please find attached herewith Policy No. : 4154/369754690/00/000 , which has been issued based on the details furnished
by the applicant in the proposal form
Name of the Applicant : TUFAN SINGH BHIL JI

Date of Birth : XX-XX-1980
Mailing Address : 1125 NA,RATLAM, RATLAM,MADHYA PRADESH - 457001
Mobile No. : 90******52
Product Name : Group HospiShield
Loan Account No : 45589170134381
Loan Tenure : 1
Nominee Name : As Per MPH Records
Nominee Relationship : SPOUSE
with Applicant
Period of Insurance : From 00:00 hrs 19-Nov-2024 To 23:59 hrs 18-Nov-2025
Policy Duration (years) : 1
Insured Details
Name of the Relationship with Date Of Birth Age in Years Occupation Pre Existing Abha No
Insured Applicant illness
TUFAN SINGH
SELF 01/01/1980 44
BHIL Ji
Please go through the details as furnished in the format and the policy document. Please confirm that same are in order. In
case there is any discrepancies / variations, you are requested to write back to us immediately at
customersupport@icicilombard.com or contact at 24 hour helpline number 1800 2666 for necessary changes / rectification.
In the absence of any communication from you in this connection within a period of 15 days of receipt of this letter, we
would take it that the issued policy is in order and as per your proposal.
ICICI Lombard General Insurance Company Limited

IRDA Reg. No. 115 CIN: L67200MH2000PLC129408 UIN : ICIHLGP22090V032122
Mailing Address: Registered Office: Toll free no.: 1800 2666
601 & 602, 6th Floor, Interface 16,ICICI Lombard House, 414, P Balu Marg, Alternate No.: +918655 222 666 (chargeable)
New Linking Road, Malad (West) Off Veer Savarkar Road, Nr Siddhi Vinayak Email:
1 / 12
Mumbai - 400 064 Temple, Prabhadevi, Mumbai 400 0025 Website: www.icicilombard.com
customersupport@icicilombard.com
Group HospiShield
Preamble
On receipt of full premium (First Installment in case the customer has opted for Periodic Premium Payment option) from the
Policyholder as named in this Schedule, Group HospiShield 4154/MSTR/250600318/00/000 dated 19-Nov-2024 has been issued at
Mumbai, by ICICI Lombard General Insurance Company Limited to the Policyholder, JANA SMALL FINANCE BANK as specified in
the Policy, and is governed by, and is subject to, the terms, conditions & exclusions therein contained or otherwise expressed in
the said Policy.
The certificate issued to the customers/employees/members of JANA SMALL FINANCE BANK under the signature of an authorized
signatory of ICICI Lombard General Insurance Company Limited, represents the availability of the Benefits under the Policy to the
Insured Person named below, subject to the terms, conditions and exclusions expressed in the said Policy, but not exceeding the
Sum Insured as specified below.
corporate
PART I OF THE SCHEDULE
Applicant Name TUFAN SINGH BHIL JI Policy No. 4154/369754690/00/000

Address 1125 NA,RATLAM, RATLAM,MADHYA Period of Insurance From 00:00 hrs 19-Nov-2024 To
PRADESH - 457001 23:59 hrs 18-Nov-2025
Contact No. 90******52 Policy Tenure (in Years) 1
Loan Account Number 45589170134381 Loan Tenure 1
Loan Sanction Date Loan Sanction Amount
Loan Disbursal Date Basis of SumInsured
Applicant PAN Number Nature of Assignment
Name of Assignee Status in the Loan
Alternate Policy No. - GSTIN Number
(Customer)
Previous Policy No. Previous Policy Period
of Insurance
Nominee Name As Per MPH Records Nominee Relationship SPOUSE
with Applicant
Email Address Policy Issued On 25-Nov-2024
Service Branch Name NOIDA SECTOR 16 Policy Issuing Office Prabhadevi, Mumbai
Servicing Branch Sector-16 NOIDANOIDA UTTAR Invoice Number 1011242049673
Address PRADESH - 201301
Politically Exposed Person (PEP)/close relative of PEP: No
Insured Details
Name of the Relationship with Date Of Birth Age in Years Occupation Pre Existing Abha No
Insured Applicant illness
TUFAN SINGH
SELF 01/01/1980 44
BHIL Ji
2. Details of the Insured Event along with the Benefits (as per tablebelow):
0
Cover Name Sum Insured Benefit Amount
Death Benefit 300000 100% of sum Insured
Hospital Daily Cash Benefit 15000 1500 per day for upto 10 days
Premium Details
Basic Premium 253.39 Stamp Duty 15
IGST % 18.0 IGST Amount 45.61
Total Tax Payable 45.61 Total Premium 299
Place of Supply MADHYA PRADESH


