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0 0 SID1212200273
Reliance HealthGain Policy Schedule

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Policyholder Details

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Policy Number: 170122028280004009 Proposal/Covernote No: R19092091333

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Name: Customer ID:
MR. RAJESH VASANT PATIL

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Correspondence Address & Place of Supply: Policy Servicing Branch:
BHARASKAR COLONY MANJARDE,SANGLI MANJARDE MAHARASHTRA A Block, Heritage House, Ground floor, 6 Ramabai Ambedkar Road,
416312 , PUNE PUNE MAHARASHTRA 411001

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KHANAPUR,SANGLI, MAHARASHTRA,
416312

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Contact No: 7028945702 Tax Invoice No. & Date: R19092091333 & 19/09/2020

Email-ID : GSTIN/UIN of Policyholder:

CGST

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Date of Birth (DD/MM/YY): 30/04/1999 Gender: Male

Plan Details

Cover Type Individual Tenure (Years) 1 Premium Payment Mode Single

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Plan Name PlanA BusinessType NEW Previous Policy No
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Policy Period Start Date: 20/09/2020 End Date: 19/09/2021 Renewable Date: 20/09/2021
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Details of the Insured 1

Name MR. RAJESH

VASANT PATIL
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Gender Male

Relationship Self
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Date of Birth 30/04/1999

(DD/MM/YYYY)
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Pre-existing Disease - NO
Name
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Pre-existing Disease - NA
Since
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Insured with the 20/09/2020

Company, since
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Base Sum Insured 300000

(Individual)
Base Sum Insured
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NA
(Family Floater)
Cumulative Bonus 0.00
(Individual)
Cumulative Bonus NA
(Family Floater)

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VLE ID VLE NAME UIN VLE Contact Number

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 17B37706 Yes Bank Limited NA

Intermediary Code Intermediary Name Intermediary Contact No. POS UID Aadhaar No./PAN

Premium Details

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Amount(`)

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Basic Premium 4700.00
Loading : Underwriting 0.00
Discount 0.00

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Net Premium 4700.00
CGST (@ 9.00 %) 423.00
SGST (@ 9.00 %) 423.00

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Total Premium 5546.00
GSTIN:27AABCR6747B1ZG,HSN: 9971
Description of Services: Accident and health insurance services

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Nominee Details

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Name VASANT PATIL Date Of Birth 19/07/1945 Relationship with proposer Father

Address of Nominee BHARASKAR COLONY MANJARDE,SANGLI MANJARDE MAHARASHTRA 416312 ,KHANAPUR,SANGLI,MAHARASHTRA,416312

Benefit Table
Benefit Basis of Offering
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Benefit Basis of Offering
Hospitalisation Expenses Medical Expenses incurred as Inpatient Wellness a- Doctor Anytime /Free Health Helpline: The
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hospitalization Day care Treatment InsuredPerson shall have the option of

Pre Hospitalisation Expenses Pre-hospitalization up to 60 days seeking medical advice from a Medical
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Post Hospitalisation Expenses Post-hospitalization up to 60 days Practitioner through the telephonic or

Domestic Road Ambulance Upto Rs 1500 per Hospitalization online mode b- Health Portal: The
Donor Expenses Upto 50% of Base SumInsured subject to InsuredPerson shall have the option to
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maximum of Rs 5 lacs access health related information and

Domiciliary Hospitalization Upto 10% of the Base SumInsured subject to a services through the Company’s/designated
maximum of Rs 50,000 website
Cumulative Bonus 33 1/3 % increase in Base SumInsured for
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every claim free year Max up to 100% of Base

SumInsured 33 1/3 % decrease in Base
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SumInsured for every claim year Max up to

earned Cumulative Bonus
Reinstatement of Base Sum Insured One re-instatement upto 100% of Base Sum
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Insured, subject to sublimit of 20% for

related Illness/ injury
Call Option Once at the end of every consecutive 4 claim
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free years
Claim Servicing Guarantee Cashless Claims – 1% for every delay of 6
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hours beyond 6 hours of receipt of all

information /documents Re-imbursement
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– 1% for every delay of 21 days beyond 21

days of receipt of all information/documents
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Maximum – 6% for a claim

CGST

Reliance General Insurance Company Limited. IRDAI Registration No. 103. An ISO 9001:2015 Certified Company
0.00
0.00Office: Reliance Centre,South Wing, 4th Floor, Off. Western Express Highway, Santacruz (East), Mumbai - 400 055.
Registered
Corporate Office: Reliance Centre,South Wing, 4th Floor, Off. Western Express Highway, Santacruz (East), Mumbai - 400 055.
Corporate Identity [Link]:RELHLIP21514V022021. RGI/MCOM/CO/2828/PS/Ver.1.5/010218.
Trade Logo displayed above belongs to Anil Dhirubhai Ambani Ventures Private Limited and used by Reliance General Insurance Company Limited under License.

