Madan Mohan Banbari Lal Q1464726 GHA POLICY

BHARTI AXA GENERAL INSURANCE COMPANY LTD
#309,310, 311 Millenium Star

Building,Near Ruby Hall Clinic TAX INVOICE
,Dhole Patil Road, Pune - CLIENT COPY
411001
Original
Tel:020-40193000 Fax:020-40193001
Email: customer.service@bhartiaxa.com
POLICY INFORMATION Policy No. : GHA/Q1464726/81 ( )

Bharti AXA Group Health Assure
Source : (02) 81004364 Probus Insurance Broker PVT LTD
Insured : MADAN MOHAN BANWARI LAL (23892810)
Advice to : MADAN MOHAN BANWARI LAL

BARA BAZAR BAREILLY 243003 UP
BAREILLY-243003
UTTAR PRADESH
INDIA 243003
Product Name: Bharti AXA Group Health Assure Product UIN: BHAHLGP20039V011920
Period Of Insurance : From 10/06/2020 To 09/06/2021

Bill No. : 1985573
Bill Currency : INDIAN RUPEE
Bill Period : 10/06/2020 To 09/06/2021
Bill Frequency : ANNUAL
Issue Date : 20/06/2020
Gross Premium GST Total Payable
17,269.00 3,108.42 20,378.42
Premium Details (INR)
Plan/Product Premium
001 Plan - 001 200000

GCAS CULT ASSURE 0.07
GCUA CURE ASSURE 10,072.86
GEXA EXTEND ASSURE 0.07
002 Plan - 002 200000
GCAS CULT ASSURE 0.04
GCUA CURE ASSURE 7,195.92
Authorized Signatory
Issued by - INB5159 On 20/06/2020 (R)

HOSTO CENTRE No.43, Millers Road, Vasanth Nagar, Bangalore - 560046. INDIA. IRDA Regn. No.139
Tel: 1800-103-2292 Fax: 80 40260101 Email: customer.service@bhartiaxa.com
Page 1 of 14
GEXA EXTEND ASSURE 0.04
Gross Premium ( INR ) 17,269.00
Page 2 of 14
Building,Near Ruby Hall Clinic BILLING STATEMENT -
,Dhole Patil Road, Pune - MEMBERSHIP LISTING
411001
Tel:020-40193000 Fax:020-40193001 Original
Source : 02 81004364 Probus Insurance Broker PVT LTD

Advice to : MADAN MOHAN BANWARI LAL
BARA BAZAR BAREILLY 243003 UP
BAREILLY-243003
UTTAR PRADESH
INDIA 243003

Bill No. : 1985573
Bill Currency : INDIAN RUPEE
Bill Period : From 10/06/2020 To 09/06/2021
Issue Date : 20/06/2020
MEMBER DETAILS
EMP Plan Plan Plan Plan Bank Effective
Name of Member Member No. Age DOB Sex FC MC ID No. Premium Details (INR) Total Premium (INR)
No. No. No. No. No. Acct. No. Date
Anil Gupta 00007 - 00 43 12/05/1977 M A 7 001 001 001 10/06/2020 Q146472600006 0.01 1,438.98 0.01 1,439.00
Ashfak Ahmad 00001 - 00 40 07/07/1979 M A 1 001 001 001 10/06/2020 Q146472600000 0.01 1,438.98 0.01 1,439.00
Page 3 of 14
Bachchu Singh 00011 - 00 41 01/01/1979 M A 11 001 001 001 10/06/2020 Q146472600010 0.01 1,438.98 0.01 1,439.00
Data Ram 00010 - 00 34 07/08/1985 M A 10 001 001 001 10/06/2020 Q146472600009 0.01 1,438.98 0.01 1,439.00
Dinesh Chandra Panday 00006 - 00 49 12/06/1970 M A 6 002 002 002 10/06/2020 Q146472600005 0.01 1,798.98 0.01 1,799.00
Krishan Gupta 00002 - 00 29 27/05/1991 M A 2 001 001 001 10/06/2020 Q146472600001 0.01 1,438.98 0.01 1,439.00
Manoj Kumar Mishra 00005 - 00 50 01/03/1970 M A 5 002 002 002 10/06/2020 Q146472600004 0.01 1,798.98 0.01 1,799.00
Prem Shankar 00003 - 00 50 15/07/1969 M A 3 002 002 002 10/06/2020 Q146472600002 0.01 1,798.98 0.01 1,799.00
Roshan Lal 00009 - 00 40 01/01/1980 M A 9 001 001 001 10/06/2020 Q146472600008 0.01 1,438.98 0.01 1,439.00
Shivam Katiha 00008 - 00 23 07/09/1996 M A 8 001 001 001 10/06/2020 Q146472600007 0.01 1,438.98 0.01 1,439.00
Teeka Ram 00004 - 00 55 01/01/1965 M A 4 002 002 002 10/06/2020 Q146472600003 0.01 1,798.98 0.01 1,799.00
Total Premium (INR) 0.11 17,268.78 0.11 17,269.00

