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Certificate of Insurance

Group Policyholder Name AIRTEL PAYMENTS BANK LIMITED

Mr Gouri Singha Barman Group Policy No.
Certificate of Insurance No.
Airtel Payments Bank Plan Name
Cover Start Date
Airtel Centre, Plot No.16, Udyog Vihar, Phase 4 Cover End Date
Nominee Name (Relationship)
Gurgaon
Premium Paid
Gurgaon 122015
Haryana 06 Premium Payment Mode
Cover type
49261762
61014852
Group Care 360°(APB)-GMC
00:00 hrs 21-Jan-2023
Midnight 20-Jan-2024
Legal_Heir (LEGAL_HEIR)
Rs. 999
(Premium Rs 847 + CGST Rs 76.23 + IGST Rs
0 + SGST/UGST Rs 76.23)
Single Premium
Individual

Details of Applicant
Applicant Date Of Birth Client ID
Gouri Singha Barman 03-Apr-1994 14634704

1
Details of Insured
Insured with
Name Client ID Date of Birth Relationship the Company Pre-existing diseases
(since)
Gouri Singha Barman 14634704 03-Apr-1994 Member 21-Jan-2023 None

Intermediary Details
Name Code Contact Number
Care Health Insurance Ltd. Direct https://www.care
0 Benefits
S No. Particulars Basis of Offering (On Annual Basis)
1 Sum Insured 50,000

2 In - patient care Up to SI

3 Day Care Treatment Up to SI

4 Domestic Road Ambulance Up to Rs.2,000 per hospitalization

5 Wait Period 30 Days,Yes (except for Injuries/Accident)

6 Named Ailment (as defined in Group Care 360 Product) 24 Months

7 Pre-existing diseases 36 Months

8 On Room rent Up to 1% of SI

9 ICU charges Up to 2% of SI

9 Declaration - I have not been hospitalized in the last 4 years other than minor ailments nor have I been advised to get
hospitalized in future for any medical reason
Key Exclusions
The company shall not be liable to make payment for any claim directly or indirectly caused by, based on, arising out of howsoever attributable to any of
the following except covered by way of an extension:
• Treatment taken from anyone who is not a Medical Practitioner or from a Medical Practitioner who is practicing outside the discipline for which he is l
licensed or any kind of self-medication.
• Charges incurred (or Treatment undergone) in connection with routine eye examinations and ear examinations, dentures, artificial teeth and all other
similar external appliances and / or devices whether for diagnosis or treatment.
• Act of self-destruction or self-inflicted Injury, attempted suicide or suicide while sane or insane or Illness or Injury attributable to consumption, use,
misuse or abuse of intoxicating drugs, alcohol or hallucinogens.
Note: This is an illustrative list of exclusions and not exhaustive. For the entire list of exclusions, please refer the Group Policy Terms and Conditions issued
to the Group Policyholder.

Note:
Named Ailments:
• Any treatment related to Arthritis (if non-infective), Osteoarthritis and Osteoporosis, Gout, Rheumatism, Spinal Disorders(unless caused by accident),
Joint Replacement Surgery(unless caused by accident), Arthroscopic Knee Surgeries/ACL Reconstruction/Meniscal and Ligament Repair
• Surgical treatments for Benign ear, nose and throat (ENT) disorders and surgeries (including but not limited to Adenoidectomy, Mastoidectomy,
Tonsillectomy and Tympanoplasty), Nasal Septum Deviation, Sinusitis and related disorders
• Benign Prostatic Hypertrophy
• Cataract
• Dilatation and Curettage
• Fissure / Fistula in anus, Hemorrhoids / Piles, Pilonidal Sinus, Gastric and Duodenal Ulcers
• Surgery of Genito-urinary system unless necessitated by malignancy
• All types of Hernia & Hydrocele
• Hysterectomy for menorrhagia or Fibromyoma or prolapse of uterus unless necessitated by malignancy
• Internal tumours, skin tumours, cysts, nodules, polyps including breast lumps (each of any kind) unless malignant
• Kidney Stone / Ureteric Stone / Lithotripsy / Gall Bladder Stone
• Myomectomy for fibroids
• Varicose veins and varicose ulcers
• Genetic disorders
• Parkinson's or Alzheimer's disease or Dementia

