HDFC ERGO General Insurance Company Limited

Date : 25/10/2018

my
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2857201940185201000

MR PRAVINSINH K SISODIYA
2292, INDIRA PRAJAPATI SOC AT POST RADHU DIS KHEDA
KHEDA AHMEDABAD, 380007
GUJARAT
Contact No : 9712941922

We have secured your health last year and we are happy to have the privilege of serving you again this year as well.

Your Health insurance policy reference no 2857201940185201000 has been renewed successfully.

For your convenience we have implemented a Lifetime Validity Health Card. For you,this simply means that the Health card issued at the time of first
policy purchase is valid throughout and as long as your policy is active with us.

We look forward to serving you in future and wish you a safe and secure year ahead.

For HDFC ERGO General Insurance Company Limited

Ankur Bahorey
Head - Retail Business Group

Signature Not Verified

Digitally signed by Nagendra
Saikumar
Date: 2018.10.25 16:56:05 IST
Reason: I'm the author
Location: India

HDFC ERGO General Insurance Company Limited. (Formerly HDFC General Insurance Limited from Sept 14, 2016 and L&T General Insurance Company Limited upto Sept 13, 2016).CIN: U66030MH2007PLC177117.
Registered & Corporate Office: 1st Floor,HDFC House, 165 - 166 Backbay Reclamation,H. T. Parekh Marg, Churchgate, Mumbai - 400 020. Customer Service Address: D-301, 3rd Floor, Eastern Business District
(Magnet Mall), LBS Marg, Bhandup (West), Mumbai - 400 078. Toll Free Number: 1800 2700 700 Te.: +91 22 6638 3600 | Fax: 91 22 6638 3699 | care@hdfcergo.com | www.hdfcergo.com.
UIN : LTGHLIP13001V021213 IRDAI Reg No.146
HDFC ERGO General Insurance Company Limited 2857201940185201000

my: health Medisure Classic Insurance

Policy No. 2857 2019 4018 5201 000 Policy Schedule

Customer Id:100482416452

Proposer Name MR. PRAVINSINH K SISODIYA PAN No. Premium Frequency Yearly
Corr. Address/ 2292, INDIRA PRAJAPATI SOC AT POST RADHU DIS KHEDA Permanent 2292, INDIRA PRAJAPATI SOC AT POST RADHU DIS KHEDA KHEDA
Place of Supply KHEDA Address AHMEDABAD,GUJARAT,380007
AHMEDABAD,GUJARAT,380007 0

Mobile 9712941922 Phone E Mail Policy Type Family Floater

Period of Insurance From Date & Time 25/10/2018 00:01 hrs To Date & Time 24/10/2019 Midnight Policy Issuance Date 24/10/2018

Renewal Yes Previous Policy Number 2857201940185200000

Double Sum Insured for Critical Illness opted No Waiver of Room Rent Sub-limits opted No
Insured Person’s Details & Sum Insured
Insured's Name Relation with Gender Date of Nominee Name Nominee 1st Policy Sum Insured CB Amount Pre Existing
policy holder Birth Relationship Inception (`) (`) Disease
PRAVINSINH K
Self Male 05/06/1989 VARSHA BEN Spouse 25/10/2013 No
SISODIYA
200000 40000
VARSHABEN P
Spouse Female 20/04/1995 PRAVIN SINH Spouse 25/10/2013 No
SISODIYA

Hospitalisation Expenses
Pre Hospitalisation Expenses
Post Hospitalisation Expenses
Day Care Treatment
Domiciliary Hospitalisation
Hospitalisation due to Accident
Maternity and New Born Baby Cover
Ayurvedic Cover
Pre-existing Diseases
Double Sum Insured for Critical Illnesses
Waiver of Room Rent Sub-limits
Coverage Details
Basic Cover
Room Rent/Boarding as per actuals limited to 1% of Sum Insured (excluding cumulative bonus) per day subject to a maximum of Rs
4,000/-per day.ICU Rent/Boarding as per actuals limited to 2% of Sum Insured (excluding cumulative bonus) per day subject to a
maximum of Rs 6,000/-per day.
30 days
60 days
Maximum upto Sum Insured
Medical Expenses incurred for medical treatment taken at home which would otherwise have required Hospitalisation for continuous 3
days.
Maximum upto Sum Insured towards Accidental Hospitalisation only when the original Sum Insured is exhausted
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 Caesarean
Section including charges for New Born Cover. This coverage is subject to waiting period of 48 months of continuous coverage
Maximum upto Rs 25,000 for listed treatments
Covered after three continuous renewals
Optional Covers(On payment of additional premium if Opted)
Maximum upto Double the Sum Insured for listed Critical Illnesses
Maximum upto Sum Insured

Value Add
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 continous 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.
The Policy Wording attached herewith includes all the standard coverages offered b y the Company to its customers. Your entitlement for coverage/benefits shall be restricted to the coverage/benefits a s mentioned in
this Policy Schedule issued to you. Please read the Policy Wording in conjunction with the Policy Schedule. For any clarification, please call our toll free number.

Premium Details (`)

Basic Premium 4009.00
Total Premium excluding Taxes 4009.00
Additional Loading 0.00
GST 18% : Central Tax 9% ( `361 ) + State Tax 9% ( `361) 722.00
Total Premium 4731.00

Payment Details
Cheque No./DD/Fund Transfer Date Bank Name
P6748473 24/10/2018

Special Conditions
Age proof/identity proof will be collected in event of claim under the policy.

