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lnsuranee Co. Ltd.
ORIGINAL
BANGLADESH NATIONAL INSURANCE CO. LTD.
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Issuing Office : &cS.4 i;l 1:.1,.':r' {3t ;i i4a*r}
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Please make sure you read andfully understand this doc:ttment beJbre you travel .from the people's Repttblic of
Bangladesh Please read cctreftrlly the.firll details of the PROCEDURE FOR OBTAINING-ASSISTANCE AND CLAIMS.
Failure tofollow the Instructions given could result to rejection of the claim.

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WHEREAS the Insured Person designated in the Overseas Mediclaim Identification and Schedule here to having by a proposal and declaration
(and Medical History and Physicians Report and Certificate if any) which shall be the basis of the contract and shall be deemed to be incorporated
therein, applied to Bangladesh National Insurance Co. Ltd. (hereinafter called the Insurers) for the Insurance hereinafter ser forth and having paid
the premium for the Insurance specified hereinafter for the number of days stated in the Overseas Mediclaim Identification and Schedule.
Now this Policy provides as follows :

DEFINITIONS:
The following definitions apply through out this Insurance :

INSURED PERSON. is that person named in the Overseas Mediclaim Identification and Schedule, of whom the appropriate
premium has been paid.
INTANA GLOBAL + SPECIALTYASSIST (Third Party Administrator), 6 Devonshire Square London,
EC2M 4YE, United kingdom, Telephonei +44 (0) 20 7902 7139, Fax : +44 (O) 20 7928 4748,
E-mail : accounts@specialty-assist.com, E-mail : ops@intana-global.com.
PHYSICIAN means a person legally qualified to practice in medicine or surgery including other 1egally qualified medical practitioners duly licensed
by their respective Jurisdiction, which person is not a member of the Insured Persons family.
MEDICAL RELAIED EXPENSES REASONABLY AND NECESSARILY INCURRED. means expenses that in the opinion of the treating
physician and INTANA GLOBAL + SPECIALTY ASSIST are medically necessary in order to maintain life and / or relieve immediate
pain or distress
PERIOD OF INSURANCE :

Thts Insurance rs valtd from the first Day of Insurance forthe number of days specified in Overseas Mediclaim Identification and Schedule but
ceases on his/her return to Bangladesh.
This Insurance is automatically extended for a period of45 days for treatment ofcovered illness or accident ifduring such treatment the policy cover
expires and the Insured person is medically incapable ofreturning home.
Extension of the period of insurance is automatic for a period not exceeding seven days and without extra charges if necessitated by delay of public
transport services beyond the control ofthe insured person.
MEDICALEXPENSES COVER :
Insurance will pay up to the limit of cover shown on the Overseas Mediclaim Identification and Schedule in total for the Insured person and
subject to a Deductible stated in the Overseas Mediclaim Identification and Schedule which Deductible applies per accident/illness in respect
of the following medical related expenses, reasonably and necessarily incurred outside the Peoples Republic of Bangladesh by the Insured person
as a direct result ofthe Insured Person suffering bodily injury, sickness, disease or death during the period oflnsurance.
Notwithstanding the above if INTANAGLOBAL+SPECIALTYASSIST recommends that continued treatment in Bangladesh is medical
appropriate the policy is extended to cover
expenses incurred in Bangladesh as specified in covered expenses herein.
PROVIDED THAT expenses will only be Paid at the usual and customary level for such services, and further provided that expenses will only be
paid for treatment incurred within the 90 days period immediately following the first manifestation of tni bodily injury sickness or clisease
and the Insured Person had to retum earlier than the expire'date ofthe trip.

Head Office:
E-mail : mail@bnid[.net
RashidTower (3rd Floor), ilot + 1'1, Road # 18, Gulshan-1, Dhaka-|212
Website : www.bnicl.net
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COVERED EXPENSES
1. Expenses for physician service, hospital, physician and medical services and local emergency medical transportation.
2. uptoUS$225orEuroequivalentperoccurrencetbrdentalser-v'icesfortheimmediatereliefofdentalpainonh.Houever.dentalcare
rendered necessary as result ofa covered accident shall be subject to the limit ofcover and Deductible stated in the Overseas
Mediclaim Identification and Scheduie.
3. Expenses for physician ordered emergency medical evacuation including Medically appropriate transponation and necessary medical
care in route to the nearest suitable hospital when the insured Person is critically i11 orinjured and no suitable local care is available,
subject tothepriorapprovai of the ProgramMedical Advisors. In dire emergcncies in a rernote arr-a \\hereI\TANAGLoBAL+seECIALTYASSIST
cannot be contacted the medical evacuation must be teported to the first available physician and to the nearest Bangladesh Consuiate.
4. Expenses lor medical evacuation including transpofiation and medical care in route to a hospital or the Insured Person's normai place
of residence in thePeoples Repubiic of Bangladesh wiren deemedmedicaily advisable bythe Program MedicalAdviserand the
attending physician.
5. If the Tnsured Person dies outside the Peopies Republic ofBangiadesh, the expenses for preparing the air transportation ofthe
remainsfor repatriationto thePeoples RepublicofBangladesh orup toanequivalentamount for alocalburial orcremationinthe
country where death occurred all expenses must be approved bv txtaul GLoBAL + spECIALTy ASSIST before the remains are prepared
for transportation to the Peoples
Republic of Bangladesh or for local burial or cremation.

