0287764082 (1)

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Policy Schedule
Tata AIG MediCare
Intermediary/ Broker Name: AXIS BANK LTD
Intermediary/Broker License Number: CA0069
Intermediary/Broker Contact No.: 1800 209 2001 (mobile or
landline)
Issuing Office : KARIMNAGAR
Client Id : 6026899220
Proposal no. : 262639024
Proposer’s Name: MR KAVANAM PANDU
Proposer’s Address: H NO 1-32/A JAMGI VILLAGE AND POST RAIKODE
MANDAL NEAR HANUMAN MANDIR
RAIKODE - 502257
MEDAK
TELANGANA
INDIA
Place of supply -TELANGANA
State code -36
Place of Supply: TELANGANA
Supply Code: 36
Policy Number: 0287764082
Product name: Tata AIG MediCare
Plan type: Floater Plan
Business Type: Renewal Business
Policy Tenure: 1 Year
Policy Period: From : 22/09/2020 00:00 hrs TO: 21/09/2021 on 11:59 PM
Insured Persons Details:
Insured
with Tata
AIG
Insured General Relationship Sum Cumulative
Person's Insurance Member Date of Restore Benefit Insured ( Accidental
Name Co. since Id birth Age to Proposer % ) Bonus ( ) Death
KAVANAM PANDU 14/09/2018 0026263902401029 06/06/1989 31 Self 100% 0.00 0.00
KAVANAM SHIVAPRIYA 14/09/2018 0026263902402021 31/05/1997 23 Spouse 100% 0.00 0.00
KAVANAM SAI
14/09/2018 0026263902403001 18/10/2016 3 Daughter 100% 300,000.00 0.00 0.00
SHREYASVI
* For Family Floater policy, Sum Insured and cumulative bonus floats among the insured members of the family as mentioned
above. This shall not be applicable for newly added members in this policy.
# Sum Insured mentioned is excluding cumulative bonus. Earned cumulative bonus is separately mentioned.
Net Premium ( ) : 9,736.56

Loadings ( ) : 0.00
Discounts ( ) : 3,786.44
Tax, Duties and cess as applicable ( ) :
UGST/SGST @9 % ( ) : 876.29
CGST @9 % ( ) : 876.29
Gross Premium ( ) : 11,489.00
http://iip-core.tataaiginsurance.in/Configurator/HTMLReportSource/pfygum45vv3n4... 11-04-2021
Gross Premium (In Words) : Rupees Eleven Thousand Four Hundred Eighty Nine And Paise 00 Only
Benefit Name Coverage Limit

Vaccination cover Upto 5000
In-Patient Treatment - Dental Upto Sum Insured
Organ Donor Upto Sum Insured
Post-Hospitalization expenses Upto 90 days
In-Patient Treatment Upto Sum Insured
Ambulance Cover Upto 3000 per Hospitalization
Compassionate travel Upto 20,000
Restore benefits Upto Sum Insured
Second Opinion Covered
Daily Cash for Accompanying an Insured Child 0.25% of base Sum Insured; maximum 2000 per day
Health Checkup Upto 1% previous of Sum Insured; max. 10,000
Consumables Benefit Upto Sum Insured
Day Care Procedures Upto Sum Insured
Pre-Hospitalization expenses Upto 60 days
Bariatric Surgery Cover Upto Sum Insured
Hearing Aid 50% of actuals; maximum 10,000
Domiciliary Treatment Upto Sum Insured
Daily Cash for choosing Shared Accommodation 0.25% of base Sum Insured; maximum 2000 per day
AYUSH Benefit Upto Sum Insured
Global Cover Upto Sum Insured
Nominee Details for Proposer :
Insured Name Nominee Name Relationship to Proposer

KAVANAM PANDU KAVANAM SHIVA PRIYA Wife
KAVANAM SHIVAPRIYA KAVANAM SHIVA PRIYA Wife
KAVANAM SAI SHREYASVI KAVANAM SHIVA PRIYA Wife
The nominee must be an immediate relative of the Proposer
Cumulative Bonus Break up in case of Sum Insured Enhancement

Member ID Effective date of SI Applicable Sum Insured Applicable CB Amount #
0026263902401029
Cumulative Bonus for family floater is on the family Sum Insured and shall not be applicable for newly added members in this
policy.
Continuity benefit is already considered for this policy no.
Policy Comments if applicable -
l TPA Details (if

