CHOLAMANDALAM MS GENERAL INSURANCE COMPANY LIMITED

Registered Office: 2nd Floor, "DARE House", 2, N.S.C. Bose Road, Chennai - 600 001.
Toll free: 1800 208 9100, T: +91 (0) 44 4044 5400, F: +91 (0) 44 4044 5550
E: [email protected];; website: www.cholainsurance.com
IRDA Regn. No. 123; PAN: AABCC6633K CIN:U66030TN2001PLC047977
GSTIN: 33AABCC6633K1ZQ

Group Health Insurance

UIN No: CHOHLGP21307V022021

Certificate Of Insurance
Certificate Number 2876/00191886/000014/000/02

UBI Account No. 322502010005661

UBI Transaction Ref No. U53225805112024125835

Name of the Insured RAJENDRA VAMAN RAHANE

Communication Address VARCHI AALI AT/POST- CHANDANAPURI TAL-SANGAMNER , SANGAMNER ,

SANGAMNER S.O , MAHARASHTRA - AHMED NAGAR-422605
Type of Policy / Plan Family Floater [ Plan Opted - UBIFAMILYPLAN300_EP_N ]

Period of Insurance From 00:00 06/11/2024 To 23:59 Midnight of 05/11/2025

INSURED DETAILS

Name of the Insured Relationship Gender Date Of Birth Age Pre-existing Disease Sum Insured

RAJENDRA VAMAN RAHANE Self Male 16-DEC-75 48 N/A Rs. 300000/-

SAVITA RAJENDRA RAHANE Spouse Female 01-JUN-79 45 N/A

SHUBHAM RAJENDRA RAHANE Child1 Male 18-APR-01 23 N/A

MOHINI RAJENDRA RAHANE Child2 Female 09-JAN-03 21 N/A

Nominee Name: SAVITA Nominee Relationship: Spouse
*As per the Nomination details provided by the insured in the Enrolment form
PREMIUM DETAILS

Premium Rs. 8399

GST Rs. 1512

Total Premium including GST Rs. 9911

TABLE OF BENEFITS
This Certificate is subject to Master Policy Terms & Conditions issued to Union Bank of India, 2876/00291702/000/00
CONTINUITY BENEFIT
For the purpose of continuity of benefits of the said policy will be treated as continuously renewed if the renewal premium as applicable is paid within 30
days from the renewal date. However the cover will commence from the receipt of such renewal premium & claims during such break in period will not be
considered.
SECTION 80D APPLICABILITY
This is to certify that a sum of Rs. 9911/- (Net Premium Rs. 8399/- and GST Rs.1511.85/- ) has been collected from Mr./Mrs. RAJENDRA VAMAN
RAHANE, towards Health Insurance policy number 2876/00291702/000/00 for the duration of 00:00:01 hrs on 06/11/2024 to midnight on 05/11/2025. This
certificate is issued for the purpose of Income Tax Deduction under Section 80 D of the Income Tax Act, 1961.
Intermediary Name : UBIN -GHULEWADI SANGAMNER Intermediary Code : 201212611772

Receipt Number : ZIC5NGC04C88DG Contact No. :

Note: The Certificate of Insurance / Policy Schedule is an important document issued based on your declaration. We request you to verify the details and
ensure that everything is in order. In case of any discrepancies, please contact us within 15 days from the date of issuance of policy.
In WITNESS WHEREOF, this Certificate of Insurance has been signed on05-NOV-24
For Cholamandalam MS General Insurance Co. Ltd
Place : Chennai

Authorised Signatory

Consolidated stamp duty paid to the Government of Tamilnadu

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 and also as per Notification No.
13/2020-CT dated 21-03-2020. This policy schedule shall be in lieu of Tax Invoice and hence no separate GST invoice required In compliance with Rule
54(2) of CGST Rules, 2017
CHOLAMANDALAM MS GENERAL INSURANCE COMPANY LIMITED
Registered Office: 2nd Floor, "DARE House", 2, N.S.C. Bose Road, Chennai - 600 001.
Toll free: 1800 208 9100, T: +91 (0) 44 4044 5400, F: +91 (0) 44 4044 5550
E: [email protected];; website: www.cholainsurance.com
IRDA Regn. No. 123; PAN: AABCC6633K CIN:U66030TN2001PLC047977
GSTIN: 33AABCC6633K1ZQ

