THE NEW INDIA ASSURANCE CO. LTD.

(Government of India Undertaking)

New India Floater Mediclaim Policy

UIN : NIAHLIP21278V042021

Policy Schedule

Current Policy No 23030034222800009887 Current Policy Period From:27/10/2022 12:00:01 AM

To:26/10/2023 11:59:59 PM
Previous Policy No 23030034212800009965 Previous Policy Period 27-OCT-21 to 26-OCT-22
Policyholder's Details
Policyholder Name KIRTIKUMAR BHUPATBHAI VITHANI . Customer ID PO45298223
PAN Card No AFGPV6174F
Mobile No/Phone No XXXXXX7177
Policyholder's E-2 502 SWEETHOME NEW Email id ravig.gheewala77@gmail.com,
address KOSAD ROAD AMROLI SURAT
SURAT

SURAT ,GUJARAT, 394107

Name of the Nominee rachna
Relation with the Policy Spouse
holder
GSTIN NA
Policy Issuing Office and Intermediary Details
Office Name and Code SURAT DO-III (230300) Office Contact No 2742296 / 2740299
Office Email Id nia.230300@newindia.co.in Development Officer DINESH DEVALIA (1D4023400)
Name of the RAVI YOGESHBHAI GHEEWALA
Agent/Intermediary (NIA1D4019984)
Office Address 104-105, 1ST FLOOR, TITANIUM Contact No. of 9898210789, 6355001130 / NA
SQUARE, OPP. INCOME TAX OFFICE, Agent/Intermediary
ADAJAN, SURAT

,395009
E-mail id of Intermediary
Regional Office SURAT RO (230000) GSTIN 24AAACN4165C2ZW
Regional Contact No NA SAC 997133 (Accident and health insurance
services)
Details Of TPA (Notice or Communication to be given in respect of claim)
Name of the TPA MDINDIA HEALTH INSURANCE TPA
PVT. LIMITED
Email-id of the TPA Address of the TPA S. NO. 46/1, E-SPACE, A-2 BUILDING,
customercare@mdindia.com 3RD FLOOR, PUNE-NAGAR ROAD,
VADGAONSHERI, PUNE-411014,,

Toll Free / Contact No of 18002097800

the TPA 18002097777 /
Fax of TPA 02025300003

Highlights of New India Floater Mediclaim Policy*

* Day one baby cover. * Ayurvedic / Homoeopathic / Unani treatments are covered up to 25% of the
Sum Insured.
* Critical Care Benefit 10% of the Sum Insured. * Optional Cover I: No Proportionate Deduction.
* Room rent and ICU Charges at 1% and 2% of Sum Insured per day * Optional Cover II: Maternity Expenses Benefit for Sum Insured 5 Lakhs and
respectively. Above.
* Hospital Cash up to 1% of Sum Insured. * Optional Cover III: Revision in Limit of Cataract (For 8 Lakhs & above Sum
Insured).
* Midterm inclusion of newly married spouse. * For Pre Existing Diseases Waiting period is 48 Months as per clause 4.1 of the
policy document.
* Cataract claims, up to 10% of Sum Insured or ` 50,000 whichever * For specified diseases waiting period is 24 months as per clause 4.3.1
less, for each eye. of the policy document.
* Please refer to policy document for detailed terms and conditions.
Important
Signature Not
Verified
Digitally signed
by SRINIVASAN
VAIDESWARAN
Date: 2022.10.13 Policy No. : 23030034222800009887Document generated by QR_RENEWAL at 13/10/2022 22:21:06 Hours.
22:21:13 IST
Regd. & Head Office: New India Assurance Bldg., 87 M.G. Road, Fort, Mumbai - 400 001. TOLL FREE No. 1 800 209 1415.
Give your valuable feedback on https://www.newindia.co.in/portal/policyFeedbackGen.

