Intermediary Name:Direct Code: 997800179 Contact Number: Nil

Note:Note:ThiscertificatemustbesurrenderedtotheInsuranceCompanyforissuanceoffreshcertificateincaseofcancellationofPolicyorany
alterationintheinsuranceaffectingthepremium.
my:healthMedisureClassicInsurance
PolicySchedule
PolicyIssuingOffice:Mumbai PolicyServicingOffice:Ahmedabad
IntermediaryName:Direct
Code:997800179
ContactNumber:Nil
PolicyHolder:
Name: Mr.SaimexKeshavlalPatel
Address:
12/AVIVEKANANDSOCIETY
NARANPURAB/HVIJAYNAGARSCHOOL
AHMEDABADGUJARAT380013
TelephoneNumber(s): 9825010983
PolicyDetails:
PolicyNumber: 316108000129040000
PolicyPeriod: From:00:00AMon
07/01/2014
To:11:59PMon06/01/2015 Tenure:OneYear
PolicyType Individual
IsRollOver/PortableCase Yes PreviousPolicyNumber 21020034120100020401
DoubleSumInsuredfor
CriticalIllnessopted
No WaiverofRoomRentSub
limitsopted
No
InsuredDetails:
Name RelationWith
PolicyHolder
Gender Dateof
Birth
IsNew/Renew/
Rollover/
Portability
Nominee
Name
Relationship Pre
existing
Illness
Cumulative
BonusEarned
% Amount
Saimex
Keshavlal
Patel
Self Male 09/01/1973 Portability Rashmi Spouse No NA NA
RashmiS,
Patel
Spouse Male 07/08/1974 Portability Saimax Spouse No NA NA
ArchanS
Patel
Son Male 10/03/2002 Portability Saimax Father No NA NA
PoojanS
Patel
Son Male 11/01/1998 Portability Saimex Father No NA NA
SumInsured:
Name First
Inception
Date
Opted(Rs.) Ported
SumInsured CB SumInsured(Rs.) CB
SaimexKeshavlalPatel 06/01/2005 200000.00 NA 100000.00 30000.00
RashmiS,Patel 06/01/2005 100000.00 NA 100000.00 30000.00
ArchanSPatel 06/01/2005 100000.00 NA 100000.00 27500.00
PoojanSPatel 06/01/2005 100000.00 NA 100000.00 27500.00
Benefits(FordetailspleasereferthePolicyWordings):
Covers SumInsured
BasicCover
HospitalisationExpenses RoomRent/Boarding&Nursingasperactualslimitedto1%ofSumInsured(excludingcumulativebonus)per
daysubjecttoamaximumofRs4,000/perdayICURent/Boarding&Nursingasperactualslimitedto2%of
SumInsured(excludingcumulativebonus)perdaysubjecttoamaximumofRs6,000/perday
PreHospitalisation
Expenses
30days
PostHospitalisation
Expenses
60days
DayCareTreatment MaximumuptoSumInsured
Domiciliary
Hospitalisation
MedicalExpensesincurredformedicaltreatmenttakenathomewhichwouldotherwisehaverequired
Hospitalisationforcontinuous3days.
Hospitalisationdueto
Accident
MaximumuptoSumInsuredtowardsAccidentalHospitalisationonlywhentheoriginalSumInsuredis
exhausted
MaternityandNewBorn
BabyCover
Maximumupto10%ofSumInsuredorRs.20,000foranormaldeliveryandupto20%ofSumInsuredorRs.
40,000foraCesareanSectionincludingchargesforNewBornCover.Thiscoverageissubjecttowaiting
periodof48monthsofcontinuouscoverage
AyurvedicCover MaximumuptoRs25,000forlistedtreatments
PreexistingDiseases Coveredafterthreecontinuousrenewals
OptionalCovers(Onpaymentofadditionalpremium)
DoubleSumInsuredfor
CriticalIllnesses(ifOpted)
MaximumuptoDoubletheSumInsuredforlistedCriticalIllnesses
WaiverofRoomRent
Sublimits(ifOpted)
MaximumuptoSumInsured
ValueAdds
HospitalCash Rs500perdaystartingfromday4today10(excessof3days)
AmbulanceCharges MaximumuptoRs1500/perhospitalization
RecoveryBenefit Rs5,000/whenhospitalisationexceeds10days
ComprehensiveHealth
Checkup
Afterevery4yearsofcontinuousclaimfreerenewals,forallInsured/InsuredPersonsuptoamaximumof1%
ofaverageSumInsuredexcludingcumulativebonus.ThislimitisavailableperInsured/InsuredPersonincase
ofanindividualPolicyandforallmembersputtogetherincaseofafloater.