601 & 602, 6th Floor, Interface 16,
ICICI Lombard House, 414, P Balu Marg, Alternate No.: +918655 222 666 (chargeable)
2 / 12
New Linking Road, Malad (West) Off Veer Savarkar Road, Nr Siddhi Vinayak
Email:
Mumbai - 400 064 Temple, Prabhadevi, Mumbai 400 0025
Website:
www.icicilombard.com
IL GSTIN Registration No. HSN/SAC Code The stamp duty of ` 15 paid vide deface no.
997133 / GENERAL INSURANCE CSD372024252885 dated 15-Jul-2024

09AAACI7904G1ZL
SERVICES
We hereby declare that though our aggregate turnover in any preceding financial year from 2017-18 onwards is more than the
aggregate turnover notified under sub-rule (4) of rule 48, we are not required to prepare an invoice in terms of the provisions of
the said sub-rule.
Agent / Broker / Intermediary Details

JANA SMALL
Name Code CA0606 Contact No. 7022653867
FINANCE BANK
SPECIAL CONDITION
A minimum of 24 hours of Hospitalization is necessary for the benefit to be triggered. No initial waiting period is applicable. Pre
Existing Diseases covered from Day 1. Maternity related claims would be admissible.
Important Notes:
1. Insurance cover will start only on receipt of full premium (First Installment in case the customer has opted f
Premium Payment option) stated in PART I of the Policy Schedule by ICICI Lombard General Insurance Company Limited.
2. Insurance cover is subject to the terms and conditions mentioned in the Policy wordings provided to you with this Certificate.
3. On renewal of policy benefits and terms & conditions of policy including premium may be subject to change.
4. The above covers would not be applicable for persons occupied in underground mines, explosives and electrical installat
high tension lines unless otherwise covered and stated in the Policy Schedule.
5. Major exclusions: Intentional self-injury, suicide or attempted suicide whilst under the influence of intoxicating liquor or drugs,
any loss arising from an act of breach of law with or without criminal intent. Please refer to the Policy wordings for a complete
list of exclusions.
6. For any endorsements such as name correction or change in nominee details, you can contact us at Toll Free Number
1800-2666 or Email us at customersupport@icicilombard.com or visit our nearest branch.
7. The claimant can contact us at Toll Free Number 1800-2666 or Email us at customersupport@icicilombard.com for lodging the
claim.
8. Address for claim notification: IL Health Care, ICICI LOMBARD HEALTHCARE ICICI BANK TOWER, PLOT NO.12,
FINANCIAL DISTRICT, NANAKRAM GUDA, GACHIBOWLI, HYDERABAD, ANDHRA PRADESH PIN CODE: 500032
D:/CLICK/images/Gaurav_Arora.png
Scan QR for Customer Information

Sheet and Policy-wordings

IRDA Reg. No. 115 CIN: L67200MH2000PLC129408
UIN : ICIHLGP22090V032122

601 & 602, 6th Floor, Interface 16,
ICICI Lombard House, 414, P Alternate
Balu Marg,
No.: +918655 222 666 (chargeable)
3 / 12
New Linking Road, Malad (West) Off Veer Savarkar Road, Nr Siddhi Vinayak
Mumbai - 400 064 Temple, Prabhadevi, Mumbai 400 0025 Email: customersupport@icicilombard.com
211
Tax Certificate
To,
TUFAN SINGH BHIL JI
1125 NA,RATLAM, RATLAM,MADHYA PRADESH - 457001
Subject: Premium certificate for the purpose of deduction under section 80D of Income Tax Act, 1961 and any
amendments made thereafter.
Dear TUFAN SINGH BHIL JI,
This is to certify that the Company has received `211 towards premium for the period from 19-Nov-2024 to 18-Nov-2025
Policy Certificate No: 4154/369754690/00/000
The following are the details of the premium received:
Premium Details
Basic Premium 178.73

