UNITED INDIA INSURANCE COMPANY LIMITED

11/1 , FEEDER ROAD , MONDAL PARA PO : TALPUKUR, BARACKPORE

NORTH TWENTY FOUR PARGANAS 700123 WEST BENGAL
PH: (033) 25922405 FAX: EMAIL:

FAMILY MEDICARE POLICY

UIN. UIIHLIP24090V052324
POLICY NO.: 0304812824P104565555

PERIOD OF INSURANCE
FROM 00:00 Hrs on 01/07/2024
To MIDNIGHT on 30/06/2025

Policyholder
MR SHAUKAT ALI
ARABINDA PALLY

743133
NORTH TWENTY FOUR PARGANAS
WEST BENGAL

IMPORTANT NOTICE: KINDLY UPDATE YOUR AADHAAR NO. AND PAN/FORM 60. PLEASE IGNORE IF ALREADY UPDATED.

Agent Name : SANJAY KR DAS

Agent Code : AGD0120306
9433163870
Mobile/Landline Number/Email :
sanjaydas7258@gmail.com

The genuineness of the policy can be verified through "Verify Your Policy" link at www.uiic.co.in.

For any Information, Service Requests and Grievances please write to 030481@uiic.co.in

For ID Cards & Claim Intimations Please contact the TPA mentioned in the Policy document.

Download Customer App(www.uiic.co.in). REGD. & HEAD OFFICE, 24, WHITES ROAD, CHENNAI - 600014.
Website: http://www.uiic.co.in
Printed By : CUSTOMER @ 28/06/2024 3:03:38 PM

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 POLICY NO.:0304812824P104565555
UIN. UIIHLIP24090V052324

FAMILY MEDICARE POLICY

Policy Number 0304812824P104565555 Previous Policy No. 0304812823P103445349

Name/ID of
MR SHAUKAT ALI /23038987704
Policyholder
Insured Detail Tel.(O) Tel.(R) Fax
EMail aparnadas396@gmail.com Mobile 7003758601
Business/Occupation Others
Period Of Insurance From 00:00hrs of 01/07/2024 To Midnight on 30/06/2025
Policy Type Family Floater Basis Family Floater SI( ) 300,000.00

Coinsurance UIIC 030481 : 100%

Insured Details
Base
Pre-Existing Inception
Sl Nominee Nominee Cover
Insured Name Age/Gender ABHA ID Relation Occupation Disease /Condition Date of first
no Name Relation Premium(
declared policy
)
ZEBA
1 SHAUKAT ALI 47/M Self Businsess None 21/06/2019 Spouse 9,829.00
SHAMIM
SHAUKAT
2 ZEBA SHAMIM 39/F Spouse Housewife None 21/06/2019 Spouse 7,022.00
ALI
SHAUKAT
3 MISBAH SHAUKAT ANSARI 16/M Son Student None 21/06/2019 Father 2,568.00
ALI
SHAUKAT
4 JUNAID SHAUKAT ANSARI 11/M Son Student None 21/06/2019 Father 2,568.00
ALI

Optional Cover & Premium Details

Hospital Daily Cash Limit (Per Policy)(
Hospital Daily Cash Limit (Per Day)( ) Not Opted Not Opted
)

Yes Pre-Existing Disease/ condition No

Restore SI Opted
loading
Maternity & New Born Baby Cover Opted No

Total Basic Premium( ) 21,987.00 Premium: 15,665.00

Add Hospital Daily Cash Premium( ) 0.00 CGST(9%) 1,410.00

0.00 SGST(9%) 1,410.00

Add Maternity Expenses/ New Born Baby Cover Premium( )
Stamp Duty: 1.00
Add Restoration of SI Premium( ) 0.00
Total: 18,485.00
Add PED Loading( ) 0.00
Receipt Number : 10103048124104966738
Less Family Discount( ) 0.00
Receipt Date: 28/06/2024
Less Direct Channel Discount( ) 0.00

Less No Claim Discount( ) 1,099.35

Less Family Floater Discount( ) 5,222.25

Less Online Discount( ) 0.00

Agent Name SANJAY KR DAS Agent/Broker Code AGD0120306

Development Officer Name Development Officer Code

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 POLICY NO.:0304812824P104565555
UIN. UIIHLIP24090V052324

Customer GST/UIN No.: Office GST No.: 19AAACU5552C1ZG

SAC Code: 997133 Invoice No. & Date: 2824I104565555 & 28/06/2024
Amount Subject to Reverse Charges-NIL

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.
Anti Money Laundering Clause:-In the event of a claim under the policy exceeding 1 lakh or a claim for refund of premium exceeding 1 lakh, the insured will
comply with the provisions of AML policy of the company. The AML policy is available in all our operating offices as well as Company's web site.

