HDFC ERGO General Insurance Company Limited

2805203720048203000

Mr Nagesh Chandranna Batla

-
-
KAILASH NAGAR YASHASHVI NAGAR
HIGHLAND ROAD
THANE
MAHARASHTRA - 400608
Contact No.: 93XXXXXXX0
Email: [email protected]

Policy No : 2805 2037 2004 8203 000

Intermediary Code Intermediary Name Intermediary Contact Number

AGENT : SUVARNA SURESH JATHAR
201893225991 91-9869030677

Renewal of Your Optima Restore Floater Insurance Policy

Dear Mr Nagesh Chandranna Batla ,

Welcome to HDFC ERGO General Insurance Company Limited. We are pleased to issue you Renewal of Your Optima Restore Floater Insurance Policy. We
advise you to retain your Policy Kit during the entire term of the Policy (including renewals).

Please note that the Policy has been issued to you based on the declarations, details and documents received from/on behalf of you in/along with the Proposal
Form submitted to us. Along with this policy you are also eligible for Wellness Benefits under our Add-on "HDFC ERGO Wellness Corner" -UIN:
HDFHLIA24051V012324. For details of the benefits, please click on the following link https://hdfcergo.onelink.me/ARLJ/v6t9r5kz

Please visit our website www.hdfcergo.com for more information about our Company, Grievance handling and any other support. To know the updated list of our
network hospitals please visit https://www.hdfcergo.com/locators/cashless-hospitals-network

We value your relationship with us and assure you our best services at all times and we look forward to serve you.

Proposer details have been updated basis the information present in the KYC documents. If you find any detail which needs to be corrected, request you
to create/ modify the eKYC ID and place a request for endorsement.

Soft copy of the policy is valid for all purposes including claims.

Warm Regards,
Location: Mumbai
Date: 14/10/2023

Authorized Signatory
Note:
1. Please update us with your latest contact details (in case of any change) so that same can be updated in our records.
2. You can either email us on [email protected] or call on our Customer care no. 022 6234 6234 / 0120 6234 6234.
3. *The Copy of the proposal form has been sent on your registered email id if policy is purchased through website.

Certificate for the purpose of deduction under Section 80 D of Income Tax Act, 1961*
This is to certify that the MR. NAGESH CHANDRANNA BATLA has paid Rs. 38298 (Rupees Thirty-Eight Thousand Two Hundred Ninety-Eight And Zero Paise
Only) towards premium for Optima Restore Floater Policy No. 2805203720048203000 issued to MR. NAGESH CHANDRANNA BATLA for period of 21/10/2023
to 20/10/2024.

For and on behalf of HDFC ERGO General Insurance Company Limited

Location: Mumbai
Date: 14/10/2023

Authorized Signatory
*Note

1. This is subject to the provisions of Section 80D of Income Tax Act, 1961 as amended from time to time.
2. This certificate must be surrendered to the company in case of cancellation of this policy. In event of incorrect representation of this declaration the
liability shall be upon the Policyholder.
3. Please note that this certificate will not be issued if the premium payment has been made in cash.
4. In case of dishonor of the premium instrument, the policy will be deemed cancelled ab initio.
5. 80D benefit is applicable for only Self, Spouse, Dependent Children and Dependent parents.

HDFC ERGO General Insurance Company Limited. IRDAI Reg No.146 UIN: HDFHLIP22193V072122. Policy Issuing/ Customer Happiness Center: D 301, 3rd Floor,Eastern
CIN : U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor, HDFC House, Business District,LBS Marg, Bhandup (West),
165/166 Backbay Reclamation, H.T.Parekh Marg, Churchgate, Mumbai - 400 020. Mumbai- 400 078.Customer Service No : +91 22-62346234/+91-120 6234 6234 | www.hdfcergo.com
HDFC ERGO General Insurance Company Limited

Policy Schedule - Optima Restore Floater

Policy Number 2805 2037 2004 8203 000

Policy Holder’s Name Mr Nagesh Chandranna Batla
Policy Holder’s Address - - KAILASH NAGAR YASHASHVI NAGAR HIGHLAND ROAD THANE MAHARASHTRA - 400608
Policy Holder State Name & Code Maharashtra(27) Place of Supply MAHARASHTRA
GSTIN/ UIN (if any) of Policy Holder
First policy inception date 18/10/2012 Policy Issuance Date 14/10/2023

