UB Arogyadaan

(UIN NO.UIIHLGP22018V012122)

Certificate of Insurance

(This certificate of insurance is valid for claiming Tax Deduction under Section 80D of IT (Amendment) Act, 1986)

A. GENERAL DETAILS

Policy No. : 0504002822P102869498

Policy Issued at : DO 4 HYDERABAD, UIIC
Issued on : 09 Jun 2022
Certificate Number 29624685

B. BANK DETAILS

Bank Reference No. : BA No.70952

Branch Code 03781
Branch Name : NAMPALLI
Account No. :037810011300329
Voucher Date : 09 Jun 2022

C. DETAILS OF ACCOUNT HOLDER

Name : Ratna Kumar

Address 42/1,KPHB Colony, Road No 02
HYDERABAD,HYDERABAD
Telangana-500080 Mobile: 9849790022
Bussiness/Occupation :

D. POLICY DETAILS

Policy Start Date : 09 Jun 2022

Policy End Date : 08-Jun-2023
Policy Plan : Plan A
Family Base Sum Insured 500000
Super TopUp Sum Insured : NOT OPTED

E. POLICY ISSUING OFFICE DETAILS

Address : UNITED INDIA INSURANCE CO LTD

DO-IV(050400), 3-5-817 & 818, Floor No.7,
United Towers, Basheerbagh, Hyderabad,
Telangana-500029.
Office GST No. : 36AAACU5552C1ZK
Tel/Fax : 040 -23230537,23230547
E-mail : ubarogyahyderabad@uiic.co.in

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(UIN NO.UIIHLGP22018V012122)
F.DETAILS OF INSURED PERSONS

First Inception Nominee

Name of Insured Person Age Gender Relation TPA ID Nominee
Date Relation

57
T Ratna Kumar Male Self UIIC.00046844452 09 Jun 2022

48 Wife
T Graceamma Female UIIC.00066843652 09 Jun 2022

Note: Kindly verify that your details as mentioned above are accurate and notify immediately in case of any errors/discrepancies to email to :
arogyadaan@fhpl.net

G. PREMIUM OVERVIEW
Base Premium 24459
Super Top-up Premium 0
CGST @9% 2021
SGST @9% 2021
Total Premium (incl. GST) 28501

In case you have a policy other than UB Arogyadaan, the onus is on you to give the copy of the previous year policy details as well as the claim
details.

H. TABLE OF BENEFITS
(Details mentioned below are indicative and brief in nature. Please refer to Policy Wordings for complete information on your coverage)

BASE COVER Coverage Details

* Room Rent, Boarding & Nursing expenses up to 1% of Sum Insured per day.
* ICU/ICCU expenses up to 2% of Sum Insured per day.
* Surgeon, Anaesthetist, Specialist Fees, Blood, Oxygen, Operation Theatre Charges, medicines and drugs, diagnostic
tests, etc. (For detailed list of covered expenses, please refer to Policy Terms & Conditions) NOTE: If you have been
admitted in a Room which costs more than 1% of Sum Insured per day,
all associated medical expenses that you incur at the hospital, except cost of pharmacy
and consumables, implants and medical devices and diagnostics, will be proportionately deducted

* Hospitalisation expenses (excluding cost of organ) incurred for donor in respect of organ transplant to the
Insured Person
Hospitalisation
* Expenses for the following illnesses/surgeries shall be restricted as follows:
- Cataract: Up to 10% of Sum Insured subject to a maximum of Rs. 25,000/-.
- Hernia: Up to 15% of Sum Insured subject to a maximum of Rs. 30,000/-.
- Hysterectomy: Up to 20% of Sum Insured subject to a maximum of Rs. 50,000/-.
- Major Surgeries*: Actual expenses incurred or 80% of the Sum Insured whichever is less
- Named Mental Illness: Up to 25% of Sum Insured

* Please refer to Policy Terms & Conditions for what constitutes as major surgeries) Above
limits are applicable per Surgery / Hospitalisation

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Day Care All medical treatments and/or surgical procedures which fall under the definition of Day Care Treatment under
Treatments Section 3.14 (Definitions) of the Policy Wordings, are covered

Pre & Post We will cover your medical expenses up to 30 days before hospitalisation & up to 60 days after your discharge from
Hospitalisation hospital, subject to a maximum of 10% of Sum Insured put together.