Union Bank of India

Group Health Insurance - Certificate Wordings
The following is an outline of the important Terms & Conditions applicable under the policy for your reference. For complete details on policy coverage,
exclusions, terms and condition, please refer to the Master Policy Wording with Union Bank of India (UBI).
Members Covered Age Limit in years
Minimum entry age Maximum entry age
Self + Spouse 18 years 70 years
Upto 3 Dependent Children 90 days 26 years

Inpatient Hospitalisation Expenses Covered

Room Charges Standard Single Occupancy AC room
Pre hospitalization Expenses Upto 60 days
Post hospitalization Expenses Upto 90 days
Day Care Procedures 141 Procedures Covered
Ambulance Charges Upto Rs.2,500/- per hospitalization
AYUSH Treatment Inpatient Hospitalisation upto Sum Insured. Naturopathy is excluded from Scope of Cover
Domiciliary Hospitalisation Upto 20% of Sum Insured per family
Accompanying Person Food Expenses Rs.500/- per day of hospital stay for an admissible claim
Maternity Cover Upto Rs.20,000/- per child for Normal Delivery & Caesarean Section

Health Check up Benefit Reimbursement upto Rs.2,000/- per family, once in every two continuous claim free years

Waiting Periods & Important Exclusions :

(Please refer to the master policy wordings available with Union Bank of India for complete list of exclusions)
The Company will not pay for any claim in respect of any Insured Person directly or indirectly for, caused by, arising from or in any way attributable to:
1. Accidental Injury covered from Day one. Initial Waiting period of 30 days applicable for claims due to Illness.
2. Pre-existing diseases/conditions are covered after a waiting period of 2 years with Chola MS
3. One Year waiting period from the date of commencement of cover for the following disease: Cataract, Benign Prostatic Hypertrophy, Hysterectomy for
Menorrhagia or Fibromyoma, Hernia, Hydrocele, Fistula in anus, Piles, internal congenital anomaly, Sinusitis and related disorders.

4. A waiting of 9 months from the date of commencement of policy for the Insured is applicable for Maternity coverage
5. Pre- and post-hospitalisation expenses are not covered under Maternity benefit.
Claim Process:
Procedure for Cashless Claims:
For planned hospitalisation or day care procedure, please call our Toll Free no. 1800 208 9100 for pre-authorisation procedures. For emergency hospitalisation,
intimate us at the earliest. Network Hospital list can be downloaded from our website www.cholainsurance.com
Procedure for Reimbursement Claims:
Please intimate us immediately in the event of hospitalization and submit all original claim documents within 30 days from the date of discharge from the
hospital. Documents can be submitted either at our regional offices/directly to Head Office:

Claims Documentation :
" Duly filled in and signed Claim Form
" Detailed discharge summary specifying the ailment & treatment details
" Final hospital bill with detailed breakup & payment receipt for the same
" Pathological reports and other investigation reports including radiology reports
" Pharmacy bills with supporting prescriptions
" Payment receipts for other expenses if any
" Implant stickers or invoice wherever applicable
" FIR/MLC copy in case of RTA's (non mandatory)
" KYC documents if claim value is more than 1 lakh
" Cancelled cheque for NEFT payment

HO Claims Office Address:

Health Claims Department,
Cholamandalam MS General Insurance Company Limited,
New No.2,Old No.234,
Dare House 2nd Floor,
N.S.C. Bose Road,
Parrys Corner,
Chennai 600001
Customer Care Toll Free No: 1800-208-9100
CHOLAMANDALAM MS GENERAL INSURANCE COMPANY LIMITED
Registered Office: 2nd Floor, "DARE House", 2, N.S.C. Bose Road, Chennai - 600 001.
Toll free: 1800 208 9100, T: +91 (0) 44 4044 5400, F: +91 (0) 44 4044 5550
E: [email protected];; website: www.cholainsurance.com
IRDA Regn. No. 123; PAN: AABCC6633K CIN:U66030TN2001PLC047977
GSTIN: 33AABCC6633K1ZQ

Cancellation:
1. The Policy may be cancelled by either parties by giving a 15 days written notice.
2. In case of cancellation by the insured, we will retain a part of the premium for the period for which you were covered under this policy.
3. For complete details, please refer to the Master Policy Wording with Union Bank of India.

