Certificate of Insurance (Group Health Insurance)
Primary Insured’s Name Mrs. SHAKUNTLA DEVI
Primary Insured’s Address 1027/C, SHIV COLONY, OLD FARIDABAD 515, HARYANA
Address Pin Code 121002
Risk/Cover Inception Date and Time 15/05/2024 12:00 AM
Risk /Cover Expiry Date and Time 14/04/2025 11:59 PM
Contact Number 8860002522
Group Policy Number 00237700201901
Group Policy Issue date 18/07/2019
Group Policy Holder’s Name BANK OF BARODA
Group Policy Holder’s Address BARODA SUN TOWER, BKC, MUMBAI -51
*Inception of risk cover is subject to receipt/realization of premium by the Insurer. This certificate shall be invalid and non-
binding in case the premium is not received /realized by the Insurer before inception of the risk.
Insured Name Certificate No Date of Birth Gender Sum Insured (Rs.)
SHAKUNTLA DEVI 12001109550 20/09/1960 Female
500000
MOHAN LAL GUPTA 12001109551 14/06/1962 Male
Nomination:
Nominee Name Relationship Appointee Details (if Nominee is minor)
GAURAV GUPTA Son NA
Benefit Summary:
Baseline cover benefits
Overall Sum Insured (SI) Rupees 500000
Product Benefit Table – Group Health Insurance (all limits in Rs unless defined as percentage)
In-patient Treatment
Doctors’ fees
Diagnostics Tests
Medicines, drugs and consumables
Covered up to Sum Insured
Intravenous fluids, blood transfusion, injection administration
charges
Cost of prosthetics and other devices or equipment if
implanted internally during a surgical operation
Operation theatre charges
Hospital Accommodation (per day) Single private room
Intensive Care Unit charges (per day) Covered up to Sum Insured
Page: 1/7
Pre and post hospitalization expenses (30 days / 60 days) Covered up to Sum Insured
including doctor's consultation, diagnostics tests,
medicines, drugs and consumables
All Day Care Treatments Covered up to Sum Insured
Organ Transplant when medically necessary Covered up to Sum Insured
Emergency Ground Ambulance Up to Rs.2,000 per hospitalization
Domiciliary Hospitalization Covered up to 20% of Sum Insured
Group Health Check-up cover (per member)(1) Rs. 1,000
In-patient treatment under Alternative Treatments(2) Up to lower of (20% of Sum Insured or Rs 2 lacs)
Optional covers (as applicable)
Group Critical Illness cover(3) (per member) 500000
Notes:
Baseline cover includes a 24 month waiting period for pre-existing conditions (however, for Critical Illness cover if
applicable, waiting period will be 48 months), 24 months waiting period for specified diseases(4) & 30 day Initial
waiting period from inception.
Age at entry: Adults: 18 years to 70 years; Children: 91 days to 21 years
(dependent children) Coverage available for Self, Spouse and up to 2 dependent
children on a Family Floater basis.
For Group Critical Illness cover (if opted), Age at entry will be 18 years to 65 years. Coverage will be available
only to adults. 20% co-payment for Insured Persons aged 60 years and above
Single Private Room (if applicable) means a hospital room where an individual patient can be accommodated and
which has an air- conditioner along with attached wash room (lavatory and bath). The room should have the provision
for accommodating an attendant. Such room shall be the most basic and the most economical of all
accommodations available as a single room in that hospital.