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 Endorsements

Particular Individual

Room Category

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Contact details for Policy & Claims Servicing Policy Servicing Claim Servicing

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Name Customer Service Team R Care
Correspondence Address Reliance General Insurance Company Limited Winway Reliance General Insurance,1-89/3/B/40 to

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Building,2nd & 3rd floor, 11/12, Block No - 4, Old No-67, 42/ks/301, 3rd floor,Krishe Block, Krishe
0.00 South Tukoganj, Indore (M.P.) - 452001 Sapphire,Madhapur, [Link] code-
500081
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E-mail ID [Link]@[Link] [Link]@[Link]

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Contact No NA NA
Fax No 022 48903009

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Website [Link] [Link]
Paid No 022 48903009 022 48903009

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Consolidated Stamp duty Paid vide Letter of Authorisation No. CSD/53/2020/1645 dated 23rd July 2020** Not Applicable for the State of J&K

Please Note: For Reliance General Insurance Co. Ltd.

-Attached with this Policy Schedule are the Policy Terms and Conditions, Endorsements, and Annexures.
Please ensure that you (Policyholder) have received, read and understood all these documents. If you
(Policyholder) have not received any of these, please email/write to the Company at
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[Link]@[Link] or contact us on 022 48903009 (Paid).
- This Policy Schedule in original must be surrendered to the Company in case of cancellation of the
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[Link] the event of any incorrect representation, the liability shall be upon the Policyholder.
- The Benefits which are mentioned in this Schedule shall only be available under the Policy. Authorised Signatory
- In witness whereof this Policy has been signed at Mumbai on policy tax invoice date in lieu of Proposal
No. as mentioned in the policy.
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-This document shall be treated as a Tax Invoice as per Rule 46 of the Central Goods and Services Tax
Rules 2017.

0 PREMIUM CERTIFICATE
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Premium Certificate for the purpose of deduction under Section 80D of Income Tax Act, 1961.
This is to certify that Reliance General Insurance Company Limited has received an amount of ` 5546.00 from Mr. Rajesh Vasant Patil towards payment of
health insurance premium as per the details mentioned above.
The premium paid for this policy is eligible for applicable tax benefits under section 80D of the Income Tax Act, 1961 and amendments thereof.
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Note :Any amount paid in cash towards the premium would not qualify for tax benefits as mentioned above.
Name of the Policyholder : MR. RAJESH VASANT PATIL
Correspondence Address : BHARASKAR COLONY MANJARDE,SANGLI MANJARDE MAHARASHTRA 416312
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,KHANAPUR,SANGLI,MAHARASHTRA,416312
Policy Number : 170122028280004009
Issue Date : 19/09/2020
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Place : Mumbai For Reliance General Insurance Co. Ltd.

CSD/53/2020/1645 & 19/09/2020
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Authorised Signatory
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Reliance General Insurance Company Limited. IRDAI Registration No. 103. An ISO 9001:2015 Certified Company
Registered Office: Reliance Centre,South Wing, 4th Floor, Off. Western Express Highway, Santacruz (East), Mumbai - 400 055.
Corporate Office: Reliance Centre,South Wing, 4th Floor, Off. Western Express Highway, Santacruz (East), Mumbai - 400 055.
Corporate Identity [Link]:RELHLIP21514V022021. RGI/MCOM/CO/2828/PS/Ver.1.5/010218.
Trade Logo displayed above belongs to Anil Dhirubhai Ambani Ventures Private Limited and used by Reliance General Insurance Company Limited under License.

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 Please Note :
- In case of any discrepancy, the Policyholder is requested to let us know immediately. You can write to us at [Link]@[Link] or call us on
022 48903009 (Paid) for necessary changes/rectification.
- These documents must be surrendered to the Company in caseare
of cancellation
available onofourthewebsite
Policy or for the issuance of a fresh Schedule in the case of any alteration

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The policy wording with detailed terms, conditions and exclusions
in the Policy. In the event of incorrect representation of this declaration, the liability shall be upon the Policyholder.