LET US JOIN THE FIGHT AGAINST CORRUPTION. PLEASE TAKE THE PLEDGE AT https://pledge.cvc.nic.in.

Date of Proposal and Declaration: 01/07/2024

IN WITNESS WHEREOF, the undersigned being duly authorised has hereunto set his/her hand at MO BARACKPORE 030481 on this 28th day of June ,2024.

For and On behalf of

United India Insurance Co. Ltd.
Affix
Policy
Stamp
Here

Authorised Signatory.
Underwritten By - SANDAS67 ( DIRECT AGENT )

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 POLICY NO.: 0304812824P104565555
UIN. UIIHLIP24090V052324

Details of TPA:
Please contact the following TPA for Issue of Identity Cards, Cashless Approvals & Claims Settlement.

Name of TPA/ID Medi Assist Insurance TPA Private Limited / TPA00010

Address Tower D, 4th Floor, IBC Knowledge Park, 4/1, Bannerghatta Road, Bangalore- 560029,Pune Nagar Road, Wadgaon -Sheri, Pin Code
: 560029, Fax No :
Toll Free number 1800 425 9449
Contact Details For General Enquiries For Cashless approval For Claim intimation For Grievances
Telephone Numbers 080 4969 8000 1800 425 9449 For sending SMS 9664172929 8049698066
Email IDs info@mediassistindia.com cashless@mediassistindia.com claimintimation@mediassistindia.com grievance@mediassistindia.com

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 UNITED INDIA INSURANCE COMPANY LIMITED
FAMILY MEDICARE POLICY
UIN. UIIHLIP24090V052324
POLICY NO.: 0304812824P104565555

Details of Previous Policies

Insurer Name Policy No. Period From Period To Sum Insured( )
UNITED INDIA INSURANCE CO.LTD. 0304812823P103445349 01/07/2023 30/06/2024 300000
UNITED INDIA INSURANCE CO.LTD. 0304812822P102894847 01/07/2022 30/06/2023 300000
UNITED INDIA INSURANCE CO.LTD. 0304812821P102947222 01/07/2021 30/06/2022 300000
UNITED INDIA INSURANCE CO.LTD. 0304812820P103229529 01/07/2020 30/06/2021 200000

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 FAMILY MEDICARE POLICY
CUSTOMER INFORMATION SHEET (CIS)
Guide to the CIS
• This document provides key information about your Family Medicare Policy. You are also advised to go through
your policy document.
Policy
S.No. Title Description Clause
No
Name of Insurance
1 Family Medicare Policy -
Policy
2 Policy Number 0304812824P104565555 -
Type of Insurance
3 Indemnity Policy I.B
Policy
Sum Insured Basis Family Floater Basis
4 II.B.18
Sum Insured Rs. 300000
Base Covers III.A.1
1. In-Patient Hospitalisation Expenses
i. Covers hospitalisation expenses for a minimum period of 24 hours.
These include expenses for Room Rent, ICU/ICCU and other associated
medical expenses.
ii. All Day Care Treatments are covered
2. Pre-Hospitalisation and Post-Hospitalisation Expenses III.A.2
Covers expenses incurred in the 30 days prior to hospitalisation and in the
60 days post hospitalisation subject to a maximum of 10% of SI for Pre &
Post combined.
3. Organ Donor Expenses Cover III.A.3
Covers hospitalisation expenses for an Organ Donor's treatment for the
harvesting of organ which is donated to Insured Person.
4. Restoration of Sum Insured III.A.4
If Sum Insured is exhausted completely or partially, then a Restored Sum
Insured equal to 100% of the Sum Insured will be automatically and
instantly available for the particular Policy Period
5. Modern Treatment Methods & Advancement in Technologies III.A.5
Covers expenses for advanced medical procedures such as Robotic
Surgeries, Oral Chemotherapy, Deep Brain Stimulation, Bronchial
Thermoplasty, Stereotactic Radio Surgeries, etc.
Policy Coverage
6. Road Ambulance Cover III.A.6
5 (What the Policy
Covers expenses incurred on transportation of the Insured Person by Road
Covers?)
Ambulance to a Hospital for treatment in an Emergency.
7. Cost of Health Check-Up III.A.7
Insured Person is entitled to a health check-up for a block of every three
claim-free years.
8. Organ Donor Benefit III.A.8
A lump sum payment of 10% of Sum Insured, to take care of medical and
other incidental expenses is payable to the Insured Person donating an
organ.
OPTIONAL COVERS III.B.1.a
1. Maternity Expenses and New Born Baby Cover
i. Expenses incurred for a delivery (including caesarean section), or
lawful medical termination of pregnancy are covered up to 10% of Sum
Insured subject to a maximum of Rs. 40,000 for normal deliveries and Rs.
60,000 for caesarean deliveries