Total Tax Payable 32.17
Total Premium 211
Place of Supply MADHYA PRADESH
The product is eligible for deduction u/s 80D of the Income Tax, 1961 and any amendments made there to.
Note: This certificate must be surrendered to the Insurance Company in case of Cancellation of the Policy. In the Event of
incorrect representation of this declaration, the liability shall be upon the policyholder.

IRDA Reg. No. 115 CIN: L67200MH2000PLC129408 UIN :
ICIHLGP22090V032122
601 & 602, 6th Floor, Interface 16, ICICI Lombard House, 414, Alternate
P Balu No.:Marg,
+918655 222 666
New Linking Road, Malad (West) Off Veer Savarkar Road, Nr Email:
Siddhi Vinayak
4 / 12
Mumbai - 400 064 Temple, Prabhadevi, Mumbai 400 0025
Website:
www.icicilombard.com
Group Hospishield
Customer Information Sheet / Know Your Policy
This document provides key information about your policy. You are also advised to go through
your policy document.
Policy Clause
S.No Title Description
Number
1 Name of insurance Group Hospishield
Product/Policy
2 Policy Number 4154/369754690/00/000
3 Type of insurance Indemnity and/Or Benefit
Product/Policy Indemnity (Where insured losses are covered up to the Sum Insured under the policy).
Benefit (Where an Insurance Policy pays a fixed amount under the policy on the
occurrence of a covered event).
Both Indemnity and Benefit (where policy has elements of both the above)
4 Sum insured (Basis) Individual Sum Insured
(Along with the Amount)
Individual Sum Insured -Where each member has a separate sum insured under the
policy)
5 Section A-Hospital Daily cash benefit
Policy Coverage (What Cover Name Cover Definition Payout Policy Clause No.
the policy covers?) Base Benefit: Hospital Daily Cash Benefit A.1.1
(Policy Clause A.1.2
Base benefit :EMI Benefit
Base benefit: Day-care Treatment Benefit A.1.3
Base Benefit: Cancer Cash Benefit A.1.4
Extension Benefit: Intensive Care Unit (Icu) A.2.1
Cash Benefit
Extension Benefit: Brain & Stroke A.2.2
Hospitalization Cash Benefit
Extension Benefit: Organ Transplant A.2.2
Hospitalization Cash Benefit
Extension Benefit: Heart Ailment Hospitalization Cash Benefit A.2.3
Extension Benefit: Fracture & Burns Cash Benefit A.2.4
Extension Benefit: Ambulance Cover Benefit A.2.5
Extension Benefit: Child Care Cash Benefit A.2.6
Extension Benefit: Hospital Attendant Cash Benefit A.2.7
Extension Benefit: Compassionate Visit Cash Benefit A.2.8
Section B.1 - Specific Vector Borne Disease Benefit
Specific Vector-Borne Disease means Malaria, Dengue, Chickungunya, Kala Azar, Japanese encephalitis, Zika
Fever and Filariasis
Base Benefit :Specific vector borne disease related Hospitalization B.1.1
Benefit.
Section B.2 - Rabies and Tetanus Benefit
• Base Benefit :Rabies and Tetanus related Hospitalization Benefit B.2.1
Section B.3 - Specific Gastrointestinal Infections Benefit
Specific Gastrointestinal Infection means Acute Inflammatory Diarrhea and Typhoid fever
Base Benefit :Specific Gastro Intestinal Infections Hospitalization B.3.1
•
Benefit
Section B.4- Specific Viral Infections Benefit
Specific Viral Infection means Viral Hepatitis (Hepatitis A, B and C), Measles, Mumps, Poliomyelitis, Avian
Influenza and Swine
Influenza