Page 1 of 5
THE NEW INDIA ASSURANCE CO. LTD.
(Government of India Undertaking)

*1.Date of Inception of first policy is the date from which the policyholder has been continuously obtaining health insurance cover in
India from any of the insurers without break subject to portability guidelines.
2.Enhanced Sum Insured under the policy will be subject to policy clauses 4.1,4.2 and 4.3
3. PED and specified diseases waiting periods for each of the merged policy shall be reckoned as per its date of inception of first policy.
* Please visit https://www.newindia.co.in for the list of network hospitals providing cashless facility. If network hospital is not
available in your city/location, please contact the concerned TPA." You are also requested to share your policy details when
you visit the network hospital.

Insured Persons details

S. No Name of the insued Date of birth(Age) Sex Relation *Date of inception of Pre Existing Disease
(Member ID) first policy
1 KIRTIKUMAR 11/07/1983(39) M SELF 27/10/2016 NA
BHUPATBHAI
VITHANI
.(PO45298223)
2 RACHNABEN 20/03/1984(38) F SPOUSE 27/10/2016 NA
.(ME05861383)
3 YUG 27/08/2009(13) M CHILD 27/10/2016 NA
.(ME05861390)
4 HIMALAY 28/07/2014(8) M CHILD 27/10/2016 NA
.(ME05861392)

Floater Sum Insured 1000000 Floater Cumulative Bonus 0

Cumulative Bonus Details

S. No Sum Insured CB percentage CB Amount
1 200000 0 0
2 800000 0 0

Optional Cover Table

Policy Level - Optional Not Opted
Cover - 1
(No Proportionate
Deduction)
Member Level - Optional Not Opted Member Level - Optional Cover - III Not Opted
Cover - II (Revision in Cataract Limit)
(Maternity Benefit)

S No Name of the Basic Premium Premium for Premium for Premium for Discount Gross Premium
Insured Optional Cover - I Optional Cover - Optional Cover -
II III
1 KIRTIKUMAR 7638 0 0 0 1146 6492
BHUPATBHAI
VITHANI .
2 RACHNABEN 7638 0 0 0 1146 6492
.
3 YUG . 3040 0 0 0 456 2584
4 HIMALAY . 3040 0 0 0 456 2584

Previous Year Policy Details

Sl. No. Previous Policy Name of From Date To Date Sum Insured Pre-existing Claim Amount
No Insured Diseases
1 230300341728 RACHNABEN 27/10/2017 26/10/2018 0 N 23892
00007915 .
2 230300341728 YUG . 27/10/2017 26/10/2018 0 N 0
00007915
3 230300341728 HIMALAY . 27/10/2017 26/10/2018 0 N 0
00007915

Policy No. : 23030034222800009887Document generated by QR_RENEWAL at 13/10/2022 22:21:06 Hours.

Regd. & Head Office: New India Assurance Bldg., 87 M.G. Road, Fort, Mumbai - 400 001. TOLL FREE No. 1 800 209 1415.
Give your valuable feedback on https://www.newindia.co.in/portal/policyFeedbackGen.

Page 2 of 5
THE NEW INDIA ASSURANCE CO. LTD.
(Government of India Undertaking)

Sl. No. Previous Policy Name of From Date To Date Sum Insured Pre-existing Claim Amount
No Insured Diseases
4 230300341828 RACHNABEN 27/10/2018 26/10/2019 0 N 23720
00007617 .
5 230300341828 YUG . 27/10/2018 26/10/2019 0 N 46572
00007617
6 230300341828 HIMALAY . 27/10/2018 26/10/2019 0 N 0
00007617
7 230300342028 KIRTIKUMAR 27/10/2020 26/10/2021 200000 N 0
00009350 BHUPATBHAI
VITHANI .
8 230300341928 RACHNABEN 27/10/2019 26/10/2020 0 N 0
00008244 .
9 230300341928 YUG . 27/10/2019 26/10/2020 0 N 0
00008244
10 230300341928 HIMALAY . 27/10/2019 26/10/2020 0 N 0
00008244
11 230300342028 RACHNABEN 27/10/2020 26/10/2021 0 N 0
00009350 .
12 230300342028 YUG . 27/10/2020 26/10/2021 0 N 0
00009350
13 230300342028 HIMALAY . 27/10/2020 26/10/2021 0 N 0
00009350
Total Gross 18152
Premium(Without
GST)
CGST(@9%) 1634
SGST(@9%) 1634
Net Premium in Words(RUPEES TWENTY-ONE THOUSAND FOUR HUNDRED TWENTY ONLY) IGST 0
Total GST 3268
Net Premium(With 21420
GST)

*This Policy is subject to terms and conditions of New India Floater Mediclaim.