Grievances Redressal Mechanism:

As an esteemed customer of our Company, the Insured can contact us to register complaint/ grievance, is any, including servicing of policy, claims etc. with
regard to the insurance policy issued. The contact details of our office are given below for your reference .
If any Grivances / issues on Health insurance related claims pertaining to Senior Citizens, Insured can register the complaint / grievance which shall be processed
on Fast Track Basis by dedicated personnel.

Cholamandalam MS General Insurance Company Limited

Customer Services
Address : H.O : Dare House 2nd Floor,
No 2 N.S. C Bose Road, Chennai 600001
Toll Free : 1800 208 9100
SMS : CHOLA to 56677* (premium SMS charges apply)
E-MAIL
[email protected]
WEBSITE : www.cholainsurance.com
If you have not received any replyfrom us within 3 days from the date of the lodgement of complaint or if you are not satisfied with the reply of the Company, you
can contact the IRDA Grievance Call Centre at the toll free no. 55255 or email at [email protected] for registering the grievance or the nearest Insurance
Ombudsman Office.
CHOLAMANDALAM MS GENERAL INSURANCE COMPANY LIMITED
Registered Office: 2nd Floor, "DARE House", 2, N.S.C. Bose Road, Chennai - 600 001.
Toll free: 1800 208 9100, T: +91 (0) 44 4044 5400, F: +91 (0) 44 4044 5550
E: [email protected];; website: www.cholainsurance.com
IRDA Regn. No. 123; PAN: AABCC6633K CIN:U66030TN2001PLC047977
GSTIN: 33AABCC6633K1ZQ

The contact details of the Insurance Ombudsman offices are as below-

Areas of Jurisdiction Office of the Insurance Ombudsman

Gujarat, UT of Dadra and Nagar Haveli, Office of the Insurance Ombudsman, Jeevan Prakash Building, 6th floor, TilakMarg,
Daman and Diu Relief Road, Ahmedabad - 380 001. Tel.: 079 - 25501201/02/05/06 Email:
[email protected]
Karnataka Office of the Insurance Ombudsman, Jeevansoudha Building, PID No.57-27-N-19,
Ground Floor, 19/19, 24th Main Road, JP Nagar, 1st Phase, Bengaluru 560078. Tel.:
080-26652048/26652049, Email: [email protected]
Madhya Pradesh and Chhattisgarh Office of the Insurance Ombudsman, Janakvihar Complex, 2nd Floor, 6, Malviya Nagar,
Opp. Airtel Office, Near New Market, Bhopal - 462003. Tel.: 0755-2769201/2769202,
Fax.: 0755-2769203, Email.: [email protected]
Odisha Office of the Insurance Ombudsman, 62, Forest Park, Bhubhaneshwar - 750009. Tel.:
0674-2596461/2586455. Fax.: 0674-2596429. Email.:
[email protected]
Punjab, Haryana(excluding Gurugram, Faridabad, Office of the Insurance Ombudsman, S.C.O. No.101, 102 & 103, 2nd Floor, Batra Building,
Sonepat and Bahadurgarh), Himachal Pradesh, Sector 17-D, Chandigarh - 160017. Tel.: 0172-2706196/2706468. Fax.: 0172-2708274,
Jammu and Kashmir, UT of Chandigarh Email.: [email protected]
Tamilnadu, UT-Pondicherry Town and Karaikal (which Office of the Insurance Ombudsman,Fatima Akhtar Court, 4th Floor, 453, Anna Salai,
are part of UT of Pondicherry) Teynampet, Chennai 600 018. Tel. 044 - 24333668/24335284. Fax. 044-24333664,
Email.: [email protected]
Delhi Office of the Insurance Ombudsman, 2/2 A, Universal Insurance Building, Asaf Ali
Road, New Delhi - 110002. Tel. 011-23239633/23237532, Fax.011-23230858, Email.:
[email protected]
Assam, Meghalaya, Manipur, Mizoram, Arunachal Office of the Insurance Ombudsman, JeevanNivesh, 5th Floor, Nr. Panbazar over bridge,
Pradesh, Nagaland and Tripura S.S. Road, Guwahati - 781001 (ASSAM). Tel.: 0361-2132204/2132205, Fax.: 0361-
2732937, Email.: [email protected]
Andhra Pradesh, Telangana and UT of Yanam-a Office of the Insurance Ombudsman, 6-2-46, 1st Floor, "Moin court", Lane Opp., Saleem
part of the UT of Pondicherry Function Palace, A.C. Guards, Lakdi-Ka-Pool, Hyderabad - 500004. Tel.: 040-
65504123/23312122, Fax.: 040-23376599, Email.: [email protected]
Rajasthan Office of the Insurance Ombudsman,JeevanNidhi - II Bldg, Gr. Fllor, Bhawani Singh Marg,
Jaipur - 302005. Tel.: 0141-2740363, Email.: [email protected]