ii. Hospitalisation expenses for New born Baby are covered from day one III.B.1.b
up to the age of 90 days and is subject to a limit of 10% of Sum Insured.

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 2. Daily Cash Allowance on Hospitalisation III.B.1.2
A cash amount will be paid daily to the Insured Person for every continuous
and completed period of 24 hours of Hospitalisation. Daily cash benefit
amount varies based on Sum Insured opted.
The following is a partial list. Please refer to Policy Wordings for the
complete list of exclusions. IV.B.4
1. Admission primarily for investigation & evaluation (Code - Excl04)
2. Admission primarily for rest cure, rehabilitation, and respite care (Code
IV.B.5
- Excl05)
3. Any expenses incurred on Out-patient treatment (OPD treatment) IV.C.4
Exclusions
6 (What the hospital 4. Any treatment related to sleep disorder or sleep apnoea syndrome IV.C.6
5. Congenital External Diseases or Defects or anomalies IV.C.10
doesn't cover)
6. Cost of hearing aids; including optometric therapy IV.C.11
7. Dental treatment or surgery of any kind unless necessitated by disease
IV.C.13
or accident and requiring hospitalisation
8. Intentional self-inflicted Injury or attempted suicide IV.C.14
9. Routine eye-examination expenses, cost of spectacles, contact lenses IV.C.15
10. Vaccination or inoculation of any kind unless it is post animal bite IV.C.20
Initial Waiting Period
IV.A.3
30 days for all illness (not applicable on renewal or for accidents)
Specific Waiting Periods IV.A.2
1. 24 months for certain specified diseases /procedures/treatments Table A
IV.A.2
2. 48 months for certain specified diseases/procedures/treatments
Table B
7 Waiting Period
3. 24 months for Maternity Expenses and New Born Baby Optional
III.B.1.a.i
Cover
4. 12 months for Organ Donor Benefit (When insured person is the
III.A.9
Donor)
Pre-Existing Diseases: Covered after forty-eight (48) months of
IV.A.1
continuous coverage
8 Financial Limits of The policy will pay only you to the limits specified hereunder for the
Coverage following diseases/procedures:
III.A.1.2.a
i.Sub-Limits i.a. Cataract
10% of Sum Insured subject to a maximum of Rs. 50,000/- per eye
b. Named Mental Illnesses 25% of Sum Insured subject to a maximum of
Rs. 3,00,000 per policy period for the following mental illnesses:
i. Schizophrenia (ICD - F20; F21; F25)
III.A.1.2.
ii . Bipolar Affective Disorders (ICD - F31; F34)
b
iii . Depression (ICD - F32; F33)
iv . Obsessive Compulsive Disorders (ICD - F42; F60.5)
v . Psychosis (ICD - F22; F23; F28; F29)
c. Pre-Hospitalisation and Post-Hospitalization Expenses:
III.A.2
10% of Sum Insured (Combined)

d. Road Ambulance:
i. 0.5% of the Sum Insured subject to a maximum of Rs. 2,500 per event
and III.A.6
ii. 1% of the Sum Insured subject to a maximum of Rs. 5,000 per policy
period
e. Health Check-Up
Up to 1% of average Sum Insured of preceding 3 policy years, subject to a
maximum of Rs. 5,000 per person for policies issued on individual sum III.A.7
insured basis/ Rs. 10,000 per policy period for policies issued on family
floater basis for a block of every three claim-free years.
ii.Co-payment ii. For persons with age of entry above 60 years in Family Medicare

