Group MediPrime
Certificate of Insurance
380-BSA-DN188271-
0260019830 - 2
BALAJI MANE
HCL INFOTECH LTD, Intermediary Code : 0015455000
E 4 , 5 SEC , Intermediary Name: Axis Bank Limited
11 ,NR SEC 11 RED LIGHT ,NOIDA, Intermediary Contact Number: 1800 209 2001
. Branch Code: Tata AIG, HO
NOIDA - 201301 - NOIDA Master Policy Number: 0260019830
UTTAR PRADESH Certificate Number: 2
Mobile No.: 9845701904 Application no. 916010087087160
Bank A/C No.: 916010087087160 Issuing Office: Tata AIG, HO
Master Policy Period : From 04/05/2019 00:00 AM (Commencement Date) To 03/05/2020 23:59 PM (Expiry Date)
Name of the insured member Member Id Gender Date of birth Age (years) Date of joining Individual Sum Insured
0260019830/9160100870
BALAJI MANE M 08/06/1991 27 04/05/2017 500000
87160/01
NOMINEE NAME: Rajeswari
Coverage details:
Individual
Basic Health Cover
Coverage (Basic Cover) Sum Insured (INR)
Inpatient Treatment Upto Sum Insured limit
Pre/Post Hospitalization (30/60 Days) Upto Sum Insured limit
Day care procedures Upto Sum Insured limit
Domiciliary Treatment Upto Sum Insured limit
Emergency Ambulance Maximum INR 2000 per Hospitalisation
Organ Donor Upto Sum Insured limit
Covered, INR 100 per day up to a maximum
Nursing Allowance
of 15 days with a deductible of 2 days
Family Transportation Upto Rs.5000
Additional conditions /exclusions (if any)
Premium Calculation:
Basic Premium (Rs.): 3178
Loading(Rs ):-
Discounts (Rs) :--
Tax as applicable(Rs.): 571
Gross Premium (Rs.):3749
Gross Premium amount (in words) :Three Thousand Seven Hundred Forty-Nine Rupees
The stamp duty of Rs. 1/- (One Rupees only) paid in cash or demand draft or by pay order, vide receipt
/challan no. CSD/272/2018/5529/18, dated 19th December, 2018.
GST Number: 27AABCT3518Q1ZW
Claim Procedure:
For any claim related query, intimation of claim and submission of claim related documents, You can contact our duly
licensed TPA through:TPAdetails(IfAny):FamilyHealthPlan(TPA)Ltd.
- Website : www.fhpl.net
- Email : info@fhpl.net
seniorcitizensdesk@fhpl.net (for Senior Citizens)
- Toll Free : 1800-425-4090
040- 23552899 (for Senior Citizens)
- Fax : +91-40-23541400
- Courier : Claims Department,
Family Health Plan Insurance TPA Limited,
Srinilaya – Cyber Spazio
Suite # 101,102,109 & 110, Ground Floor,
Road No. 2, Banjara Hills,
Hyderabad-500 034
Documents for claims:
Claim documentation will include but is not limited to the following:
i) Our claim form -duly completed and signed for on behalf of the Insured Person.
ii) Original Bills (including but not limited to pharmacy purchase bills, consultation bills, diagnostic bills) and any
attachments thereto like receipts or prescriptions in support of any amount claimed which will then become Our
property.
iii) All reports, including but not limited to all medical reports, case histories, investigation reports treatment papers,
discharge summaries.
iv) A precise diagnosis of the treatment for which a claim is made.
v) A detailed list of the individual medical services and treatments provided and a unit price for each.
vi) Prescriptions that name the Insured Person and, in the case of drugs, the drugs prescribed, their price and a receipt
for payment. Prescriptions must be submitted with the corresponding Medical Practitioner’s invoice.
The Policyholder(s) shall have right to exercise an option to change the TPA within 30 days prior to the date of Renewal of
the Policy from empanelled TPA’s for serving and process claim under the Group MediPrime Policy.
This is only a summary of the product features. The actual benefits available are as described in the policy and will be
subject to the enclosed policy terms, conditions and exclusions.
This is to certify that BALAJI MANE has paid an amount of Rs. 3749 towards premium for the aforesaid policy for the
period 04/05/2019 to 03/05/2020 and is eligible for tax exemption (upto Rs.25,000) under Section 80D of Income Tax Act.
For and on behalf of Tata-AIG General Insurance Company Limited
Place: Mumbai Authorized Signatory
Date: 07/05/2019
Member Id : 0260019830/916010087087160/01
Name : BALAJI MANE
Age : 27
Gender : Male
Policy No. : 0260019830
Group : Axis Bank Limited
Valid Through: 04/05/2019 To 03/05/2020
380
PROPOSAL DETAILS
Dear Mr. / Miss / Ms. Customer BALAJI MANE
Please note, you have been enrolled in the TATA AIG General Insurance Company’s Group Mediprime policy (UIN :
TATHLGP14004V011314) based on information provided by you over the telephone to our representativeThis information provided to our
representative on the telephone call was as follows. we request you to go through the details carefully and thoroughly to ensure that all the
details have been captured accurately and intimate us if there is a discrepancy.
Application number: 916010087087160 Bank A/c No: 916010087087160
Proposal Date: 04/05/2019 Policy Number: 0260019830 2
Policy Type: Individual Plan Type: Adult Policy Term: 1year
Policy Commencement date: 04/05/2019 Policy Expiry Date: 03/05/2020
Name of the Proposer: BALAJI MANE Date of Birth:08/06/1991
Policy Holder’s Address: HCL INFOTECH LTD,, E 4 , 5 SEC ,, 11 ,NR SEC 11 RED LIGHT ,NOIDA,, ., NOIDA, NOIDA, UTTAR PRADESH-
201301
Contact Detail (R): (O): (M): 9845701904 Email Id: balaji.sg26@gmail.com
Marital Status: Nationality: Indian PAN No:____________
Aadhaar No. _____________
Insured Persons Details:
Insured Person's Name Date of Birth Gender Relationship with Proposer Nominee Name Sum Insured
1. BALAJI MANE 08/06/1991 M Self Rajeswari 500000
* For Family Floater policy Sum Insured floats among the insured members of the family as mentioned above
Nominee Details:
In the event of death of an Insured Person any payment due under the Policy shall become payable to the nominee in accordance with the
policy terms and conditions.. The nominee for all other Insured Persons proposed to be insured shall be the Proposer himself/herself.
Sr. No. Nominee Name Relationship
1. Rajeswari Mother
Commencement of risk cover under the policy is subject to receipt of premium by Tata AIG General Insurance
Company Limited.
Note - You are entitled to a voice copy of the call any time as per your need, during the tenure of the policy and
till satisfactory settlement of the claims whichever is later.
Tata AIG General Insurance Company Limited
Insurance is the subject matter of the solicitation. For more details on risk factors, terms and conditions, please read sales brochure carefully, before concluding a
sale. Tata AIG General Insurance Company Ltd. Registered office: Peninsula Business Park, Tower A, 15th Floor, G.K. Marg, Lower Parel,
Mumbai - 400013. Toll Free Nos. 1800 266 7780 . For more information Visit us at www.tataaig.com,Email us at customersupport@tataaig.com UIN:TATHLGP14004V011314
IRDA of India Registration No.: 108 CIN : U85110MH20000PLC128425 PAN: AABCT3518Q
