MANJUNATH H Policy

Group Medicare
Certificate of Insurance
(Applicable in case of Non-Employer-Employee group)
New Business-0238452957-00200593---
Intermediary Name : CANARA BANK
Issuing Office : BELGAUM
Name of the Policy Holder : CANARA BANK Intermediary Code : CA0045
Name of Insured Person : MR MANJUNATH R HIREMATH Intermediary Contact No : 18004250018
Address : BASAV NAGAR GOKAK
BELGAUM
KARNATAKA
591307
Branch Code : 90945

Business Type : New Business
Master Policy No : 0238452957 GSTIN No :
Renewal No: 00
Endorsement No: 00
Certificate No : 00200593
Insured Person ID : CANARA2889298828
Place of Supply : KARNATAKA
State Code : 29
Contact details of Insured Person :
• Phone/Mobile No.: 9449860558 • Email id : cb10580@canarabank.com
Certificate Period : From 26/10/2021 00:01 Hrs (Commencement date) To 25/10/2022 23:59 Hrs (Expiry Date)
Date of First Policy inception with us : 26/10/2021
Type of Plan : Individual
Details of Insured Persons Covered :
Name Of The Insured Relationship With Date Of Bi Member Unique Sum Insured
Member ID Age
Person Insured Person rth Since ID (Rs.)
CANAR
0238452957/CANARA28 MANJUNATH R
Self 22/07/1999 22 26/10/2021 A28892 300,000.00
89298828/01 HIREMATH
98828
Nominee Details :
Nominee Name Relationship With Insured Person
RAMAYAA S HIREMATH Father
Details of Coverage :
Coverage Coverage Details Sum Insured Details
In-Patient Treatment Upto Sum Insured Rs.300,000
60 days pre hospitalisation and 90 days post
Pre/Post Hospitalization Expenses, 60/90 Rs.300,000
hospitalisation
Upto 100% of In-Patient Treatment Sum
Day Care Procedures 541 Day Care Procedures Covered
Insured
Domiciliary Treatment Covered
Insured
Organ Donor Covered
Insured
Ambulance Cover Covered up to Rs 2000 per hospitalisation Upto Rs. 2,000
Covered within In-Patient Treatment Sum
Family Transportation Benefit Rs.300,000
Insured
Details of Additional Covers :
Additional Covers Coverage Details Sum Insured Details
Insurance is the subject matter of the solicitation.For more details on risk factors, terms and conditions, please read salesbrochure carefully before concluding a sale.
TATA AIG General Insurance Company Limited
Registered office : Peninsula Business Park, Tower A,15th Floor, G.K Marg,Lower Parel, Mumbai-400013
24*7 Toll free Number : 1800 266 7780 Fax : 022 6693 8170 Email : customersupport@tataaig.com website : www.tataaig.com
IRDA of India Registration No : 108 CIN : U85110MH2000PLC128425 PAN:AABCT3518Q UIN :TATHLGP21248V022021
Page 1 of 9
Group Medicare
Details of Additional Covers :
SI Rs 1lac benefit Rs 1500 & SI Rs 2lac
benefit Rs 2000 & SI Rs 3lac benefit Rs 2200
& SI Rs 5lac benefit Rs 2500 & SI Rs 6lac
benefit Rs 2800 & SI Rs 7.5 lac benefit Rs
3000 & SI Rs 10 lac benefit Rs 3500 & SI Rs
12 lac benefit Rs 3700 & SI Rs 15 lac benefit
Rs 4000 & At the end of each year We will
Health Check-up pay upto the amount mentioned below Applicable for All Members,Upto Rs.4,000
towards the cost of a preventive medical
check-up & This benefit is available ONLY to
those Insured Persons who were insured in
the previous Policy Year & Any claim made in
respect of this benefit will not be subject to
In-patient Sum Insured and will not affect
entitlement to a Cumulative bonus
Upto 5 lacs INR 500 for a max upto 30 days
Applicable for All Members, Per day amount
Hospital Cash Benefit and Above 5 lacs INR 1000 for a max upto 30
Rs.500 Above SI Limit,No. Of Day :30
days
Automatic restore full sum insured if
Restore Sum Insured Benefit Applicable for All Members,Upto Rs.300,000
executed within same policy year
Applicable for All Members,Maximum Amount
Emergency Air Ambulance Cover Covered covered upto Rs 100000
Payable: Rs.100,000
Covered for Primary Insured Member & equal
Applicable for Self,AD Sum Insured : Rs.0
Accidental Death to 100% inpatient sum insured which is
Above SI Limit
above SI limit