EXCLUSIONS
L No Claim will be paid in respect of a medical condition that 'nvas known by the insured person to exist and or had been treated in one
year immediately preceding the effective date of this coverage.
2. No clairn will be paid where the Insured Person :

(a) Is traveling against the advice ifa phl,sician; or

(b) Is on a waiting list for specified medical treatment declared in the Physicians Reporl and Certificate; or
(c) Is traveling tbr the purpose obtaining medical treatment; or
(d) has received a terminal prognosis for a medical condition.
3. No claim wiii be paid in respect of e xpenses for treatment which could reasonably be delayed until the insured Person's retum to the
Peoples Republic of Bangladesh. The question of rvhat can or cannot be reasonably delayed will be decided jointly by the treating
physician and the Program medical Adviser.
4. No claim will be paid where the expenses are less than the Deductible stated in the Overseas Mediclaim Identihcation and Schedule
The Deductible shall apply to each insured event and shall be borne by the Insured Person.
5. No claim in respect of cosmetic surgery will be paid, unless such cosmetic surgery is rendered necessary as a result of a covered
accident.
6. No claim will be paid arising as a result of acquire immune Deficiency Syndrome (AIDS ) or AIDS related complex (ARC)
howsoever this syndrome has been acquired or may be Named.
7. No claim will be paid arising fron.r suicide, attempted suicide, willful self-inflicted injury venereal disease or the abuse of drugs or
alcoholic drinks.
8. No claim u,ill be paid in respect of routine physical examinations or any other examination r.vhere there is no objective indication of
impaiment of nomral health.
9. No claim will be paid in respect of medical treatment and related ser-vices obtained within the Peoples Repubiic of Bangladesh.
10. No clairn will be paid arising from the Insured Person taking parl in naval, military or air force operations.
11. No claim will be paid arising from war, Invasion or civil war.
12.Thisinsurance does notcover any claimarising fromthe lossor destruction ordamage to anypropeftywhatsoeveroranylossor
expenses whatsoever resulting or arising there from or any consequential loss dilectiy or Indirectly caused by or contributed to
by/or arising from:
(a) longing radiation or contamination by radioactivity frorr-r any nuclear u,aste from the combustion of nuclear fuel, or
(b) the radioactive toxic explosive or other hazardous propcrties ofany explosive nuclear assembly or nuciear component thereof.
1 3. No claim will be paid arising from Aviation unless the Insured Person flies as a Passengcr in an aircraft properly licensed to carry
passengefs
14. No claim rvill be paid arising from the insured person parlicipation in mountainering (where ropes or guides are customarily used)
riding or driving in races or relies pot holing skin diving or other underwater activity. In addition any other hazardous or potentially
dangerous spofi for which the Insured is either untrained. Not physically fit or uses Improper equipment.
15. No Claim will be paid arising frorn the Insured person participating in Water Sports.
16. Insurer are not liable to pay under this insurance any amount covered under any occupational benefit plan, other health Insurance,
National health insurance scheme or public assistancc programlnee or any other lnsurance covering the same iirterest. In thc event that
Insurers make payment on behall of, or to, an insnred Person of amounts covered under any other such assistance or lnsurance
scheme, the Insured Person agrees to assign to Insurcrs any right ofrecovery under such scherne(s).
I 7. This Insurance will not cover pregnancy. lncluding resulting childbifih miscarriage abortion or complication of any of these.
 ORIGINAL
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BANGLADESH NATIONAL INSURANCE CO. LTD.
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BN ICL
ovERSEAS MEDICLAt M IDENTt FICAT|ON (B&H) SCHEDU LE.