WaitingPeriods/ExclusionsunderthePolicy(FordetailspleasereferthePolicyWordings):
Name 30daywaitingperiod Timeboundexclusion
of2years
Preexistingdisease Maternitycover
SaimexKeshavlalPatel Waived Waived Waived NA
RashmiS,Patel Waived Waived Waived NA
ArchanSPatel Waived Waived Waived NA
PoojanSPatel Waived Waived Waived NA
SpecialConditions(ifany):
TPADetails:
EMeditek(TPA)ServicesLtd.
208209,TurfEstate,Off.Dr.EMosesRoad,
NearMahalaxmiStation,Mahalaxmi,Mumbai
400011
PremiumDetails:
NetPremium: Rs.8058
AdditionalLoading(ifapplicable) Rs.0
FamilyDiscount(ifapplicable): Rs.895
EmployeeDiscount(ifapplicable): Rs.0
TwoYearDiscount(ifapplicable) Rs.0
ServiceTax: Rs.996
TotalPremium Rs.9054
(ServiceTaxRegistrationNo:AABCL5045NSD001ReceiptNumber:RC011400212PANNumber:AABCL5045N
Category:GeneralInsuranceBusinessServices)
Note
Intheeventofdishonorofcheque,thispolicydocumentautomaticallystandscancelledfrominception,irrespectiveofwhethera
separatecommunicationissentornot.
PolicySchedulehastobereadinconjunctionwithPolicywordingsattached.
ThisPolicyhasbeenissuedbasedontheinformationprovidedbyyouontheproposalform.Incaseyoufindanydiscrepancyinthe
same,pleasecontactusimmediately.
Foranyclaimsassistance,pleasecontactusat18002095846(LTIN)(tollfree)orvisitusaswww.ltinsurance.com.OratL&TGeneral
InsuranceCoLtd,6thFloor,City2,PlotNo177CstRoad,NearBandraKurlaTelephoneExchange,KalinaSantacruzEast,Mumbai
400098orWriteUsatmyhealthclaim@ltinsurance.com
ForanygrievancerelatedtothepolicyyoumaywritetoTheGrievanceOfficeratthepolicyissuingofficeaddressmentionedaboveor
writetohimatgrievance@ltinsurance.com
Youmayalsoemailathelp@ltinsurance.comorSMSLTIto5607058(56070LT)
Inwitness,whereofthisPolicyhasbeensignedatMumbaion07/01/2014
ForandonbehalfofL&TGeneralInsuranceCompanyLimited
AuthorizedSignatory
StampDutyofRs.1.00hasbeenpaidvidereceipt1016dated10/04/2012.
PREMIUMCERTIFICATE
PremiumCertificateforthepurposeofdeductionunderSection80(D)ofIncomeTax(Amendment)Act1986.
ThisistocertifythatMr.SaimexKeshavlalPatelhaspaidanamountofRs9054/
'RupeesNineThousandFiftyFour'(inwords)towardsPremiumforHealthInsuranceforthePeriodFrom00:00AMon07/01/2014To
midnightof06/01/2015.
PolicyNumber 316108000129040000
Date: 07/01/2014 Place Mumbai
AuthorizedSignatory
Note:ThiscertificatemustbesurrenderedtotheInsuranceCompanyforissuanceoffreshcertificateincaseofcancellationofPolicyor
anyalterationintheinsuranceaffectingthepremium.