Policy Period From 00:01 hrs on 21/10/2023 To 24:00 hrs on 20/10/2024

2ND FLOOR, DANGAT SADAN, OFFICE NO. 18/19, 63, MODI STREET, FORT, MUMBAI MUMBAI Tel :
Issuing/Servicing Office
+91-22-66383600
GSTIN 27AABCL5045N1Z8
EIA Number Not provided
Intermediary Name AGENT : SUVARNA SURESH JATHAR Intermediary Contact No 91-9869030677
Intermediary Code 201893225991 Description/ Harmonized System Of Accident and Health insurance
Nomenclature Code Services/9971
Insured Person Details
Member 1 Member 2 Member 3 Member 4 Member 5 Member 6
NAGESH Mrs Laxmi Nagesh Miss Harshali Baby Khushi Nagesh
Particulars / Member ID CHANDRANNA Batla / Nagesh Batla / Batla /
BATLA / 2020010002229551 2020010002229552 2020010002229553
2020010002229550
Date of Birth (Age) 27/02/1973 (50) 06/06/1973 (50) 14/01/1998 (25) 21/09/2002 (21) - -
Relationship to Policy Holder Self Wife Daughter Daughter - -
Base Sum Insured (`) 300000
Multiplier Benefit SI (`) 300000
ABHA ID - - - - - -
Protector Rider Sum
70402.12
Insured(`)
Co-payment % -
Deductible -
Total Sum Insured(`) 670402.12
Note : In case any insured person's wish to generate his/her ABHA ID kindly visit link given below :
https://https://healthid.ndhm.gov.in/register

Protector Rider - HDHHLIP21335V022021 | Individual Personal Accident Rider - APOPAIP19004V011920 | Hospital Daily Cash Rider - HDHHLIP21344V022021
| Critical Advantage Rider HDHHLIP21342V022021 | my:health Critical Illness - HDFHLIA22141V032122 | Optima Wellbeing (Add-on) - HDFHLIA24099V012324

Other Riders and Benefits ( `)

Protector Rider Opted
Hospital Daily Cash Rider SI
-
(Max. 30 days)
Critical Advantage Rider SI
- - - - - -
($)
IPA Rider SII - - - - - -
my: health Critical Illness
Sum Insured (Rs.)
my: health Critical Illness
Plan
Unlimited Restore Benefit No
Optima Wellbeing Rider No
Nominee Details
Nominee Name : Relationship to Policyholder:
The nominee must be an immediate relative of the policyholder. For all other Insured Persons the policy holder shall be the nominee.
Premium Calculation (`)
Net Premium 32456 CGST@9% 2921
Discounts 0 SGST/UTGST@9% 2921
Loadings 0 IGST@18% 0
Taxable Premium 32456 Any other Cess or Taxes 0
Gross Premium 38298
Gross Premium (in words) Rupees Thirty-Eight Thousand Two Hundred Ninety-Eight And Zero Paise Only
The stamp duty of Rs. 1/- ( Rupees One And Zero Paise Only ) paid vide e-stamp Certificate No. (LOA/ENF-1/CSD/34/2023/ Validity Period Dt. 28/12/2023 to Dt.
31/12/2026. OW No. 6045 Date 27/Dec/2023 GRN NO. MH011651000202324M Dt. 05/12/2023, SBI Bank & DEFACE No. 0006692260202324 Dt. 21/12/2023)
dated 27/12/2023 as prescribed in Government of Maharashtra Order No. Mudrank-2017/CR.97/M-1, dated the 09th January 2018.
I/ We hereby declare that though our aggregate turnover in any preceding financial year from 2017-18 onwards is more than the aggregate turnover notified under
sub-rule (4) of rule 48, we are not required to prepare an invoice in terms of the provisions of the said sub-rule
Original for Recipient/ Duplicate for Supplier

HDFC ERGO General Insurance Company Limited. IRDAI Reg No.146 UIN: HDFHLIP22193V072122. Policy Issuing/ Customer Happiness Center: D 301, 3rd Floor,Eastern
CIN : U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor, HDFC House, Business District,LBS Marg, Bhandup (West),
165/166 Backbay Reclamation, H.T.Parekh Marg, Churchgate, Mumbai - 400 020. Mumbai- 400 078.Customer Service No : +91 22-62346234/+91-120 6234 6234 | www.hdfcergo.com
HDFC ERGO General Insurance Company Limited

Policy Schedule - Optima Restore Floater

Whether tax is payable on reverse charge basis: No

For declared and accepted pre-exiting medical conditions, waiting period (s) shall apply per policy terms and conditions from 1st policy inception date
of the policy, fresh waiting period (s) shall apply on enhanced sum insured.
Exclusion(s) / Special Condition(s) (Refer the leaflet attached in the policy document w.r.t. exclusions) :
Member ID No. Name Exclusion Type Applicable Health Condition Exclusion Portability/ Renewal Benefit
on SI Duration
(Years)
2020010002229550 NAGESH CHANDRANNA For Rs 300000(Rupees Three Lakhs)
BATLA Sec C1 (i) and Sec C1 (ii) Sec C1 (iii)
of the policy wording is waived.
2020010002229551 Mrs Laxmi Nagesh Batla For Rs 300000(Rupees Three Lakhs)
Sec C1 (i) and Sec C1 (ii) Sec C1 (iii)
of the policy wording is waived.
2020010002229552 Miss Harshali Nagesh Batla For Rs 300000(Rupees Three Lakhs)
Sec C1 (i) and Sec C1 (ii) Sec C1 (iii)
of the policy wording is waived.
2020010002229553 Baby Khushi Nagesh Batla For Rs 300000(Rupees Three Lakhs)
Sec C1 (i) and Sec C1 (ii) Sec C1 (iii)
of the policy wording is waived.