Psychiatric Ailment Covered upto Rs 25000 on Inpatient basis Applicable for All Members
Covered upto 100% of the SI in government
hospital or in any institute recognized by Applicable for All Members,100% of
AYUSH Cover
government and/or accredited by Quality In-Patient Treatment Sum Insured
Council of India
Limit on Room Rent No Capping Amount Mentioned/day Rs.
Covered for Primary Insured Member & equal
Applicable for Self, Permanent Total Disability
Permanent Total Disability to 100% inpatient sum insured which is
SI : Rs.300,000
above SI limit
Details of Waiting Period :
Waivers Waiver Details Sum Insured Details
Fresh Policy Not Waived Off (Applicable) and
30 Days Waiting Period Applicable for All Members
Renewal Policy Waived Off (Not Applicable)
Fresh Policy Covered after waiting period of
24 Months and First Renewal Covered after
Specified Disease Waiting Period waiting period of 12 Months and Second Applicable for All Members
Renewal Waived Off (Renewal include
portability with continuity)
Fresh Policy Covered after waiting period of
36 Months and First Renewal Covered after
waiting period of 24 Months and Second
PED Waiting Period Applicable for All Members
Renewal Covered after waiting period of 12
Months and Third Renewal Waived Off
(Renewal include portability with continuity)
The enclosed policy wordings (including additional cover wordings) shall be applicable only for covers as mentioned on Policy
Schedule/Certificate of Insurance.
Important Exclusions
Medical Exclusions:
1. "Expenses related to any admission primarily for diagnostics and evaluation purposes only "
2. "Treatment for, Alcoholism, drug or substance abuse or any addictive condition and consequences thereof"
3. "Expenses related to any unproven treatment, services and supplies for or in connection with any treatment. Unproven treatments are
treatments, procedures or supplies that lack significant medical documentation to support their effectiveness"
Page 2 of 9
Group Medicare
Non-Medical Exclusions:
i) War or any act of war, act of foreign enemy or war like operations.
ii) Intentional self injury or attempted suicide while sane or insane.
iii) Any Insured Person attempting to commit a breach of law with criminal intent.
Enclosures: This is only a summary of product features/terms/conditions. For more details please refer our website www.tataaig.com.Policy
wordings only of the opted benefits shall be applicable and must be read in conjunction with this certificate of insurance
General Conditions
l You have a period of 15 days from the date of receipt of the policy document to review the policy terms/conditions. In case of any
policy related objections, you have the option to cancel the policy and premium would be refunded as per freelook regulation laid down
by Insurance Regulatory & Development Authority of India.
l There will be no premium refund in case of cancellation due to nondisclosure of material facts, misrepresentation or fraud. In case of
noncooperation, premium shall be refunded on short rate table basis as specified in the policy.
l The policy is lifelong renewable upon timely payment of premium. Grace period of 30 days from the policy expiry is available. Renewal
premium will change only when you move into higher age group or change your plan/coverage.
l Any product revision/modification/future withdrawal will be done with the approval of Insurance Regulatory & Development Authority
of India and will be intimated to You at least 3 months in advance. In case of withdrawal, you have an option to migrate to our similar
health insurance product.
l Portability is applicable under this policy and which shall be in accordance with portability guidelines as defined by the Insurance
Regulatory & Development Authority of India from time to time.
l Nobody can be covered more than once in this policy.
Claims Procedure Details :