SUMMARY
Plan Description No. of No. of No. of Total

No. Members Spouse Children
001 Plan - 001 200000 7 7

002 Plan - 002 200000 4 4
Total 11 11
Page 4 of 14

Building,Near Ruby Hall Clinic BILLING STATEMENT
,Dhole Patil Road, Pune - MEMBERSHIP LISTING
411001
Original
Tel:020-40193000 Fax:020-40193001
MADAN MOHAN BANWARI LAL Policy No. : GHA/Q1464726/81 ( )

Family Code (FC) : A - Members Only Movement Code (MC) : N - New Member / Dependent
B - Member + Spouse C- Membership Changes
C - Member + Children T- Terminated Member / Dependent
D - Member + Family
NOTE : If movement date is prior to period of insurance the adjustment is interpreted as

back-dated.
This document is digitally signed BHARTI AXA GENERAL INSURANCE COMPANY LTD
Signer: DS BHARTI AXA GENERAL

INSURANCE COMPANY LIMITED 3
Date: Mon, Jun 22, 2020 10:51:34 IST Authorized Signatory
Location: MUMBAI
Issued by - INB5159 On 20/06/2020 ( R )

Page 5 of 14
Building,Near Ruby Hall Clinic NEW BUSINESS
,Dhole Patil Road, Pune - POLICY SCHEDULE
411001
Original
Tel:020-40193000 Fax:020-40193001

: BARA BAZAR BAREILLY 243003 UP

BAREILLY-243003
UTTAR PRADESH
INDIA 243003

Transaction Number : 00001
Effective Date : 10/06/2020
Issue Date : 20/06/2020
PLAN APPLICATION
Plan - 001 200000 : Plan 001 - GCUA

Plan - 002 200000 : Plan 002 - GCUA

Page 6 of 14
411001
Original
Tel:020-40193000 Fax:020-40193001
Service Tax Registration No. : AADCB2008DST001
Schedule of Annual Premium ( INR )

Plan Product Member Member & Member & Member & Description
No. Spouse Child Family
001 GCAS 0.01 CULT ASSURE
002 GCAS 0.01 CULT ASSURE
001 GCUA 1,438.98 CURE ASSURE

002 GCUA 1,798.98 CURE ASSURE
001 GEXA 0.01 EXTEND ASSURE
002 GEXA 0.01 EXTEND ASSURE

Page 7 of 14
411001
Original
Tel:020-40193000 Fax:020-40193001
BENEFIT SCHEDULE ( INR )

Cover Plan No Plan No
Benefit Limit Reimburse(%) Benefit Limit Reimburse(%)

& Basis / Diductible & Basis / Diductible
GCAS001 GCAS002
Plan Level Limit
ROOM & BOARDING EXPENSE 2000 2000
- Rs./Day - Rs./Day
ROOM & BOARDING EXPENSE - ICU 4000 4000
- Rs./Day - Rs./Day
30 DAYS WAITING PERIOD WAIVER As Charged As Charged
RED/WAIVER OF PED WP As Charged As Charged
RED/WAIVER OF SP. AILMENTS WP As Charged As Charged
GCUA001 GCUA002
Plan Level Limit 200000 200000
- Rs./PlYear - Rs./PlYear
IN-PATIENT CARE EXPENSES As Charged As Charged
AYUSH 10000 10000
- Rs./Sur - Rs./Sur
DAY CARE TREATMENT EXPENSES As Charged As Charged
POST HOSPITALIZATION As Charged As Charged
PRE-POST HOSPITALIZATION EXPNS As Charged As Charged
GEXA001 GEXA002
Plan Level Limit