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-The policy wording with detailed terms, conditions and exclusions are available on our website [Link]
(Policy wordings link : [Link]
You can also write to us at [Link]@[Link] or call us on 1800 3009 (toll free)/ 022 4890 3009 (Paid) to avail the policy wording.

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In case of a renewal, the benefits provided under the policy and/or terms and conditions of the policy including premium rate may be subject to change.
Grievance Clause : For resolution of any query or grievance, Insured may contact the respective branch office of the Company or may call at 1800 3009 or
may write an email at [Link]@[Link]. In case the insured is not satisfied with the response of the office, insured may
contact the Nodal Grievance Officer of the Company at [Link]@[Link]. In the event of unsatisfactory response from

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the Nodal Grievance Officer, insured may email to Head Grievance Officer at [Link]@[Link]. In the event of
unsatisfactory response from the Head Grievance Officer, he/she may, subject to vested jurisdiction, approach the Insurance
Ombudsman for the redressal of grievance. Details of the offices of the Insurance Ombudsman are available at IRDAI website
[Link] or on company website [Link] or on [Link]. The insured may also contact the following
office of the Insurance Ombudsman within whose territorial jurisdiction the branch or office of the Company is [Link] of the

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Insurance Ombudsman,3rd Floor,Jeevan Seva Annexe,S. V. Road,Santacruz (W), Mumbai - 400 054. Tel.: 022 - 26106552 / 26106960
Fax: 022 - 26106052 Email: [Link]@[Link] | Shri. A. K. Sahoo Office of the Insurance Ombudsman,Jeevan Darshan
Bldg.,3rd Floor,C.T.S. No.s. 195 to 198,N.C. Kelkar Road,Narayan Peth, Pune – 411 030. Tel.: 020-41312555 Email:
[Link]@[Link]

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Reliance General Insurance Company Limited. IRDAI Registration No. 103. An ISO 9001:2015 Certified Company
Registered Office: Reliance Centre,South Wing, 4th Floor, Off. Western Express Highway, Santacruz (East), Mumbai - 400 055.
Corporate Office: Reliance Centre,South Wing, 4th Floor, Off. Western Express Highway, Santacruz (East), Mumbai - 400 055.
Corporate Identity [Link]:RELHLIP21514V022021. RGI/MCOM/CO/2828/PS/Ver.1.5/010218.
Trade Logo displayed above belongs to Anil Dhirubhai Ambani Ventures Private Limited and used by Reliance General Insurance Company Limited under License.

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 Know your policy

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Remember to carefully go through the policy documents and confirm your details.
In case of any discrepancy in the policy details, kindly revert within 15 days from the policy start date on 022 48903009 (Paid) or visit any of our

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branches or mail us at [Link]@[Link]
Kindly refer to the Customer Information Sheet and Policy Wording to understand your policy better and learn more about the policy coverages & Policy Exclusion.

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How to register a Claim - Cashless

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Get admitted in Submit pre-auth form, RCare Member needs RCare
our network Photo ID card and adjudicates the to pay towards settles the claim

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hospital other relevant case as approval/ non payable items (as per policy
documents at the denial or seeks (and security deposit terms & condition)
TPA desk additional details at certain hospitals)

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How to register a Claim - Reimbursement
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Get admitted in Intimate the Pay the hospital bills Submit all the RCare adjudicates If Claim is approved,
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your preferred claim details on our & collect all the original documents the case as approval/ payment will be
hospital Paid No. original documents and bills to denial or seeks made to you by
022 48903009 RCare additional NEFT
details
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What documents do you require to register a Claim

1. Duly filled Claim form. 7. Medico Legal Certificate (MLC) for all accident cases.
2. Discharge summary details, Final Hospital Bill (detailed breakup),interim 8. For miscellaneous charges - detailed bills with supporting prescription of
bills & Payment Receipts. the consulting doctor.
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3. Doctor’s consultation papers. 9. Copy of Health card & any other related documents.
4. Photo Id proof of insured & patient. 10. CTS 2010 compliant original Cancelled Cheque which should bear
5. All original investigation reports & all pharmacy bills, supported by doctor printed name of account holder, IFSC Code & Account No.
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prescriptions.
6. Implant sticker / invoice, if used (Eg. lens details in cataract case,stent
details in angioplasty).
Note: As soon as a claim occurs, please intimate immediately to our call centre 022 48903009 (Paid). Delay in intimation would result in the violation of policy
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condition.