Invoice No. 201940185201000 HSN Code 9971

For Claim Services Phone 1800 2 700 700 Fax no. 1860 2000 600 E-mail healthclaims@hdfcergo.com
Processing Centre HDFC ERGO General Insurance Company Ltd. 5th floor, Tower 1, Steller IT Park, C-25, Sector-62,Noida-201301.
For any other query call toll-free 1800 2700 700 or email us at care@hdfcergo.com or log on to www.hdfcergo.com

If the premium is not realised the policy shall be void from inception.
Consolidated stamp duty for this Insurance Policy i s paid b y Demand Draft, vide Receipt/Challan no. CSD/137/2018/3774/18 dated 30/08/2018 a s prescribed in Government of Maharashtra Order No.
Mudrank-2017/CR.97/M-1, dated the 09th January 2018". . Goods & Services Tax Registration No: 24AABCL5045N1ZE. Goods and Services Tax for this invoice is not payable under reverse charge basis.
Branch :AHMEDABAD - 206, SECOND FLOOR,SHOPPER PLAZA IV,OPP. BSNL TELEPHONE EXCHANGE ROAD, NAVARANGPURA,AHMEDABAD - 380006
AHMEDABAD, 380006. Phone No. :+91-79-39883600

HDFC ERGO General Insurance Company Limited. (Formerly HDFC General Insurance Limited from Sept 14, 2016 and L&T General Insurance Company Limited upto Sept 13, 2016).CIN: U66030MH2007PLC177117.
Registered & Corporate Office: 1st Floor,HDFC House, 165 - 166 Backbay Reclamation,H. T. Parekh Marg, Churchgate, Mumbai - 400 020. Customer Service Address: D-301, 3rd Floor, Eastern Business District
(Magnet Mall), LBS Marg, Bhandup (West), Mumbai - 400 078. Toll Free Number: 1800 2700 700 Te.: +91 22 6638 3600 | Fax: 91 22 6638 3699 | care@hdfcergo.com | www.hdfcergo.com.
UIN : LTGHLIP13001V021213 IRDAI Reg No.146
HDFC ERGO General Insurance Company Limited 2857201940185201000

my: health Medisure Classic Insurance

Agent Name :SMITA JAGATSINH CHAVDA For HDFC ERGO General Insurance Company Limited

Agent Code :201170951408 Tel No. : 91-9712941922

Duly Constituted Attorney

*$*PARTHANIL_GHOSH#$#

HDFC ERGO General Insurance Company Limited. (Formerly HDFC General Insurance Limited from Sept 14, 2016 and L&T General Insurance Company Limited upto Sept 13, 2016).CIN: U66030MH2007PLC177117.
Registered & Corporate Office: 1st Floor,HDFC House, 165 - 166 Backbay Reclamation,H. T. Parekh Marg, Churchgate, Mumbai - 400 020. Customer Service Address: D-301, 3rd Floor, Eastern Business District
(Magnet Mall), LBS Marg, Bhandup (West), Mumbai - 400 078. Toll Free Number: 1800 2700 700 Te.: +91 22 6638 3600 | Fax: 91 22 6638 3699 | care@hdfcergo.com | www.hdfcergo.com.
UIN : LTGHLIP13001V021213 IRDAI Reg No.146
 HDFC ERGO General Insurance Company Limited 2
Policy No.:2857201940185201000 This card is for identification purpose only.
Valid From: 25/10/2018 Renewal Date: 24 October
Card has to be presented to the Network Service Provider at the time of admission/ availing
cashless hospitalization o r any other services. Insurance claim will be processed in accordance
Insured Name Date Of Birth Gender
with the policy term & conditions. Card does not guarantee cashless hospitalization or any other
service. For more details and updated list of Network Service Provider please refer our website or
PRAVINSINH K SISODIYA 05/06/1989 Male call our call centre. This card is valid till the time policy is active.

VARSHABEN P SISODIYA 20/04/1995 Female

Phone Number : 1800 2 700 700
Fax Number : 1860 2000 600
Email : healthclaims@hdfcergo.com
Processing Centre : HDFC ERGO General Insurance Company Ltd. 5th floor,
Tower 1, Steller IT Park, C-25, Sector-62,Noida-201301.
Website : www.hdfcergo.com

HDFC ERGO General Insurance Company Limited. (Formerly HDFC General Insurance Limited from Sept 14, 2016 and L&T General Insurance Company Limited upto Sept 13, 2016).CIN: U66030MH2007PLC177117.
Registered & Corporate Office: 1st Floor,HDFC House, 165 - 166 Backbay Reclamation,H. T. Parekh Marg, Churchgate, Mumbai - 400 020. Customer Service Address: D-301, 3rd Floor, Eastern Business District
(Magnet Mall), LBS Marg, Bhandup (West), Mumbai - 400 078. Toll Free Number: 1800 2700 700 Te.: +91 22 6638 3600 | Fax: 91 22 6638 3699 | care@hdfcergo.com | www.hdfcergo.com.
UIN : LTGHLIP13001V021213 IRDAI Reg No.146