Page 8 of 14
411001
Original
Tel:020-40193000 Fax:020-40193001
BENEFIT SCHEDULE ( INR )

Cover Plan No Plan No
Benefit Limit Reimburse(%) Benefit Limit Reimburse(%)

& Basis / Diductible & Basis / Diductible
EPIDEMIC As Charged As Charged

TERRORISM As Charged As Charged

Page 9 of 14
411001 Original
Tel:020-40193000 Fax:020-40193001
POLICY ENDORSEMENT
Transaction No. : 00001 Effective Date : 10/06/2020
Conditions applicable:-
1.Sum Insured-200000 ; Non Floater
2.Family Defination :Self Only ; Plan - 001 200000 Plan - 002 200000
3.Age Band - 18 to 60 years
4.First 30 days Waiting Period - Not Applicable
5.Max Entry Age - 60 Years

6.Pre-Existing Disease - Covered After 36 Months
7.Room Rent Limit - 1% of S.I for Normal and 2% of S.I for ICU
8.Proportionate Deduction - Applicable
9.In-patient Hospitalization - Covered
10.Day-Care Procedures - Covered
11.Pre-Post Hospitalization - 30 days and 60 Days Respectively
12.AYUSH - Covered upto INR 10,000.(On IPD In Govt. Registered Hospitals)
13.Maternity - Not Covered
13.Female member Count /Total Member Count - Upto 20%
14.Waiting Period for Maternity - Not Applicable
15.Limit For Maternity, If Opted - Not Applicable
16.Disease Wise Capping - Not Applicable
17.Sum Insured Type - Uniform
18.Standard Conditions :
a.If VAS is opted then this will be available upto 3 month of Policy
inception date
b.In addition to the conditions mentioned above,all other terms,conditions
and exclusions will be as per the Group Health Assure Policy Wording.
c.Minimum Group size at inception should be of 7 Members to underwrite
a group policy.The Company is not obliged to accept the risk,
if the minimum group size criteria is not fulfilled.
d.Additions and deletions of employee/member will be done on prorate
basis from day 1 for additions subject to sufficient CD balance being
maintained. Data for such additions and deletions has to be shared
not later than 45 days from the date of joining of the employee.
e.In case of claims, all cases should be intimated to TPA/Bharti AXA
General Insurance Co. Ltd. within 24 hours from the date of
admission
f.Claim must be filed within 30 days from the date of completion of
treatment. However, the Company may at its absolute discretion

Page 10 of 14
411001 Original
Tel:020-40193000 Fax:020-40193001
POLICY ENDORSEMENT
Transaction No. : 00001 Effective Date : 10/06/2020
consider waiver, of this Condition in extreme cases of hardship

where it is proved to the satisfaction of the Company that under the
circumstances in which the insured was placed it was not possible
for him or any other person to give such notice or file claim within
the prescribed time-limit. The claim would invite additional 10%
co-payment over and above payable amount as per policy terms

and conditions
g.All Reimbursement Claims must be intimated to the TPA/Bharti
AXA General Insurance Co. Ltd. within 24 hrs of Admission, in case
of non-intimation/Delayed intimation 10% Co-pay would be
applicable except for Accidental claims. If the member is getting
admitted in any network hospital and filing for reimbursement
claims such claims will be settled to members with 15% co-pay.
h.Claim servicing of the policy will be done by TPA(FHPL)

Page 11 of 14
Building,Near Ruby Hall Clinic
,Dhole Patil Road, Pune - ENDORSEMENT
411001
Original
Tel:020-40193000 Fax:020-40193001