601 & 602, 6th Floor, Interface 16, ICICI Lombard House, 414, P Balu Marg, Alternate No.: +918655 222 666 (chargeable)
New Linking Road, Malad (West) Off Veer Savarkar Road, Nr Siddhi Vinayak Email: customersupport@icicilombard.com
5 / 12
• Base Benefit : Specific Viral Infections Hospitalization Benefit B.4.1
Section B.5 - Specific Nervous System Infections Benefit
Specific Nervous System Infection means Meningitis, Encephalitis, Creutzfeldt-Jakob disease, and Guillain-Barre
syndrome
Basic Benefit: Specific Nervous System Infections Hospitalization B.5.1
•
Benefit
Section C - Accidental Injury Benefits
Base Benefit: Accidental Death Benefit C.1.1
Base Benefit: Permanent Total Disablement (PTD) Benefit C.1.2
Base Benefit: Permanent Partial Disablement (PPD) Benefit C.1.3
Base Benefit: Temporary Total Disablement (TTD) Benefit C.1.4
Base Benefit: Children’s Education Grant Benefit C.1.5
Base Benefit: Accidental Hospitalization Expenses Reimbursement C.1.6
Benefit
Base Benefit: Accidental Hospitalization Daily Cash Benefit C.1.7
Base Benefit: Loss Of Job Benefit C.1.8
Base Benefit: Recovery Benefit C.1.9
6 Exclusions (What the EXCLUSIONS AND LIMITATIONS APPLICABLE TO SECTION A As per Exclusion
policy does not cover) We shall not be liable to make any payment for any claim under section of policy
Section A of this Policy in respect of an Insured Person, directly wordings
or indirectly for, caused by, arising from or in any way attributable
to any of the following:
I. STANDARD EXCLUSIONS
1. 30-day waiting period (Code – Excl 03) -
2. Pre-existing Disease (Code – Excl – 01) -
3. Unproven Treatment (Code – Excl 18) -
4. Maternity (Code – Excl 18) -
5. Sterility and Infertility (Code – Excl 17)
6.Cosmetic or Plastic Surgery (Code – Excl 08)
7. Refractive Error (Code – Excl 15) -
8. Investigation & Evaluation (Code – Excl 04)
9. Obesity/Weight Control (Code – Excl 06) -
10. Change of Gender Treatment (Code – Excl
11. Hazardous or Adventure Sport (Code – Excl 09
12. Breach of Law (Code – Excl 10)
13. Treatment for Alcoholism, drug or substance abuse or any
addictive condition and consequences thereof. (Code – Excl 12)
14. Treatments received in heath hydros, nature cure clinics, spas
or similar establishments or private beds registered as a nursing
home attached to such establishments or where admission is
arranged wholly or partly for domestic reasons.(Code – Excl 13)
15. Dietary supplements and substances that can be purchased
without prescription.(Code – Excl 14)
16. Excluded providers (Code – Excl 11) -
17. Rest Cure, rehabilitation and respite care (Code – Excl 05)-
18. Specified disease/procedure waiting period (Code – Excl 02)
II. SFECIFIC EXCLUSIONS

1. All dental treatment or dental surgery of any kind unless
necessitated due to an Accident
2. Any treatment received outside India.
3. Circumcision unless necessary for treatment of an underlying

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3. Circumcision unless necessary for treatment of an underlying
diseases.
4. Routine medical, dental, eye and ear examinations is not
covered.
5. Treatment of venereal disease.
6. Intentional self-Injury, suicide or attempt to suicide.
7. Any Injury that has occurred prior to the commencement of
Policy.
8. Any external congenital anomalies.
9. Any event which occurs whilst the Insured Person is operating
or learning to operate any aircraft or common carrier other than as
a passenger (fare-paying or otherwise) in any scheduled airline
anywhere in the world.
10. Treatment by a Family Member and self-medication or any
treatment that is not scientifically recognized.
11. War, invasion, act of foreign enemy hostilities or warlike
operations (whether war be declared or not) or civil commotion or
rebellion, revolution, insurrection, mutiny, arrests, detainments of
all kinds and political gatherings, police, military, naval or air
service, engaging in aviation other than as a passenger (fare
paying or otherwise) in any licensed standard type of aircraft.
12. Death, disablement (whether of a permanent nature or of a
temporary nature), Injury, Illness or Hospitalization arising from or
caused by ionizing radiation or contamination by radioactivity from
any nuclear fuel (explosive or hazardous form) or resulting from or
from any other cause or event contributing concurrently or in any
other sequence to the loss, claim or expense from any nuclear
waste from the combustion of nuclear fuel, nuclear, chemical or
biological attack.
SPECIFIC EXCLUSIONS APPLICABLE TO SECTION C (Except

