Reliance HealthGain Policy Schedule 10/01/ /05/2017 Cover Type : Tenure : Premium Payment Mode : Quarterly

Transcription

1 False 357. Reliance HealthGain Policy Schedule BID Policy Issued at Mumbai Issue Date 3/5/216 Proposal : R Policyholder Details Name : Correspondence Address : Policy Mr. Rakesh Kumar Mishra S/o Pitambar Mishra,at-near Durga Mandir Khunti,mishra Toli Duhugutu,durga Mandir,khunti,Khunti,ranchi,jharkhand,83521 Customer ID : Date of Birth Contact : id bantimishra156@gmail.com Plan Details Policy Period : Start Date : End Date : 3/5/217 Renewable Date : 31/5/217 Cover Type : Tenure : 1 Business Type : NEW Plan Name : PlanA Premium Payment Mode : Quarterly Previous Policy : minee Details Name Date of Birth Relationship with proposer Address of minee Mita Mishra 21/2/1989 Spouse S/o Pitambar Mishra,at-near Durga Mandir Khunti,mishra Toli Duhugutu,durga Mandir,khunti,Khunti,ranchi,jharkhand,83521 Details of the Insured: Name Base Sum Insured (`) Relationship Date of Birth (DD/MM/YYYY) Mr. Rakesh Kumar Mishra 3. Self Mrs. Mita Mishra Female Spouse 21/2/1989 Mr. Vinayak Mishra 14/8/213 Mr. Raksham Mishra 23/8/215 Pre-existing Disease Name Pre-existing Disease Since Insured with the Company, since Cumulative Bonus ` Special Exclusion Endorsements BID Particulars Room Category Benefit Premium Installment Clause. BID53 3 Spo 2/2. Fem Mrs 3 Dep 8/1. Mr. 9- / Fals 8 Premium Details Amount ( ` ) Basic Premium Loading : Underwriting. Discounts Net Premium (Annual) First Installment Premium Amount Service Tax % of Net Premium Swachh Bharat Cess Secondary and Higher Education Cess (% of Service Tax) Total Amount under First Installment Premium Reliance General Insurance Company Limited IRDA Registration. 13. Registered Office Reliance Centre, 19, Walchand Hirachand Marg,Ballard Estate,Mumbai Corporate Office Reliance Centre, South Wing, 4th Floor, Off. Western Express Highway, Santacruz (East), Mumbai Corporate Identity U6663MH2PLC1283. An ISO 91:28 Certified Company

2 BID Installment Installment Due Date Premium Installment Amount Service Tax Swachh Bharat Cess /8/ As Applicable As Applicable 3/11/ As Applicable As Applicable 28/2/ As Applicable As Applicable Please note service tax, swach bharat cess or any other applicable tax would be payable additional by the Policyholder on the Installment premium as per the prevailing rates as on the date of payment receipt of the respective installment premium. In case of non-receipt of any installment within its due date, the policy shall stand cancelled without any notice from the date and time of such non-receipt of installment premium. (Service Tax Registration : AABCR6747BST1) Category-General Insurance Business Service 445 Benifit Hospitalisation Expenses Pre Hospitalisation Expenses Post Hospitalisation Expenses Cumulative Bonus Reinstatement of Base Sum Insured Call Option Claim Servicing Guarantee Domestic Road Ambulance Basis of Offering Medical Expenses incurred as Inpatient hospitalization Day care Treatment Pre-hospitalization up to 6 days Post-hospitalization up to 6 days 33 1/3 % increase in Base SumInsured for every claim free year Max up to 1% of Base SumInsured 33 1/3 % decrease in Base SumInsured for every claim year Max up to earned Cumulative Bonus One re-instatement upto 1% of Base Sum Insured, subject to sublimit of 2% for related Illness/ injury Once at the end of every consecutive 4 claim free years Cashless Claims 1% for every delay of 6 hours beyond 6 hours of receipt of all information /documents Re-imbursement Claims 1% for every delay of 21 days beyond 21 days of receipt of all information/documents Maximum 6% for a claim Upto Rs 15 per Hospitalization Domiciliary Hospitalization Upto 1% of the Base SumInsured subject to a maximum of Rs 5, Donor Expenses Wellness Upto 5% of Base SumInsured subject to maximum of Rs 5 lacs a- Doctor Anytime /Free Health Helpline: The InsuredPerson shall have the option of seeking medical advice from a Medical Practitioner through the telephonic or online mode b- Health Portal: The InsuredPerson shall have the option to access health related information and services through the Company s/designated website Contact details for Claims &Policy Servicing Policy Servicing Claims Servicing Name Customer Service Team RCARE Correspondence Address Reliance General Insurance, Correspondence Unit, C- 42, Pawane, T.T.C, Industrial Area, M.I.D.C, Turbhe, Navi Mumbai, Maharashtra, INDIA 475 Reliance General Insurance Company.Ltd. HCMT HUB, # to 333,Sagar Plaza, Abids Road, Hyderabad - 51 Contact. Rgicl.services@relianceada.com Rgicl.rcarehealth@relianceada.com Fax Website Toll Free : (toll free) (toll free) For Reliance General Insurance Company Limited Consolidated Stamp duty Paid vide GRAS GRN. MH E dated 23 February 216** ** t Applicable for the State of Jammu & Kashmir Authorized Signatory PLEASE TE : 1) Attached with this Policy Schedule are the Policy Terms and Conditions, Endorsements, and Annexures. Please ensure that the Policyholder has received, read and understood all these documents. If the Policyholder has not received any of these, please / write to the Company at Rgicl.services@relianceada.com or contact us on (toll free). 2) This Policy Schedule in original must be surrendered to the Company in case of cancellation of the Policy. In the event of any incorrect representation, the liability shall be upon the Policyholder. 3) The Benefits which are mentioned in this Schedule shall only be available under the Policy. Reliance General Insurance Company Limited IRDA Registration. 13. Registered Office Reliance Centre, 19, Walchand Hirachand Marg,Ballard Estate,Mumbai Corporate Office Reliance Centre, South Wing, 4th Floor, Off. Western Express Highway, Santacruz (East), Mumbai Corporate Identity U6663MH2PLC1283. An ISO 91:28 Certified Company

3 Premium Certificate for the purpose of deduction under Section 8D of Income Tax Act, Premium Certificate This is to certify that Reliance General Insurance Company Limited has received an amount of Rs 357. from Mr. Rakesh Kumar Mishra towards payment of health insurance premium as per the details mentioned above. The premium paid for this policy is eligible for applicable tax benefits under section 8D of the Income Tax Act, 1961 and amendments thereof. te - Any amount paid in cash towards the premium would not qualify for tax benefit as mentioned above. Name of the Policyholder: Mr. Rakesh Kumar Mishra Correspondence Address: S/o Pitambar Mishra,at-near Durga Mandir Khunti,mishra Toli Duhugutu,durga Mandir,khunti,Khunti,ranchi,jharkhand,83521 Policy Number : Date :3/5/216 Place: Mumbai For Reliance General Insurance Company Limited Authorized Signatory Reliance General Insurance Co. Ltd. Policy Issue Date : 3/5/216 Agency Name & Code : Anand Kumar Goyal, 24A12675 Agent Contact :, te: 1.In case of any discrepancy, the Policyholder is requested to contact the Company immediately. 2.This document must be surrendered to the Company in case of cancellation of the Policy or for the issuance of a fresh Schedule in the case of any alteration in the Policy. In the event of incorrect representation of this declaration, the liability shall be upon the Policyholder. Reliance General Insurance Company Limited IRDA Registration. 13. Registered Office Reliance Centre, 19, Walchand Hirachand Marg,Ballard Estate,Mumbai Corporate Office Reliance Centre, South Wing, 4th Floor, Off. Western Express Highway, Santacruz (East), Mumbai Corporate Identity U6663MH2PLC1283. An ISO 91:28 Certified Company

4 BID Online Proposal Form for Reliance HealthGain Proposal. : R Proposer Details Name of the Proposer* Date of Birth* (DD/MM/YYYY) Marital Status Address of the Proposer Mr. Rakesh Kumar Mishra Nationality Indian S/o Pitambar Mishra,at-near Durga Mandir Khunti,mishra Toli Duhugutu,durga Mandir,khunti,Khunti,ranchi,jharkhand,83521 Pan. Monthly Income Plan\Policy Details BQMPM137N Mobile Number* bantimishra156@gmail.com NEW a) Plan Opted: PlanA b) Cover Type: c). of members to be covered : (Minimum 2 Members in case of ) d) Annual Base Sum insured: e) Installment Type: 4 3 Quarterly mination Details The nominee as declared hereunder shall become eligible for claim payment under the policy as per the terms and conditions of the Policy, in the event of the death of the Policyholder. The receipt of proceeds by the nominee would be sufficient discharge to the