: BARA BAZAR BAREILLY 243003 UP

BAREILLY-243003
UTTAR PRADESH
INDIA 243003

Transaction Number : 00001

Effective Date : 10/06/2020
POLICY ENDORSEMENT
Conditions applicable:-
1.Sum Insured-200000 ; Non Floater
2.Family Defination :Self Only ; Plan - 001 200000 Plan - 002 200000
3.Age Band - 18 to 60 years
4.First 30 days Waiting Period - Not Applicable
5.Max Entry Age - 60 Years
6.Pre-Existing Disease - Covered After 36 Months
7.Room Rent Limit - 1% of S.I for Normal and 2% of S.I for ICU
8.Proportionate Deduction - Applicable
9.In-patient Hospitalization - Covered
10.Day-Care Procedures - Covered
11.Pre-Post Hospitalization - 30 days and 60 Days Respectively
12.AYUSH - Covered upto INR 10,000.(On IPD In Govt. Registered Hospitals)
13.Maternity - Not Covered
13.Female member Count /Total Member Count - Upto 20%
14.Waiting Period for Maternity - Not Applicable
15.Limit For Maternity, If Opted - Not Applicable
16.Disease Wise Capping - Not Applicable
17.Sum Insured Type - Uniform
18.Standard Conditions :
a.If VAS is opted then this will be available upto 3 month of Policy
inception date
b.In addition to the conditions mentioned above,all other terms,conditions
and exclusions will be as per the Group Health Assure Policy Wording.
c.Minimum Group size at inception should be of 7 Members to underwrite
a group policy.The Company is not obliged to accept the risk,

Page 12 of 14
POLICY ENDORSEMENT
if the minimum group size criteria is not fulfilled.

d.Additions and deletions of employee/member will be done on prorate
basis from day 1 for additions subject to sufficient CD balance being
maintained. Data for such additions and deletions has to be shared
not later than 45 days from the date of joining of the employee.
e.In case of claims, all cases should be intimated to TPA/Bharti AXA
General Insurance Co. Ltd. within 24 hours from the date of
admission
f.Claim must be filed within 30 days from the date of completion of
treatment. However, the Company may at its absolute discretion
consider waiver, of this Condition in extreme cases of hardship
where it is proved to the satisfaction of the Company that under the
circumstances in which the insured was placed it was not possible

for him or any other person to give such notice or file claim within
the prescribed time-limit. The claim would invite additional 10%
co-payment over and above payable amount as per policy terms
and conditions
g.All Reimbursement Claims must be intimated to the TPA/Bharti
AXA General Insurance Co. Ltd. within 24 hrs of Admission, in case
of non-intimation/Delayed intimation 10% Co-pay would be
applicable except for Accidental claims. If the member is getting
admitted in any network hospital and filing for reimbursement
claims such claims will be settled to members with 15% co-pay.
h.Claim servicing of the policy will be done by TPA(FHPL)

Page 13 of 14
TAX INVOICE U/S 31 of CGST Act, 2017
Supplier's Name : BHARTI AXA GENERAL INSURANCE COMPANY LTD

Supplier's address : #309,310, 311 Millenium Star
Building,Near Ruby Hall Clinic
,Dhole Patil Road, Pune -
411001
Tel:020-40193000 Fax:020-40193001
Email: customer.service@bhartiaxa.com GSTIN of Supplier : 27AADCB2008D1ZC
Sold To Invoice No. : GD01985573

Buyer Name : MADAN MOHAN BANWARI LAL Date : 20/06/2020
Buyer Address BARA BAZAR BAREILLY 243003 UP

BAREILLY-243003
UTTAR PRADESH
INDIA 243003
Contact Number :
Email Id :
Location of Recipient (State) : 09 -Uttar Pradesh Location of Supply (State) : 27 -Maharashtra
GSTIN of the buyer/ Unique ID : 09AAAHM7478N1ZF
IGST CGST SGST

Sr. No. Description SAC Gross Total Value
Value
Rate Amount Rate Amount Rate Amount
Q1464726/00001
1 997133 0.11 18.00 0.02 0.00 0.00 0.00 0.00 0.13
GCAS/001
Q1464726/00001
2 997133 17,268.78 18.00 3,108.38 0.00 0.00 0.00 0.00 20,377.16
GCUA/001
Q1464726/00001
3 997133 0.11 18.00 0.02 0.00 0.00 0.00 0.00 0.13
GEXA/001
20,377.42
Total Invoice Value (In figures) 20,378.42
Total Invoice Value (In words) Twenty Thousand Three Hundred Seventy Eight Rupees and Forty Two Paisa
Remarks, if any
For Bharti Axa General Insurance Co. Ltd.
Authorised Signatory
Page 14 of 14

