Reliance Healthwise Policy Schedule
Policy Issuing Office: Policy Servicing Branch Office :
Reliance General Insurance Co.Ltd.,570,Naigaum Cross Road,
Next to Royal Industrial Estate,Wadala(W),Mumbai-400031
Mr. RAVIKIRAN BASAVARAJ CHIKKAMATH
302/229 KALMESHWARA KRUPA, 3RD MAIN RD, OPP POST OFFICE, PARVATHI NAGAR BELLARY, KARNATAKA, Bellary (CMC) - 583103
Agency Name & Code: Direct ()
Policy Number: 282510637646
Details of previous policy (in case of renewal)
Previous Policy No: NA
Date of expiry: NA
Plan : Silver
Sum Insured : As Indicated Below
Period of Insurance : From 00:00 hour on 22/01/2010 To mid-night on 21/01/2011
Policy Tenure : 1 year(s)
Insured Details
Sr. Name of Insured Gender DOB Relationship Occupation Pre-existing illness Nominee Relationship Roll-Over
No. person with Insured Name
1 Mr. RAVIKIRAN Male 13/01/1977 Self Service No
BASAVARAJ
CHIKKAMATH
2 CHAITANYA R Female 21/03/1985 Spouse Housewife No
CHIKKAMATH
3
4
Benefits Sum Insured
Hospitalisation Expenses 4 Lakh
Domiciliary Hospitalisation 10% of Sum Insured
Day Care Treatment Covered
Pre Hospitalisation 60 days
Post Hospitalisation 90 days
Pre-Existing Disease After 2nd year renewal
Donor Expenses Covered
Nursing Allowance Rs. 250 per day for a maximum of 5 days
Ambulance Charges Maximum of Rs.750/-
Expenses on accompanying person at the Hospital Rs. 250 per day for a maximum of 5 days (excluding first 5 days)
Cost of Health Check-up 1% and 1.25% of Average Sum Insured for Individuals and Family Floater
respectively applicable in a block of 4 claim free years.
• Note: All benefits mentioned above are subject to the total sum insured applicable. In case of two year policies, the Sum Insured mentioned above is the limit for the first year. These limits will lapse at the end of
the first year and the fresh limits up to the full Sum Insured as mentioned above will be applicable again for the second year.
• All Coverages and Exclusions under the policy would be applicable for the New Member with effect from the date of inclusion of the member.
• Policy would be considered as a fresh policy if there would be break of more than 15 days between the previous policy expiry date and current policy start date.
• The enhanced Sum insured will not be available for an illness, diseases, injury already contracted under the preceding policy periods.
• This Insurance is subject to the terms and conditions of policy attached.
Special condition, if any : - Definition of Pre-exisiting Disease should read as: Any condition, ailment or injury or related condition(s) for
which you had signs or symptoms and / or were diagnosed and / or received medical advice/treatment,
within 48 months prior to your first policy with us.Exclusions for Pre-exisiting should be read as: Benefits will
not be available for any condition(s) defined in the policy until 24 months of continuous coverage have
elapsed, since inception of the first policy with us.
Premium Details Amount (Rs.)
Net Premium 2838.62
Service Tax(12% of Net Premium) 283.86
Education Cess (2% of Service Tax) 5.68
Secondary and Higher Education Cess (1% of Service Tax 2.84
3,131.00
Total Premium
(Service Tax Registration No. AABSR6747BST001)
Consolidated Stamp duty Paid vide Receipt No. 34948 dated 17-Dec-09**
** Not Applicable for the State of Jammu & Kashmir.
Note: In the event of dishonor of the cheque, this policy document automatically stands cancelled from inception, irrespective of
whether a separate communication is sent or not.
In witness whereof this policy has been signed at Corporate Office(Servicing) on 22/01/2010
For any assistance with claims,please contact us on 1 800 3002 8282 (toll free) and 3989 8282 (local charges apply) or email us at
services.rgicl@relianceada.com
For and on behalf of Reliance General Insurance Company Limited.
Authorised Signatory
T P A Details
TPA Name: Medi Assist India Pvt. Ltd.
Address: 49, Shilpa Vidya Road, 1st Main,J.P.Nagar, 3rd Phase,Bangalore – 560078
24 x 7 Customer Helpline Number – 1 800 425 9449 (Toll Free)/ (080) – 26584811
Fax Number : 1 800 425 9559 (Toll Free)/ (080)- 2658 4812
Email id: rgi@mediassistindia.com
Premium Certificate
Premium Certificate for the purpose of deduction under Section 80-(D) of Income Tax (Amendment) Act 1986.
This is to certify that RAVIKIRAN BASAVARAJ CHIKKAMATH has paid Rs.3131.00 (Three Thousand One Hundred Thirty One Only) towards premium for
Health Insurance for the Period From 00:00 on 22/01/2010 to Midnight of 21/01/2011
Policy No : 282510637646
Date : 22/01/2010 Place : Corporate Office(Servicing)
Note: This certificate must be surrendered to the Insurance Company for issuance of fresh certificate in case of cancellation of policy or any alteration in the
insurance affecting the premium.
For and on behalf of Reliance General Insurance Company Limited.
Authorised Signatory