Benefit C.1.6, C.1.7 and C.1.9)
We shall not be liable to make any payment for any claim under
Section C of this Policy in respect of an Insured Person, directly
or indirectly for, caused by, arising from or in any way attributable
to any of the following:
1. War, invasion, act of foreign enemy hostilities or warlike
all kinds and political gatherings, engaging in aviation other than as
a passenger (fare paying or otherwise) in any licensed standard
type of aircraft.
2. Any Injury sustained while performing duty in army, navy, air
force, paramilitary force, police or any other such institution.
3. Any event which occurs whilst the Insured Person is operating
or learning to operate any aircraft or common carrier other than as
a passenger (fare-paying or otherwise) in any scheduled airline
anywhere in the world.
4. Breach of law or while being involved in any unlawful activity.
5. Any Injury / Illness arising from intentional self- Injury, suicide
or attempted suicide.
6. Any Injury / Illness arising whilst under the influence of alcohol

or intoxicating drugs or substance abuse of any kind.
7. Any Injury / Illness occurring whilst working in underground
mines or explosives magazines, or involving electrical installation
with high tension supply, or as jockeys or circus personnel

New Linking Road, Malad (West) Off Veer Savarkar Road, Nr Siddhi Vinayak Email:
7 / 12
with high tension supply, or as jockeys or circus personnel
8. Any Accidental Injury / Illness directly or indirectly caused by
venereal disease
9. Injury sustained whilst engaging in Adventure Sports (Unless
specifically covered and mentioned in the policy certificate
10. Any Injury that has occurred prior to the commencement of
Policy of Cover.
11. Expenses incurred on eyeglasses, contact lenses, hearing aids
and examination for the prescription or fitting thereof.
12. Any Illness, complication or ailment not arising out of or
connected to Injury.
13. Payment of compensation in respect of death, disablement
(whether of a permanent nature or of a temporary nature), Injury,
or illness of the Insured Person resulting directly from, or
indirectly caused by, or contributed to or aggravated or prolonged
by, childbirth or pregnancy or in consequence thereof.
14. Death, disablement (whether of a permanent nature or of a
temporary nature), Injury, or Illness arising from or caused by
ionizing radiation or contamination by radioactivity from any
nuclear fuel (explosive or hazardous form) or resulting from or
from any other cause or event contributing concurrently or in any
other sequence to the loss, claim or expense from any nuclear
waste from the combustion of nuclear fuel, nuclear, chemical or
biological attack.
15. Circumcision or strictures, vaccination, inoculation, sex
change, beauty treatment of any description, intentional
self-Injury, (which expression shall cover also general debility, "run
down" conditions), venereal disease, use of intoxicating drugs, or
any Illness, Injury, death or disablement directly or indirectly due
to any one or more of them.
16. Dental treatment, eye treatment and plastic surgery unless
medically necessitated as a consequence of an Injury sustained in
an Accident during the Period of Cover.
17. Any Hospitalization not arising out of an Injury sustained in an Accident during the Period of Co
18. Routine medical, dental, eye and ear examinations.
19. All cosmetic/aesthetic surgeries including but not limited to
EXCLUSIONS APPLICABLE TO BENEFITS C.1.6, C.1.7 & C.1.9
We shall not be liable to make any payment for any claim under
Benefits C.1.6, C.1.7 & C.1.9 of this Policy in respect of an
Insured Person, directly or indirectly for, caused by, arising from
or in any way attributable to any of the following:
I. STANDARD EXCLUSIONS
• All dental treatment or dental surgery of any kind unless
necessitated due to an Accident
• Unproven Treatment (Code – Excl 16) -
o Medical treatment expenses traceable to childbirth (including

complicated deliveries and caesarean sections incurred during
hospitalization) except ectopic pregnancy;
o Expenses towards miscarriage (unless due to an accident) and
lawful medical termination of pregnancy during the policy period;
• Cosmetic or Plastic Surgery (Code – Excl 08)
o Investigation & Evaluation (Code – Excl 04) -
o Any Injury / Illness occurring whilst engaging in any Adventure