Madan Mohan Banbari Lal Q1464726 GHA POLICY

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Madan Mohan Banbari Lal Q1464726 GHA POLICY

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BHARTI AXA GENERAL INSURANCE COMPANY LTD

#309,310, 311 Millenium Star

POLICY INFORMATION Policy No. : GHA/Q1464726/81 ( )

Source : (02) 81004364 Probus Insurance Broker PVT LTD

Insured : MADAN MOHAN BANWARI LAL (23892810)

Advice to : MADAN MOHAN BANWARI LAL

Period Of Insurance : From 10/06/2020 To 09/06/2021

Gross Premium GST Total Payable

17,269.00 3,108.42 20,378.42

Premium Details (INR)

001 Plan - 001 200000

Issued by - INB5159 On 20/06/2020 (R)

BHARTI AXA GENERAL INSURANCE COMPANY LTD

Source : 02 81004364 Probus Insurance Broker PVT LTD

Insured : MADAN MOHAN BANWARI LAL (23892810)

Period Of Insurance : From 10/06/2020 To 09/06/2021

Total Premium (INR) 0.11 17,268.78 0.11 17,269.00

BHARTI AXA GENERAL INSURANCE COMPANY LTD

Plan Description No. of No. of No. of Total

001 Plan - 001 200000 7 7

BHARTI AXA GENERAL INSURANCE COMPANY LTD

MADAN MOHAN BANWARI LAL Policy No. : GHA/Q1464726/81 ( )

NOTE : If movement date is prior to period of insurance the adjustment is interpreted as

Signer: DS BHARTI AXA GENERAL

Issued by - INB5159 On 20/06/2020 ( R )

BHARTI AXA GENERAL INSURANCE COMPANY LTD

POLICY INFORMATION Policy No. : GHA/Q1464726/81 ( )

Source : (02) 81004364 Probus Insurance Broker PVT LTD

Insured : MADAN MOHAN BANWARI LAL (23892810)

: BARA BAZAR BAREILLY 243003 UP

Period Of Insurance : From 10/06/2020 To 09/06/2021

Plan - 001 200000 : Plan 001 - GCUA

BHARTI AXA GENERAL INSURANCE COMPANY LTD

Schedule of Annual Premium ( INR )

001 GCAS 0.01 CULT ASSURE

002 GCAS 0.01 CULT ASSURE

001 GCUA 1,438.98 CURE ASSURE

002 GCUA 1,798.98 CURE ASSURE

001 GEXA 0.01 EXTEND ASSURE

002 GEXA 0.01 EXTEND ASSURE

BHARTI AXA GENERAL INSURANCE COMPANY LTD

MADAN MOHAN BANWARI LAL Policy No. : GHA/Q1464726/81 ( )

BENEFIT SCHEDULE ( INR )

Benefit Limit Reimburse(%) Benefit Limit Reimburse(%)

BHARTI AXA GENERAL INSURANCE COMPANY LTD

MADAN MOHAN BANWARI LAL Policy No. : GHA/Q1464726/81 ( )

BENEFIT SCHEDULE ( INR )

Benefit Limit Reimburse(%) Benefit Limit Reimburse(%)

EPIDEMIC As Charged As Charged

BHARTI AXA GENERAL INSURANCE COMPANY LTD

MADAN MOHAN BANWARI LAL Policy No. : GHA/Q1464726/81 ( )

Transaction No. : 00001 Effective Date : 10/06/2020

5.Max Entry Age - 60 Years

BHARTI AXA GENERAL INSURANCE COMPANY LTD

MADAN MOHAN BANWARI LAL Policy No. : GHA/Q1464726/81 ( )

Transaction No. : 00001 Effective Date : 10/06/2020

consider waiver, of this Condition in extreme cases of hardship

co-payment over and above payable amount as per policy terms

BHARTI AXA GENERAL INSURANCE COMPANY LTD

POLICY INFORMATION Policy No. : GHA/Q1464726/81 ( )

Source : (02) 81004364 Probus Insurance Broker PVT LTD

Insured : MADAN MOHAN BANWARI LAL (23892810)

: BARA BAZAR BAREILLY 243003 UP

Period Of Insurance : From 10/06/2020 To 09/06/2021