Group HospiCash Policy

Primary Insured Name and Address: Group / Master Policy No: 25500000002/00/000000/0
Rahul Bairagi
Certificate No.: 25500000002/00/007861/0
5 Bapu farm near new sant nagar, 452001 Period of Insurance: 00:00 HRS on 03-Jan-2020 to Midnight 02-
Jan-2021
Policy type: Individual
UIN No: DHFHLGPI9085V011819

Insured Person(s) Details

Relationship
Sr Member Name of Date of with Nominee
Gender Age
No Id Insured Person Birth Primary Name
Insured
1 001 Rahul Bairagi 1991-01-04 male 28 - -

Specific Conditions: Claims related payment shall be credited to bank account belonging to insured member

Premium Amount in (Rs.)

Net Premium 189.83
SGST @ 0%
CGST @ 0%
IGST @ 18% 34.17
UTGST @ 0% 0
Total Payable Premium 224
This is subject to master policy terms & conditions issued to Bhanix Finance And Investment Limited

Stamp Duty: The Stamp Duty of Rs. 0.50 paid vide defaced no. 0003525202201819 dated 27/09/2018

Policy & Claim Service Office

Place: Mumbai Date: 03-01-2020

Email: mycare@dhflinsurance.com Website: www.dhflinsurance.com

Toll Free Number: 1800 123 0004 HSN: 9971

IRDAI Registration Number: 155 CIN Number: U66000MH2016PLC283275

Address: DHFL General Insurance Ltd, 402, 403 & 404, A & B Wing, 4th Floor, Fulcrum, Sahar Road, Next to Hyatt Regency, Andheri (East),
Mumbai 400099. Maharashtra

Important Notice – This Certificate, Policy terms and conditions and Endorsement shall be read together and word or expression to which a specific meaning has been attached in any part of this Policy or
of the Schedule shall bear the same meaning wherever it may appear. Any amendments/modifications/alterations made on this system generated policy document is not valid and Company shall not be
liable for any liability whatsoever arising from such changes. Any changes required to be made in the policy once issued, would be valid and effective, only after written request is made to the Company
and Company accepts the requested amendments/modifications/alterations and records the same through separate endorsement to be issued by the Company. Our grievance redressal procedure and
details about ombudsman is also available in our policy wording. Please note that any misrepresentation, non-disclosure or withholding of material facts will lead to cancellation of policy ab-initio with
forfeiture of premium and non-consideration of claim, if any.

Document is digitally signed

Signer: Peeyush Agarwal

Date: Fri, Jan 3, 2020 16:12:54 IST
Location: MUMBAI
Coverage details:

Sr.no. Benefits / Limitation Sum Insured & Limits

1 Daily Benefit Amount Rs. 500/-

No. of Hospitalisation Days

2 10 Days
(per year)

Normal Room - Rs. 500/- per day

3 Sickness Hospital Cash
ICU Room - Rs. 1,000/- per day

Normal Room - Rs. 500/- per day

4 Accident Hospital Cash
ICU Room - Rs. 1,000/- per day

5 Day Care Procedure Cash Rs. 500/- per day

6 Deductible NIL

Waiting Period for Pre-

7 Existing Disease / Waived
Condition

Waiting period for Named

8 Waived
Ailments

9 Waiting period for 30 days Applicable for first 30 days

Claim Procedure –

1. For Claim Intimation, you can email us on mycare@dhflinsurance.com or call our Customer Care Toll free number 1800 123 0004 within
seven (7) days of occurrence of event. (For intimations beyond stipulated period, valid reason for delay should be provided
2. Submit the documents for processing within 15 days from date of completion of treatment / date of discharge from hospital to Us at our
Corporate office. (For document submission beyond stipulated period, valid reason for delay should be provided. However, no proof will be
accepted if furnished later than one (1) year from the time the event occurred)
3. Documents to be submitted are

Claim Form Duly Filled and Signed (Original)