How to renew your policy conveniently Payment Modes

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Visit [Link] and Call 022 48903009 Submit a cheque/DD

renew online and renew along with signed Renewal Notice
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to branch/agent and renew

The content on this page is for additional information & should not be considered as part of the policy document / Schedule

Reliance General Insurance Company IRDAI Registration No. 103. An ISO 9001:2015 Certified Company
Registered Office: Reliance Centre,South Wing, 4th Floor, Off. Western Express Highway,Santacruz (East), Mumbai - 400 055.
Corporate Office: Reliance Centre,South Wing, 4th Floor, Off. Western Express Highway,Santacruz (East), Mumbai - 400 055.
Corporate Identity [Link]:RELHLIP21514V022021. RGI/MCOM/CO/2828/PS/Ver.1.5/010218.
Trade Logo displayed above belongs to Anil Dhirubhai Ambani Ventures PrivateLimited and used by Reliance General Insurance Company Limited under License.

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 Online Proposal Form for Reliance HealthGain Proposal No. : R19092091333

Proposer Details
Name of the Proposer* MR. RAJESH VASANT PATIL

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Gender Male

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Date of Birth* 30/04/1999 Nationality Indian

NE Marital Status Single

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Address of the Proposer BHARASKAR COLONY MANJARDE,SANGLI MANJARDE MAHARASHTRA 416312
,KHANAPUR,SANGLI,MAHARASHTRA,416312

Pan No. FFXPP1566K

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Occupation Agriculturist Mobile Number* 7028945702
Monthly Income NA E-mail

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Plan\Policy Details
a) Plan Opted : PlanA
b) Cover Type : Individual

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c) No. of members to be covered : 1
(Minimum 2 Members in case of Floater)
d) Annual Base Sum insured : 0

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e) Installment Type : Single

Nomination Details
The nominee as declared hereunder shall become eligible for claim payment under the policy as per the terms and conditions of the Policy, in the event of the
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death of the Policyholder. The receipt of proceeds by the nominee would be sufficient discharge to the Company. Nominee for all other person(s) proposed shall
be the proposer himself/herself.
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Name of Nominee D.O.B Relationship with Proposer Address of Nominee

VASANT PATIL 19/07/1945 Father BHARASKAR COLONY MANJARDE,SANGLI MANJARDE
MAHARASHTRA 416312
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Section A: Details of person(s) proposed to be insured

Details Member 1
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Name MR. RAJESH

VASANT PATIL
SID1212200273
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Gender Male

Relationship Self
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Date of Birth 30/04/1999

(DD/MM/YYYY)
Marital Status Single
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Height (In cm) 0

Weight (In kg) 0

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Has any person to be No

insured been diagonsed/
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hospitalized/ under any

treatment for any illness/
disease or injury
during any time in past?
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Eg.
• Injury
• Diabetes
• Hypertension
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• Cancer/ Tumour
• Kidney Disease(s)
• Paralysis/ Stroke
• Respiratory Disorder(s)
• HIV/ AIDS/ STD
• Liver Disease(s)
• Heart Disease(s)
• Arthiritis/ Joint Pain
• Congenital Disease(s)
• Others (please specify)

Does any person No

proposed to be insured
smoke or consume
tobacco or alcohol? If yes,
please indicate quantity
per week

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 Are you an employee of Reliance Group No 0
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If yes, please mention Employee Code
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Premium Payment Details
Premium Amount : 5546.00 Payment Mode : Online Date : 19/09/2020

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Bank Name : Amount in words : Five Thousand Five Hundred Forty Six Only

Declaration & Warranty on Behalf of All Persons Proposer to be Insured

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i. I have read and understood the brochure/prospectus/sales literature/terms and conditions of the Policy and confirm to abide by the same.
ii. I understand that the information provided by me will form the basis of the insurance policy, is subject to the Board approved underwriting policy of the
insurance Company and that the policy will come into force only after full receipt of the premium chargeable.
iii. I/We further declared that I/We will notify in writing any change occurring in the occupation or general health of the life to be insured/proposer after the
proposal has been submitted but before communication of the risk acceptance by the Company.