Portability/Renewability
S No. Particulars
1 Renewal under the scheme is subject to continuation of this scheme by Group Policyholder
2 You can port from this scheme to Insurer’s Health Insurance policy subject to Underwriting guidelines of such Health Insurance Policy under
following conditions:
a) Group Policyholder chooses not to continue this scheme
b) If you choose not to continue the enrollment under this scheme
The premium payable under this scheme shall be reviewed on annual basis and may subject to revision.

for Claims & Assistance: Call 1800-102-4488

Grievance Redressal/Complaints
The Company has developed proper procedures and effective mechanism to address of complaints by the customers. The Company is committed to
comply with the Regulations, standards which have been set forth in the Regulations, Circulars issued by the Authority (IRDAI) from time to time in this
regard.
(a) If the Policyholder / Insured Person has a grievance that the Policyholder / Insured Person wishes the Company to redress, the Policyholder / Insured
Person may contact the Company with the details of the grievance through:;
Website: www.careinsurance.com
Email: customerfirst@careinsurance.com
Contact No.:1800-102-6655
Courier: Any of Company’s Branch Office or corporate office

The Policyholder/Insured Person may also approach the grievance cell at any of the Company’s branches with the details of his/her grievance during the
Company’s working hours from Monday to Friday.

Exclusively for Senior Citizens, the Company has a separate extension on the Customer Service Toll Free Number. This separate customer service channel
prioritizes and routes any kind of request / grievance raised by Senior Citizens through various fast track internal escalations leading to lesser
Turn-Around-Time (TAT) for request / grievance addressal.
(b) If the Policyholder / Insured Person is not satisfied with the Company's redressal of the Policyholder's / Insured Person’s grievance through one of the
above methods, the Policyholder / Insured Person may contact the Company’s Head of Customer Service at:
Head – Customer Services,
Care Health Insurance Limited
(Formerly known as Religare Health Insurance Company Limited)
Unit no 604 - 607, 6th Floor, Tower C, Unitech Cyber Park,
Sector 39, Gurgaon -122001.(HARYANA)

For Care Health Insurance Limited

(Formerly known as Religare Health Insurance Company Limited)

Authorized Signatory Date of Issue : 20-Jan-2023 Place of Issue :Gurgaon, Haryana

Service Branch : CHIL, Vipul Tech Square, Tower-C, 3Rd Floor, Golf Course Road, Gurgaon , Haryana - 122009 Branch Contact No. : 1800-102-4488 20-J

Correspondence Address:
Care Health Insurance Limited
(Formerly known as Religare Health Insurance Company Limited)
Website : www.careinsurance.com Email : customerfirst@careinsurance.com
Unit no 604 - 607, 6th Floor, Tower C, Unitech Cyber Park,
SAC: 997133 and Description of Service: Accident and Health Insurance Services State GSTIN No.: 06AADCR6281N1ZW IRDA Registration Number - 148 UIN : RHIHLGP20126V011920

Consolidated Stamp Duty paid vide E-Challan GRN no. 92250132 dated 07 July 2022, RCM Applicability- N/A

Registered office address : 5th Floor, 19 Chawla House, Nehru Place, New Delhi - 110019
CIN : U66000DL2007PLC161503

Note:
1. Validity of this certificate is subject to terms and conditions of Group Policy issued to the Group Policyholder.
2. In event of non-receipt of Premium, this certificate of insurance automatically stands cancelled from inception, irrespective of whether a separate communication is sent or not. This policy is based on
the information provided by the Insured to the Group Administrator. In case you find any discrepancy in the same, please contact us immediately.
3. This Certificate of Insurance is governed by and is subject to the Terms and Conditions of the referred Group Policy.
1 NB

Premium Acknowledgement

Policy No. 61014852

Client ID 14634704
Policyholder Mr Gouri Singha Barman
Address Airtel Payments Bank
Airtel Centre, Plot No.16, Udyog Vihar, Phase 4
Gurgaon
Gurgaon 122015, Haryana
Policy Period 21-Jan-2023 to 20-Jan-2024

Premium Details
84 Amount (in Rs.) S.no. Receipt Number Amount Mode of Payment
Particulars
1 A0056205 999 Payment Gateway

Gross Premium
Group Care 360° 847.00

V
Goods & Services Tax (GST) 152.46

Total 999.00

The Premium is rounded off to the nearest rupee.

