my:healthMedisureClassicInsurance

PolicySchedule

PolicyIssuingOffice:Mumbai PolicyServicingOffice:Ahmedabad

Code:NIL
IntermediaryName:Direct ContactNumber:NIL
PolicyHolder:

Name: Mr.VinodbhaiJPatel

51SHAYOWADARSHANBUNGLOWS
Address: GHATLODIYACHANAKYAPURITOKARGILPETROLPUMPROAD

AHMEDABADGUJARAT380061

TelephoneNumber(s): 9825061021 EMailID:

PolicyDetails:

PolicyNumber: 316108000123310200

PolicyPeriod: From:00:00AMon To:11:59PMon27/12/2016 Tenure:OneYear

28/12/2015

PolicyType Individual

IsRollOver/PortableCase Yes PreviousPolicyNumber 316108000123310100

DoubleSumInsuredfor No WaiverofRoomRentSub No
CriticalIllnessopted limitsopted

InsuredDetails:

Name RelationWith Gender Dateof IsNew/Rollover/ Nominee Relationship Preexisting CumulativeBonus

PolicyHolder Birth Portability Name IllnessDeclared Earned

% Amount

VinodbhaiJ Self Male 01/06/1963 Renew Vasanti Spouse No NA 250000.00

Patel

VasantibenV Spouse Female 09/01/1970 Renew Vinod Spouse No NA 60000.00

Patel

SumInsured:

Name First Opted(Rs.) Ported

Inception
Date SumInsured CB SumInsured(Rs.) CB

VinodbhaiJPatel 28/12/2006 500000.00 250000.00 NA NA

VasantibenVPatel 28/12/2006 200000.00 60000.00 NA NA

Benefits(FordetailspleasereferthePolicyWordings):

Covers SumInsured

BasicCover

HospitalisationExpenses RoomRent/Boarding&Nursingasperactualslimitedto1%ofSumInsured(excludingcumulativebonus)per
daysubjecttoamaximumofRs4,000/perdayICURent/Boarding&Nursingasperactualslimitedto2%of
SumInsured(excludingcumulativebonus)perdaysubjecttoamaximumofRs6,000/perday

PreHospitalisation 30days
Expenses

PostHospitalisation 60days
Expenses

DayCareTreatment MaximumuptoSumInsured

Domiciliary MedicalExpensesincurredformedicaltreatmenttakenathomewhichwouldotherwisehaverequired
Hospitalisation Hospitalisationforcontinuous3days.

Hospitalisationdueto MaximumuptoSumInsuredtowardsAccidentalHospitalisationonlywhentheoriginalSumInsuredis
Accident exhausted
 Covers SumInsured

BasicCover

HospitalisationExpenses RoomRent/Boarding&Nursingasperactualslimitedto1%ofSumInsured(excludingcumulativebonus)per
daysubjecttoamaximumofRs4,000/perdayICURent/Boarding&Nursingasperactualslimitedto2%of
SumInsured(excludingcumulativebonus)perdaysubjecttoamaximumofRs6,000/perday

PreHospitalisation 30days
Expenses

PostHospitalisation 60days
Expenses

DayCareTreatment MaximumuptoSumInsured

Domiciliary MedicalExpensesincurredformedicaltreatmenttakenathomewhichwouldotherwisehaverequired
Hospitalisation Hospitalisationforcontinuous3days.

Hospitalisationdueto MaximumuptoSumInsuredtowardsAccidentalHospitalisationonlywhentheoriginalSumInsuredis
Accident exhausted

MaternityandNewBorn Maximumupto10%ofSumInsuredorRs.20,000foranormaldeliveryandupto20%ofSumInsuredorRs.
BabyCover 40,000foraCaesareanSectionincludingchargesforNewBornCover.Thiscoverageissubjecttowaiting
periodof48monthsofcontinuouscoverage

AyurvedicCover MaximumuptoRs25,000forlistedtreatments

PreexistingDiseases Coveredafterthreecontinuousrenewals

OptionalCovers(Onpaymentofadditionalpremium)

DoubleSumInsuredfor MaximumuptoDoubletheSumInsuredforlistedCriticalIllnesses
CriticalIllnesses(ifOpted)

WaiverofRoomRent MaximumuptoSumInsured
Sublimits(ifOpted)

ValueAdds

HospitalCash Rs500perdaystartingfromday4today10(excessof3days)

AmbulanceCharges MaximumuptoRs1500/perhospitalization

RecoveryBenefit Rs5,000/whenhospitalisationexceeds10days

ComprehensiveHealth Afterevery4yearsofcontinuousclaimfreerenewals,forallInsured/InsuredPersonsuptoamaximumof1%
Checkup ofaverageSumInsuredexcludingcumulativebonus.ThislimitisavailableperInsured/InsuredPersonincase
ofanindividualPolicyandforallmembersputtogetherincaseofafloater.

