Reliance General Insurance Company Limited

Digitally signed by
Reliance General
Insurance Company
Limited
Date: 2022.06.21
01:06:13 IST
SID0621220027
https://rgiclservi
Reliance HealthGain Policy Schedule
Policyholder Details
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Policy Number: 120122228280008485 Proposal/Covernote No: R11062216670
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Name:
Customer ID:
MR. MANDA RANJITH OPHIR
Correspondence Address & Place of Supply:
Old no - 398, new No 824/1, 3rd Floor, R.N.G
13-C2-35 NFC NAGAR GHATKESAR,GHATKESAR ,
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Policy Servicing Branch: Tower Nandanam,Anna Salai CHENNAI
HYDERABAD, TELANGANA,
CHENNAI TAMIL NADU 600035
501301
Contact No:9030783436 Tax Invoice No. & Date: R11062216670 & 20/06/2022
Email-ID : mandaranjithophir@gmail.com GSTIN/UIN of Policyholder:
Date of Birth (DD/MM/YY): 25/08/1989 Gender: Male
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Plan Details
Premium Payment
Cover Type Individual Tenure (Years) 1 Single
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Mode
Plan Name PlanA BusinessType NEW Previous Policy No
Policy Period Start Date: 20/06/2022 End Date: 19/06/2023 Renewable Date 20/06/2023
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Details of the Insured 1 2 3 4 5 6
MRS. NISSI
Name
JERUSHA
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Gender Female
Relationship Spouse
Date of
03/06/1997
Birth(DD/MM/YYYY)
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Pre-existing Disease -
NO
Name
Pre-existing Disease -
NA
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Since
Insured with the
20/06/2022
Company, since
Base Sum Insured
300000
(Individual)
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Base Sum Insured

NA
(Family Floater)
Cumulative
0
Bonus(Individual)
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Cumulative
Bonus(Family Floater) NA
NEW
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0 VLE ID VLE Name UIN VLE Contact Number

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17B37706 YES BANK LIMITED NA

POS UID Aadhaar
Intermediary Code Intermediary Name Intermediary Contact No No. / PAN No.
Premium Details Amount (`) Details
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Basic Premium 4700.00

Loading : Underwriting 0.00
Discount 0.00
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Net Premium 4700.00

IGST (@ 18.00 %) 846.00
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Total Premium 0 5546.00

GSTIN:33AABCR6747B1ZN,HSN: 997133
Description of Services:Accident and Health Insurance Service
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"As per the GST regulations, the amount of GST will not be refunded if the policy / endorsement is cancelled after 30th September of the next financial year"
Consolidated Stamp duty Paid vide Letter of Authorisation "NO.LOA/CSD/300/2022/(Validity Period Dt.30/03/2022 to 30/03/2023)/1380" date 28th Mar 2022 at
General Stamp Office, Mumbai.** Not Applicable for the State of Jammu & Kashmir
Reliance General Insurance Company Limited. IRDAI Registration No. 103 An ISO 9001:2015 Certified Company
Registered & Corporate Office: Reliance General Insurance Company Limited, 6th Floor, Oberoi Commerz, International Business Park, Oberoi Garden City, Off Western
Express Highway, Goregaon (East), Mumbai - 400 063.
Corporate Identity No.U66603MH2000PLC128300. UIN:RELHLIP21514V022021. Trade Logo displayed above belongs to Anil Dhirubhai Ambani Ventures Private Limited
and used by Reliance General Insurance Company Limited under License. RGI/MCOM/CO/2828/PS/Ver.1.5/010218.
Page 1 of 1
Nominee Details
Relationship with
Name MANDA RANJITH OPHIR Date Of Birth 25/08/1989 Self
proposer
Address of Nominee 13-C2-35 NFC NAGAR GHATKESAR,GHATKESAR ,HYDERABAD,TELANGANA,501301
Benefits Table
Benefit Basis of Offering Benefit Basis of Offering
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Hospitalisation Expenses Medical Expenses incurred as Inpatient Wellness a- Doctor Anytime /Free Health Helpline: The
hospitalization Day care Treatment InsuredPerson shall have the option of
Pre Hospitalisation Expenses Pre-hospitalization up to 60 days seeking medical advice from a Medical
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Post Hospitalisation Expenses Post-hospitalization up to 60 days Practitioner through the telephonic or
Domestic Road Ambulance Upto Rs 1500 per Hospitalization online mode b- Health Portal: The
Donor Expenses Upto 50% of Base SumInsured subject to InsuredPerson shall have the option to
maximum of Rs 5 lacs access health related information and
Domiciliary Hospitalization Upto 10% of the Base SumInsured subject to a services through the Company’s/designated
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maximum of Rs 50,000 website
Cumulative Bonus 33 1/3 % increase in Base SumInsured for
every claim free year Max up to 100% of Base
SumInsured 33 1/3 % decrease in Base
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SumInsured for every claim year Max up to
earned Cumulative Bonus
Reinstatement of Base Sum One re-instatement upto 100% of Base Sum
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Insured
Insured, subject to sublimit of 20% for
related Illness/ injury
Call Option Once at the end of every consecutive 4 claim
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free years
Claim Servicing Guarantee Cashless Claims – 1% for every delay of 6
hours beyond 6 hours of receipt of all
information /documents Re-imbursement
Claims
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– 1% for every delay of 21 days beyond 21
days of receipt of all information/documents
Maximum – 6% for a claim
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Endorsements
Particular
Room Category
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Contact details for Policy &