(1) Health check-up cover (if applicable) shall be available for Adults only. Health check-up plans will be as per grid below:
Health Checkup Plans
1. Complete Blood Count and Erythrocyte Sedimentation Rate (ESR) 11. Hepatitis B surface antigen (HbsAg or Australia
Tests Antigen test)
2. Urine Routine & Microscopic 12. Tread mill Test (TMT) or Stress Test
3. Fasting Blood Sugar Test and Post Prandial (lunch) 13. Thyroid Function test (TFT)
4. Lipid Profile 14. Prostate Exam (males only)
5. ECG 15. Mammography (females only)
6. Chest X-ray 16. HIV
7. Blood Test for average plasma sugar concentration in past 90 17. Blood Grouping & Rh Factor
days (Hba1c)
8. Ultrasound whole abdomen 18 Uric Acid
9. Liver Function Test (LFT) 19 Pap Smear of Cervix (Females)
10. Kidney Function Test (KFT) 20. Pulmonary Function Test (PFT)
(2) In-patient treatment under Alternative Treatments: We will reimburse expenses incurred as the Medical Expenses under
In-patient care of base product taken under Alternative Treatments provided that:
If we accept any claim under this benefit, then We will not make any payment under allopathic treatment of the
same Insured Person and the same Illness or Accident under this Policy
We will not accept any claim under this benefit for Unani and Sidha forms of treatment
Page: 2/7
(3) List of 11 Critical Illnesses:
Cancer of Specified Severity, First heart attack of Specified Severity, Open chest CABG, Open Heart Replacement or
Repair of Heart Valves, Coma of Specified Severity, Kidney failure Requiring Regular Dialysis, Stroke resulting in Permanent
Symptoms, Major organ /bone marrow transplant, Paralysis of Limbs, Motor neurone disease with permanent symptoms,
Multiple sclerosis with persisting symptoms.
Please note that the Insured person should survive for a minimum period of at least 30 days from the date of diagnosis of
such Critical Illness for the claim to be admissible.
(4) Specified diseases:
Stones in the urinary system, Stones in billiary system, Surgery on tonsils / adenoids, Uterine Polyps, Any type of breast
lumps, Any type of treatment of Spondylosis /Spondylitis, Inter Vertebral Disc Prolapse (IVDP) or such other degenerative
disorders, Cataract, BPH – Benign prostatic hypertrophy, Hysterectomy / Myomectomy done due to Menorrhagia /
fibroids,Fistula in ano, Fissure in ano, Piles, Hernia, Hydrocele, Sinusitis, Knee / hip joint replacement, Chronic Renal
Failure(CRF) or end stage renal failure, Any type of Carcinoma / sarcoma / blood cancer, Osteo Arthritis of any joint, Gastric
and duodenal Ulcers, Varicocele, Spermatocele, Dilatation and Curettage ( D&C), Diabetic Nephropathy and Retinopathy,
Mastoidectomy (operation to remove piece of bone behind the ear), Tympanoplasty (Surgery to repair tympanic
membrane i.e. eardrum), Gout, Rheumatism, Varicose veins, Varicose ulcers, Internal Congenital Anomaly
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. : 06 / NA
Premium Details:
Net Premium SGST CGST IGST Gross Premium Gross Premium
(Rs.) (0 %) (0 %) (18 %) (Rs.) (Rs.) (in words)
48511.00 0.00 0.00 8731.98 57242.00 Fifty Seven Thousand Two Hundred Forty Two Only
*Premium amount is inclusive of all taxes & fees and will be rounded off to nearest rupee value where-ever
applicable. Income tax benefit u/s 80D is available as per the existing Income Tax Laws. Please consult your tax
advisor for more details.
Policy issuing office : Delhi , Consolidated Stamp Duty deposited as per the order of Government of National Capital Territory of
Delhi.
The cover may be renewed on sole discretion of Max Bupa Health Insurance Co. Ltd. subject to the member being the part
of the group at the time of renewal also. In case the insured beneficiary ceases to be a member of the group, basis the
Group Policy Holder intimation to Max Bupa, the cover will stand cancelled as per terms and conditions of the
policy.
For claims procedure kindly refer Terms & Conditions forming part of this Certificate of Insurance.
For and on behalf of Max Bupa Health Insurance Co. Ltd.
Location: New Delhi
Date: 16/05/2024 Chief Operating Officer
Insurance is the subject matter of solicitation. Max Bupa Health Insurance Co. Ltd. (IRDA Registration No. 145). ‘Max’, ‘Max
logo’, ‘Bupa’ and HEARTBEAT logo are trademarks of their respective owners and are being used by Max Bupa Health
Insurance Company Limited under License. Registered Office: Max House, 1 Dr. Jha Marg, Okhla, New Delhi – 110020; Corporate
Office: B-1/I-2, Mohan Cooperative Industrial Estate, Mathura Road, New Delhi – 110044; Fax: +91 11 30902010; Helpline No.:
1860-3010-3333 www.maxbupa.com; CIN No.