WaitingPeriods/ExclusionsunderthePolicy(FordetailspleasereferthePolicyWordings):

Name 30daywaitingperiod Timeboundexclusionof2 Preexistingdisease Maternitycover

years

VinodbhaiJPatel Waived Waived Waived NA

VasantibenVPatel Waived Waived Waived Waived

SpecialConditions(ifany):

EMeditek(TPA)ServicesLtd.
TPADetails: 208209,TurfEstate,Off.Dr.EMosesRoad,
NearMahalaxmiStation,Mahalaxmi,Mumbai
400011

PremiumDetails:

NetPremium: Rs.12497

AdditionalLoading(ifapplicable) Rs.0

FamilyDiscount(ifapplicable): Rs.0

EmployeeDiscount(ifapplicable): Rs.0

TwoYearDiscount(ifapplicable) Rs.0

ServiceTaxandSwachhBharatCess: Rs.1812

TotalPremium Rs.14309

(ServiceTaxRegistrationNo:AABCL5045NSD001ReceiptNumber:RC121505103PANNumber:AABCL5045N
Category:GeneralInsuranceBusinessServices)

Note

Intheeventofdishonorofcheque,thispolicydocumentautomaticallystandscancelledfrominception,irrespectiveofwhetheraseparatecommunicationissentor
not.
 Name 30daywaitingperiod Timeboundexclusionof2 Preexistingdisease Maternitycover
years

VinodbhaiJPatel Waived Waived Waived NA

VasantibenVPatel Waived Waived Waived Waived

SpecialConditions(ifany):

EMeditek(TPA)ServicesLtd.
TPADetails: 208209,TurfEstate,Off.Dr.EMosesRoad,
NearMahalaxmiStation,Mahalaxmi,Mumbai
400011

PremiumDetails:

NetPremium: Rs.12497

AdditionalLoading(ifapplicable) Rs.0

FamilyDiscount(ifapplicable): Rs.0

EmployeeDiscount(ifapplicable): Rs.0

TwoYearDiscount(ifapplicable) Rs.0

ServiceTaxandSwachhBharatCess: Rs.1812

TotalPremium Rs.14309

(ServiceTaxRegistrationNo:AABCL5045NSD001ReceiptNumber:RC121505103PANNumber:AABCL5045N
Category:GeneralInsuranceBusinessServices)

Note

Intheeventofdishonorofcheque,thispolicydocumentautomaticallystandscancelledfrominception,irrespectiveofwhetheraseparatecommunicationissentor
not.
PolicySchedulehastobereadinconjunctionwithPolicywordingsattached.
ThisPolicyhasbeenissuedbasedontheinformationprovidedbyyouontheproposalform.Incaseyoufindanydiscrepancyinthesame,pleasecontactus
immediately.
Foranyclaimsassistance,pleasecontactusat18002095846(LTIN)(tollfree)orvisitusaswww.ltinsurance.com.OratL&TGeneralInsuranceCoLtd,6th
Floor,City2,PlotNo177CstRoad,NearBandraKurlaTelephoneExchange,KalinaSantacruzEast,Mumbai400098orWriteUsat
myhealthclaim@ltinsurance.com

ForanygrievancerelatedtothepolicyyoumaywritetoTheGrievanceOfficeratthepolicyissuingofficeaddressmentionedaboveorwritetohimat
grievance@ltinsurance.com
Youmayalsoemailathelp@ltinsurance.comorSMSLTIto5607058(56070LT)

Inwitness,whereofthisPolicyhasbeensignedatMumbaion28/12/2015

ForandonbehalfofL&TGeneralInsuranceCompanyLimited

AuthorizedSignatory

ServicingBranchAddress:Ahmedabad,102,ShukanArcade,1stFloorSwastikCrossRoadC.G.Road,Ahmedabad,Gujarat,Pin380009

StampdutyRs.1paidvideGRASDefaceNo.0000360534201516dtd.28/04/2015.

PREMIUMCERTIFICATE

PremiumCertificateforthepurposeofdeductionunderSection80(D)ofIncomeTax(Amendment)Act1986.

ThisistocertifythatMr.VinodbhaiJPatelhaspaidanamountofRs14309/
'RupeesFourteenThousandThreeHundredNine'(inwords)towardsPremiumforHealthInsuranceforthePeriodFrom00:00AMon28/12/2015Tomidnightof
27/12/2016.

PolicyNumber 316108000123310200

Date: 28/12/2015 Place Mumbai

ForandonbehalfofL&TGeneralInsuranceCompanyLimited

AuthorizedSignatory

ServicingBranchAddress:Ahmedabad,102,ShukanArcade,1stFloorSwastikCrossRoadC.G.Road,Ahmedabad,Gujarat,Pin380009

StampdutyRs.1paidvideGRASDefaceNo.0000360534201516dtd.28/04/2015.

PREMIUMCERTIFICATE

PremiumCertificateforthepurposeofdeductionunderSection80(D)ofIncomeTax(Amendment)Act1986.

ThisistocertifythatMr.VinodbhaiJPatelhaspaidanamountofRs14309/
'RupeesFourteenThousandThreeHundredNine'(inwords)towardsPremiumforHealthInsuranceforthePeriodFrom00:00AMon28/12/2015Tomidnightof
27/12/2016.

PolicyNumber 316108000123310200

Date: 28/12/2015 Place Mumbai

ForandonbehalfofL&TGeneralInsuranceCompanyLimited

AuthorizedSignatory

Note:ThiscertificatemustbesurrenderedtotheInsuranceCompanyforissuanceoffreshcertificateincaseofcancellationofPolicyoranyalterationinthe
insuranceaffectingthepremium.

Note:Note:ThiscertificatemustbesurrenderedtotheInsuranceCompanyforissuanceoffreshcertificateincaseofcancellationofPolicyorany
alterationintheinsuranceaffectingthepremium.