8 / 12
o Any Injury / Illness occurring whilst engaging in any Adventure
Sports as an Amateur.
• Hazardous or Adventure Sport (Code – Excl 09) - Expenses
related to any treatment necessitated due to participation as a
professional in hazardous or adventure sports, including but not
limited to, para-jumping, rock climbing, mountaineering, rafting,
motor racing, horse racing or scuba diving, hand gliding, sky
diving, deep-sea diving.
o Breach of Law (Code – Excl 10)
• Treatment for, Alcoholism, drug or substance abuse or any
addictive condition and consequences thereof.(Code – Excl 12)
o Rest Cure, rehabilitation and respite care (Code – Excl 05) -
• Treatments received in heath hydros, nature cure clinics, spas or
similar establishments or private beds registered as a nursing
home attached to such establishments or where admission is
arranged wholly or partly for domestic reasons (Code – Excl 13)
• Dietary supplements and substances that can be purchased
without prescription, (Code – Excl 14)
• Excluded Providers (Code – Excl 11)
II. SPECIFIC EXCLUSIONS

• Routine medical, dental, eye and ear examinations is not
covered.
• Any Injury that has occurred prior to the commencement of
Policy.
• War, invasion, act of foreign enemy hostilities or warlike
all kinds and political gatherings, engaging in aviation other than as
a passenger (fare paying or otherwise) in any licensed standard
type of aircraft.
• Any Injury sustained while performing duty in army, navy, air
force, paramilitary force, police or any other such institution.
• Any event which occurs while operating the air craft or common
carrier except the fare paying passenger.
• Any Injury / Illness arising from intentional self- Injury, suicide or
attempted suicide.
• Any Illness, complication or ailment not arising out of or
connected to Injury.
The above is indicative list of exclusions, please refer policy
wordings for detailed description.
7 Waiting period •Time period during which specified diseases/treatments are

not covered It is counted from the beginning of the policy
coverage.
Should fetch from Special conditions of the policy schedule
Financial limits of coverage
i. Sub-limit (It is a predefined limit and the insurance company

will not pay any amount in excess of this limit)
ii. Co-payment (It is a specified amount/percentage of the

admissible claim amount to be paid by policyholder/insured).
9 Claims / Claims • Upon the happening of any event giving rise or likely to give rise
procedure to a claim under this policy, the Insured shall intimate and register

9 / 12
to a claim under this policy, the Insured shall intimate and register
the claim with the Company on our 24x7 toll free helpline
18002666 and in writing at Our address.
• The list of documentation required is provided under each
specific Section.
• The Insured shall intimate the claims with all the necessary
documents to Our claim processing team immediately and in any
event within 7 days of the event giving rise to a claim.
• Customer to send documents to Company at :- ICICI Lombard
General Insurance Company Limited
1st, 4th (Half) , 5th and 6th floors, Varun Towers- II , Opp.
Hyderabad Public school , Begumpet
• Benefits payable under this policy will be paid within 15 days of
the receipt of claim along with claim form and required documents
Download the Claim Form here

https://www.icicilombard.com/downloads
Find our extensive list of hospitals providing services on our

website https://www.icicilombard.com/health-insurance/health-claim
/partner-hospital or on the IL TakeCare App.
List of excluded providers/delisted hospitals is available on our