Kerala, UT of (a) Lakshadweep, (b) Mahe-a part Office of the Insurance Ombudsman, 2nd Floor, Pulinat Bldg., Opp. Cohin Shipyard,
of UT of Pondicherry M. G. Road, Ernakulam - 682015, Tel.: 0484-2358759/2359338, Fax.: 0484-
2359336, Email.: [email protected]
West Bengal, UT of Andaman and Nicobar Office of the Insurance Ombudsman, Hindustan Bldg, Annexe, 4th Floor, 4, C.R. Avenue,
Islands, Sikkim Kolkata - 700072. Tel. 033-22124339/22124340. Fax. 033-22124341, Email.:
[email protected]
Districts of Uttar Pradesh, Laitpur, Jhansi, Mahoba, Office of the Insurance Ombudsman, 6th Floor, Jeevanbhawan, Phase-II, Nawal Kishore
Hamirpur, Banda, Chitrakoot, Allahabad, Mirzapur, Road, Hazratganj, Lucknow - 226001. Tel.: 0522-2231330/2231331. Fax.: 0522-2331310.
Sonbhabdra, Fatehpur, Pratapgarh, Jaunpur, Varanasi, Email: [email protected]
Gazipur, Jalaun, Kanpur, Lucknow, Unnao, Sitapur,
Lakhimpur, Bahraich, Barabanki, Raebareli, Sravasti,
Gonda, Faizabad, Amethi, Kaushambi, Balrampur, Basti,
Ambedkarnagar, Sultanpur, Maharajgang,Santkabirnagar,
Azamgarh, Kushinagar, Gorkhpur, Deoria, Mau, Ghazipur,
Chandauli, Ballia, Sidharathnagar

Goa, Mumbai Metropolitan Region excluding Navi Office of the Insurance Ombudsman, 3rd Floor, Jeevanseva Annexe, S.V. Road, Santacruz
Mumbai & Thane (W), Mumbai - 400054. Tel.: 022-26106552/26106960. Fax: 022-26106052. Email:
[email protected]
State of Uttarakhand and the following districts of Uttar Office of the Insurance Ombudsman, Bhagwansahai Palace, 4th floor, Main Road, Naya
Pradesh: Agra, Aligarh, Bagpat, Bareilly, Bijnor, Baudam, Bans, Sector 15, Distt: gautambhuddh Nagar, U.P - 201301. Tel.: 0120-
Bulandshehar, Etah, Kanooj, Mainpuri, Mathura, Meerut, 2514250/2514251/2514253. Email.: [email protected]
Moradabad, Muzaffarnagar, Oraiyya, Pilibhit, Etawah,
Farrukhabad, Firozbad, Gautambodhanagar, Ghaziabad,
Hardoi, Shahjahanpur, Hapur, Shamli, Rampur, Kashganj,
Sambhal, Amroha, Hathras, Kanshiramnagar, Saharanpur

Office of the Insurance Ombudsman, 1st Floor, Kalpana Arcade Building, Bazar
Bihar, Jharkhand
Samiti Road, Bahadurpur, Patna 800006, Email: [email protected]
Maharashtra, Area of Navi Mumbai and Thane Office of the Insurance Ombudsman, JeevanDarshan Bldg, 3rd floor, C.T.S. No.s 195
excluding Mumbai Metropolitan Region to198, N.C. Kelkar Road, Narayan Peth, Pune-411030 Tel: 020-32341320, Email:
[email protected]