Copy of attested Hospital summary / Discharge Summary
Copy of attested Final Hospital Bill with detail bill break up like Room charges; ICU charges etc.
Copy of cancelled cheque mentioning name of the policyholder and/ or Copy of bank statement / passbook mentioning name, bank account
number and IFSC code
Copy of KYC documents (Photo ID proof, Pan Card, Aadhar Card etc.)
Any other document as requested by Claims official

4. Claim shall be settled/ rejected within 30 days of the receipt of the last “necessary” documents or within 45 days in case where we have
initiated investigation.
5. In case of delay in the payment beyond the stipulated timelines, We shall be liable to pay interest at a rate of two percent (2%) above the
Bank Rate from the receipt of the last relevant document from the insured /claimant by insurer till the date of actual payment.
Important Exclusions / Conditions –

1. We will not pay any claim for hospitalization which commences within below waiting periods. However, if a waiver of such waiting period(s) is
opted then restriction in coverage will not be applicable.

S. No. Waiting Period Restriction

1 30 Days All Hospitalizations except due to Accident

2 1 Year Hospitalisation related to specific listed illnesses (named ailments) except where underlying cause is cancer

3 2 Year Hospitalization related to any Named Mental Illness or any complication arising from the same

Hospitalization related to any pre—existing disease/illness/injury, Mental Illness, HIV/ AIDS, Internal Congenital
4 4 Year
Condition or any complication arising from any of it

2. We will not make any payment under this policy unless specifically covered by Us, howsoever attributable to -

Breach of law with Criminal Intent; Self-inflicted injury,

Alcoholism, Drug or substance abuse or any addictive condition,
Obesity or weight control program; Cosmetic, plastic surgeries,
investigation & Evaluation, unproven/ experimental treatment,
Birth control Sterility and Infertility, participation as a professional in hazardous or adventure sports
External congenital diseases, Refractive error
Hospitalization for rest Cure, rehabilitation and respite care, custodial care, nursing facility for personal care etc.

*The above list of exclusion is indicative in nature. For complete list of terms, conditions and exclusions, please refer to policy wording
available with master policy holder (group administrator)

3. The certificate of insurance shall be void and all premium paid shall be forfeited to Us, in the event of misrepresentation, mis-description or
non-disclosure of any material facts, fraud by the insured.
4. The certificate of insurance may be renewed subject to the renewal premium being paid and the Group Policy is in force, on or before the
renewal due date. The benefits provided under the policy and /or terms and conditions of the policy including premium rate may be subject to
change. Grace period of thirty (30) days is allowed for renewal of the policy.
5. The insured covered under this Group Health Insurance Policy can opt to migrate to a suitable Individual Health Insurance Policy offered by
Us. The member shall apply for portability at least forty-five (45) days before the premium renewal date.
6. Product will be withdrawn after approval from IRDAI. In such a case, we will inform the Group Organizer/Administrator. For policies which fall
due for renewal within 15 days from the date of withdrawal – There will be one-time option for the Group Administrator to renew the existing
policy with Us or migrate to modified or new similar health insurance policy with Us. For policies which fall due for renewal after fifteen (15)
days from the date of withdrawal – The only option will be to migrate to modified or new similar health insurance policy with Us. You will have
an option to opt for similar health insurance policy with Us subject to Portability norms is vogue.
7. You may request to cancel this Certificate by sending fifteen (15) days’ notice in writing to Us. We shall refund the amount post retention of
the premium (as per the short period table) for the period the policy has been in force. However, in case of claim in the policy, there will be no
refund of premium.

Grievance Redressal

At DHFL General Insurance Limited, we want your relationship with insurance to be much beyond than what you’ve experienced yet. To understand,
appreciate, and enjoy insurance-we’re here for you.

