632ad54b4ee74b378f84f5c5e38afd40-policy

PREMIAEntered By : For Star Health and Allied Insurance Company Ltd.

Authorised Signatory

This is an electronicallygenerated document(PolicySchedule).

FAMILY HEALTH OPTIMA INSURANCE POLICY - SCHEDULE

P/181313/01/2014/004042Policy No. P/181313/01/2013/004353Previous Policy No. ::

181313Issuing Office Code :

Padappengad PO,Balesugiri

Kooveri,Kannur,Kerala-670581

Address :

KERALA

Allumpurath

0/0/Phone No : 0497 2764211:E-mail id 0:

: 14/01/2013 Fulfiller Code SH4362:

First YearReceipt No : 1091004216

Premium 8,515.00: Rs 1,052.00Service Tax : Rs

1.00 9,567.00Stamp Duty Total Premium: Re : Rs

Total Premium In Words : Rupees Nine Thousand Five Hundred Sixty-Seven Only

PERIOD OF INSURANCE

SCHEME - DESCRIPTION : 2 ADULTS

Details of Insured Persons :

Sl.No.

Name of the Insured ID Card NoSex Relationship withProposer

Date of Birth Age-Yrs/Mths Pre Existing Disease/s

1

2

THOMAS.A.A

VALSAMMA

MALE

FEMALE

DEPENDANTPARENT

DEPENDANTPARENT

10-12-1956

25-01-1958

57 Yrs 1 Mths

55 Yrs 11 Mths

2678318-1

2678318-2

NIL

NIL

: 09/01/2014

Renewal Year :

E-mail id : [email protected]

Phone No : 0490-2421235/9400421235

: SURESH K S

: BA0000041861Intermediary Code

Name

Warranted that in case of dishonor of premium cheque(s), the Company shall not be liable under the policy and the policy shall be void abinitio(from inception).

THE INSURANCE UNDER THIS POLICY IS SUBJECT TO CONDITIONS, CLAUSES, WARRANTIES, EXCLUSIONS ETC., ATTACHED.

IMPORTANT

IN THE EVENT OF HOSPITALIZATION OF INSURED PERSON, INTIMATION SHOULD BE GIVEN TO THE COMPANY IMMEDIATELY,HOWEVER, WITHIN 24 HRS FROM THE TIME OF ADMISSION.

Toll Free No : 1800 425 2255 / 1800 102 4477 Email: [email protected] Fax No: 1800 425 5522.

In witness whereof the undersigned being authorized by and on behalf of the company has set his hand at Branch Office -Kannur on 09th Day of January 2014.

Sector : Rural

FROM : :TO14/01/2014 00:00:00 Midnight Of 13/01/2015

Address :Fort Road, Kannur - 670001I Floor, Grand Plaza

KANNUR

E-mail id : [email protected]

Proposer's Code 2678318:

Proposer's Name JISO THOMAS: Issuing Office Name Branch Office - Kannur:

Toll Free No

Expenses relating to the hospitalisation will be in proportion to the room rent stated in the policy.

Date of Inception of first policy : 14/01/2013

Proposal date

Receipt Date

/-/-

/- /-

:Bonus

BASIC FLOATER SUM INSURED : Rs.

LIMIT OF COVERAGE : 220000 /-Rs.

200000 /-

20000 /-Rs.

Revision in sum insured:In case of an upward revision in sum insured on renewal, in respect of disease, sickness, illness the sum insured will be restricted to that policy sum insured when the signs or symptoms was diagnosed or received medical advice ortreatment.

( Two Lakhs Only)




P/181313/01/2014/004042

It is hereby declared and agreed that

Point No 1.0 (A) appearing in the policy shall read as follows:

Room, Boarding expenses as provided by the Hospital / Nursing Home at:

2% of the Sum Insured, subject to a maximum of Rs.5,000/- per day in Class "A" Cities,

1% of the Sum Insured, subject to a maximum of Rs.3,000/- per day in Class "B" Cities and

1% of the Sum Insured, subject to a maximum of Rs.1,000/- per day in other locations.Further the definition of Class A and Class B cities mentioned in the policy stands amended as follows:

Class "A" cities means Ahmedabad, Bangalore, Chennai, Hyderabad including Secunderabad, Kolkata, Mumbai including Thane, Pune , New Delhi including Noida,Gurgaon,Faridabad and Ghaziabad

Class "B" cities means

Agra, Baroda, Coimbatore, Cochin, Indore, Kanpur, Ludhiana, Surat, Meerut, Jalandhar, Amritsar , Nagpur and All State Capitals other thanthose falling under Class "A".

Other Locations means

Rest of India not falling under Class A and Class B above.

All other terms and conditions of the policy remain unaltered.

Attached to and forming part of Policy No.




The clause no. 1.0 (A) of the policy stands amended as follows.

A) Room, Boarding, Nursing Expenses as provided by the Hospital / Nursing Home as per the table given below :-

Sum Insured(Rs)

Class A Cities Class B Cities Other Locations

1,00,000/-2,00,000/-

4,00,000/-

2% of the suminsured subject toa maximum ofRs.5,000/- perday


1% of the suminsured subject to a maximum ofRs.2,000/- perday

5,00,000/-


upto a maximum ofRs.7,500/- perday

upto a maximum of Rs.7,500/- perday

10,00,000/-

3,00,000/-



upto a maximumof Rs.10,000/- perday

15,00,000/-

2% of the suminsured subject to a maximum ofRs.10,000/- per day


upto a maximumof Rs.10,000/- per day

All other terms and conditions remains unaltered.

Attached to and forming part of Policy No. P/181313/01/2014/004042

This is to certify that JISO THOMAS has paid Rs 9567 (Total Premium In Words : Indian Rupees Nine Thousand FiveHundred Sixty-Seven Only ) towards Premium for Hospitalization Insurance vide Policy No: P/181313/01/2014/004042 for thePeriod 14-JAN-14 To 13-JAN-15 issued on 09-JAN-14 .Payment received by Cheque/Credit/Debit Card vide collection No: 1091004216 09-JAN-14

Premium Certificate for the purpose of deduction under Section 80 D of Income Tax (Amendment) Act,1986

181313 - Branch Office - Kannur Issue Office

Hospitalisation Benefit Policy

P/181313/01/2014/004042 Policy No

Note :- This Certificate must be surrendred to the Insurance Company for issuance of fresh Certificate in case of Cancellationof the Policy or any alteration in the Insurance affecting the Premium.

FHO-PolicyType Of Policy ::

:

Email [email protected]:

0497 2764211Toll Free No :

I Floor, Grand Plaza

Fort Road, Kannur - 670001

Address :

For Star Health and Allied Insurance CompanyLtd.


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