Details of Claims Administrator :
Name of TPA : Tata AIG Health Claim
Website: www.tataaig.com
Email: healthclaimsupport@tataaig.com
Toll Free: 18002667780
1800229966 (For Senior Citizens)
Fax: 022 66938170
Submit claim: TAGIC Health Claims,
5th and 6th Floor, Imperial Towers, H.No 7-1-6-617/A,
GHMC no - 615,616, Ameerpet, Hyderabad – 500016,
Telangana.
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Group Medicare
Documents for claims :
Claim documentation will include but is not limited to the following :
i. Our claim form -duly completed and signed for on behalf of the Insured Person.
ii. Original Bills (pharmacy purchase bills, consultation bills, diagnostic bills) and any attachments thereto like receipts or prescriptions in
support of any amount claimed which will then become Our property.
iii. All medical reports, case histories, investigation reports, indoor case papers/ treatment papers (in reimbursement cases, if available),
. discharge summaries.
iv.A precise diagnosis of the treatment for which a claim is made.
v.A detailed list of the individual medical services and treatments provided and a unit price for each in case not available in the submitted
...hospital bill.
vi. All pre and post investigation, treatment and follow up (consultation) records pertaining to the present ailment for which claim is being made,
.. . if and where applicable.
Please refer policy wordings for details on supporting claims documents.
Premium Details :
Particulars Amount(Rs.)
Net Premium (Rs.) 4,216.00
UGST/SGST(9%) 379.44
CGST(9 %) 379.44
Total Gross Premium (Rs.) 4,975.00
Total Gross Premium (in words) Rupees Four Thousand Nine Hundred Seventy-Five And Paise Zero Only
GSTIN: 29AABCT3518Q1ZS-BELGAUM , SAC CODE: 997133
Stamp duty details :

The stamp duty of 15 (RUPEES AND PAISE) paid by Demand Draft, vide Receipt/Challan no.LOA/CSD/155/2021/4250 dated 13/10/2021
80 D certificate of Income Tax Act, 1986
This is to certify that the MR MANJUNATH R HIREMATH has paid an amount of Rs 4,975.00 towards the premium for Group Medicare Product
Certificate No 0238452957 00200593 for the period From 26/10/2021 To 25/10/2022 and is eligible for a tax exemption under section 80 D of IT
Act.
Commencement of risk cover under the policy is subject to receipt of premium by Tata AIG General Insurance Company Limited.
Prohibition of Rebates - Section 41 of the Insurance Act, 1938 as amended by Insurance Laws (Amendment) Act, 2015.
1. No person shall allow or offer to allow, either directly or indirectly, as an inducement to any person to take out or renew or continue an
insurance in respect of any kind of risk relating to lives or property in India, any rebate of the whole or part of the commission payable or any
rebate of the premium shown on the policy, nor shall any person taking out or renewing or continuing a policy accept any rebate, except such
rebate as may be allowed in accordance with the published prospectuses or tables of the insurer.
2. Any person making default in complying with the provisions of this section shall be liable for a penalty which may extend to ten lakh rupees.
Policy Servicing Office:

Registered Addres:- SHREE KRISHNA TOWER,14 KHANAPUR ROAD, 1ST FLOOR,,TILAKWADI, BELGAUM,BELGAUM,KARNATAKA,BELGAUM-590006
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Group Medicare
RECEIPT
Receipt No : 109451024136145 Receipt Date : 26/10/2021
Policy No: 0238452957 00200593
Received with thanks from MANJUNATH R HIREMATH a sum of `4975( Rupees Four Thousand Nine Hundred Seventy-Five And
Paise Zero Only)Direct Debit, Branch Bank Branch Name - CANARA BANK , Belgaum towards
Sl.No. Policy Number Total Premium Utilized from the receipt for policy Balance
1 0238452957 4,975.00 4,975.00 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: 29AABCT3518Q1ZS-BELGAUM , SAC CODE: 997133
Revenue (Consolidated) Stamp Duty paid vide challan No. date for applicable cases.