U66000DL2008PLC182918; Product UIN- IRDA/NL-HLT/MBHI/P-H/V.I/16/13-14
Page: 3/7
Terms & Conditions
These Terms & conditions shall form an integral part of the Certificate of Insurance. Key features applicable for
persons covered by the Policy (“Insured Person”) are provided herein. Max Bupa Health Insurance Company Limited
(“We/Us/Our”) requests You to refer to the detailed terms and conditions of the Policy provided in Policy Document
available with Bank of Baroda. In the event of any conflict between the features mentioned herein and the terms and
conditions of the Policy Document, the later shall prevail.
Benefits
In-patient Treatment: Medical Expenses for Doctor’s fees, diagnostic procedures, medicines, drugs and consumables,
operation theatre charges, intensive care unit, intravenous fluids, blood transfusion, injection administration charges,
the cost of prosthetics and other devices or equipment if implanted internally during a Surgical Procedure.
b. Hospital Accommodation: Reasonable charges for Hospital and Intensive Care Unit accommodation. Single Private
Room (if applicable) means a hospital room where an individual patient can be accommodated and which has an air-
conditioner along with attached wash room (lavatory and bath). The room should have the provision for
accommodating an attendant. Such room shall be the most basic and the most economical of all accommodations
available as a single room in that hospital. If the Insured Person is admitted in the hospital in a room category/Room
Rent higher than the eligibility as specified in the Schedule of Insurance Certificate, then We shall be liable to pay
only a pro-rated proportion of the total Associated Medical Expenses (including surcharge or taxes thereon) in the
proportion of the difference between the Room Rent actually incurred and the entitled room category/eligible Room
Rent to the Room Rent actually incurred. Associated Medical Expenses shall include Room Rent, nursing charges for
Hospitalization as an Inpatient excluding private nursing charges, Medical Practitioners’ fees excluding any charges
or fees for Standby Services, investigation and diagnostics procedures directly related to the current admission,
operation theatre charges and Intensive Care Unit charges. In case of non-network provider, Room tariff of the
entitled room category shall be duly signed and stamped by the hospital in which treatment is taken. In case Insured
Person is unable to submit such document, then We shall consider the reasonable and customary charges of the Insured
Person’s eligible room category of Our network provider within the same geographical area for identical or similar
services.
Pre & Post Hospitalization Medical Expenses: Medical Expenses incurred due to Illness immediately before Insured
Person’s admission and after an Insured Person’s discharge from a Hospital.
Day-Care Procedures: Medical Expenses for Day-Care Procedures where such procedures are undertaken by an
Insured Person in a Hospital requiring stay for a continuous period of less than 24 hours. Any procedure undertaken on an
out-patient basis in a Hospital will not be covered
Organ Donor: Medical Expenses for an organ donor’s treatment for harvesting of the organ.
Emergency Ground Ambulance: Ambulance expenses incurred to transfer the Insured Person following an Emergency to
the nearest Hospital by surface transport.
Domiciliary Hospitalisation: Medical Expenses for medical treatment taken at home if the treatment continues for an
uninterrupted period of 3 days and the condition for which treatment is taken would otherwise have necessitated
hospitalization.
Group Health check-up cover: Cost of health checkup taken by an Insured Person up to the limit as shown under the
Schedule of Insurance Certificate.
In-patient treatment under Alternative Treatments: We will reimburse expenses incurred as the Medical Expenses
under In-patient care of base product taken under Alternative Treatments provided that:
a)If we accept any claim under this benefit, then We will not make any payment under allopathic treatment of the same
Insured Person and the same Illness or Accident under this Policy
b)We will not accept any claim under this benefit for Unani and Sidha forms of treatment
Optional Benefit (if opted)
Group Critical Illness cover
If an Insured Person suffers a Critical Illness (list of Critical Illnesses covered is specified below), We will pay the Critical Illness Sum
Insured specified in the Schedule of Insurance Certificate provided that:
The Critical Illness occurs or first manifests itself during the Policy Period; and
The Insured Person survives for a minimum period of at least 30 days from the date of diagnosis of such Critical Illness
for the claim to be admissible
If We have admitted a claim under this cover for an Insured Person in any Policy Period, this cover shall not be renewed
in respect of that Insured Person for any subsequent Policy Period
Our total and cumulative liability for a Insured Person under this benefit will be limited to the Critical Illness Sum Insured
List of 11 Critical Illnesses:
Cancer of Specified Severity, First heart attack of Specified Severity, Open chest CABG, Open Heart Replacement or
Repair of Heart Valves, Coma of Specified Severity, Kidney failure Requiring Regular Dialysis, Stroke resulting in Permanent
Symptoms, Major organ /bone marrow transplant, Paralysis of Limbs, Motor neurone disease with permanent symptoms,
Multiple sclerosis with persisting symptoms.
