Mrs.

MANJUSHREE NAYAK
FLAT NO B-109 KRISHNAM AVENUE, PATERI NEAR
VITS COLLEGE ROAD SATNA MADHYA PRADESH -
485001
Mobile No: 8982898257

Certificate of Insurance (COI) - Max health plus

 Certificate of Insurance (COI) - Max health plus

Group Master Policy Number 50095800202000 Group Master PolicyHolder's Name Indian Bank

Group Master Policyholder's 254-260, AVVAI SHANMUGAM Group Master Policy Issue date 09/11/2020
Address & Pincode SALAI ROYAPETTAH , 600014

Certificate Number 134000342878 Proposer’s Name Mrs. MANJUSHREE NAYAK

Cover Inception Date and Time 28/12/2020 12:00 AM Proposer’s Address & Pincode FLAT NO B-109 KRISHNAM
AVENUE, PATERI NEAR VITS
COLLEGE ROAD SATNA MADHYA
PRADESH - 485001

Cover Expiry Date and Time 27/12/2021 11:59 PM Contact Number 8982898257

Insured details
Certificate No. Salutation Insured Name Date of Birth/ Age Gender Relationship Sum Insured

134000342878 MANJUSHREE NAYAK 15/06/1982 F SELF

134000342879 ROHIT KUMAR SAHOO 21/05/1979 M SPOUSE INR 15 Lacs with 2 Lacs deductible

134000342880 MEHEK SAHOO 04/05/2013 F DAUGHTER

Nominee details
Nominee Name Relationship Appointee Details (if nominee is minor)

ROHIT KUMAR SAHOO SPOUSE NA

Benefit Structure

Policy Tenure 1 year

Plans 2A1C

Options INR 15 Lacs Indemnity cover with INR 2 Lac deductible

• Nursing charges excluding private

nursing charges
• Medical Practitioners’ fees,
excluding any charges or fees for
Standby Services
• Medicines, drugs and
consumables
• Physiotherapy, investigation and
diagnostics procedures directly Up to Base Sum Insured
Hospitalisation Cover related to admission
Inpatient Care • Intravenous fluids, blood
transfusion, injection administration
charges and /or consumables
• Operation theatre charges
• The cost of prosthetics and other
devices or equipment if implanted
internally during Surgery

Hospital accommodation- Room

Single Private Room
Rent/day

Hospital accommodation- ICU/day Covered up to Sum Insured

 Listed 536 Day Care Treatments covered up to
Day Care Treatment
Base Sum Insured

Pre - hospitalization Medical Expenses Up to Base Sum Insured (30 days)

Post- hospitalization Medical Expenses Up to Base Sum Insured (60 days)

Domiciliary Hospitalization Up to Base Sum Insured

Hospitalisation Cover Organ Transplant Up to Base Sum Insured

Emergency Ground Ambulance- Within India(one transfer

INR 1000
per Hospitalization)

Waiting period for Pre-Existing Diseases (PED) 24 months

Initial Waiting Period 30 days

Specific Disease waiting period 24 months

Common Features

Free Look Period 15 days

Intermediary Details

Intermediary Name Intermediary Code Intermediary Contact No

M/S INDIAN BANK BNK0130001 1800 4250 0000

GST Details:
GSTI No.: 07AAFCM7916H1ZA SAC Code / Type of Service : 997133 / General Insurance Services

Max Bupa State Code : 07 Customer State Code / Customer GSTI No. : 23 / NA

Premium Details
Net CGST SGST/UTGST IGST Gross Gross Premium (Rs.) (in words) Premium
Premium (0.00%) (0.00%) (18.00%) Premium frequency
(Rs.) (Rs.)

1347.00 0.00 0.00 286.20 1590.00 One Thousand Five Hundred Ninety Only Single

Income tax benefit u/s 80D is available as per the existing Income Tax Laws. Please consult your tax advisor for more details.
This Policy is subject to the terms, conditions and exclusions mentioned in the MAX HEALTH PLUS, UIN : MAXHLIP21408V022021
The contract will be cancelled ab intio in case; the consideration under the policy is not realized.
Policy issuing office : Delhi , Consolidated Stamp Duty deposited on the Master Policy.
Goods and Service Tax Registration No.: 07AAFCM7916H1ZA
Pursuant to Notification no 13/2020– Central Tax and Notification no 14/2020– Central Tax both dated 21st March 2020 read with rule 54 (2) of
CGST Rules 2017, the provisions of E Invoicing & QR code are not applicable to an Insurance company, hence E Invoice number and QR code has
not been printed on this document. GST under RCM: NIL
The cover may be renewed on sole discretion of Niva Bupa Health Insurance Company Limited (formerly known as Max Bupa Health Insurance Co.
Ltd.) subject to member being the part of the group at the time of renewal also. In case You cease to be a member of the group, the cover will stand
cancelled as per T&C of the policy
Where the proposal form is not received, information obtained from insured, whether orally or otherwise, is captured in the policy document.
Discrepancies, if any, in the information contained in the policy document may be pointed out by an insured within 15 days from the policy issue
date after which information contained in the policy document shall be deemed to have been accepted as correct.

Location: New Delhi

Director - Operations & Customer Service
Date: 16/10/2021
For and on behalf of Niva Bupa Health Insurance Co. Ltd.
(Formerly known as Max Bupa Health Insurance Co. Ltd.)