Registered office : Peninsula Business Park, Tower A,15th Floor, G.K Marg, Lower Parel, Mumbai-400013
24*7 Toll free Number : 1800 266 7780 Fax : 022 6693 8170 Email : customersupport@tataaig.com website:www.tataaig.com
IRDA of India Registration No : 108 CIN : U85110MH2000PLC128425 PAN:AABCT3518Q UIN : TATHLGP21248V022021
Page 5 of 9
Group Medicare
Terms and Conditions

Group Medicare 1. Pre-authorization is Compulsory From TPA prior to all planned admission and within 24 hours for
emergencies.
2. Admission for investigation/evaluation not covered.
3. All terms and conditions of the policy would be applicable.
Member Id : 0238452957/CANARA2889298828/01 4. Please refer to Tata AIG General Insurance customer guidebook for further details.
5. Cashless hospitalisation in network hospital can be obtained in conjuction with this card, an
Name : MANJUNATH R HIREMATH authorization letter issued by the TPA and photo identification such as voters ID, driving licence,
Age : 22 passport,etc.
Gender : MALE 6.Photo ID Proof to be presented with this card at the time of availing benifits.
Policy No : 0238452957 00 00 Tata AIG General Insurance Company Limited

Regd Office: 15th Floor, Tower A,Peninsula Business Park
Group : CANARA2889298828 G. K. Marg,, Lower Parel, Mumbai-400 013
Valid through : 26/10/2021 To 25/10/2022 Toll Free No .(24x7): 1800 266 7780, 1800 229966 (For Senior citizens)
Fax: 022 6693 8170 EMAIL : customersupport@tataaig.com
IRDA of india Registration No: 108 Website : www.tataaig.com
TAGIC Health Claims,
CIN: U85110MH2000PLC128425 UIN: TATHLGP21248V022021
5th and 6th Floor, Imperial Towers, H.No 7-1-6-617/A,GHMC no - 615,616,
Ameerpet, Hyderabad – 500016,Telangana, Toll Free : 18002667780

Registered office : Peninsula Business Park, Tower A, 15th Floor, G.K Marg, Lower Parel, Mumbai-400013
Page 6 of 9
Group Medicare
ENROLMENT FORM FOR GROUP HEALTH POLICY
URN NO : URN No. AH/2018-19/HL-06
Partner Reference No. /

Name of the Group Administrator CANARA BANK CANARA2889298828
Application No
Customer ID / Account No 6097126542 Intermediary code CA0045
This is an application for Insurance & will form the basis of the policy certificate that We may issue. Every information, this application seeks is
important & mandatory. Please read all questions and answer them carefully. You must provide complete and correct information.
Incomplete/incorrect/partially correct information may lead to cancellation of proposal and policy certificate even if it is issued. We are under
no obligation to accept any proposal for insurance. If We accept a proposal for insurance, it shall be subject to the Policy terms and
conditions and We shall have no liability to make any payment under the Policy if proposal is not accepted by us or premium is not received by
Us in full and in time, or non-fulfillments of additional information requested by us, if any or if the proposal is under-process & claim arises in the
interim period before the decision on the proposal is given by us.
Commencement of risk cover under the policy is subject to receipt of premium by Tata AIG General Insurance Company Limited.
Please fill-up this form in CAPITAL LETTERS
Section I: Applicant Information
Name: First Name Middle Name Last Name

(Mr/Mrs/Ms)
MR MANJUNATH R HIREMATH
Date Of Birth: 22/07/1999 Gender: MALE Nationality: INDIAN RESIDENT

Mobile: 9449860558 Email ID: cb10580@canarabank.com
Occupation Salaried Self-employed Others (please specify):_______________________________________________
:Address for communication: BASAV NAGAR GOKAK Landmark: District: GOKAK , City: GOKAK , State: KARNATAKA , Pin
code: 591307
Unique id no. : PAN (incase of premium > Rs.50, 000) :
Group Medicare
Part A: Plan Details:

Sum Insured (in Lacs) : 300,000
Deductible (in Lacs) :
Tenure (in years) : 1 year
Plan Type : Individual
Part B: Proposed Insured Persons details:
NAME OF THE RELATIONSHIP WITH

S.No Date of BIRTH GENDER OCCUPATION Adhar NO
INSURED PERSON APPLICANT
MANJUNATH R HIREM
1 Self 22/07/1999 MALE Self Employed
ATH

Page 7 of 9
Group Medicare
Part C: Medical & Lifestyle Information:

Note: This section is applicable for all the persons to be insured
Medical Information Yes/No
Have you or any of the persons proposed for insurance, ever suffered from or taken treatment, or No
hospitalized for or have been recommended to take investigations / medication / surgery or undergone a
surgery for any of the following medical condition?
l Cancer/Kidney failure/Stroke/Heart disease/Paralysis

l Any disease of major organs including but not limited to brain, heart, kidney, lungs, liver or any
neurological disorder
l Any joint disorder including restriction in movement or any form of arthritis
Are you or any of the persons proposed for insurance in good health? Yes
Are you or any of the persons proposed for insurance undergoing/awaiting any treatment for any No
illness?
Part D Premium Paid for product (including taxes):

Section V: Nominee Details
Nominee Name: RAMAYAA S HIREMATH Relationship with the Applicant: Father
In the event of the death of the Applicant any payment due under the Policy shall become payable to the nominee in accordance with the
Policy terms and conditions. Nominee for any of the persons proposed to be insured shall be the Applicant. The nominee must be an
immediate relative of the Applicant. The nominee for all other Insured Persons proposed to be insured shall be the Applicant himself/herself.
Section VI: Declaration & Warranty On Behalf Of All Persons Proposed To Be Insured
I/ We hereby declare, on my behalf and on behalf of all persons proposed to be insured that the above statements, answers and/or
particulars given by me are true and complete in all respects to the best of my knowledge and that I/We am/ are authorized to propose on
behalf of these other persons.
I understand that the information provided by me will form the basis of insurance policy, is subject to the Board approved underwriting
policy of the Insurance company and that the policy will come into force only after full payment of the premium chargeable.
I/ We further declare that I/We will notify in writing any change occurring in the occupation or general health of the life to be insured/
proposer after the proposal has been submitted but before communication of the risk acceptance by the company.
I/We declare and consent to the company seeking medical information from any doctor or hospital who/which at anytime has attended on
the person to be insured/ proposer or from any past or present employer concerning anything which affects the physical or mental
health of the person to be insured/proposer and seeking information from any insurance company to whom an application for insurance
on the person to be insured/ proposer has been made for the purpose of underwriting the proposal and/or claim settlement.
I/ We authorize the company to share information pertaining to my proposal including the medical records of the insured/proposer for the
sole purpose of proposal underwriting and/or claims settlement and with any Governmental and/or Regulatory Authority.
Signature of the Applicant: MANJUNATH R HIREMATH Date: 26/10/2021 Place: BELGAUM
The content of this form along with product benefits, terms/conditions and exclusions have been clearly explained to me. I/we have understood
these and confirm to abide by the policy terms & conditions.
Signature of the Applicant: MANJUNATH R HIREMATH
Name & Signature of agent/intermediary/Specified Person: CANARA BANK
Code: CA0045

Page 8 of 9
Group Medicare
Vernacular Declaration (Certification in case the applicant has signed in vernacular/thumb print)
The content of this form along with product benefits, terms/conditions and exclusions have been clearly explained by me in vernacular to the
applicant who has understood and confirmed the same.
Signature/Thumb impression of the Applicant:________________________________
Name & Signature of agent/intermediary/Specified Person: CANARA BANK
Prohibition of Rebates - Section 41 of the Insurance Act, 1938 as amended by Insurance Laws (Amendment) Act, 2015.
1. No person shall allow or offer toallow, either directly or indirectly, as an inducement to any person to takeout or renew or continue an
insurance in respect of any kind of risk relatingto lives or property in India, any rebate of the whole or part of the commissionpayable or
any rebate of the premium shown on the policy, nor shall any persontaking out or renewing or continuing a policy accept any rebate,
except suchrebate as may be allowed in accordance with the published prospectuses or tables of the insurer.
2.
No person shall allow or offer toallow, either directly or indirectly, as an inducement to any person to takeout or renew or continue an
insurance in respect of any kind of risk relatingto lives or property in India, any rebate of the whole or part of the commissionpayable or
any rebate of the premium shown on the policy, nor shall any persontaking out or renewing or continuing a policy accept any rebate,
except suchrebate as may be allowed in accordance with the published prospectuses or tables of the insurer.
For office use only :