Policy Servicing Claim Servicing
Claims Servicing
Name Customer Service Team R Care
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Reliance General Insurance,1-89/3/B/40 to

Reliance General Insurance Company Limited Winway
42/ks/301, 3rd floor,Krishe Block, Krishe
Correspondence Address Building,2nd & 3rd floor, 11/12, Block No - 4, Old No-67, South
Sapphire,Madhapur, Hyderabad.Pin code-
Tukoganj, Indore (M.P.) - 452001
500081
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E-mail ID rgicl.services@relianceada.com Rgicl.rcarehealth@relianceada.com

Contact No NA NA
Fax No (022) 48903009
Website www.reliancegeneral.co.in www.reliancegeneral.co.in
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Paid No (022) 48903009 (022) 48903009
For Reliance General

Please Note:
Insurance Co. Ltd.
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-Attached with this Policy Schedule are the Policy Terms and Conditions, Endorsements, and Annexures. Please ensure that you
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(Policyholder) have received, read and understood all these documents. If you (Policyholder) have not received any of these,
please email/write to the Company at rgicl.services@relianceada.com or contact us on 022 48903009(Paid no).
- This Policy Schedule in original must be surrendered to the Company in case of cancellation of the Policy.In the event of any
incorrect representation, the liability shall be upon the Policyholder.
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- The Benefits which are mentioned in this Schedule shall only be available under the Policy.
- In witness whereof this Policy has been signed at Mumbai on policy tax invoice date in lieu of Proposal No. as mentioned in the
policy.
-This document shall be treated as a Tax Invoice as per Rule 46 of the Central Goods and Services Tax Rules 2017.
IGST Authorised Signatory
Page 2 of 2
PREMIUM CERTIFICATE
Premium Certificate for the purpose of deduction under Section 80D of Income Tax Act, 1961.
This is to certify that Reliance General Insurance Company Limited has received an amount of ` 5546.00 from Mr. Manda Ranjith Ophir towards payment of health
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insurance premium as per the details mentioned above.
The premium paid for this policy is eligible for applicable tax benefits under section 80D of the Income Tax Act, 1961 and amendments thereof. 0
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Note :Any amount paid in cash towards the premium would not qualify for tax benefits as mentioned above.
Name of the Policyholder MR. MANDA RANJITH OPHIR
Correspondence Address 13-C2-35 NFC NAGAR GHATKESAR,GHATKESAR ,HYDERABAD,TELANGANA,501301
Lim
Policy Number 120122228280008485
Issue Date 20/06/2022
Place Mumbai
For Reliance General Insurance Co. Ltd.
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Authorised Signatory
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Please Note :
- In case of any discrepancy, the Policyholder is requested to let us know immediately. You can write to us at rgicl.services@relianceada.com or call us on 022
48903009(Paid) for necessary changes/rectification.
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- These documents must be surrendered to the Company in case of cancellation of the Policy or for the issuance of a fresh Schedule in the case of any alteration in
the Policy. In the event of incorrect representation of this declaration, the liability shall be upon the Policyholder. In case of a renewal, the benefits provided under the
policy and/or terms and conditions of the policy including premium rate may be subject to change.
-The policy wording with detailed terms, conditions and exclusions are available on our website www.reliancegeneral.co.in
(Policy wordings link : https://www.reliancegeneral.co.in/Insurance/About-Us/Downloads.aspx)
You can also write to us at rgicl.services@relianceada.com or call us on 1800 3009 (toll free)/ 022 4890 3009 (Paid) to avail the policy wording.
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Grievance Clause : For resolution of any query or grievance, Insured may contact the respective branch office of the Company or may call at 1800 3009 or
may write an email at rgicl.services@relianceada.com. In case the insured is not satisfied with the response of the office, insured may
contact the Nodal Grievance Officer of the Company at rgicl.grievances@relianceada.com. In the event of unsatisfactory response
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from the Nodal Grievance Officer, insured may email to Head Grievance Officer at rgicl.headgrievances@relianceada.com. In the event
of unsatisfactory response from the Head Grievance Officer, he/she may, subject to vested jurisdiction, approach the Insurance
Ombudsman for the redressal of grievance. Details of the offices of the Insurance Ombudsman are available at IRDAI website
www.irda.gov.in or on company website www.reliancegeneral.co.in or on www.gbic.co.in. The insured may also contact the following
office of the Insurance Ombudsman within whose territorial jurisdiction the branch or office of the Company is located.Office of the
Ins
Insurance Ombudsman,Fatima Akhtar Court,4th Floor,453, Anna Salai,Teynampet,CHENNAI – 600 018. Tel.: 044 - 24333668 /
24335284 Fax: 044 - 24333664 Email: bimalokpal.chennai@gbic.co.in
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Page 3 of 3
Know your policy
Remember to carefully go through the policy documents and confirm your details.
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In case of any discrepancy in the policy details, kindly revert within 15 days from the policy start date on 022 48903009(Paid No)or visit
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any of our branches or mail us at rgicl.services@relianceada.com
Kindly refer to the Customer Information Sheet and Policy Wording to understand your policy better and learn more about the policy
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coverages & Policy Exclusion.
How to register a Claim - Cashless
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How to register a Claim - Reimbursement nc
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What documents do you require to register a Claim