Eligibility of Premium for Deduction u/s 80D of the Income Tax Act, 1961

This is to certify that Care Health Insurance Ltd. (Formerly known as Religare Health Insurance Company Limited) has received an amount of Rs.
999.00/- from Mr Gouri Singha Barman towards Payment of Health insurance premium as per the details mentioned above. The premium paid for this
policy is eligible for applicable tax benefits u/s 80D of the Income Tax Act, 1961 and amendments thereof.

For Care Health Insurance Limited

(Formerly known as Religare Health Insurance Company Limited)

Authorized Signatory Date of Issue: 21-Jan-2023 Place of Issue: Gurgaon, Haryana

Care Mr fro 847 towa
Registered office address : 5th Floor, 19 Chawla House, Nehru Place, New Delhi - 110019
CIN : U66000DL2007PLC161503

Note
1) In case of any discrepancy, the Policyholder is requested to contact the Company immediately.
2) Any amount paid in cash towards the premium would not qualify for tax benefits as mentioned above.
3) This document must be surrendered to Us in case of Cancellation of the Certificate of Insurance or for the issuance of a fresh Certificate of Insurance in the case of any alteration. In event of
incorrect representation of this declaration this liability shall be upon the policy holder.
4) We may credit upto Rs. 1/- to your account for validation, before remitting any further payment.
61014852

14634704 03-Apr-1994 GOURI SINGHA BARMAN

 लाभ

�म �ववरण पेशकश का आधार (वा�षर्क आधार पर)

1 अस्पताल म� रोगी क� भत� बीिमत रािश तक

2 डे केयर ��टम�ट बीिमत रािश तक

3 घरे लू सड़क एम्बुल�स अस्पताल म� �ित भत� 2,000 रु. तक

4 �तीक्षा अविध चोट/दघ

ु ट
र् ना को छोड़कर, 30 �दन

नािमत बीमार� (जैसा �क �ुप केयर 360 उत्पाद म�

5 24 मह�ने
प�रभा�षत �कया गया है , �जसका उल्लेख नीचे है )

6 पहले से मौजूद बीमा�रयाँ 36 मह�ने

3 लाख क� बीिमत रािश पर बीिमत रािश का 1% तक, 5 लाख के

7 कमरे के �कराये क� सीमा
िलए िसंगल �ाइवेट कमरा

3 लाख तक क� बीिमत रािश पर बीिमत रािश का 2% तक, 5 लाख

8 आईसीयू शुल्क
के िलए कोई सीमा नह�ं

घोषणा: म� �पछले 4 साल� म� मामुली बीमा�रय� के अलावा, �कसी भी कारण से अस्पताल म� भत� नह�ं◌ं हुआ हूँ; और न ह� मुझे �कसी
डॉक्टर �ारा �कसी इलाज के िलए भत� होने क� सलाह द� गयी है

