Health QuBE Insurance Policy Schedule

Policy Issuing Unit No. 421 , Fourth Floor, Wave Silver Tower, Sector 18, Noida - 201301, Uttar Pradesh, Gautam Buddh Nagar, Noida, Gautam Buddh Nagar, Uttar
Office: Pradesh - 201301
Phone: +91 Null Fax: +91 22 4231 3777
Policy Servicing Unit No. 421 , Fourth Floor, Wave Silver Tower, Sector 18, Noida - 201301, Uttar Pradesh, Gautam Buddh Nagar, Noida, Gautam Buddh Nagar, Uttar
Office: Pradesh - 201301
Phone: +91 Null Fax: +91 22 4231 3777

Policy RQBE01-113219-00-000 1 6 0 6 2 0 2 3
Number Period of From
Proposer Prince Pandey Insurance 00:00
Name Hrs of 1 5 0 6 2 0 2 4
Contact 9792765131 To
Number 23:59
Hrs of
Mailing PATEL KISHOR KUMAR CHHAGANBHAI 47 WADIYA NAGAR SOC NEAR IH BOGHRA SCHOOL GUJRAT
Address CIRCLE ADAJAN, SURAT CITY, SURAT, GUJARAT - 395009 Policy 1 Year(s)
Tenure

Proposer
GSTN No Business New Business
Type
UIN Code RQBHLIP20141V031920

Intermediary Name Policybazaar Insurance Brokers Pvt. Ltd.

Intermediary Code 01011985 Intermediary Contact No. 18002088787
Intermediary UID Intermediary Pan Number
POS Name POS ID

Details of Plan

Policy Type Individual Plan Name Super saver

No of Members 1

Details of Insured Persons

Name Member ID Date of Birth Age Gender Relationship Policy Inception Basic Sum Cumulative Nominee Nominee Pre
(DD/MM/YYYY) with Insured Date Insured Bonus Name Relationship existing
(DD/MM/YYYY) Disease

MR PRINCE RQBE113219A 09/09/1998 24 Male Self 16/06/2023 500000 0 PROMD Father NO

PANDEY PANDEY

Details of Coverage
 Name of product - Super saver

SNO Benefit Basis of offering

1 Hospitalization Benefit
2 PrePost Hospitalization Benefit
3 Ambulance Cover
4 Organ Donor Benefit
5 Recharge / Replenish Benefit
6 Health Check up per year
Maximum Upto Rs.500000 + applicable NCB per Policy Year
i. Room Rent = 1% of Sum Insured per day
ii. ICU Charges = 2% of Sum Insured per day
iii. Medical Practitioner Fees = 25% of Sum Insured per Claim
Pre-hospitalization up to 60 days
Post-hospitalization up to 90 days
Maximum Upto Rs.1500 per Claim
Maximum Upto 20% of Sum Insured
One re-instatement up to Sum Insured per Policy Year
Yes

7 Non Medical Expenses(On Cashless Maximum Upto Rs.1000 per Day

Hospitalisation)

8 Sum Insured Increase (On Cashless Benefit of additional sum insured of 10% of the Claimed amount. I.e, We will reduce only 90% of the claim amount
Hospitalisation) from the sum insured

9 NCB No Claim Bonus 5% increase in Sum Insured for each claim free year

10 Inbuilt Co-payment Add on Mandatory 20% Co-payment on each admissible claim

Pre-Existing Disease/Permanent Exclusion Details :

Member Name Pre-Existing Disease/s Permanent Exclusion/s

Prince Pandey NA NA

Schedule of Premium

Premium Details(Rs.)
Basic Premium : 2400.00
Loading : 0.00
Policy Tenure Discount : 0.00
Loyalty Discount : 0.00
Employee Discount : 0.00
Net Premium 2400.00
GST: Central Tax 9% + State Tax 9% 432.06
Total Premium 2832.00
I/We hereby declare that though our aggregate turnover in any preceding financial year from 2017-18 onwards is more than the aggregate turnover notified under sub-rule (4)
of rule 48, we are not required to prepare an invoice in terms of the provisions of the said sub-rule.

Conditions

This Policy of Insurance is Contract between the Company and the Insured Person(s). The Insured Person(s) shall not transfer, assign, alienate or in any way pass the
benefits and /or liabilities to any other person, Institution , Hospital, Company or Body Corporate without specific approval in writing by a duly authorised officer of the
Company. However, if the Insured Person(s) is permanently incapacitated or deceased, the legal heirs of the Insured may represent him in respect of Claim under the Policy.
All terms, conditions and exclusions are as per the Policy Wordings attached with this Schedule of the Policy.
 Contact Details for Claims Assistance & Policy Servicing

Intimation of Claim:‘Claim must be intimated at least 48 hours prior to planned hospitalization and within 24 hours of hospitalization in case of emergency hospitalization.’

TPA Name: Medi Assist India TPA Pvt. Ltd.

Address & Contact IBC Knowledge Park, Tower D, 4th Floor, Banerghatta Main Road, Bangalore-560029, Banglore, Banglore,
Details: Karnataka - 560029 , Toll Free No.
Toll Free number: 18004259449 1800 102 7723 (9 am to 8 pm,
Mon to Sat)
E-mail ID for Policy info@mediassistindia.com
servicing:
E-mail ID for Claims : info@mediassistindia.com
TPA Website Address: www.mediassistindia.com
Company Website: www.rahejaqbe.com

Receipt No : 1202370017775
GST Registration Number : 27AADCR7145R1ZM
IRDA Registration Number : 141
CIN : U66030MH2007PLC173129 For and on behalf of Raheja QBE General Insurance Co. Ltd.

Date of Issue : 1 7 0 6 2 0 2 3

Place : DELHI

(Authorized Signatory)

"Consolidated Stamp Duty Paid by General Stamp Office Mumbai Under letter of Authorization Number : LOA/CSD/15/2023/2128 Dated : 21st April 2023"

Premium Certificate for the purpose of deduction under Section 80-(D) of Income Tax.

This is to certify that the policyholder has paid Rs. 2832.00 (amount in words) Rupees Two Thousand Eight Hundred Thirty Two and Zero Paisa Only towards premium for
Health QuBE Policy No. RQBE01-113219-00-000 issued to Prince Pandey for the period 16/06/2023 to 15/06/2024.

Signature Not Verified

Location:DELHI For and on behalf of Raheja QBE General Insurance Co.DLigittadll.y signed by DS RAHEJA QBE
GENERAL INSURANCE COMPANY LIMITED 8
Date: 2023.06.17 14:35:30 +05:30
Reason: Reason
Location: Location

(Authorized Signatory)
Date: 1 7 0 6 2 0 2 3

Note :
1. This is subject to the provisions of Section 80D of income tax (Amendment) Act, 1986 as amended from time to time.
2. This certificate would not be valid
- in case of cancellation of this policy
- in the event of any incorrect representation any future liability therefrom shall be upon the policy holder.
- if the premium payment has been made in cash.
3. Collection Mode : Online Collections