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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.