I For Non Schenoen Countries & World-wide excluding USA & CANADA
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Address of Policy lssuing Head Office (Online), Rashid Tower, Plot# 11, Road # 18, Gutshan-1, Dhaka
Office :-

Telephone No:- PABX-8832234-5

E-Mail/ Telex No/ Fax no :- E-mail: mail@bnicl.net Fax: BB-02-8832154

I Seventy Nine ) Years of age who are undertat<ing bonafide tiips outside Bangladesh which will not inrolu-e a"n1)
]form of manual work and do not exceed 180 ( One hundred eighty ) days in duration unless specifically
extended.

Po I i cy Num beE- eN I cffi 6i0 L/o rvr ( B & H t e -ooozt o t t zoa lssue Date: 1010112021
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1

-i ,-trtame oathe lnsureO Per:son ( As

indicated on Passport )
2 Age of lnsured Person ( in completed 31 Completed Years Date of birth 10/06/'1990
years ) :-
Residence Address : DtGRtRCHAn, SnrAcHnn, VAonnrPUn,

5 lnsured's Occupation (Specify) .-

6 Passport Number :-

7 Name of the Usual Physician with Hasan Mahmud (MBBS), Central Hospital Ltd, Dhaka-
Telephone No :-

8 Plan Type :-

re@edica
Countries (Excluding USA / CANADA) :

( Both iltness
lllness & Accident )

i
9.b Emergency Dental rreatment :- USD : 500/= or Euro equivalent,
L...- 1 ...
 OR"XGTNAL

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Our Re-lnsurer-SBC has confirmed that COVID :151s in factl

covered under the OMP - 2020 - Contract for all countries but ]

Pre - existing Covid - 19 is not coverd. l

Deductible
For Non Countries :- USD : 100 /=
For Schengen Countries :- >>>>> No Deductible

Emergency Dental Treatment/Care : USD : 50 /=

Premium Computation :- Standard BDf 3,195.00

Total Premium BDT 3,195.00

Vat 15% BDT 479.25
Gross Amount BDT. 3,674.00
-+
12 Date of Purchase of Policy :- 10t41t2021
l

90 lNinety )days From: 11101121 To 10104121

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First day of lnsurance : Date & Time

10-iAN-2'1
(Commencing from the.lime of
boarding the aircraft or other mode of
. '."''".' ,--.
i transport from Banglades,h-';'
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-1s I Wrrranty - Warranted that if any alteration / modification / cancellation of
--.== this Policy is needed. the lnsured must inform M/S:
BANGLADESH NATIONAL INSURANCE COMPANY LIMITED in
writing 48 hours before his / her departure from Bangladesh
l

+
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15.a Special Warranty : I

ThisPolicyisnotrefundaolelAo1ustab1eunderany
circumstances. I

Claims lmportant lnformation Notice :- Claims lmportant lnformation sheet attached herewith I
L

17 Money Receipt No & Date : I!1R No.. 5002 Date: 10-JAN-21

Policv Sioned SIGNED for and on behalf of Bangladesh National lnsurance Co.
Ltd. at Dhaka 1010112021

Prepared by : Checked by Countersinged by :

'
For & On behalf of
Bangladesh National lnsurance Co. Ltd,

PlN. : 241 Fully Reinsured with Shadharan

Bima Corporation
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 CONDITIONS

The conditions beiow apply throughout this Insurance. Failure to comply with thern may be prejudicial to a claim.

1. It is a condition precedent to liability hereunder that in the cvent that an Insured person suffers serious illness or injury or is in any event
to bc hospitalizcd the Insured person or his representative must contact INTANA GLOBAL + SPECIALTYASSIST immediately fbr
emergency assistance or advice and consultation. The insured Person or this representative should quote to INTANA GLOBAL +
SPECIALTYASSISTas much informationconceming the illness or accident as is available, including the name of the treating Doctor
name and telephone number of thc hospital, the OMP Policy Number and its date of issue.

2. Medical. dental and transportation related claims u'ill not be paid except at the usual customary and reasonable level of charges for such
servi c es.

3. A11 medical evacuationor transporlation of mortal remains must be approved in advance by INTANAGLOBAL+SPECIALTYASSIST
and their Program Medical Adr"isors. In dire emergences in remote or primitive areas where the Program Medical Advisor
cannot be contacted the medical evacuation must be reporled to the first available physician and to the nearest Bangladesh Consulate.

4. lnsurers shal1 be fu1l1' and cornpletely subrogated to the rights of the Insured person against parlies who may be liable to provide
indemnity or make a contribution in respect of any matter which is the subject of a clairn under this insurance.

The lnsured Person further agrees to co-operate fully with Insurers in seeking such indemnity or contribution including where
appropriate. insurers instituting proceedings at their ou,n expenses against such parlies in the Names of the Insured person.

