This Document is Digitally Signed

The Oriental Insurance Company Limited

Signer: RASHMI RAMAN SINGH
Date: Sat, Oct 1, 2022 10:52:01 IST
Location: NOIDA
Reason: Signing Policy for OICL

HAPPY FAMILY FLOATER-2015 POLICY SCHEDULE

UIN: OICHLIP445V032021

Policy No. : 141701/48/2020/2430 Prev. Policy No. : 141701/48/2019/2587

Cover Note No. : - Cover Note Date : -
Insured's Code : 90700806 Issue Office Code : 141701
Insured Name : MAHENDRABHAI R PATEL (GSTIN: Issue Office Name : BO VIRAMGAM (GSTIN:
0) 24AAACT0627R2Z4)
Address : KISAN SOCIETY AT KELIYA VASNA Address : 1ST FLOOR
SUMERU COMPLEX
TAL DHOLKA NEAR S.T.STAND, VIRAMGAM
DT AHMEDABAD GUJARAT 382150
AHMEDABAD GUJARAT 387810

Tel./Fax/Email : / / 0 / NA Tel./Fax/Email : 02715-33035 / /

[email protected]
Agent/Broker Details
Dev.Off.Code : NA0000005854 MR.B.H.SHAH
Agent/Broker : BA0000073844 KIRTIKANT R. PATEL
Address : I-3, SUVAS APARTMENT,,GULAB TOWER,,THALTEJ,
AHMEDABAD.,AHMEDABAD,GUJARAT,380054
Tel/Fax/Email : 9825798400//[email protected]

Period of Insurance : FROM 00:00 ON 29/10/2019 TO MIDNIGHT OF 28/10/2020

Collection No. & Dt. : DU A/C AA0000000001 GST INVOICE NO :241810435570 UIN :0
Gross Premium : 9,412 GST 1694 Stamp Duty : .5 Total : 11,106

Co-insurance Details : Nil

TPA Details :
TPA ID : YA0000000333
TPA Name : M/S HERITAGE HEALTH INSURANCE TPA PRIVATE
LIMITED
Address :
Nicco House, 5 th Floor 2 Hare Street Kolkota [email protected]
Telephone No : CALCUTTA 700001 Toll Free No. : 18003453477
033-22486430 Toll free FAX No. : 033-22100837
18003453477
Number of persons covered : 2 Plan Type : SILVER Plan Sum Insured : 200000
Particulars of the Persons covered :
Sr. Name of The Relationship Pre-Existing
Gender Date of Age Co-Pay PA Capital
No. Persons With Diseases
Birth (%) Sum Insured (INR)
Proposer

1 MAHENDRABHAI R M 09/04/1960 59 Self NO 10

PATEL
2 ASHABEN M F 08/03/1964 55 Spouse NO 10
PATEL Unemployed

Place : For and on behalf of

Date : 14/10/2019 The Oriental Insurance Company Limited

This is an electronically generated document (Policy

Schedule).The Policy document duly stamped will be sent by post

In case of any query regarding the Policy please call Toll

Free No. 1800 11 8485 and 011 33208485. Authorised Signatory

CIN: U66010DL1947GOI007158 All the Amounts mentioned in this policy are in Indian Rupees Page 1 of 3
IRDA Regn. No. 556 - Now you can buy and renew selected policies online at www.orientalinsurance.org.in
 This Document is Digitally Signed

The Oriental Insurance Company Limited

Signer: RASHMI RAMAN SINGH
Date: Sat, Oct 1, 2022 10:52:01 IST
Location: NOIDA
Reason: Signing Policy for OICL

Attached to and forming part of policy number 141701/48/2020/2430

Nominee Details
Name Of the Nominee Relationship With the Insured Age Of the Nominee M/F/TG*

Optional Covers
Value
LIFE HARDSHIP BENEFIT NO
RESTORATION OF SI NO

Total Premium in words : Indian Rupees Eleven Thousand One Hundred Six Only

The insurance under this policy is extended to cover risks of Domiciliary Hospitalisation up to 10 % of sum insured subject to maximum Rs
50000 only ( Fifty Thousand Only).
The insurance under this policy is extended to cover risks of :
Personal Accident Cover, Domiciliary Hospitalisation Limit.
Deductible : Nil
The insurance under this policy is subject to conditions, clauses, warranties,endorsements as per forms attached.
The policy shall pay for hospitalisation expenses for medical/surgical treatment taken as an in-patient at any Nursing
Home/Hospital in INDIA as defined in the policy.