1. Duly filled Claim form. 7. Medico Legal Certificate (MLC) for all accident cases.
2. Discharge summary details, Final Hospital Bill (detailed breakup),interim bills 8. For miscellaneous charges - detailed bills with supporting
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& Payment Receipts. prescription of the consulting doctor.

3. Doctor’s consultation papers. 9. Copy of Health card & any other related documents.
4. Photo Id proof of insured & patient. 10. CTS 2010 compliant original Cancelled Cheque which
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5. All original investigation reports & all pharmacy bills, supported by doctor should bear printed name of account holder, IFSC Code &
prescriptions. Account No.
6. Implant sticker / invoice, if used (Eg. lens details in cataract case,stent
details in angioplasty).
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Note: As soon as a claim occurs, please intimate immediately to our call centre 022 48903009(Paid No).Delay in intimation would result in
the violation of policy condition.
How to renew your policy conveniently
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The content on this page is for additional information & should not be considered as part of the policy document / Schedule
Page 4 of 4
Online Proposal Form for Reliance HealthGain Proposal No. : R11062216670
Proposer Details NEW

Name of the Proposer* MR. MANDA RANJITH OPHIR
Gender Male
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Date of Birth*
25/08/1989 Nationality Indian
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Marital Status Married
Address of the Proposer 13-C2-35 NFC NAGAR GHATKESAR,GHATKESAR ,HYDERABAD,TELANGANA,501301
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Pan No. CEJPM4641A
Occupation Software Professional Mobile Number* 9030783436
Monthly Income NA E-mail mandaranjithophir@gmail.com
Plan\Policy Details
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a) Plan Opted : PlanA
b) Cover Type : Individual
c) No. of members to be covered :
1
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(Minimum 2 Members in case of Floater)
d) Annual Base Sum insured :
300000
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e) Installment Type : Single
Nomination Details
The nominee as declared hereunder shall become eligible for claim payment under the policy as per the terms and conditions of the Policy, in the event of the death
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of the Policyholder. The receipt of proceeds by the nominee would be sufficient discharge to the Company. Nominee for all other person(s) proposed shall be the
proposer himself/herself.
Name of Nominee D.O.B Relationship with Proposer Address of Nominee
13-C2-35 NFC NAGAR
MANDA RANJITH OPHIR 25/08/1989 Self GHATKESAR,GHATKESAR
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,HYDERABAD,TELANGANA,501301
Section A: Details of person(s) proposed to be insured

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Details Member 1 Member 2 Member 3 Member 4 Member 5 Member 6

MRS. NISSI
Name
JERUSHA
Gender Female
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Relationship Spouse
Date of
03/06/1997
Birth(DD/MM/YYYY)
Marital Status
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Married
Height (In cm) 0

