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THE NEW INDIA ASSURANCE CO. LTD.

(Government of India Undertaking)

THE NEW INDIA ASSURANCE CO. LTD.


REGISTERED & HEAD OFFICE:87,MAHATMA GANDHI ROAD,MUMBAI 400001.

GOOD HEALTH POLICY CERTIFICATE

Certificate No. 712500/GH/DEC2018/4138 Period of Insurance From 01/12/2018


To 30/11/2019
SRIRAMA MURTHY IPPILI Card Number : 4386XXXXXXXX9349
C/O. S.RAJANI, NO:1/P Master Policy No. : 71250034182100000017
VIMANAPURI COLONY
QUTHBULLAPUR
SECUNDERABAD
TELANGANA,INDIA 500075 Clause attached : GH 2013-OCT
Mobile No:7675979908 Email Id:SRM.IPPILI@GMAIL.COM Service Tax Registration : AAACN4165CST178
GSTIN/UIN : NA / NA GSTIN : NA
: SAC : 0
Personal Accident Mediclaim Section Hospital Cash Benefit Nomination Particulars for PA Coverage
Section
Name of the Insured Sum Premium + Sum Premium + Limit per Max. no. Name Relation
Person Insured GST Insured GST day (`) of days
(`In (`) (`In (`)
Lakhs) Lakhs)
I LAKSHMI 0.5 1352 100 15
I LOKESWARI 5 16555
I SUNDARA RAO 5 16555
Total Premium including GST 0 34462

Nomination for Certificate Name: LATIKA Relation: WIFE


Holder for Mediclaim

Cumulative Bonus for Mediclaim


Name of the Insured DOB Customer % Applicable Effective date Pre-existing diseases/Disabilities
Person code S.I. excluded - refer Clause No.4.1(for
Mediclaim)
I LAKSHMI 21/07/1991 20091220423 45 50000 Not Applicable
I LOKESWARI 02/12/1960 20091220424 45 400000 Not Applicable
I SUNDARA RAO 01/11/1958 20091220425 45 400000 Not Applicable

Terms & Conditions forming part of this Policy No. 71250034182100000017 may be downloaded from our website,
newindia.co.in/citibank.

Notice or communication to be given in respect of claims to TPA


Name and Address of MD INDIA HEALTHCARE SERVICES(TPA) Contact TOLL FREE: 1800-233-1166
TPA PVT.LTD. Details
GUNA COMPLEX, NEW DOOR NO.443&445, FAX TOLL FREE: 1860-233-4449
OLD DOOR NO.304 & 305,
ANNA SALAI,TEYNAMPET, CHENNAI-600018. PAN UAN: 1860-233-4446, 1860-233-4448
Email Id citibank_chennai@mdindia.com Website www.mdindiaonline.com

Signature Not
Verified
Digitally signed
by Srinivasan Document generated by null at 05/12/2018 05:00:12 Hours.
Vaideswaran Regd. & Head Office: New India Assurance Bldg., 87 M.G. Road, Fort, Mumbai - 400 001. TOLL FREE No. 1 800 209 1415.
Date: 2018.12.05
For 05:01:31
redressal of your grievance, if any,you may approach any one of the following offices- 1. Policy issuing office 2. Regional office 3. Head office.In case, you are not satisfied with
IST
our own grievance redressal mechanism; you may also approach Insurance Ombudsman. For details of our office addresses and addresses of office of Insurance Ombudsman, please
visit our website http://newindia.co.in.
THE NEW INDIA ASSURANCE CO. LTD.
(Government of India Undertaking)

This certificate is issued based on the application made by the Citibank Card Members / Account Holders in writing / over
internet / Phone in respect of self and/or family members and/or domestic employess such application shall be the basis of
this Contract of Insurance Coverage.
The benefits in respect of the within mentioned insured persons are subject to definitions,terms,conditions and exclusions
under the respective policies.
This policy is subject to Good Health Policy Clause GH 2013-OCT.
Address of the Policy Divisional Office : 712500 In witness whereof the undersinged being duly authorised
issuing Office II Floor, Mount Casa Blanca Building, by the Insurers and on behalf of the Insurers has (have)
No.260, Anna Salai,Chennai-600006 hereunder set his (their)hand(s) on this 01st day of December
2018.
Phone Numbers 044-23456824 /826 / 827
Fax 044-23456825
Email Id nia.gh712500@newindia.co.in
Website newindia.co.in/citibank

For The New India Assurance Company


Limited

M.V. CHANDRASEKAR
Senior Divisional Manager

Document generated by null at 05/12/2018 05:00:12 Hours.


Regd. & Head Office: New India Assurance Bldg., 87 M.G. Road, Fort, Mumbai - 400 001. TOLL FREE No. 1 800 209 1415.
For redressal of your grievance, if any,you may approach any one of the following offices- 1. Policy issuing office 2. Regional office 3. Head office.In case, you are not satisfied with
our own grievance redressal mechanism; you may also approach Insurance Ombudsman. For details of our office addresses and addresses of office of Insurance Ombudsman, please
visit our website http://newindia.co.in.
THE NEW INDIA ASSURANCE CO. LTD.
(Government of India Undertaking)

THE NEW INDIA ASSURANCE CO. LTD.


REGISTERED & HEAD OFFICE:87,MAHATMA GANDHI ROAD,MUMBAI 400001.

MEDICLAIM PREMIUM CERTIFICATE FOR THE PURPOSE OF DEDUCTION UNDER SECTION 80 D OF


INCOME TAX (AMENDMENT) ACT 1986
(in respect of self / spouse / dependent children / dependent parents only)

Insurer : CITIBANK DO (712500)


Office Code
Address : II FLOOR, MOUNT CASA BLANCA BUILDING,
NO. 260, ANNA SALAI, CHENNAI 600006
TAMIL NADU
Telephone : 044-23456824 / 826 / 827
Fax : 044-23456825
Policy : 71250034182100000017
Number

This is to certify that Mr./Mrs. SRIRAMA MURTHY IPPILI has paid ` 33110 (Rupees Thirty-Three
Thousand One Hundred Ten Only) towards premium for Mediclaim Insurance GH DEC2018 4138
for the period 01/12/2018 to 30/11/2019.

(You are not eligible to claim Income Tax Deduction in the event of Cancellation of this
Certificate).

For The New India Assurance Company


Limited

M.V. CHANDRASEKAR
Senior Divisional Manager

Document generated by null at 05/12/2018 05:00:12 Hours.


Regd. & Head Office: New India Assurance Bldg., 87 M.G. Road, Fort, Mumbai - 400 001. TOLL FREE No. 1 800 209 1415.
For redressal of your grievance, if any,you may approach any one of the following offices- 1. Policy issuing office 2. Regional office 3. Head office.In case, you are not satisfied with
our own grievance redressal mechanism; you may also approach Insurance Ombudsman. For details of our office addresses and addresses of office of Insurance Ombudsman, please
visit our website http://newindia.co.in.
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.

Document generated by null at 05/12/2018 05:00:12 Hours.


Regd. & Head Office: New India Assurance Bldg., 87 M.G. Road, Fort, Mumbai - 400 001. TOLL FREE No. 1 800 209 1415.
For redressal of your grievance, if any,you may approach any one of the following offices- 1. Policy issuing office 2. Regional office 3. Head office.In case, you are not satisfied with
our own grievance redressal mechanism; you may also approach Insurance Ombudsman. For details of our office addresses and addresses of office of Insurance Ombudsman, please
visit our website http://newindia.co.in.

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