Copayment
If an Insured Person is older than the age specified in the Schedule of Insurance Certificate on the date of commencement of
coverage under the Policy, We will pay only 80% of any amount We assess for payment or reimbursement in respect of
any claim under the Policy
Page: 4/7
For Example: If the assessed total claim amount, for any Insured Person older than the age specified in the Schedule of
Insurance Certificate covered is Rs.100,000 then We would be liable to settle only up to Rs.80,000 i.e. 80% of Rs.100,000.
Balance Rs.20,000 i.e. 20% of Rs.100,000 would be borne by the insured
Page: 5/7
Waiting Periods
a. Pre-Existing Diseases
Benefits will not be available for Pre-Existing Diseases until 24 months of continuous coverage have elapsed (48 months for
Group Critical Illness cover) from the date of commencement of coverage for the Insured Persons.
b. 30 Days Waiting Period
We will not cover any treatment taken during the first 30 days since the date of commencement of coverage for the
Insured Persons, unless the treatment needed is the result of an Accident or Cardio or Neurological
Emergency.
c. Specified disease Waiting Period
For all Insured Persons the conditions listed below will be subject to a waiting period of 24 months from the date of
commencement of coverage for the Insured Person:
Stones in the urinary system, Stones in billiary system, Surgery on tonsils / adenoids, Uterine Polyps, Any type of breast
lumps, Any type of treatment of Spondylosis /Spondylitis, Inter Vertebral Disc Prolapse (IVDP) or such other degenerative
disorders, Cataract, BPH – Benign prostatic hypertrophy, Hysterectomy / Myomectomy done due to Menorrhagia /
fibroids,Fistula in ano, Fissure in ano, Piles, Hernia, Hydrocele, Sinusitis, Knee / hip joint replacement, Chronic Renal
Failure(CRF) or end stage renal failure, Any type of Carcinoma / sarcoma / blood cancer, Osteo Arthritis of any joint, Gastric
and duodenal Ulcers, Varicocele, Spermatocele, Dilatation and Curettage ( D&C), Diabetic Nephropathy and Retinopathy,
Mastoidectomy (operation to remove piece of bone behind the ear), Tympanoplasty (Surgery to repair tympanic
membrane i.e. eardrum), Gout, Rheumatism, Varicose veins, Varicose ulcers, Internal Congenital Anomaly
Permanent Exclusions
Addictive conditions and disorders; treatment for ageing and puberty; artificial life maintenance; circumcision beyond
treatment of a disease or accident; treatment for illness due to any conflict and disaster other than natural; external
congenital anomaly; hospital accommodation solely for convalescence and rehabilitation without receiving any
treatment; cosmetic surgery; dental/oral treatment except a surgical operation with hospitalization; drugs and dressings for
OPD treatment or take-home use except as included in post-hospitalization expenses; eyesight treatment to correct
refractive errors of the eye examinations; contact lenses; spectacles or laser eye sight correction; unproven/experimental
treatment; health hydros; nature cure; wellness clinics; treatment for HIV and AIDS; treatment of hereditary conditions
;items of personal comfort and convenience; psychiatric and psychosomatic conditions treatment; treatment for obesity; out-
patient treatment; reproductive medicines; self-inflicted injuries; treatment for sexually transmitted diseases; sleep and
speech disorders; developmental problems; treatment received outside india; treatment through an unrecognized
physician or hospital; Unani, Yoga and Siddha treatment; unlawful activity and genetic disorders; any expenses as
mentioned under the List of Generally Excluded under Hospitalization Cover. For complete list of exclusions, please
refer the terms and conditions of the policy.
Claims Procedure
In respect of any claim
Cashless Hospitalization Facility for Network Hospitals:
(1) The Insured Person should notify Max Bupa in writing at least 72 Hours before a planned Hospitalization.