In the event of a claim under the policy exceeding Rs. 1 lac or a claim for refund of premium exceeding Rs. 1 lac,the
insured will comply with the provisions of the AML policy of the Company.The AML policy is available in all our operaing
offices as well as Company's website.

Warranted that in case the person covered under the policy has lodged any claim under the previous policy and the sum
insured is enhanced under the current policy, for a further claim for the same disease during the current policy, the earlier
limit of Sum Insured shall be applicable and not the enhanced sum insured.

Warranted that in case of dishonour of premium cheque(s) the Company shall not be liable under the policy and the policy
shall be void abinitio (from inception).

"We at Oriental continuously strive to ensure that you get the best possible treatment from our network hospitals.
Please contact your TPA or any of the Oriental offices for our preferred hospitals in your area before going for a
treatment. This will help us serve you in the best possible manner"

In witness whereof the undersigned being authorised by and on behalf of the Company has/have herein to set his/their hands
at BO VIRAMGAM (GSTIN: 24AAACT0627R2Z4) on 14-OCT-19.

1.Claim to be reported within 48 hrs of admission but before discharge.

2.Claim documents to be submitted within 15 days of discharge.

For complete details please refer to policy condition.

Place : For and on behalf of

Date : 14/10/2019 The Oriental Insurance Company Limited

This is an electronically generated document (Policy

Schedule).The Policy document duly stamped will be sent by post

In case of any query regarding the Policy please call Toll

Free No. 1800 11 8485 and 011 33208485. Authorised Signatory

CIN: U66010DL1947GOI007158 All the Amounts mentioned in this policy are in Indian Rupees Page 2 of 3
IRDA Regn. No. 556 - Now you can buy and renew selected policies online at www.orientalinsurance.org.in
 This Document is Digitally Signed

The Oriental Insurance Company Limited

Signer: RASHMI RAMAN SINGH
Date: Sat, Oct 1, 2022 10:52:01 IST
Location: NOIDA
Reason: Signing Policy for OICL

Attached to and forming part of policy number 141701/48/2020/2430

Policy History Data

Policy No. Period From Period To Insurer Name Sum Insured

141701/48/2019/2587 29-OCT-18 28-OCT-19 The Oriental Insurance Company Ltd. 200000

Claim History Data

Policy no. Claimant Name Claim No. Claim OS Claim Paid

141701/48/2019/2587 MAHENDRABHAI R 141701/48/2019/000500 .00 23,756

PATEL

"In case of grievance related to any issue related to this policy the same may be addressed to the office In-Charge or the Grievance Officer
at above policy address. If the grievance remains pending, it may be escalated to Grievance Officer of the concerned Regional Office 3 RD
FLOOR NAVJEEVAN TRUST BUILDING,B/H GUJARAT VIDYAPEETH NAVJEEVAN,TRUST BUILDING OFF ASHRAM
ROAD,AHMEDABAD. The next escalation in case grievance remains unresolved is CSD, Head Office, situated at Oriental House, A-25/27,
Asaf Ali Road, New Delhi-110002.
If the insured is not satisfied with the resolution/reply provided by the company, he/she may approach the Office of Insurance Ombudsman,
within his/her jurisdiction. The list of offices of Ombudsman is available on Company's portal."

Entered By : BA0000073844
For and on behalf of
Policy Printed By : OICL IP : The Oriental Insurance Company Limited

Policy Printed On : 01-OCT-22 10:52:06 MAC :

Authorised Signatory

Place : For and on behalf of

Date : 14/10/2019 The Oriental Insurance Company Limited

This is an electronically generated document (Policy

Schedule).The Policy document duly stamped will be sent by post

In case of any query regarding the Policy please call Toll

Free No. 1800 11 8485 and 011 33208485. Authorised Signatory

CIN: U66010DL1947GOI007158 All the Amounts mentioned in this policy are in Indian Rupees Page 3 of 3
IRDA Regn. No. 556 - Now you can buy and renew selected policies online at www.orientalinsurance.org.in