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my: health Medisure Classic Insurance
Policy Schedule
Policy Issuing Office: Mumbai Policy Servicing Office:Ahmedabad
Intermediary Name:DirectCode : 997800179Contact Number : Nil
Policy Holder:
Name: Mr. Saimex Keshavlal Patel
Address:
12/A VIVEKANAND SOCIETY
NARANPURA B/H VIJAY NAGAR SCHOOL
AHMEDABAD GUJARAT 380013
Telephone Number(s): 9825010983
Policy Details:
Policy Number: 316108000129040000
Policy Period: From: 00:00 AM on
07/01/2014
To: 11:59 PM on 06/01/2015 Tenure: One Year
Policy Type Individual
Is Roll Over / Portable Case Yes Previous Policy Number 21020034120100020401
Double Sum Insured for
Critical Illness opted
No Waiver of Room Rent Sub-
limits opted
No
Insured Details:
N ame Relation With
Policy Holder
Gender Date of
Birth
Is New / Renew /
Rollover /Portability
Nominee
Name
Relationship P re-
existingIllness
Cumulative
Bonus Earned
% Amount
Saimex
Keshavlal
Patel
Self Male 09/01/1973 Portability Rashmi Spouse No NA NA
Rashmi S,
Patel
Spouse Male 07/08/1974 Portability Saimax Spouse No NA NA
Archan S
Patel
Son Male 10/03/2002 Portability Saimax Father No NA NA
Poojan S
Patel
Son Male 11/01/1998 Portability Saimex Father No NA NA
Sum Insured:
Name First
Inception
Date
Opted (Rs.) Ported
Sum Insured CB Sum Insured (Rs.) CB
Saimex Keshavlal Patel 06/01/2005 200000.00 NA 100000.00 30000.00
Rashmi S, Patel 06/01/2005 100000.00 NA 100000.00 30000.00
Archan S Patel 06/01/2005 100000.00 NA 100000.00 27500.00
Poojan S Patel 06/01/2005 100000.00 NA 100000.00 27500.00
Benefits (For details please refer the Policy Wordings):
Covers Sum Insured
Basic Cover
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Hospitalisation Expenses Room Rent/Boarding & Nursing as per actuals limited to1% of Sum Insured (excluding cumulative bonus) per
day subject to a maximum of Rs 4,000/- per day ICU Rent/Boarding & Nursing as per actuals limited to 2% of
Sum Insured (excluding cumulative bonus) per day subject to a maximum of Rs 6,000/- per day
Pre Hospitalisation
Expenses
30 days
Post Hospitalisation
Expenses
60 days
Day Care Treatment Maximum upto Sum Insured
Domiciliary
Hospitalisation
Medical Expenses incurred for medical treatment taken at home which would otherwise have required
Hospitalisation for continuous 3 days.
Hospitalisation due to
Accident
Maximum upto Sum Insured towards Accidental Hospitalisation only when the original Sum Insured is
exhausted
Maternity and New Born
Baby Cover
Maximum upto 10% of Sum Insured or Rs.20,000 for a normal delivery and upto 20% of Sum Insured or Rs.
40,000 for a Cesarean Section including charges for New Born Cover. This coverage is subject to waiting
period of 48 months of continuous coverage
Ayurvedic Cover Maximum upto Rs 25,000 for l isted treatments
Pre-existing Diseases Covered after three continuous renewals
Optional Covers (On payment of additional premium)
Double Sum Insured for
Critical Illnesses (if Opted)
Maximum upto Double the Sum Insured for listed Critical Illnesses
Waiver of Room Rent
Sub-limits (if Opted)
Maximum upto Sum Insured
Value Adds
Hospital Cash Rs 500 per day starting from day 4 to day 10 ( excess of 3 days)
Ambulance Charges Maximum upto Rs 1500/- per hospitalization
Recovery Benefit Rs 5,000/- when hospitalisation exceeds 10 days
Comprehensive Health
Check-up
After every 4 years of continuous claim free renewals, for all Insured/Insured Persons upto a maximum of 1%
of average Sum Insured excluding cumulative bonus. This limit is available per Insured/Insured Person in case
of an individual Policy and for all members put together in case of a floater.
Waiting Periods/Exclusions under the Policy ( For details please refer the Policy Wordings):
Name 30 day waiting period Time bound exclusion
of 2 years
Pre existing disease Maternity cover
Saimex Keshavlal Patel Waived Waived Waived NA
Rashmi S, Patel Waived Waived Waived NA
Archan S Patel Waived Waived Waived NA
Poojan S Patel Waived Waived Waived NA
Special Conditions (if any) :
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TPA Details:
E-Meditek (TPA) Services Ltd.
208-209, Turf Estate, Off. Dr.E Moses Road,
Near Mahalaxmi Station, Mahalaxmi ,Mumbai -400011
Premium Details:
Net Premium: Rs. 8058
Additional Loading (if applicable) Rs. 0
Family Discount(if applicable): Rs. 895
Employee Discount(if applicable): Rs. 0
Two Year Discount (if applicable) Rs. 0
Service Tax: Rs. 996
Total Premium Rs. 9054
(Service Tax Registration No: AABCL5045NSD001 Receipt Number: RC011400212 PAN Number :AABCL5045N
Category:General Insurance Business Services)
Note
In the event of dishonor of cheque , this policy document automatically stands cancelled from inception, irrespective of whether a
separate communication is sent or not.
Policy Schedule has to be read in conjunction with Policy wordings attached.
This Policy has been issued based on the information provided by you on the proposal form. In case you find any discrepancy in the
same, please contact us immediately.
For any claims assistance, please contact us at 1800-209-5846 (LTIN) (toll free) or visit us as www.ltinsurance.com. Or at L&T General
Insurance Co Ltd,6th Floor, City 2,Plot No 177 Cst Road, Near Bandra Kurla Telephone Exchange, Kalina Santacruz East, Mumbai
400098 or Write Us at myhealthclaim@ltinsurance.com
For any grievance related to the policy you may write to The Grievance Officer at the policy issuing office address mentioned above or
write to him at grievance@ltinsurance.com
You may also email at help@ltinsurance.com or SMS LTI to 5607058(56070LT)
In witness, whereof this Policy has been signed at Mumbai on 07/01/2014
For and on behalf of L&T General Insurance Company Limited
Authorized Signatory
Stamp Duty of Rs.1.00 has been paid vide receipt 1016 dated 10/04/2012.
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Note: Note: This certificate must be surrendered to the Insurance Company for issuance of fresh certificate in case of cancellation of Policy or any
alteration in the insurance affecting the premium.
PREMIUM CERTIFICATE
Premium Certificate for the purpose of deduction under Section 80-(D) of Income Tax (Amendment) Act 1986.
This is to certify that Mr. Saimex Keshavlal Patel has paid an amount of Rs 9054/-
'Rupees Nine Thousand Fifty Four' (in words) towards Premium for Health Insurance for the Period From 00:00 AM on 07/01/2014To
midnight of 06/01/2015.
Policy Number 316108000129040000
Date: 07/01/2014 Place Mumbai
For and on behalf of L&T General Insurance Company Limited
Authorized Signatory
Note: This certificate must be surrendered to the Insurance Company for issuance of fresh certificate in case of cancellation of Policy or
any alteration in the insurance affecting the premium.
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