You can connect with us on the following channels:

1. Call us on our Toll-free 1800-123-0004 (From 8 am to 8 pm) for any queries that you may have.
2. E-mail your queries to mycare@dhflinsurance.com
3. For Senior Citizens, we have a special cell and our Senior Citizen Customers can email us at seniorcare@dhflinsurance.com for priority
resolution.
4. Visit our website www.dhflinsurance.com to register your policy related requests.
5. Please walk-in to any of our branches or partner locations.
6. You can also dispatch your letters to us at: DHFL General Insurance Limited 402, 403 & 404, A & B Wing, 4th Floor, Fulcrum, Sahar Road,
Next to Hyatt Regency, Andheri (East), Mumbai, Maharashtra - 400 099.
7. Call us at our policy service office/Head office on 022-40018100.

We request you to please mention your complete details:

Full Name
Policy Number / Certificate of Insurance Number
Contact Details

in all your communications, to enable our customer experience expert to connect with you and provide you with quickest possible solution.

We’ll ensure to acknowledge your service request within 3 working days and try and resolve it to your satisfaction within 15 working days. That’s a
promise!
Escalation Matrix

Level 1

While we attempt to give you best-in-class and prompt resolution for any concerns, sometimes it may not be perfect. If you feel that you weren’t
offered a perfect resolution, please feel free to share your feedback with our Manager Customer Experience team at
Manager.CustomerExperience@dhflinsurance.com

Level 2

If you still are not happy about the resolution provided , then you may please write to our Grievance Redressal Officer (GRO) and Head
Customer Experience at Head.CustomerExperience@dhflinsurance.com or contact GRO at 022-40018100.

Level 3

If you are not happy with the resolution, you may approach IRDAI by calling on the Toll Free no. 155255 (or) 1800 4254 732. You can also register an
online complaint on the website http://igms.irda.gov.in.

If your concern remains unresolved till one month from the date of registering your complaint, you may please approach the Insurance Ombudsman
for redressal. To know who your Insurance Ombudsman is, simply refer to the Ombudsman list overleaf.

List of Insurance Ombudsmen

SR NO CONTACT DETAILS JURISDICTION

AHMEDABAD - Shri/Smt........

Office of the Insurance Ombudsman,

Jeevan Prakash Building, 6th Floor, State of Gujarat and Union Territories of Dadra & Nagar Haveli
1
Tilak Marg, Relief Road, and Daman and Diu
Ahmedabad - 380 001.
Tel.: 079 - 25501201/02/05/06
Email: bimalokpal.ahmedabad@ecoi.co.in

BENGALURU

Office of the Insurance Ombudsman,

2 Jeevan Soudha Building, PID No. 57-27-N-19, Karnataka
Ground Floor, 19/19, 24th Main Road,
JP Nagar, 1st Phase, Bengaluru - 560 078.
Tel.: 080 - 26652048 / 26652049
Email: bimalokpal.bengaluru@ecoi.co.in

BHOPAL

Office of the Insurance Ombudsman,

Janak Vihar Complex, 2nd Floor,
3 6, Malviya Nagar, Opp. Airtel Office, States of Madhya Pradesh and Chattisgarh
Near New Market, Bhopal - 462 003.
Tel.: 0755 - 2769201 / 2769202
Fax: 0755 - 2769203
Email: bimalokpal.bhopal@ecoi.co.in

BHUBANESHWAR

Office of the Insurance Ombudsman,

4 62, Forest Park, Bhubneshwar - 751 009. State of Orissa
Tel.: 0674 - 2596461 / 2596455
Fax: 0674 - 2596429
Email: bimalokpal.bhubaneswar@ecoi.co.in

CHANDIGARH

Office of the Insurance Ombudsman,

S.C.O. No. 101, 102 & 103, 2nd Floor, States of Punjab, Haryana, Himachal Pradesh, Jammu &
5 Batra Building, Sector 17 - D, Kashmir and Union territory of Chandigarh
Chandigarh - 160 017.
Tel.: 0172 - 2706196 / 2706468
Fax: 0172 - 2708274
Email: bimalokpal.chandigarh@ecoi.co.in
SR NO CONTACT DETAILS JURISDICTION

