THE NEW INDIA ASSURANCE CO. LTD.

(Government of India Undertaking)

New India Floater Mediclaim Policy

UIN : NIAHLIP20105V031920

Policy Schedule

Current Policy No 67020034202800000523 Current Policy Period From:25/11/2020 12:00:01 AM

To:24/11/2021 11:59:59 PM
Previous Policy No 67020034200400000033 Previous Policy Period
Policyholder's Details
Policyholder Name RAGHAVENDRA M Customer ID PO85165178
PAN Card No ALJPR1590G
Mobile No/Phone No 9901455116
Policyholder's NO.144, 39TH MAIN, 4TH Email id raghavawrites@gmail.com,
address CROSS, BTM 2ND STAGE,
BANGALORE-560076

BANGALORE ,KARNATAKA,
560076
Name of the Nominee Mahabaleshwara
Relation with the Policy Father
holder
GSTIN NA
Policy Issuing Office and Intermediary Details
Office Name and Code THE NEW INDIA ASSURANCE CO.LTD., Office Contact No 08022269215 / 08022269127 /
CITY DO II (670200) 8022204448
Office Email Id nia.670200@newindia.co.in Development Officer DIRECT BUSINESS . (1D7821752)
Name of the Mrs. P. ABIRAMI . (NIAAG00140702)
Agent/Intermediary
Office Address CITY DIVISIONAL OFFICE II , BRIGADE Contact No. of 9663808380 / NA
PLAZA,N-202,S C ROAD, Agent/Intermediary
ANANDA RAO CIRCLE
BANGALORE,560009
E-mail id of Intermediary abirami1824@gmail.com, /
Regional Office BANGALORE R.O. (670000) GSTIN 29AAACN4165C2ZM
Regional Contact No 08022224812/08022224813 SAC 997139 (Other non-life insurance
services excl RI)
Details Of TPA (Notice or Communication to be given in respect of claim)
Name of the TPA MEDI ASSIST INSURANCE TPA PVT.
LTD.
Email-id of the TPA Address of the TPA MEDI ASSIST INDIA TPA PVT. LTD.,
info@mediassistindia.com TOWER D, FOURTH FLOOR,,IBC
KNOWLEDGE PARK, 4/1,
BANNERGHATTA ROAD,,BANGALORE

Toll Free / Contact No of 18004259449

the TPA 18002089449 / 8049698000
Fax of TPA 18004259559

Highlights of New India Floater Mediclaim Policy*

* Day one baby cover. * Ayurvedic / Homoeopathic / Unani treatments are covered up to 25% of the
Sum Insured.
* Critical Care Benefit 10% of the Sum Insured. * Optional Cover I: No Proportionate Deduction.
* Room rent and ICU Charges at 1% and 2% of Sum Insured per day * Optional Cover II: Maternity Expenses Benefit for Sum Insured 5 Lakhs and
respectively. Above.
* Hospital Cash up to 1% of Sum Insured. * Optional Cover III: Revision in Limit of Cataract (For 8 Lakhs & above Sum
Insured).
* Midterm inclusion of newly married spouse. * For Pre Existing Diseases Waiting period is 48 Months as per clause 4.1 of the
policy document.
* Cataract claims, up to 10% of Sum Insured or ` 50,000 whichever * For specified diseases waiting period is 24 months as per clause 4.3.1
less, for each eye. of the policy document.
Signature Not
Verified
Digitally signed
by Srinivasan
Vaideswaran
Date: 2020.11.25 Policy No. : 67020034202800000523Document generated by 40109 at 25/11/2020 17:42:38 Hours.
17:42:40 IST
Regd. & Head Office: New India Assurance Bldg., 87 M.G. Road, Fort, Mumbai - 400 001. TOLL FREE No. 1 800 209 1415.
Give your valuable feedback on https://www.newindia.co.in/portal/policyFeedbackGen.

Page 1 of 5
THE NEW INDIA ASSURANCE CO. LTD.
(Government of India Undertaking)

* Please refer to policy document for detailed terms and conditions.

Important
*1.Date of Inception of first policy is the date from which the policyholder has been continuously obtaining health insurance cover in
India from any of the insurers without break subject to portability guidelines.
2.Enhanced Sum Insured under the policy will be subject to policy clauses 4.1,4.2 and 4.3
3. PED and specified diseases waiting periods for each of the merged policy shall be reckoned as per its date of inception of first policy.
* Please visit https://www.newindia.co.in for the list of network hospitals providing cashless facility. If network hospital is not
available in your city/location, please contact the concerned TPA." You are also requested to share your policy details when
you visit the network hospital.

Insured Persons details

S. No Name of the insued Date of birth(Age) Sex Relation *Date of inception of Pre Existing Disease
(Member ID) first policy
1 RAGHAVENDRA 31/03/1982(38) M SELF 02/02/2017 NA
M(PO85165178)
2 MAHABALESHW 02/11/1953(67) M PARENTS 10/06/2018 HAD
ARA
.(ME12668316)
3 PARVATHAMMA 01/01/1966(54) F PARENTS 10/06/2018 NA
.(ME12668318)

Floater Sum Insured 300000 Floater Cumulative Bonus 0

Optional Cover Table
Policy Level - Optional Not Opted
Cover - 1
(No Proportionate
Deduction)
Member Level - Optional Not Opted Member Level - Optional Cover - III Not Opted
Cover - II (Revision in Cataract Limit)
(Maternity Benefit)

S No Name of the Basic Premium Premium for Premium for Premium for Discount Gross Premium
Insured Optional Cover - I Optional Cover - Optional Cover -
II III
1 RAGHAVEND 4255 0 0 0 426 3829
RA M
2 MAHABALESH 16827 0 0 0 1683 15902
WARA .
3 PARVATHAM 11900 0 0 0 1190 10710
MA .