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iv. I/We declare and consent to the Company seeking medical information from any Doctor or from a hospital who at anytime has attended on the life to be
insured/proposer or from any past or present employer concerning anything which affects the physical or mental health of the life to be assured/ proposer and
seeking information from any insurance Company to which an application form insurance on the life to be assured / proposer has been made for the purpose of
underwriting the proposal and / or claim settlement.

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v. I/we authorized the Company to share information pertaining to my proposal including the medical records for the sole purpose of proposal underwriting and/or
claims settlement and with any Government and/or Regulatory Authority.
vi. Receipt of the Proposal form by the Company shall not be construed as acceptance of proposal. I hereby agree that the insurance coverage shall commence
only on realization of full premium and on receipt of complete medical reports (wherever applicable) and subject to individual underwriting by the Company. The
Company at its sole discretion reserves the right to accept or reject or load any proposal without assigning any reason thereof.

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vii. I understand that the Policy shall become void at the Company’s option, in the event of any untrue or incorrect statement, misrepresentation, non-description
or non-disclosure of any material fact in the Proposal form/personal statement, declaration and connected documents or any material information having been
withheld by me or anyone acting on my behalf.
viii. I hereby declare that the person(s) proposed to be insured would submit to medical examinations, before the nominated doctors of the Company, or undergo
diagnostic or other medical tests, as suggested by the Company for its underwriting.
ix. I consent to provide a valid age proof and identity proof at the time of claims or any other time when required by the Company.
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x. I/We consent to receive information from the Company through physical, electronic or telecommunication means from time to time.
xi. I authorize the Company to exchange, share or part with the information relating to myself/person(s) to be insured with any external entity other than
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regulatoryand statutory bodies, as may be required and I will not hold the Company or its agents liable for use/sharing of this information. Yes/No (non selection,
the optionshall be constructed as “Yes” by the Company)
xii. I here by declare on my behalf & on behalf of all person proposed to be insured that the above statements, answers and/or particulars given by me in
thisproposal form are true and complete in all respects to the best of my knowledge and that I/We am/are authorized to propose on behalf of these other
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persons.
xiii. I declare that I am submitting a proposal for Health insurance policy to Reliance General Insurance Company Ltd. (Company) through the Company's
website/Portal, after satisfying myself of the truthfulness of the statements made by me herein and of the need to disclose all material facts.
xiv. I further declare that the premium is being paid from my credit/ debit card/internet bank account.
xv. You are requested to please verify the details of the online proposal form and cross-check against the policy schedule. In case of any discrepancy, you
should report it within 15days of the receipt of the proposal form at our Paid no: 022 48903009, else it will be presumed that everything is in order.
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xvi. Applicable if 'Quarterly premium option is selected'. I also understand and agree that upon non receipt of my installment by the Company, on or before the
due dates the policy shall cease to operate from the unpaid installment due date and the Company shall not be liable for any Claim under the Policy.

SID1212
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IMPORTANT
• The policy has been issued based on the telephonic conversation / online proposal form, details provided wherein have been recorded in this proposal form. In
case of any discrepancy you are requested to contact our call centre at 022 48903009(Paid) and record the discrepancy within 15days of receipt of the policy.
In case we do not get any communication from your side we will presume that all the details provided in the policy & proposal form all complete and accurate.
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• The information that you give to Reliance General Insurance on this online form will be treated as the proposal form and details in any supplemental information
form or documentation supplied by you or on your behalf will influence our decision to offer insurance and the terms upon which to offer it. It is therefore
important that your answers are complete and accurate in all respect.
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• I have read and understood the terms and conditions governing the online transaction facility of Reliance General Insurance Company Ltd.
Prohibition of Rebates - Section 41 of the Insurance Act, 1938 as amended by Insurance Laws (Amendment) Act, 2015.
• No person shall allow or offer to allow, either directly or indirectly as an inducement to any person to take out or renew or continue an insurance in respect of
any kind of risk relating to lives or property, in India, any rebate of the whole or part of the commission payable or any rebate of the premium shown on the
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policy, nor shall any person taking out or renewing or continuing a policy accept any rebate, except such rebate as may be allowed in accordance with the
published prospectuses or tables of the Insurer.
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• Any person making default in complying with the provisions of this section shall be punishable with fine, which may extend to five hundred rupees.
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