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Weight (In kg) 0

Has any person to be No
insured been
diagonsed/hospitalized/
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under any treatment for

any illness/disease or
injury during any time in
past?
Eg.
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• Injury
• Diabetes
• Hypertension
• Cancer/ Tumour
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• Kidney Disease(s)
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• Paralysis/ Stroke
• Respiratory Disorder(s)
• HIV/ AIDS/ STD
• Liver Disease(s)
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• Heart Disease(s)
• Arthiritis/ Joint Pain
• Congenital Disease(s)
• Others (please specify)
Page 5 of 5
Does any person No
proposed to be insured
smoke or consume
tobacco or alcohol? If
yes,
please indicate quantity
per week
Are you an employee of Reliance Group NO
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If yes, please mention Employee Code
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Premium Payment Details
Premium Amount : 5546.00 Payment Mode :Online Date :11/06/2022
Amount in words :FIVE THOUSAND FIVE HUNDRED FORTY
Bank Name :
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SIX ONLY
Declaration & Warranty on Behalf of All Persons Proposer to be Insured

i. I have read and understood the brochure/prospectus/sales literature/terms and conditions of the Policy and confirm to abide by the same.
ii. I understand that the information provided by me will form the basis of the insurance policy, is subject to the Board approved underwriting policy of the insurance
Company and that the policy will come into force only after full receipt of the premium chargeable.
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iii. I/We further declared that I/We will notify in writing any change occurring in the occupation or general health of the life to be insured/proposer after the proposal
has been submitted but before communication of the risk acceptance by the Company.
iv. I/We declare and consent to the Company seeking medical information from any Doctor or from a hospital who at anytime has attended on the life to be
insured/proposer or from any past or present employer concerning anything which affects the physical or mental health of the life to be assured/ proposer and
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seeking information from any insurance Company to which an application form insurance on the life to be assured / proposer has been made for the purpose of
underwriting the proposal and / or claim settlement.
v. I/we authorized the Company to share information pertaining to my proposal including the medical records for the sole purpose of proposal underwriting and/or
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claims settlement and with any Government and/or Regulatory Authority.
vi. Receipt of the Proposal form by the Company shall not be construed as acceptance of proposal. I hereby agree that the insurance coverage shall commence only
on realization of full premium and on receipt of complete medical reports (wherever applicable) and subject to individual underwriting by the Company. The Company
at its sole discretion reserves the right to accept or reject or load any proposal without assigning any reason thereof.
vii. I understand that the Policy shall become void at the Company’s option, in the event of any untrue or incorrect statement, misrepresentation, non-description or
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non-disclosure of any material fact in the Proposal form/personal statement, declaration and connected documents or any material information having been withheld
by me or anyone acting on my behalf.
viii. I hereby declare that the person(s) proposed to be insured would submit to medical examinations, before the nominated doctors of the Company, or undergo
diagnostic or other medical tests, as suggested by the Company for its underwriting.
ix. I consent to provide a valid age proof and identity proof at the time of claims or any other time when required by the Company.
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x. I/We consent to receive information from the Company through physical, electronic or telecommunication means from time to time.
xi. I authorize the Company to exchange, share or part with the information relating to myself/person(s) to be insured with any external entity other than
regulatoryand statutory bodies, as may be required and I will not hold the Company or its agents liable for use/sharing of this information. Yes/No (non selection, the
optionshall be constructed as “Yes” by the Company)
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xii. I here by declare on my behalf & on behalf of all person proposed to be insured that the above statements, answers and/or particulars given by me in
thisproposal form are true and complete in all respects to the best of my knowledge and that I/We am/are authorized to propose on behalf of these other persons.
xiii. I declare that I am submitting a proposal for Health insurance policy to Reliance General Insurance Company Ltd. (Company) through the Company's
website/Portal, after satisfying myself of the truthfulness of the statements made by me herein and of the need to disclose all material facts.
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xiv. I further declare that the premium is being paid from my credit/ debit card/internet bank account.
xv. You are requested to please verify the details of the online proposal form and cross-check against the policy schedule. In case of any discrepancy, you should
report it within 15days of the receipt of the proposal form at our 022 48903009(Paid No), else it will be presumed that everything is in order.
xvi. Applicable if 'Quarterly premium option is selected'. I also understand and agree that upon non receipt of my installment by the Company, on or before the due
dates the policy shall cease to operate from the unpaid installment due date and the Company shall not be liable for any Claim under the Policy.
xvii) All the insured person's at the time of first enrollment under health gain policy are below the age of 61 year .then no co -payment shall be applicable even on
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renewal subject to no break in policy. However the applicable premium for such polices on renewal (when age of senior most member >=61 year) shall be loaded by
10%.
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IMPORTANT
• The policy has been issued based on the telephonic conversation / online proposal form, details provided wherein have been recorded in this proposal form. In
case of any discrepancy you are requested to contact our call centre at 022 48903009(Paid No) and record the discrepancy within 15days of receipt of the policy. In
case we do not get any communication from your side we will presume that all the details provided in the policy & proposal form all complete and accurate.
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• The information that you give to Reliance General Insurance on this online form will be treated as the proposal form and details in any supplemental information
form or documentation supplied by you or on your behalf will influence our decision to offer insurance and the terms upon which to offer it. It is therefore important
that your answers are complete and accurate in all respect.
• I have read and understood the terms and conditions governing the online transaction facility of Reliance General Insurance Company Ltd.
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Prohibition of Rebates - Section 41 of the Insurance Act, 1938 as amended by Insurance Laws (Amendment) Act, 2015.
• No person shall allow or offer to allow, either directly or indirectly as an inducement to any person to take out or renew or continue an insurance in respect of any
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kind of risk relating to lives or property, in India, any rebate of the whole or part of the commission payable or any rebate of the premium shown on the policy, nor
shall any person taking out or renewing or continuing a policy accept any rebate, except such rebate as may be allowed in accordance with the
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published prospectuses or tables of the Insurer.