Company. minee for all other person(s) proposed shall be the proposer himself/herself. Name of minee D.O.B Relationship with Proposer Address of minee Mita Mishra 21/2/1989 Spouse S/o Pitambar Mishra,at-near Durga Mandir Khunti,mishra Toli Duhugutu,durga Mandir,khunti,Khunti,ranchi,jharkhand,83521 Section A: Details of person(s) proposed to be insured Details Member1 Member2 Member3 Member4 Name Mr. Rakesh Kumar Mishra Mrs. Mita Mishra Mr. Vinayak Mishra Mr. Raksham Mishra Date of Birth (DD/MM/YYYY) 21/2/ /8/213 23/8/215 (M/F) Female Relationship with Proposer Self Spouse Marital Status Single Single Height (in cm) Weight (in kg) Has any person to be insured been diagonsed/ hospitalized/ under any treatment for any illness/ disease or injury during any time in past? Eg. Injury Diabetes Hypertension Cancer/ Tumour Kidney Disease(s) Paralysis/ Stroke Respiratory Disorder(s) HIV/ AIDS/ STD Liver Disease(s) Heart Disease(s) Arthiritis/ Joint Pain Congenital Disease(s) (please specify) Does any person proposed to be insured smoke or consume tobacco or alcohol? If yes, please indicate quantity per week BID Are you an employee of Reliance Group Company? If yes, please mention Employee SAP ID False Reliance General Insurance Company Limited IRDA Registration. 13. Registered Office Reliance Centre, 19, Walchand Hirachand Marg,Ballard Estate,Mumbai Corporate Office Reliance Centre, South Wing, 4th Floor, Off. Western Express Highway, Santacruz (East), Mumbai Corporate Identity U6663MH2PLC1283. An ISO 91:28 Certified Company

5 NEWPremium Payment Details BI D Premium Amount : 357. Payment Mode : Cheque Date: 29/5/216 Bank Name: NEW Amount in words : Three Thousand Fifty Seven Premium payment frequency : Quarterly First Installment premium : Premium Amount : Two Thousand Six Hundred Seventy BI D Declaration & Warranty on Behalf of All Persons Proposer to be Insured i. I have read and understood the brochure/prospectus/sales literature/terms and conditions of the Policy and confirm to abide by the same. ii. I understand that the information provided by me will form the basis of the insurance policy, is subject to the Board approved underwriting policy of the insurance Company and that the policy will come into force only after full receipt of the premium chargeable. iii. I/We further declared that I/We will notify in writing any change occurring in the occupation or general health of the life to be insured/proposer after the proposal has been submitted but before communication of the risk acceptance by the Company. iv. I/We declare and consent to the Company seeking medical information from any Doctor or from a hospital who at anytime has attended on the life to be insured/proposer or from any past or present employer concerning anything which affects the physical or mental health of the life to be assured/ proposer and seeking information from any insurance Company to which an application form insurance on the life to be assured / proposer has been made for the purpose of underwriting the proposal and / or claim settlement. v. I/we authorized the Company to share information pertaining to my proposal including the medical records for the sole purpose of proposal underwriting and/or claims settlement and with any Government and/or Regulatory Authority. vi. Receipt of the Proposal form by the Company shall not be construed as acceptance of proposal. I hereby agree that the insurance coverage shall commence only on realization of full premium and on receipt of complete medical reports (wherever applicable) and subject to individual underwriting by the Company. The Company at its sole discretion reserves the right to accept or reject or load any proposal without assigning any reason thereof. vii. I understand that the Policy shall become void at the Company s option, in the event of any untrue or incorrect statement, misrepresentation, non-description or non-disclosure of any material fact in the Proposal form/personal statement, declaration and connected documents or any material information having been withheld by me or anyone acting on my behalf. viii. I hereby declare that the person(s) proposed to be insured would submit to medical examinations, before