Medical Examination Report

Transcript of the Tele Medical Examination Report

This is the transcript of the answers provided by Life to be assured verbally to the questions asked below in a Tele verification by the underwriting team of HDFC Life Insurance Company Ltd. The answers
provided by the Life to be assured would form a part of the application for insurance.
We request you to go through the transcript carefully. In case of any disagreement, you are requested to highlight the same within 15 days of the receipt of this transcript; otherwise this would be
taken as acceptable to you and thereby binding on you. Please retain this transcript for future reference.

Case Type CRF

Case Login Type

Type of MER TELEMER

Mode of Completion TELE OUTBOUND

Application No. 1410101033036 Date 24-Dec-2022

Life to be Assured (LA) Mr Dipenkumar Arvindkumar Khamar Contact No. 9033596945

Existing Application Email Id dipenkhamar407@gmail.com

Question Details shared by HDFC Details Collected by Dr. Recommendation

Date of Birth 21-Aug-1989 31-Aug-1989 Ref to uw

Gender MALE Male STP

Product Category HDFC Life Click 2 Protect 3D Plus

Education Qualification Post Graduate Post Graduate STP

Occupation Salaried Salaried STP

Height 178 177.8 STP

Weight 85 85 STP

Smoker Status No STP

Geo Tagging NA

S.No Question Answer Recommendation

Have either of your Natural Parents or siblings suffered or Suffering from Cancer/Heart Disease/ Stroke/ HTN/ Diabetes/ Thalesamia /
1 No STP
Sickle cell anemia or any such Familial disorders?

2 Have you ever in the past or currently consuming Alcohol? No STP

3 Have you ever in the past or currently consuming any form of tobacco? No STP

4 Any History of Diabetes or elevated blood sugar No STP

5 Any History of Hypertension or High Blood Pressure No STP

6 Any History of Cholesterol related problems No STP

7 Any History of Stress, Depression, Anxiety problems or any such mental disorder No STP

8 Any history of Hospitalization within 5 years for Medical treatment/ Accident/ Surgery No STP

9 Any history of sudden and unplanned weight gain or loss No STP

10 Any history of Blood related disorder No STP

11 Any history of Eye or vision problems including retinopathy (other than using Specs / Lens) No STP

12 Any history of Ear / Nose / Throat problems Yes STP

Have you recovered Are you under any Any Reports available related
Category Select Problem Period of Diagnosis Any surgery under 3 months
completely medication to the event

Left ear Tympanoplasty One day

Ear Tympanoplasty Greater than 10 years
hospitalisation

13 Any history or events of Nervous disorders No STP

14 Any history of thyroid disorders No STP

15 Any history of Respiratory disorders No STP

16 Any history of Heart Problems / Disorders No STP

17 Any history of Digestive System Disorders No STP

18 Any history of Kidneys or Bladder Disorders No STP

19 Any history of Bone/Joint/Muscular Disorders No STP

20 Any history of Disability / Disorder No STP

21 Any history of Cancer or Growth No STP

 22 Any history of Viral Infections Yes STP

Are you under any Any Reports available related

Disorder Period of infection Date of infection Have you recovered completely
medication to the diease

At the age of 10 years

Malaria Greater than 10 years Completely recovered in 5 days
malaria

23 Have you been tested positive for Covid19 Yes Ref to uw

Date of infection November 2020

Have you been hospitalised for the event? If yes,enter the duration No hospitalisation

Any further complications No

Have you recovered completely Fully recovered

Are you under any medication (If yes,Enter medication details) Quarantine for 21 days, Paracetamol, Dolo 650 , Vitamin C zinc tablets for one week

Have you undergone any investigation like - CT Scan, Chest Xray, Pulmorary
RAT, rtpcr
function test etc

24 Are you vaccinated - Yes STP

1st Dose Date - DD/MM/YYYY 21 April 2021

2nd Dose Date - DD/MM/YYYY 7 August 2021

Vaccination Name Covishield

25 Booster dose taken - No STP

26 [For Male] History of Reproductive Organ disease involving testies, prostate or pennis No STP

27 Please confirm your Marital Status Yes STP

Marital Please provide the Date of Marriage -

Children Chidren Details
Status Month/YYYY

Single

28 [For Female]Are you currently pregnant No STP

29 [For Female] Any pregnancy complications incl miscarriage or MTP No STP

30 [For Female] Any history of Menstrual irregularity No STP

31 [For Female] Any history of disease of Uterus, Breast, Cervix, Ovaries, Fibroid, Lump, Cyst etc. No STP

Is there anything else you would like to share with us with respect to your health or habits in the past or present which is not covered
32 No STP
in above questions? Or Do you have undergone any routine health check investigation recently

33 Any Specific Disclosure by LA not covered above No STP

34 Any Specific Identification by the Doctor not covered above No STP

35 Any Specific Identification by the Doctor (Technical Remarks) No STP

Do you want to Change the Recommendation? No

Final Recommendation (Auto Generated) Ref to uw

We thank you for having taken the time to confirm the details. We will process your application based on the information provided.

Name and Signature of the Medical Doctor/ Medical Underwriter

Dr. Dr. Nishat Ansari

Reg no: 2019127199

Dated Time of Medical Verification 25-Dec-2022