Employee ID :
Partner ID :
Insurance is the subject matter of the solicitation. For more details on risk factors, terms and conditions please read policy
document carefully before concluding a sale.
CUSTOMER ACKNOWLEDGEMENT
Application Number: 282021005449632 Date: 26/10/2021

Name of the Applicant: MANJUNATH R HIREMATH
We acknowledge with thanks the receipt of your application and amount by cash/cheque/Demand Draft/others of amount of Rs 4,975.00.
Neither the submission to us of this completed enrollment form for insurance nor any payment towards this application obliges us to agree to
issue a policy, which decision is and always shall be in our sole and absolute discretion. If we accept a proposal for insurance, it shall be
subject to the policy terms and conditions and we shall have no liability to make any payment if proposal is not accepted by us or premium is not
received by us in full and in time, or non-fulfillments of Pre-Policy Checkup (if applicable) and/or additional information requested by us. Failure to
deposit the entire premium or non-fulfillments of pre-policy check up (if applicable) or furnish additional information requested by us within 15
days from the date of proposal, we shall cancel your application and refund the premium paid without any interest subject to deduction of
pre-policy charges (if applicable & conducted). If we do not accept the proposal, we will inform you and refund any payment received from
you, towards this application, without interest within next 10 days.
We shall have no liability to make any payment under the Policy if proposal is under-process & claim arises in the interim period before the
decision on the proposal is given by us.

Page 9 of 9

MANJUNATH H Policy

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MANJUNATH H Policy

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Group Medicare

Branch Code : 90945

l Nobody can be covered more than once in this policy.

Claims Procedure Details :

Please refer policy wordings for details on supporting claims documents.

Stamp duty details :

80 D certificate of Income Tax Act, 1986

Policy Servicing Office:

Receipt No : 109451024136145 Receipt Date : 26/10/2021

Policy No: 0238452957 00200593

GSTIN: 29AABCT3518Q1ZS-BELGAUM , SAC CODE: 997133

TATA AIG General Insurance Company Limited

Terms and Conditions

Policy No : 0238452957 00 00 Tata AIG General Insurance Company Limited

TATA AIG General Insurance Company Limited

ENROLMENT FORM FOR GROUP HEALTH POLICY

URN NO : URN No. AH/2018-19/HL-06

Partner Reference No. /

Customer ID / Account No 6097126542 Intermediary code CA0045

Section I: Applicant Information

Name: First Name Middle Name Last Name

Date Of Birth: 22/07/1999 Gender: MALE Nationality: INDIAN RESIDENT

Unique id no. : PAN (incase of premium > Rs.50, 000) :

Part A: Plan Details:

Part B: Proposed Insured Persons details:

NAME OF THE RELATIONSHIP WITH

TATA AIG General Insurance Company Limited

Part C: Medical & Lifestyle Information:

Medical Information Yes/No

l Cancer/Kidney failure/Stroke/Heart disease/Paralysis

Part D Premium Paid for product (including taxes):

Nominee Name: RAMAYAA S HIREMATH Relationship with the Applicant: Father

Signature of the Applicant: MANJUNATH R HIREMATH Date: 26/10/2021 Place: BELGAUM

TATA AIG General Insurance Company Limited

For office use only :

Application Number: 282021005449632 Date: 26/10/2021

TATA AIG General Insurance Company Limited

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