the nominated doctors of the Company, or undergo diagnostic or other medical tests, as suggested by the Company for its underwriting. ix. I consent to provide a valid age proof and identity proof at the time of claims or any other time when required by the Company. x. I/We consent to receive information from the Company through physical, electronic or telecommunication means from time to time. xi. I authorize the Company to exchange, share or part with the information relating to myself/person(s) to be insured with any external entity other than regulatoryand statutory bodies, as may be required and I will not hold the Company or its agents liable for use/sharing of this information. Yes/ (non selection, the optionshall be constructed as Yes by the Company) xii. I here by declare on my behalf & on behalf of all person proposed to be insured that the above statements, answers and/or particulars given by me in thisproposal form are true and complete in all respects to the best of my knowledge and that I/We am/are authorized to propose on behalf of these other persons. xiii. I declare that I am submitting a proposal for Health insurance policy to Reliance General Insurance Company Ltd. (Company) through the Company's website/portal, after satisfying myself of the truthfulness of the statements made by me herein and of the need to disclose all material facts. xiv. I further declare that the premium is being paid from my credit/ debit card/internet bank account. xv. You are requested to please verify the details of the online proposal form and cross-check against the policy schedule. In case of any discrepancy, you should report it within 15days BID of the receipt of the proposal form at our toll free no :333282, else it will be presumed that everything is in order. 4 xvi. Applicable if 'Quarterly premium option is selected'. I also understand and agree that upon non receipt of my installment by the Company, on or before the due dates the policy shall cease to operate from the unpaid installment due date and the Company shall not be liable for any Claim under the Policy. IMPORTANT The policy has been issued based on the telephonic conversation / online proposal form, details provided wherein have been recorded in this proposal form. In case of any discrepancy you are requested to contact our call centre at (Toll Free) and record the discrepancy within 15days of receipt of the policy. In case we do not get any communication from your side we will presume that all the details provided in the policy & proposal form all complete and accurate. The information that you give to Reliance General Insurance on this online form will be treated as the proposal form and details in any supplemental information form or documentation supplied by you or on your behalf will influence our decision to offer insurance and the terms upon which to offer it. It is therefore important that your answers are complete and accurate in all respect. I have read and understood the terms and conditions governing the online transaction facility of Reliance General Insurance Company Ltd. Prohibition of Rebates - Section 41 of the Insurance Act, 1938 as amended by Insurance Laws (Amendment) Act, 215. person shall allow or offer to allow, either directly or indirectly as an inducement to any person to take out or renew or continue an insurance in respect of any kind of risk relating to lives or property, in India, any rebate of the whole or part of the commission payable or any rebate of the premium shown on the policy, nor shall any person taking out or renewing or continuing a policy accept any rebate, except such rebate as may be allowed in accordance with the published prospectuses or tables of the Insurer. Any person making default in complying with the provisions of this section shall be punishable with fine, which may extend to five hundred rupees. Reliance General Insurance Company Limited IRDA Registration. 13. Registered Office Reliance Centre, 19, Walchand Hirachand Marg,Ballard Estate,Mumbai Corporate Office Reliance Centre, South Wing, 4th Floor, Off. Western Express Highway, Santacruz (East), Mumbai Corporate Identity U6663MH2PLC1283. An ISO 91:28 Certified Company