• Any person making default in complying with the provisions of this section shall be punishable with fine, which may extend to five hundred rupees.
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Page 6 of 6
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https://rgiclservi
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Name : Mrs. NISSI JERUSHA
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Date of Birth : 03/06/1997
Gender : Female
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UHID : 28282220074120
Policy No : 120122228280008485
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Valid Upto : 19/06/2023
Scan the QR code for details
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Call 1800 3009(Toll Free) 022 4890 3009(Paid) 7400422200
Email: rgicl.rcarehealth@relianceada.com
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Please quote your UHID No. for assistance
- This card is invalid if the policy is cancelled
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- Immediate intimation to RCare is must in case of hospitalization

- To avail cashless facility at our Network hospitals, please produce your
Health cards & Photo ID proof of the Hospital Helpdesk
- Updated list of Network Hospitals is available on www.reliancegeneral.co.in
RCare
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Reliance General Insurance

No 1-89/3/B/40 to 42/ks/301, 3rd floor, Krishe block, Krishe Sapphire,
Madhapur,Hyderabad-50008
IRDAI Registration No. 103 Reliance General Insurance Company Limited.

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Registered & Corporate Office: Reliance General Insurance Company Limited, 6th Floor,
Oberoi Commerz, International Business Park, Oberoi Garden City, Off Western Express
Highway, Goregaon (East), Mumbai - 400 063.
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Corporate Identity No.U66603MH2000PLC128300. UIN:RELHLIP21514V022021.

Trade Logo displayed above belongs to Anil Dhirubhai Ambani Ventures Private Limited and
used by Reliance General Insurance Company Limited under License.
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RGI/MCOM/HL-11/HEALTH CARD/Ver 1.2/060617

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Page 7 of 7

Reliance General Insurance Company Limited

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Digitally signed by

Base Sum Insured

0 VLE ID VLE Name UIN VLE Contact Number

17B37706 YES BANK LIMITED NA

Basic Premium 4700.00

Net Premium 4700.00

Total Premium 0 5546.00

Contact details for Policy &

Reliance General Insurance,1-89/3/B/40 to

E-mail ID rgicl.services@relianceada.com Rgicl.rcarehealth@relianceada.com

Paid No (022) 48903009 (022) 48903009

For Reliance General

How to register a Claim - Cashless

What documents do you require to register a Claim

& Payment Receipts. prescription of the consulting doctor.

Proposer Details NEW

Section A: Details of person(s) proposed to be insured

Details Member 1 Member 2 Member 3 Member 4 Member 5 Member 6

Height (In cm) 0

Weight (In kg) 0

under any treatment for

Are you an employee of Reliance Group NO

Declaration & Warranty on Behalf of All Persons Proposer to be Insured

published prospectuses or tables of the Insurer.

Scan the QR code for details

- Immediate intimation to RCare is must in case of hospitalization

Reliance General Insurance

IRDAI Registration No. 103 Reliance General Insurance Company Limited.

Corporate Identity No.U66603MH2000PLC128300. UIN:RELHLIP21514V022021.

RGI/MCOM/HL-11/HEALTH CARD/Ver 1.2/060617

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