Claim Administrator : HDFC ERGO General Insurance Company Ltd For and on behalf of HDFC ERGO General Insurance Company Limited

Location: Mumbai Authorized Signatory

Date: 14/10/2023

"For detailed policy terms and conditions please visit our website https://www.hdfcergo.com/download/policy-wordings "
SCHEDULE OF BENEFITS
In-patient Treatment Upto 300000
Pre-Hospitalization Upto 300000 for 60 days
Post-Hospitalization Upto 300000 for 180 days
Day Care Procedures Upto 300000
Domiciliary Treatment Upto 300000
Organ Donor Upto 300000
Daily Cash for choosing Shared Accommodation Rs.800 per day, Maximum Rs.4,800
E-Opinion in respect of a Critical Illness One per policy year
Restore Benefit 100% of Basic SI (for any illness or any insured person)
Bonus of 50% of Basic Sum Insured post completion of each Policy Year irrespective of claims, maximum upto 100% of Basic
Multiplier Benefit
Sum Insured

HDFC ERGO General Insurance Company Limited. IRDAI Reg No.146 UIN: HDFHLIP22193V072122. Policy Issuing/ Customer Happiness Center: D 301, 3rd Floor,Eastern
CIN : U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor, HDFC House, Business District,LBS Marg, Bhandup (West),
165/166 Backbay Reclamation, H.T.Parekh Marg, Churchgate, Mumbai - 400 020. Mumbai- 400 078.Customer Service No : +91 22-62346234/+91-120 6234 6234 | www.hdfcergo.com
HDFC ERGO General Insurance Company Limited

Terms and Conditions

(1) This card would be valid till your relationship with HDFC ERGO General Insurance
Policy No.: 2805203720048203000 Company Limited / This card is invalid if the policy is cancelled (2) In case of renewal please
refer original policy number (3) This card is issued for the purpose of identification only and does not
entail automatic cashless facility at the network hospital. (4) A photo ID issued b y any government
authority i s to be produced to avail cashless facility. (5) Please apply for cashless facility 48 hours prior
to admission in case of planned admissions and within 24 hours of admission in case of emergency.(6) All
Insured Name Member ID Date of Birth Gender terms and conditions of the policy would be applicable while processing your cashless request. (7) In case
Nagesh Chandranna Batla 2020010002229550 27/02/1973 M your cashless facility i s denied due to any reason, please submit the claim for reimbursement. Denial of
Mrs Laxmi Nagesh Batla 2020010002229551 06/06/1973 F cashless facility does not indicate rejection of the claim. (8) Please read policy documents carefully for
detailed terms and conditions. For claim status visit help section on our web site www.hdfcergo.com.
Miss Harshali Nagesh Batla 2020010002229552 14/01/1998 F Alternatively you may write to us at [email protected].
Baby Khushi Nagesh Batla 2020010002229553 21/09/2002 F
HDFC ERGO General Insurance Company Limited. IRDAI Reg. No.146 CIN: U66030MH2007PLC177117.
Registered & Corporate Office: 1st Floor, HDFC House, 165-166 Backbay Reclamation, H. T. Parekh
Marg, Churchgate, Mumbai – 400 020. Health Claim Services Address : HDFC ERGO General Insurance
Company Limited Stellar IT Park, Tower-1 , 5th Floor, C - 25, Noida, Sector 62, 201301, Uttar Pradesh.
Service No. 022-62346234/ 0120-62346234Email: [email protected] Logo displayed
above belongs to HDFC Ltd and ERGO International AG and used by the Company under license.

HDFC ERGO General Insurance Company Limited. IRDAI Reg No.146 UIN: HDFHLIP22193V072122. Policy Issuing/ Customer Happiness Center: D 301, 3rd Floor,Eastern
CIN : U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor, HDFC House, Business District,LBS Marg, Bhandup (West),
165/166 Backbay Reclamation, H.T.Parekh Marg, Churchgate, Mumbai - 400 020. Mumbai- 400 078.Customer Service No : +91 22-62346234/+91-120 6234 6234 | www.hdfcergo.com