PolicySchedule
Code:997800179
ContactNumber:Nil
PolicyHolder:
Address:
PolicyDetails:
PolicyNumber: 316108000129040000
07/01/2014
DoubleSumInsuredfor
limitsopted
No
InsuredDetails:
Name RelationWith
PolicyHolder
Gender Dateof
Birth
IsNew/Renew/
Rollover/
Portability
Nominee
Name
Relationship Pre
existing
Illness
Cumulative
BonusEarned
% Amount
Saimex
Keshavlal
Patel
RashmiS,
Patel
ArchanS
Patel
PoojanS
Patel
SumInsured:
Name First
Inception
Date
Opted(Rs.) Ported
RashmiS,Patel 06/01/2005 100000.00 NA 100000.00 30000.00
ArchanSPatel 06/01/2005 100000.00 NA 100000.00 27500.00
PoojanSPatel 06/01/2005 100000.00 NA 100000.00 27500.00
Covers SumInsured
BasicCover
PreHospitalisation
Expenses
30days
PostHospitalisation
Expenses
60days
Domiciliary
Hospitalisation
Accident
exhausted
MaternityandNewBorn
BabyCover
DoubleSumInsuredfor
WaiverofRoomRent
Sublimits(ifOpted)
ValueAdds
ComprehensiveHealth
Checkup
of2years
TPADetails:
400011
PremiumDetails:
NetPremium: Rs.8058
ServiceTax: Rs.996
Note
AuthorizedSignatory
PREMIUMCERTIFICATE
PolicyNumber 316108000129040000
AuthorizedSignatory
PolicySchedule
Code:997800179
ContactNumber:Nil
PolicyHolder:
Address:
PolicyDetails:
PolicyNumber: 316108000129040000
07/01/2014
DoubleSumInsuredfor
limitsopted
No
InsuredDetails:
Name RelationWith
PolicyHolder
Gender Dateof
Birth
IsNew/Renew/
Rollover/
Portability
Nominee
Name
Relationship Pre
existing
Illness
Cumulative
BonusEarned
% Amount
Saimex
Keshavlal
Patel
RashmiS,
Patel
ArchanS
Patel
PoojanS
Patel
SumInsured:
Name First
Inception
Date
Opted(Rs.) Ported
RashmiS,Patel 06/01/2005 100000.00 NA 100000.00 30000.00
ArchanSPatel 06/01/2005 100000.00 NA 100000.00 27500.00
PoojanSPatel 06/01/2005 100000.00 NA 100000.00 27500.00
Covers SumInsured
BasicCover
PreHospitalisation
Expenses
30days
PostHospitalisation
Expenses
60days
Domiciliary
Hospitalisation
Accident
exhausted
MaternityandNewBorn
BabyCover
DoubleSumInsuredfor
WaiverofRoomRent
Sublimits(ifOpted)
ValueAdds
ComprehensiveHealth
Checkup
of2years
TPADetails:
400011
PremiumDetails:
NetPremium: Rs.8058
ServiceTax: Rs.996
Note
AuthorizedSignatory
PREMIUMCERTIFICATE
PolicyNumber 316108000129040000
AuthorizedSignatory
PolicySchedule
Code:997800179
ContactNumber:Nil
PolicyHolder:
Address:
PolicyDetails:
PolicyNumber: 316108000129040000
07/01/2014
DoubleSumInsuredfor
limitsopted
No
InsuredDetails:
Name RelationWith
PolicyHolder
Gender Dateof
Birth
IsNew/Renew/
Rollover/
Portability
Nominee
Name
Relationship Pre
existing
Illness
Cumulative
BonusEarned
% Amount
Saimex
Keshavlal
Patel
RashmiS,
Patel
ArchanS
Patel
PoojanS
Patel
SumInsured:
Name First
Inception
Date
Opted(Rs.) Ported
RashmiS,Patel 06/01/2005 100000.00 NA 100000.00 30000.00
ArchanSPatel 06/01/2005 100000.00 NA 100000.00 27500.00
PoojanSPatel 06/01/2005 100000.00 NA 100000.00 27500.00
Covers SumInsured
BasicCover
PreHospitalisation
Expenses
30days
PostHospitalisation
Expenses
60days
Domiciliary
Hospitalisation
Accident
exhausted
MaternityandNewBorn
BabyCover
DoubleSumInsuredfor
WaiverofRoomRent
Sublimits(ifOpted)
ValueAdds
ComprehensiveHealth
Checkup
of2years
TPADetails:
400011
PremiumDetails:
NetPremium: Rs.8058
ServiceTax: Rs.996
Note
AuthorizedSignatory
PREMIUMCERTIFICATE
PolicyNumber 316108000129040000
AuthorizedSignatory

Intermediary Name:Direct Code: 997800179 Contact Number: Nil

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Note:Note:ThiscertificatemustbesurrenderedtotheInsuranceCompanyforissuanceoffreshcertificateincaseofcancellationofPolicyorany

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