website https://www.icicilombard.com/docs/default-source
/apps/healthclaims/assets/files/delisted-hospital-list.pdf
10 Policy Servicing/ • You may contact us on our Toll Free no: 1800 2666, or email to
customersupport@icicilombard.comor use our IL TakeCare App or
send a Hi to RIA, our Responsive Intelligent Assistant on
WhatsApp (7738282666) for policy services.
For details of Company officials kindly visit our
website https://www.icicilombard.com/customer-support.
11 Grievances/ In case of any grievance the insured person may contact the Part III - 16
Complaints Company through
Website: www.icicilombard.com
Toll free: 1800 2666 Email: customersupport@icicilombard.
com
ICICI Lombard General Insurance Co. Ltd. Ground floor- Interface
11, Sixth floor- Interface 16 ,
Office no 601 & 602, New linking Road, Malad (West), Mumbai –
400064
There is an interactive voice response (IVR) facility for senior

citizens’ grievance redressal for easy and faster resolution
lnsured person may also approach the grievance cell at any of the company's branches with the de
grievance. For branch details, please visit https://www.icicilombard.
com/docs/default-source/policy-wordings-product-brochure/final-gro-mapping.pdf.
lf lnsured person is not satisfied with the redressal of grievance ,

insured person may contact the grievance redressal officer at the details provided in the below link
https://www.icicilombard.com/grievanceredressal.com
lf lnsured person is not satisfied with the redressal of grievance,

the insured person may also approach Insurance Regulatory and Development Authority of India (I
through the Bima Bharosa Portal - https://bimabharosa.irdai.gov.in/
or IRDA Grievance Call Centre(IGCC) at their toll free no. 1800


10 / 12
the insured person may also approach Insurance Regulatory and
Development Authority of India (IRDAI) through the Bima Bharosa
Portal - https://bimabharosa.irdai.gov.in/ or IRDA Grievance Call
Centre(IGCC) at their toll free no. 1800 4254 732 / 155255
Insured may also approach Insurance Ombudsman, subject to

vested jurisdiction, for the redressal of grievance. Details of
Insurance Ombudsman offices are available at IRDAI website:
www.irdai.gov.in, or on the Company’s website at
www.icicilombard.
com or on https://www.cioins.co.in/Ombudsman
12 Things to remember Free look:

• Every insured of new health insurance policies, except for those
policies with tenure of less than a year, shall be provided a free
look period of 30 days beginning from the date of receipt of policy
document, whether received electronically or otherwise, to review
the terms and conditions of such policy. If the insured cancels the
policy within free look period then the insured shall be entitled to a
refund of the premium paid subject only to a deduction of a
proportionate risk premium for the period of cover and the
expenses, if any, incurred by the insurer on medical examination
of the insured and stamp duty charges.• Benefits payable under
this policy will be paid within 15 days of the receipt of claim along
with claim form and required documents • The Policy may be
renewed per the relevant regulatory prescription. t. Policy wording
can be referred for further details
Migration: In case of migration of indemnity based health

insurance policy (except Personal Accident and Travel Policies)
with the same Insurer, the insured can transfer the credits gained
to the extent of the Sum Insured and benefits available in the
previous policy to the migrated policy. The Company may
underwrite the proposal in case of migration, if the insured is not
continuously covered for 36 months.
Portability:
a. The insured has the choice to port his / her policies from one
Insurer to another. An Insured desirous of porting his/her policy to
another insurer shall apply to such insurer to port the entire policy
along with all the members of the family, if any, at least 30 days
before, but not earlier than 60 days from the due date for renewal.
b. The insured is entitled to transfer the credits gained to the

extent of the sum insured and the benefits available in the
previous policy, subject to the underwriting policy of the Company
c. The Company shall decide and communicate on the proposal

upon receipt of information from Existing insurer within prescribed
timelines .
d. This benefit is not applicable for enhanced sum insured
Change in Sum Insured: Sum Insured can be changed