In an Emergency the Insured Person (or person on behalf of the Insured Person) should notify Us in writing
within 48 hours of Hospitalization; and
(2) For cashless Hospitalization We will make the payment of the amounts assessed to be due directly to the
Network Hospital. In case the Insured is covered under the Co-payment clause, We would pay the final bill as
assessed and approved by Us, to the Network Hospital, net of the applicable Co-payment applied to the approved
amount. The balance amount and other inadmissible costs will be borne by the Insured and paid directly by the
Insured to the Network Hospital
Out-Of-Network Hospitals & All Other Claims for Reimbursement:
(1) In all Hospitalizations which have not been pre-authorized, We must be notified in writing within 48
hours of the Insured Person’s admission to the Hospital or before the Insured Person’s discharge from the Hospital,
whichever is earlier. The notification should be provided by the Insured Person. In the event the Insured Person is
unable to provide the notification due to ill health, then the notification should be provided by an immediate
adult member of the Insured Person’s family.
(2) For any Illness or Accident or medical condition that requires Hospitalization, the Insured Person shall
deliver to Max Bupa the claims documents, at his own expense, within 15 days of the Insured Person's discharge
from Hospital (when the claim is only in respect of post-hospitalization, within 15 days of the completion of
the post-hospitalization)
(3) For any medical treatment taken from an Out-Of-Network Hospital We will only pay Medical Expenses
which are Reasonable Charges. Delayed payments shall attract interest as per applicable regulations.
In all cases:
(1) We reserve the right to call for:
Any other documentation or information that We believe may be required; and
A medical examination by Our doctor or for an investigation as often as We believe this to be necessary. Any
expenses related to such examinations or investigations shall be borne by Us.
(2) In the event of the Insured Person's death during Hospitalization, written notice accompanied by a copy of the
post mortem report (if any) shall be given to Us within 14 days regardless of whether any other notice has been
given to Us. We reserve the right to seek an autopsy.
Page: 6/7
All claims are to be notified to Us within timelines as mentioned above. In case where the delay in intimation is proved
to be genuine and for reasons beyond the control of the Insured Person or Nominee specified in the Schedule of
Insurance Certificate, We may condone such delay and process the claim, We reserve the right to decline such
requests for claim process where there is no merit for a delayed claim.
If You hold an indemnity policy with Us, a single notification for claim will apply to both the indemnity plan as well
as any other Policy. For registration of claims You may contact us at:
Claims Department
Max Bupa Health Insurance Company Limited, B-1/I-2, Mohan Cooperative Industrial Estate, Mathura Road, New
Delhi - 110044 Fax No.: 1800-3070-3333 Or contact Us at 1860-3010-3333 Or reach Us on
[email protected]
Disclosures on Continuity
If a Primary Insured ceases to be group member during the Policy Period, then cover under the Policy for that Primary
Insured and his Dependents (who are named as Insured Persons in the Schedule) will immediately and automatically
cease. Upon being informed the Primary Insured can give Us a written request prior to or within 5 days of the date of
cessation of group membership, to issue a new retail health insurance policy to himself and his Dependents (who were
named as Insured Persons in the Schedule) for cover up to his Sum Insured under the Policy, on payment of premium
in full for the new policy. This shall be subject to the following:
underwriting requirements, as prevailing at the time of issuance of the retail policy, and We may seek additional
information before issuing a new policy;
We are not bound to continue all terms and conditions of the present cover under the new policy, however for
calculation of waiting periods including for pre-existing conditions under the new policy the time spent by Primary
Insured and his Dependents under this Policy may be taken into account, provided new policy is taken without
any break from this Policy.
Insurance is the subject matter of solicitation | Max Bupa Health Insurance Co. Ltd. (IRDA Registration No. 145). 'Max', 'Max logo',
'Bupa' and HEARTBEAT logo are trademarks of their respective owners and are being used by Max Bupa Health Insurance
Company Limited under license. Registered Office: Max House, 1 Dr. Jha Marg, Okhla, New Delhi – 110020. Corporate Office:
B-1/I-2, Mohan Cooperative Industrial Estate, Mathura Road, New Delhi – 110044
Page: 7/7