5. The Insurers may require the Insured person to fumish at his own expense all cerlificates, inforrnation, proofs or other evidence of
clairns. The Insurers may approach any physician u'ho may have treated the insured person during the period ofthree years prior to the
commencelnent of this insurance and the lnsured person must co-operate in this respect.

6. The lega1 representative ofan Insured person sha1l have the ri-eht to act for an insured person u'ho is incapacitated or deceased.

1. This lnsurance does not operate beyond a period of 180 days continuous absence from the peoples Republic ofBangladesh unless
specilicalll agrced.

8. This polic-v and the Overseas Mediclaim Identification and Schedule shall be read together as one conkact and any wording or
expression to rvhich a specific meaning has been attached in any parl of this policy or the Overseas Mediclairn Identification and
Schednle shal1 bear such specific. meaning wherer er it rnal appear.

9. DISPUTE RESOLUTION PROCEDURE: This contract of insurance includes the following dispute resolution procedure u.hich is
exclusive and a rnaterial pad ofthis contract oflnsurance.

10. CHOICE OF LAW: The parlies to this Insr-rrance policy expressly agree that the laws of the peoples republic of Bangladesh shall
govern the vaiidity, construction, interpretation and effect ofthis policy.

li. ARBITRdTION: If any difference arises as to the amount to be paid under this policy (liability being othem,'ise admitted) such
differcnce shall be referred to the decision ofan arbitrators to be appointed in writing by the parties in difference or ifthey can not agree
upon singlc arbitrator to the decision of tw'o arbitrators, one to be appointed in writing by each of the parlies within one calendar r.nonth
afier having been required in u'riting so to do by either ofthe parties, or in case the arbitrators do not agree an unrpire to be appointed in
u-riting b1' the arbitrators beforc the latter enter upo11 the reference. Thc umpire shall sit rvith the arbitrators and preside at their
meetings. The rnaking of an award shall be a condition precedent to any right of action against the insurers.

12. RESTRICTED COVER: In the event that the proposer is unable to present himself for medical examination u,here calle<l for by
Bangladesh National Insurance Co. Ltd, the limit of Indemnity, under this Insurance is reduced to US $ 10.000 in respect of and limited
to the expenses lor physician service hospital physician and medical serwices and iocal emergency transporlation. Such limit applies to
medical expcnses incurred through illness or disease only.

IN \\'IT-\ESS WHEREOF the undersigned being duly authorized by ancl on behalf of the Company has here to set his hand.

Place :

Date :

For & on behalf of

Bangladesh National Insurance Co. Ltd

Nahar Sultarra
Sr' Mallager
BaoglsdeshN+tioaal Iasueuce 00, Ltd. '
I. SUBJECT TO ELECTRONIC DATE RECOGNITION EXCLUSION (EDRE) AS UNEDR:
This insurance does not cover any loss, damage cost, claim or expense, u"hethel preventative, remedial or othenr.ise. directh'or
indirectly arising out of or relation to :
a) The calculation comparison, differentiation, sequencing or processing of date involving the date change to year 2000, or an) other date
change, including leap year calculations, by any computer system. hardware. programmee or softrvare and/or any microchip, integrated
circuit or similar device in computer equipmint or non-computer equipment, whether the property of the insurcd or not; or
b) any change alteration or modification involving the date change to the year 2000 or any other date change, Including leap year
calculation, to any such computer systcm, hardware, programmee or software andior any microchip, integrated circuit or similar devicc in
computer equipment or non-computer equipment, whether the propefiy of the insured or not.
This insurance does not cover any loss, damage cost, clairn or expense, whether preventative, remedial or othenvise, directly or indirectly
arising out ofor relation to :

2. Subject to JHA War. Terrorism and Mass Destruction Exclusion as Under:

Notwithstanding any provision to the contrary within this insurance/reinsurance (delete as applicable), or any endorsement thereto, it is
agreed that this insurance/reinsurence (delete as applicable) excludes any Loss or expense of whatsoever nature directly or indirectly
arising out of, contributed to, caused by, resulting from, or in connection with any of the follou'ing regardless of any other cause or event
contributing concurrentiy or in any other sequence to the loss or expense:

01. War, hostilities or war like operations (whether war be declared 02. Invasion,
or not) 04. Civil war,
03. Act of a enemy foreign to the nationality of the Insured person 06. Rebellion.
or the country in or over which the act occurs, 08. Revolution,
05. Riot. 10. Civil commotion assuring the proportions of, or amounting to,
07. Insurection, an upflslng,
09. Overthrow of the legally consulated government, t2. Explosions of war weapons,
11. Military or usurped power, t1. Murder or Assault subsequently proved beyond reasonable
13. Utiluzation of Nuclear, Chemical or Biological rneapons of doubt to have been the act of agents of a state foreign to the
mass destruction howsoever these may be distributed or combined. nationaiity ofthe insured person whether
15. Terrorist activity.
For the purpose of this exclusion.
i) Terrorist activity means an act, or acts, of any person, or group (s) of persons committed for political, religious, Ideological or similar
purposes with the intention to Influence any government and/or to put the public, or any section of the public, In fear, Terrorist
activity can include, but not be limited to, the actual use of force or violence and or the threat of such use, Furthermore, the
perpetrators ofterrorist activity can either be acting alone, or on behalfof, or in connection lvith any organization (s) or governments (s).
ii) Utilization of Nuclear weapons of mass destruction means the use of any explosive nuclear weapon or device or the emission,
discharge, dispersal, release or escape of fissile material Emeting a leve1 of capable of causing Incapacitating disablement of death
amongst people or animals.
iii) Utilization of Chemical weapons of .mass destruction means the emission, discharge dispersal, release or escape of any solid, liquid or
gaseous chemical compound which, when suitably distributed, is capable of causing Incapacitating disablement or death amongst
people or animals.
iv) Utilization of Biologicai weapons of mass destruction means the emission, discharge dispersal, release or escape of any pathogenic
(disease producing) micro-organism (s) and/or biologically produced toxin (s) (including genitically modified organisms and
chemically synthesis toxins) which are capable of causing incapacitating disablement or death amongst people or animals.
Also excluded hereon is any loss or expense ofwhatsoever nafure directly or Indirectly arising out of, contributed to, caused by, resulting
from, or in connection with any action taken in controlling, preventing, or suppressing any, or all, of(1) to (15) above. In the event any
portion to this exclusion is found to be invalid or unenforceable, the remainder shall remain in full force and effect.
3. Claims Important Information :

WHAT TO DO IN THE CASE OFA MEDICAL EMERGENCY

In the event 6f i[ness or Accident abroad Which May Lead to Hospital treatment or Curtailment of your trip
Please Contact

Intana Global + Specialty Assist

6 Devonshire Square
London, EC2M 4YE
United kingdom

Telephone: +44 (0) 20 79027139

Fax : +44 (0\ 20 7928 4748

E-mail : accounts@specialty-assist.com
E-mail : ops@intana-global.com

NB: (l)
To avoid reverse change calls the claimant and/or someone calling on his,/her behalf over above telephone / fax be requested to
give his/her telephone number so that the Intana Global + Specialty Assist, can Immediately call back asking for other particulars.
(2) IntanaGlobal+SpeCialtyAssist, are acting as Third PartyAdministrators/Assistance provider to render services in respect of
claims to the Overseas Mediclaim Policy holders.
In the event of a claim, please apply to IntanaGlobal+SpecialtyAssist for a Claim Form When completed please submit direct to
Intana Global + Specialty Assist together with the lnsurance Certificate and relevant documentation.
4. Subject to other Terms & Condition as Under :
(i) Professional Sports and Sports team of any sort are .excluded.
(ii) Waranted that if any alteration/modification/cancellation of this policy is needed the insured must inform the BANGLADESH
NATIONAL INSURANCE CO. LTD., in writing before his/her deparhrre (date as mentioned in the policy) from Bangiadesh.
(iii) Applicable in respect of Children aged 5 and under : This Policy excludes cover for treatment relating to "Mumps, Chicken pox,
measles, German Measles, Spina Bifida, Whooping-Cough, Diptheria, Poliomyelities, Meningitis and Scarlet-Fever" and for
consequences attributable thereto, accelerated
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Head Office: Rashid Tower (3rd Floor), Plot # 1 1, Road # 1 8, Gulshan-1, Dhaka-1212
Tel : 8832234-5, 8832215,8832217, Hotline : 0961 31 1 2233, Fax 88-02-88321 54, E-mail:
.

mail@bnicl.net
5002
MONEY RECEIPT
Original
Money Receipt No. : 5002 BIN : 002063525-0101 lD No | 241

Money Receipt Date : 10-JAN-21 Branch Name : Head Office (Online) Class:Miscellaneous

Received with thanks from ROBIN DHALI Tk. 3,674.00 (Three Thousand Six Hundred Seventy Four ) only in dated
drawn on against document # BNIC/HO/OL/OM(B&H)/P-000210112021

For and on behalf of

Bangladesh National Insurance Co. Ltd
Premium Tk 3 195.00

VAT Tk 479.25

Stamp duty Tl( 0.00

Total Tk. 3,674.00

A*

Website: www.bnicl.net