CHENNAI

Office of the Insurance Ombudsman,

Fatima Akhtar Court, 4th Floor, 453,
6 Anna Salai, Teynampet, State of Tamil Nadu and Union Territories - Pondicherry Town
Chennai - 600 018. and Karaikal (which are part of Union Territory of Pondicherry)
Tel.: 044 - 24333668 / 24335284
Fax: 044 - 24333664
Email: bimalokpal.chennai@ecoi.co.in

DELHI

Office of the Insurance Ombudsman,

7 2/2 A, Universal Insurance Building, State of Delhi
Asaf Ali Road, New Delhi - 110 002.
Tel.: 011 - 23232481 / 23213504
Fax: 011 - 23230858
Email: bimalokpal.delhi@ecoi.co.in

GUWAHATI

Office of the Insurance Ombudsman,

Jeevan Nivesh, 5th Floor, States of Assam, Meghalaya, Manipur, Mizoram, Arunachal
8 Nr. Panbazar Over Bridge, S.S. Road, Pradesh, Nagaland and Tripura
Guwahati - 781001 (ASSAM).
Tel.: 0361 - 2132204 / 2132205
Fax: 0361 - 2732937
Email: imalokpal.guwahati@ecoi.co.in

HYDERABAD

Office of the Insurance Ombudsman,

6-2-46, 1st ?oor, "Moin Court",
Lane Opp. Saleem Function Palace, States of Andhra Pradesh, Telangana and Union Territory of
9
A. C. Guards, Lakdi-Ka-Pool, Yanam - a part of the Union Territory of Pondicherry
Hyderabad - 500 004.
Tel.: 040 - 65504123 / 23312122
Fax: 040 - 23376599
Email: bimalokpal.hyderabad@ecoi.co.in

JAIPUR

Office of the Insurance Ombudsman,

10 Jeevan Nidhi - II Bldg., Gr. Floor, State of Rajasthan
Bhawani Singh Marg, Jaipur - 302 005.
Tel.: 0141 - 2740363
Email: bimalokpal.jaipur@ecoi.co.in

ERNAKULAM

Office of the Insurance Ombudsman,

2nd Floor, Pulinat Bldg., Kerala, Lakshadweep, Mahe-a part of
11 Opp. Cochin Shipyard, M. G. Road,
Ernakulam - 682 015. Pondicherry
Tel.: 0484 - 2358759 / 2359338
Fax: 0484 - 2359336
Email: bimalokpal.ernakulam@ecoi.co.in

KOLKATA

Office of the Insurance Ombudsman,

Hindustan Bldg. Annexe, 4th Floor, States of West Bengal, Sikkim and Union Territories of Andaman
12
4, C.R. Avenue, Kolkata - 700 072. and Nicobar Islands
Tel.: 033 - 22124339 / 22124340
Fax: 033 - 22124341
Email: bimalokpal.kolkata@ecoi.co.in
 SR NO CONTACT DETAILS JURISDICTION

LUCKNOW District of Uttar Pradesh: Lalitpur, Jhansi, Mahoba, Hamirpur,

Banda, Chitrakoot, Allahabad, Mirzapur, Sonbhabdra, Fatehpur,
Office of the Insurance Ombudsman, Pratapgarh, Jaunpur, Varansi, Gazipur, Jalaun, Kanpur,
6th Floor, Jeevan Bhawan, Lucknow, Unnao, Sitapur, Lakhimpur, Bahraich, Barabanki,
13 Phase-II, Nawal Kishore Road, Raebareli, Sravasti, Gonda, Faizabad, Amethi, Kaushambi,
Hazratganj, Lucknow - 226 001. Balrampur, Basti, Ambedkarnagar, Sulanpur, Maharajganj,
Tel.: 0522 - 2231330 / 2231331 Santkabirnagar, Azamgarh, Kaushinagar, Gorkhpur, Deoria,
Fax: 0522 - 2231310 Mau, Chandauli, Ballia, Sidharathnagar
Email: bimalokpal.lucknow@ecoi.co.in