In WITNESS WHEREOF,the undersigned being duly authorized by the Insurers and on behalf of the Insurers has(have) hereunder set
his/her(their) hand(s) on this 27th day of October 2022.

Date of Issue: 13/10/2022

(MR. ANIL DHANGAR)

[SR. DIV MANAGER]

FOR AND ON BEHALF OF

THE NEW INDIA ASSURANCE COMPANY LIMITED
DULY CONSTITUTED ATTORNEY(S)

Policy No. : 23030034222800009887Document generated by QR_RENEWAL at 13/10/2022 22:21:06 Hours.

Regd. & Head Office: New India Assurance Bldg., 87 M.G. Road, Fort, Mumbai - 400 001. TOLL FREE No. 1 800 209 1415.
Give your valuable feedback on https://www.newindia.co.in/portal/policyFeedbackGen.

Page 3 of 5
THE NEW INDIA ASSURANCE CO. LTD.
(Government of India Undertaking)

Insurer Office Code : SURAT DO-III (230300)

Address : 104-105, 1ST FLOOR, TITANIUM SQUARE, OPP.
INCOME TAX OFFICE, ADAJAN, SURAT

,395009
Telephone : 2742296 / 2740299
Fax :

New India Floater Mediclaim

PREMIUM CERTIFICATE FOR THE PURPOSE OF DEDUCTION UNDER SECTION 80 D OF INCOME TAX ( AMENDMENT ) ACT 1986

This is to certify that Mr./Mrs. KIRTIKUMAR BHUPATBHAI VITHANI . has paid ` 21420 towards premium for New India Floater
Mediclaim for the period 27/10/2022 12:00:01 AM to 26/10/2023 11:59:59 PM

Policy no. : 23030034222800009887

Receipt no. & date : 10000089221000279778
13/10/2022

Date of Issue: 13/10/2022

(MR. ANIL DHANGAR)

[SR. DIV MANAGER]
Authorized Signatory For and on behalf of
The New India Assurance Company
Limited
(Note: This certificate must be surrendered to the Insurance Company for issuance of fresh certificate in case of cancellation
of the policy or any alteration in the Insurance affecting the premium)

Policy No. : 23030034222800009887Document generated by QR_RENEWAL at 13/10/2022 22:21:06 Hours.

Regd. & Head Office: New India Assurance Bldg., 87 M.G. Road, Fort, Mumbai - 400 001. TOLL FREE No. 1 800 209 1415.
Give your valuable feedback on https://www.newindia.co.in/portal/policyFeedbackGen.

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 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 Regulation 2016 and IRDAI (Protection of Policyholders' Interest) Regulations, 2017 are
available on the website of IRDAI.

Beware of spurious calls offering alluring benefits. Never share any policy details with unknown callers.
Call 1800-209-1415 for any enquiry or contact the nearest operating office of New India Assurance Co Ltd.

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.

Tax Invoice No : 23030022P0032183

IRDA Registration Number: 190

NIA PAN NUMBER: AAACN4165C

Policy No. : 23030034222800009887Document generated by QR_RENEWAL at 13/10/2022 22:21:06 Hours.

Regd. & Head Office: New India Assurance Bldg., 87 M.G. Road, Fort, Mumbai - 400 001. TOLL FREE No. 1 800 209 1415.
Give your valuable feedback on https://www.newindia.co.in/portal/policyFeedbackGen.

Page 5 of 5