11 / 12
Change in Sum Insured: Sum Insured can be changed
(increased/decreased) only at the time of renewal or at any time,
subject to underwriting by the company. For increase in Sl, the
waiting period if any shall start afresh only for the enhanced
portion of the sum insured
Moratorium Period: After completion of sixty continuous months
of coverage (including portability and migration) in health insurance
policy, no policy and claim shall be contestable by the company
on grounds of non-disclosure, misrepresentation, except on
grounds of established fraud. This period of sixty continuous
months is called as moratorium period. The moratorium would be
applicable for the sums insured of the first policy. Wherever, the
sum insured is enhanced, completion of sixty continuous months
would be applicable from the date of enhancement of sums
insured only on the enhanced limitsWithdrawal of Policy
i. ln the likelihood of this product being withdrawn in future, the
Company will intimate the insured person about the same 90 days
prior to expiry of the policy.
ii. lnsured Person will have the option to migrate to similar health
insurance product available with the Company at the time of
renewal with all the accrued continuity benefits such as cumulative
bonus, waiver of waiting period, provided the policy has been
maintained without a break.
13 Your Obligations Please disclose all material information (Including Pre-Existing

Diseases) before buying the policy.
Any changes in the exposure /Sum insured/ Occupancies of the
insured members during the policy tenure should be immediately
notified to the insurer
• Non-Disclosure may affect the claim settlement.
• Cooperation from the Insured/claimant is solicited in providing all
or sufficient documents as per the claims procedure in support of
claim.
Declaration by the Policy holder:
I have read the above and confirm having noted the details
Place
Dated Signature
NOTE: In case of any conflict, the terms and conditions mentioned in the policy document shall prevail.
Signature Not Verified

Digitally signed by DS ICICI
LOMBARD GENERAL
INSURANCE CO LTD 1
Date: 2024.11.25 20:06:22 IST

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RISK ASSUMPTION LETTER

Ref. No.: W372151419

Dear Sir / Madam,

Name of the Applicant : TUFAN SINGH BHIL JI

ICICI Lombard General Insurance Company Limited

PART I OF THE SCHEDULE

Applicant Name TUFAN SINGH BHIL JI Policy No. 4154/369754690/00/000

Politically Exposed Person (PEP)/close relative of PEP: No

ICICI Lombard General Insurance Company Limited

Mailing Address: Registered Office: Toll free no.: 1800 2666

997133 / GENERAL INSURANCE CSD372024252885 dated 15-Jul-2024

Agent / Broker / Intermediary Details

Scan QR for Customer Information

ICICI Lombard General Insurance Company Limited

Mailing Address: Registered Office: Toll free no.: 1800 2666

Dear TUFAN SINGH BHIL JI,

Policy Certificate No: 4154/369754690/00/000

The following are the details of the premium received:

Basic Premium 178.73

ICICI Lombard General Insurance Company Limited

ICICI Lombard General Insurance Company Limited

II. SFECIFIC EXCLUSIONS

3. Circumcision unless necessary for treatment of an underlying

ICICI Lombard General Insurance Company Limited

SPECIFIC EXCLUSIONS APPLICABLE TO SECTION C (Except

6. Any Injury / Illness arising whilst under the influence of alcohol

ICICI Lombard General Insurance Company Limited

EXCLUSIONS APPLICABLE TO BENEFITS C.1.6, C.1.7 & C.1.9

o Medical treatment expenses traceable to childbirth (including

ICICI Lombard General Insurance Company Limited

II. SPECIFIC EXCLUSIONS

7 Waiting period •Time period during which specified diseases/treatments are

i. Sub-limit (It is a predefined limit and the insurance company

ii. Co-payment (It is a specified amount/percentage of the

ICICI Lombard General Insurance Company Limited

Download the Claim Form here

Find our extensive list of hospitals providing services on our

List of excluded providers/delisted hospitals is available on our

There is an interactive voice response (IVR) facility for senior

lf lnsured person is not satisfied with the redressal of grievance ,

lf lnsured person is not satisfied with the redressal of grievance,

ICICI Lombard General Insurance Company Limited

Mailing Address: Registered Office: Toll free no.: 1800 2666

Insured may also approach Insurance Ombudsman, subject to

12 Things to remember Free look:

Migration: In case of migration of indemnity based health

b. The insured is entitled to transfer the credits gained to the

c. The Company shall decide and communicate on the proposal

d. This benefit is not applicable for enhanced sum insured

Change in Sum Insured: Sum Insured can be changed

ICICI Lombard General Insurance Company Limited

13 Your Obligations Please disclose all material information (Including Pre-Existing

Signature Not Verified

ICICI Lombard General Insurance Company Limited

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