MUMBAI

Office of the Insurance Ombudsman,

3rd Floor, Jeevan Seva Annexe, S. V. Road, States of Goa, Mumbai Metropolitan Region excluding Navi
14
Santacruz (W), Mumbai - 400 054. Mumbai & Thane
Tel.: 022 - 26106552 / 26106960
Fax: 022 - 26106052
Email: bimalokpal.mumbai@ecoi.co.in

NOIDA States of Uttaranchal and the following Districts of Uttar

Office of the Insurance Ombudsman,
15 Bhagwan Sahai Palace, 4th Floor,
Main Road, Naya Bans, Sector 15,
Distt: Gautam Buddh Nagar, U. P. - 201301.
Tel.: 0120 - 2514250 / 2514252 / 2514253
Email: bimalokpal.noida@ecoi.co.in
Pradesh: Agra, Aligarh, Bagpat, Bareilly, B?nor, Budaun,
Bulandshehar, Etah, Kanooj, Mainpuri, Mathura, Meerut,
Moradabad, Muza?arnagar, Oraiyya, Pilibhit, Etawah,
Farrukhabad, Firozabad, Gautam Budh Nagar, Ghaziabad,
Hardoi, Shahjahanpur, Hapur, Shamli, Rampur, Kashganj,
Sambhal, Amroha, Hathras, Kanshiramnagar, Saharanpur

PATNA

Office of the Insurance Ombudsman,

16 1st Floor, Kalpana Arcade Building, States of Bihar and Jharkhand
Bazar Samiti Road, Bahadurpur,
Patna - 800 006.
Tel.: 0612-2680952
Email: bimalokpal.patna@ecoi.co.in

PUNE

Office of the Insurance Ombudsman,

Jeevan Darshan Bldg., 3rd Floor, States of Maharashtra, Area of Navi Mumbai and Thane
17
C.T.S. No. 195 to 198, N. C. Kelkar Road, excluding Mumbai Metropolitan Region
Narayan Peth, Pune - 411 030.
Tel.: 020 - 41312555
Email: bimalokpal.pune@ecoi.co.in

Disclaimer - The information regarding scope of cover, exclusions, claim procedure and terms/conditions mentioned in the Policy
Certificate is indicative and brief in nature. For more details, please refer to the policy wordings available on our website
www.dhflinsurance.com or with master policy holder (group administrator)

PREMIUM RECEIPT (For the purpose of deduction under sec 80D of Income Tax Act, 1961 and amendments thereof)

This is to certify that Rahul Bairagi has paid Rs. 224 (Net Premium Rs. 189.83 and (CGST+SGST/ UTGST) / IGST ) whichever is applicable Rs.
34.17 ) towards premium for Group HospiCash Policy number 25500000002/00/007861/0 for the period 00:00 HRS on 03-Jan-2020 to Midnight 02-
Jan-2021.
 Tax Invoice

Invoice No : DG19200000007861

Date : 03-Jan-2020

Policy No : 25500000002/00/007861/0

To Servicing Branch Address :

Rahul Bairagi 402,403 & 404 A & B Wing 4th Floor, Fulcrum,
5 Bapu Farm Near New Sant Nagar, 452001 Sahar Road, Next to Hyatt Regency, Andheri (East), Mumbai 400099

GSTIN : GSTIN : 27AAFCD7985H1Z4

PAN : PAN : AAFCD7985H

Place of Supply : Madhya Pradesh State Name : Maharashtra

State Code : State Code : 27

PARTICULARS AMOUNT IN INR

Net premium (Taxable Value) 189.83

IGST @ 18 % 34.17

CGST @ 0 %

SGST @ 0 %

UTGST @ 0 % 0

Invoice Value 224

Tax Payable in Reverse Charge No

HSN Code 9971

Notes

Refund requests received after September following the financial year in which this tax invoice was issued will be processed exclusive of GST.
Wherever the GST amount is refunded for which input tax credit was availed by the Customer, the same shall be reversed by the Customer on
receipt of the Credit Note.
In case the tax deduction entitled to DHFL-GI because of such refund is disallowed due to non-reversal of input tax credit by the customer, the said
tax portion should be separately recoverable (along with interest) from the Customer.