any) :
l Name of TPA : Tata AIG Health Claim
l Website : www.tataaig.com
l Email : customersupport@tataaig.com
l Toll Free : 18002667780
: 1800229966 (For Senior Citizens)
l Fax : 022 66938170
l Submit claim : TATA AIG Health Claims Claims processing HUB ,
TATA AIG General Insurance Company Limited
5th and 6th Floor, Imperial Towers H.No 7-1-6-617/A,
GHMC no - 615,616, Ameerpet Hyderabad - 500016,
Telangana Phone-040-66864900
The stamp duty of 1.00/- ( Rupee One And Paise 00 Only) is paid Service Tax Registration No: AABCT3518QST004
Policy Servicing Address :
Policy Servicing Office
Tata AIG General Insurance Company Limited
H NO: 3-1-67,68,69,70,71,72, "CITY CENTER", SHOP NO 7, 7/A, 1ST FLOOR,,KARIMNAGAR,TELANGANA,AREPALLE-505001
Tel No:--
For and on behalf of Tata AIG General Insurance Company Limited Date:
Authorized Signatory
In the event of non-realization of premium, the Company shall not be liable under the policy and the policy shall stand
cancelled ab initio (from inception).
Insurance is the subject matter of the solicitation. For more details on risk factors, terms and conditions, please read sales
brochure carefully before concluding a sale.
TATA AIG General Insurance Company Ltd. Regd. Office: 15th floor, Tower A, Peninsula Business Park,Ganpatrao Kadam Marg,
Off Senapati Bapat Marg, Lower Parel, Mumbai- 400 013.
IRDA Registration No.108, CIN No : U85110MH2000PLC128425, PAN : AABCT3518Q UIN No : TATHLIP18004V011819
Website: www.tataaig.com 24X7 Tollfree Helpline 1800-266-7780 E-mail: customersupport@tataaig.com
Certificate for the purpose of deduction under Section 80 D of Income Tax (Amendment) Act, 1986*
This is to certify that the Proposer has paid 11489.14 ( Rupees Eleven Thousand Four Hundred Eighty Nine And Fourteen Paise
And Paise 00 Only) towards premium for health Policy No 0287764082 02 00 issued to KAVANAM PANDU for the period
22/09/2020 to 21/09/2021
* Note
1. This is subject to the provisions of Section 80D of Income Tax (Amendment) Act, 1986 as amended from time to time.
This certificate must be surrendered to the company in case of cancellation of this policy. In the event of incorrect
2.
representation of this declaration the liability shall be upon the policyholder
3. This certificate will not be issued if the premium payment has been made in cash/demand draft.
RECEIPT
Receipt No. : 106001016012366 Receipt Date : 23/09/2020
Policy No : 0287764082 02 00
Received with thanks from KAVANAM PANDU a sum of 11,489.00 ( Rupees Eleven Thousand Four Hundred
Eighty Nine And Paise 00 Only)
Utilized from the

Sr. Policy
Total Premium ( ) receipt for Balance ( )
No. Number
policy ( )
1 0287764082 02 00 11,489.00 11,489.00 0.00
Note:
1. This is a computer generated receipt and does not require a signature.
2. Upon issuance of this Receipt, all previously issued temporary receipts, if any, related to this Policy shall be
considered null and void.
3. Amounts received by cheque shall be subject to realisation.
4. Any amount received in excess of the Premium is being/shall be refunded by the Company.
GSTIN : 36AABCT3518Q1ZX - TELANGANA Service Accounting Code : 99713333
Revenue (consolidated) Stamp Duty duly paid vide challan No.CSD/349/2020/1055/2020 date 06/03/2020 for
applicable cases.
Insurance is the subject matter of the solicitation. For more details on risk factors, terms and conditions, please read sales
brochure carefully before concluding a sale.
TATA AIG General Insurance Company Ltd. Regd. Office: 15th floor, Tower A, Peninsula Business Park,Ganpatrao Kadam Marg,
Off Senapati Bapat Marg, Lower Parel, Mumbai- 400 013.
IRDA Registration No.108, CIN No : U85110MH2000PLC128425,PAN : AABCT3518Q
Website: www.tataaig.com 24X7 Tollfree Helpline 1800-266-7780 E-mail: customersupport@tataaig.com
Tata AIG
MediCare
Name : KAVANAM PANDU
Age : 31
Gender : M
Policy No. : 0287764082 02 00
From : 22/09/2020 To 21/09/2021
Member ID : 0026263902401029
TAGIC Health ClaimsTATA AIG General Insurance
Company Limited
5th and 6th Floor, Imperial Towers, H.No 7-1-6-617/A,
GHMC no - 615,616, Ameerpet, Hyderabad -
500016,Telangana,
Toll Free : 18002667780, Website : www.tataaig.com
Tata AIG
MediCare
Name : KAVANAM SHIVAPRIYA
Age : 23
Gender : F
Policy No. : 0287764082 02 00
From : 22/09/2020 To 21/09/2021
Member ID : 0026263902402021
Company Limited
500016,Telangana,
Tata AIG
MediCare
Name : KAVANAM SAI SHREYASVI
Age : 3
Gender : F
Policy No. : 0287764082 02 00
From : 22/09/2020 To 21/09/2021
Member ID : 0026263902403001
Company Limited
500016,Telangana,

0287764082 (1)

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Policy Schedule Page 1 of 8

Insured Persons Details:

Net Premium ( ) : 9,736.56

Benefit Name Coverage Limit

Nominee Details for Proposer :

Insured Name Nominee Name Relationship to Proposer

The nominee must be an immediate relative of the Proposer

Cumulative Bonus Break up in case of Sum Insured Enhancement

Continuity benefit is already considered for this policy no.

Policy Comments if applicable -

l TPA Details (if

Receipt No. : 106001016012366 Receipt Date : 23/09/2020

Utilized from the

GSTIN : 36AABCT3518Q1ZX - TELANGANA Service Accounting Code : 99713333

Name : KAVANAM PANDU

Policy No. : 0287764082 02 00

From : 22/09/2020 To 21/09/2021

Name : KAVANAM SHIVAPRIYA

Policy No. : 0287764082 02 00

From : 22/09/2020 To 21/09/2021

Name : KAVANAM SAI SHREYASVI

Policy No. : 0287764082 02 00

From : 22/09/2020 To 21/09/2021

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