Ayurvedic, Unani We will cover your medical expenses up to 30 days before hospitalisation & up to 60 days after your discharge from
Siddha & hospital, subject to a maximum of 10% of Sum Insured put together.
Homeopathic

Modern Treatments
The below mentioned advanced medical procedures shall be covered up to 50% of Sum Insured per Policy
Period:
* Uterine Artery Embolization & High Intensity Focussed Ultrasound (HIFU)
* Balloon Sinuplasty
* Oral Chemotherapy
* Immunotherapy – Monoclonal Antibody to be given as injection
* Intra vitreal injections
* Robotic Surgeries (Including Robotic Assisted Surgeries)
* For SI = 3 Lacs, limit shall be upto 75% of SI per policy period for claims involving Robotic Surgeries for (i)the
treatment of any disease involving Central Nervous System irrespective of aetiology,(ii)Malignancies
* Stereotactic radio Surgeries
* Bronchial Thermoplasty
* Vaporisation of the Prostate (Green laser treatment for holmium laser treatment)
* Intra Operative Neuro Monitoring (IONM)
The below mentioned advanced medical procedures do not have any additional sub-limit:
* Deep Brain stimulation
*Stem Cell Therapy: Hematopoietic Stem Cells for bone marrow transplant for haematological conditions to be
covered only

Home Care We will cover treatment availed by the Insured Person at home for Covid on positive diagnosis of Covid in a
Treatment Government authorized diagnostic Centre which in normal course would require care and treatment at a hospital
Expenses but is actually taken at home maximum up to 14 days and also subject to a maximum
of Rs. 15,000 per policy period.
Road Ambulance We will cover Road Ambulance expenses up to Rs. 1,500 per event. preceding
three claim-free years for a block of every three claim-free years.

Restoration of Sum If the Basic SI is exhausted completely or partially due to admissible claims, then a Restore SI equal to 50% of
Insured for Base SI will be automatically and instantly available only for Hospitalization due to an accident of the Insured
Accidental
Hospitalisation Person.
Automatic Restoration of Basic Sum Insured is available only for sum insured options = Rs. 3,00,000.

Super TopUp Cover Any claim under this section shall be payable by the Company only if the aggregate of covered Medical 50% of
Base SI will be automatically and instantly available only for Hospitalization due to an accident of
Expenses in a policy year in respect of Hospitalisation(s) of Insured Person exceeds Rs.10/Rs.12 Lakhs

I. KEY EXCLUSIONS
You will not be covered for the following:
* Change of Gender Treatments
* Alcoholism, Drug or Substance Abuse
* Refractive Error
* Unproven Treatments
* Cosmetic or Plastic Surgery
* Obesity/Weight Control
* Rest Cure, Rehabilitation and Respite Care
* Nuclear, chemical, or biological attacks
* Sterility & Infertility
* War and war like occurrences
*Maternity and medical expenses traceable to
*Vaccination or Inoculation of any kind, unless it is post
childbirth/Miscarriage
animal bite
* Cost of Spectacles, Contact Lenses, Hearing Aids
* Congenital External diseases or anomalies

(This list is only indicative and not exhaustive. For full list of exclusions, please refer to Policy Wordings)

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(UIN NO.UIIHLGP22018V012122)
J. DETAILS OF THIRD PARTY ADMINISTRATOR (TPA)
Please contact the following TPA for issue of identity cards, Cashless Approvals & Claim Settlement: Name
of the TPA : Family Health Plan Insurance TPA Ltd
TPA Address
: Ground Floor, Srinilaya – Cyber Spazio, Road no 2,
Banjara Hills, Hyderabad – 500034, Telangana, India.
Mobile No of Primary Contact : 9154955045 / 7337048573
Toll Free No : 1800-203-2230 / 1800-102-4033 (24/7)
Website : www.fhpl.net

Important
Notice or communication in respect of claim or for any other reason to be given to TPA as per Notification of Claim Clause in the Policy. This
Certificate of Insurance only provides a summary of the key features of the Policy. Please refer to the Policy Wordings for complete information on
what your Policy covers.

K. GRIEVANCES
In case you have any grievance, you can contact any of the following:
TPA : Family Health Plan Insurance TPA Ltd
Ground Floor, Srinilaya – Cyber Spazio, Road no 2,
Banjara Hills, Hyderabad, Telangana–500034, India.

INSURER : UNITED INDIA INSURANCE CO LTD

DO-IV(050400), 3-5-817 & 818, Floor No.7, United Towers
Basheerbagh, Hyderabad, Telangana-500029, India.
(or) send email to Uni Customer Care department at ubarogyahyderabad@uiic.co.in
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Policy subject to terms, conditions, exclusions, and definitions. Summary of terms and conditions of the policy can be downloaded from
https://uiic.co.in/home
The detailed terms and conditions can be obtained from Union Bank of India branch or United India Insurance Company Office. The
proposal and declaration by the Insured is the basis of this contract and deemed to be incorporated.

Policy created on :09 Jun 2022

Specified Person :
SP Code :

Authorized Signatory:

For and on behalf of

UNITED INDIA INSURANCE COMPANY LIMITED

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(UIN NO.UIIHLGP22018V012122)