Previous Year Policy Details

Sl. No. Name of Company Previous From Date To Date SI PED in Claim No Claim
Insured Policy No Previous Amount
Policy

Total Gross 30441

Premium(Without
GST)
CGST(@9%) 2740
SGST(@9%) 2740
Net Premium in Words(RUPEES THIRTY-FIVE THOUSAND NINE HUNDRED TWENTY-ONE ONLY) IGST 0
Total GST 5480
Net Premium(With 35921
GST)

*This Policy is subject to terms and conditions of New India Floater Mediclaim.

Policy No. : 67020034202800000523Document generated by 40109 at 25/11/2020 17:42:38 Hours.

Regd. & Head Office: New India Assurance Bldg., 87 M.G. Road, Fort, Mumbai - 400 001. TOLL FREE No. 1 800 209 1415.
Give your valuable feedback on https://www.newindia.co.in/portal/policyFeedbackGen.

Page 2 of 5
THE NEW INDIA ASSURANCE CO. LTD.
(Government of India Undertaking)

In WITNESS WHEREOF,the undersigned being duly authorized by the Insurers and on behalf of the Insurers has(have) hereunder set
his/her(their) hand(s) on this 25th day of November 2020.
at ______________ this _______________ day of _______________ 20

Date of Issue: 25/11/2020

FOR AND ON BEHALF OF

THE NEW INDIA ASSURANCE COMPANY LIMITED
DULY CONSTITUTED ATTORNEY(S)

Policy No. : 67020034202800000523Document generated by 40109 at 25/11/2020 17:42:38 Hours.

Regd. & Head Office: New India Assurance Bldg., 87 M.G. Road, Fort, Mumbai - 400 001. TOLL FREE No. 1 800 209 1415.
Give your valuable feedback on https://www.newindia.co.in/portal/policyFeedbackGen.

Page 3 of 5
THE NEW INDIA ASSURANCE CO. LTD.
(Government of India Undertaking)

Insurer Office Code : THE NEW INDIA ASSURANCE CO.LTD., CITY DO II

(670200)
Address : CITY DIVISIONAL OFFICE II , BRIGADE PLAZA,N-
202,S C ROAD,
ANANDA RAO CIRCLE
BANGALORE,560009
Telephone : 08022269215 / 08022269127 / 8022204448
Fax : 08022374968

New India Floater Mediclaim

PREMIUM CERTIFICATE FOR THE PURPOSE OF DEDUCTION UNDER SECTION 80 D OF INCOME TAX ( AMENDMENT ) ACT 1986

This is to certify that Mr./Mrs. RAGHAVENDRA M has paid ` 35921 towards premium for New India Floater Mediclaim for the
period 25/11/2020 12:00:01 AM to 24/11/2021 11:59:59 PM

Policy no. : 67020034202800000523

Receipt no. & date : 67020081200000005145
25/11/2020

Date of Issue: 25/11/2020

Authorized Signatory For and on behalf of
The New India Assurance Company
Limited
(Note: This certificate must be surrendered to the Insurance Company for issuance of fresh certificate in case of cancellation
of the policy or any alteration in the Insurance affecting the premium)

Policy No. : 67020034202800000523Document generated by 40109 at 25/11/2020 17:42:38 Hours.

Regd. & Head Office: New India Assurance Bldg., 87 M.G. Road, Fort, Mumbai - 400 001. TOLL FREE No. 1 800 209 1415.
Give your valuable feedback on https://www.newindia.co.in/portal/policyFeedbackGen.

Page 4 of 5
 THE NEW INDIA ASSURANCE CO. LTD.
(Government of India Undertaking)

IMPORTANT

This policy is subject to the terms and conditions contained in the policy document (Clauses).

This policy is governed by Health Insurance Regulations 2016 issued by Insurance Regulatory
Development Authority of India on 12.07.2016.

This policy is also governed by IRDAI (Protection of Policyholders' Interest) Regulations, 2017.

This Schedule comes attached with the policy document (Clauses). If not attached, please ask for the
same.

Health Insurance Regulations 2016 and IRDAI (Protection of Policyholders' Interest) Regulations, 2017 are
available on the website of IRDAI.

Tax Invoice No : 67020020P0006044

IRDA Registration Number: 190

Policy No. : 67020034202800000523Document generated by 40109 at 25/11/2020 17:42:38 Hours.

Regd. & Head Office: New India Assurance Bldg., 87 M.G. Road, Fort, Mumbai - 400 001. TOLL FREE No. 1 800 209 1415.
Give your valuable feedback on https://www.newindia.co.in/portal/policyFeedbackGen.

Page 5 of 5