ना�मत बीमा�रयाँ:
● ग�ठया (य�द असं�ामक है ), ऑ�स्टयोआथर्राइ�टस एवं ऑ�स्टयोपोरोिसस, गाउट, �रयुमे�टज्म, र�ढ़ क� हड्ड� म� �वकार (जब तक
�क दघ र् ना के कारण न हो), जॉइं ट �रप्लेसम�ट सजर्र� (जब तक �क दघ
ु ट ु ट
र् ना के कारण न हो), आथ�स्को�पक घुटने क� सजर्र� /
एसीएल र�कंस्�क्शन / मेिनस्कल और िलगाम�ट �रपेयर से संबंिधत कोई भी उपचार
● कान, नाक और गले (ईएनट�) के सामान्य �वकार का स�जर्कल उपचार और सजर्र�ज (एडे नोइडे क्टोमी, मास्टोइडे क्टोमी,
टॉ�न्सल्लेक्टोमी और टाइम्पेनोप्लास्ट� व अन्य), नजल सेप्टम डे �वएशन, साइनसाइ�टस और संबंिधत �वकार
● सामान्य �ोस्टे �टक हाइपर�ोफ�
● मोितया�बंद
● डाइलेटेशन और क्युरे�टज
● गुदा म� �फशर /भगंदर, बवासीर / पाइल्स, पाइलोिनडल साइनस, गै�स्�क और डु ओडे नल अल्सर
● जेिनटो-यू�रनर� िसस्टम क� सजर्र�, जब तक �क यह मैिलग्न�सी के चलते ज़रूर� न हो
● सभी �कार के हिनर्या और हाइ�ोसील
● मेनोरे �जया या फाइ�ोमायोमा या गभार्शय के �ोलैप्स के िलए �हस्टे रेक्टॉमी जब तक �क यह मैिलग्न�सी के चलते ज़रूर� न हो
● आंत�रक ट्यूमर, त्वचा के ट्यूमर, िसस्ट, नोड्यूल, स्तन म� गांठ स�हत पॉलीप्स (�कसी भी �कार का) जब तक �क यह
मैिलग्न�ट न हो
● �कडनी स्टोन / यूरेटे�रक स्टोन / िलथो��प्सी / गॉल ब्लैडर स्टोन
● फाइ�ॉएड्स के िलए मायोमेक्टोमी
● वै�रकाज़ वेन्स और वै�रकाज़ अल्सर
● आनुवंिशक �वकार
● पा�क�संस या अल्जाइमर रोग या मनो�ंश;

दाव� और सहायता के �लए: 1800-102-4488 पर कॉल कर�

�शकायत �नवारण/�शकायत

कंपनी ने �ाहक� �ारा िशकायत� के समाधान के िलए उिचत ���या और �भावी तं� �वकिसत �कया है ।
(a) य�द पॉिलसीधारक/बीिमत व्य�� चाहता है �क उसके िशकायत का िनवारण कंपनी �ारा �कया जाये, तो पॉिलसीधारक/बीिमत

व्य�� िशकायत के �ववरण के साथ कंपनी से संपकर् कर सकता है :;

वेबसाइट: www.careinsurance.com
ईमेल:
Customerfirst@careinsurance.com
संपकर् नंबर: 1800-102-6655
कू�रयर: कंपनी का कोई भी शाखा कायार्लय या कॉप�रे ट कायार्लय

पॉिलसीधारक/बीिमत व्य�� अपनी �कसी िशकायत के िलए सोमवार से शु�वार तक कंपनी के कायर् समय के दौरान अपनी िशकायत
के �ववरण के साथ कंपनी क� �कसी भी शाखा के िशकायत �को� से संपकर् कर सकते ह� । �वशेष रूप से व�र� नाग�रक� के िलए,
कंपनी के �ाहक सेवा टोल �� नंबर पर एक अलग एक्सट� शन है ।

(b) य�द पॉिलसीधारक/बीिमत व्य�� कंपनी �ारा पॉिलसीधारक/बीिमत व्य�� क� िशकायत के िनवारण से संतु� नह�ं है , तो

पॉिलसीधारक/बीिमत व्य�� कंपनी के �ाहक सेवा �मुख से यहां संपकर् कर सकते ह� :

�मुख - �ाहक सेवाएं,
केयर हे ल्थ इं श्योर� स िलिमटे ड
(पूवर् नाम रे िलगेयर हे ल्थ इं श्योर� स कंपनी िलिमटे ड)
यूिनट नंबर 604 - 607, छठ� मं�जल, टॉवर सी, यूिनटे क साइबर पाकर्, सेक्टर 39, गुड़गांव -122001।(ह�रयाणा)

Signature Not
Verified
Digitally signed by
MANISH DODEJA
Date: 2023.01.20
13:36:03 IST
Reason: I'm the author
Location: India