7 / 12
 Policy, every admissible claim under Clauses III.A.1-III.A.7 of the policy
V.B.5
wordings shall be subject to a co-payment of 10% on the admissible claim
amount.
iii.Deductible iii .Deductible equivalent to Daily Cash Allowance for the first 24 hours
Hospitalization
iv.Any Other Limit iv. In-Patient Hospitalisation expenses
1% of Sum Insured per
• SI < 5 Lakhs:
day
1% of Sum Insured or III.A.1.i
Room Rent
Single Occupancy
• SI >= 5 Lakhs:
Standard AC Room III.A.1.ii
Charges
ICU/IC CU 2% of Sum Insured per
• SI < 5 Lakhs:
charges day
Proportionate Payment Clause:
In case of admission to a room at rates exceeding the aforesaid limits, the
payment of all associated medical expenses incurred at the Hospital shall III.A.1.1.i
be effected in the same proportion as the admissible rate per day bears to
the actual rate per day of Room Rent.
Turn Around Time (TAT) for claims settlement:
i. TAT for preauthorization of cashless facility 2 hours
ii. TAT for cashless final bill authorization 3 hours
Link for below: V.B.5
i. Network Hospitals details: https://ui ic.co.in/en/tpa - ppn-network-
9 Claims Procedure
hospitals
ii. Helpline number: https://uiic.co.in/en /tpa-ppnnetwork- hospi tals IV.B.11
iii. Excluded Providers:
https://uiic.co.in/sites/default/files/Excluded_Providers_List.pdf
iv. Downloading claim form: https://uiic.co.in/en/claims/claim-forms
Call service number of insurer: Please contact your Policy issuing office, Clause
details of which are mentioned in your Policy Schedule. Details of V.A.14
company officials: Please contact your Policy issuing office, details of
which are mentioned in your Policy Schedule.
In case of any grievance, you may contact UIIC through:
10 Policy Servicing
a. Website: www.uiic.co.in
b. Toll Free Number: 1800 425 333 33
c. E-Mail: customercare@uiic.co.in
d. You may also approach the grievance cell at any of our branches with
details of the grievance
In case of any grievance, you may contact UIIC through: Clause
a.Website: www.uiic.co.in V.A.14
b.Toll Free Number: 1800 425 333 33
c.E-Mail: customercare@uiic.co.in
d.You may also approach the grievance cell at any of our branches with
11 Grievance/Complaint details of the grievance
Alternatively, you may lodge a complaint at the IRDAI Integrated Grievance
Management System (https://igms.irda.gov.in/) OR approach the Office of
the Insurance Ombudsman in your respective Area/Region. Details of
Insurance Ombudsman offices have been provided as Annexure - 3 in the
Policy Wordings.
Free Look cancellation : You are allowed a period of 15 days from date
of receipt of the policy document to review its terms and conditions and to
return the policy if not acceptable to you. This is not applicable on
V.A.7
renewals.
If the Insured has not made any claim during the free look period, the
Insured shall be entitled to:

8 / 12
 i. A refund of the premium paid less any expenses incurred by the
Company on medical examination of the insured persons and the stamp V.A.7.i
duty charges or
ii. Where the risk has already commenced and the option of return of the
policy is exercised by the insured person, a deduction towards the V.A.7.ii
proportionate risk premium for period of cover or
iii. Where only a part of the insurance coverage has commenced, such
proportionate premium commensurate with the risk covered during such V.A.7.iii
period
Policy renewal: Except on grounds of fraud, moral hazard or
misrepresentation or non -cooperation, renewal of your policy shall not be V.A.15
denied, provided the pol icy is not withdrawn.
Migration: Insured Person has the option to migrate the policy to other
12 Things to remember
health insurance products/plans offered by UIIC by applying at least 30 V.A.8
days before the policy renewal date.
Portability: Insured Person has the option to port the entire policy to an
individual health insurance product offered by another Insurer by applying
V.A.12
at least 45 days before policy renewal date. Portability is subject to
underwriting.
Change in Sum Insured: Sum Insured can be changed
(increased/decreased) only at the time of renewal or at any times subject
to underwriting by the Company. For increase in S.I, the waiting period if V.B.3
any shall start afresh only for the enhanced portion of the sum
insured.
Moratorium Period: After completion of eight continuous years under the
policy no look back to be applied. This period of eight years is called as
moratorium period. The moratorium would be applicable for the sum
insured of the first policy and subsequently completion of eight continuous
V.A.9
years would be applicable from date of enhancement of sum insured only
on the enhancement limits. After the expiry of Moratorium Period no health
insurance policy shall be contestable except for proven fraud and
permanent exclusions specified in the policy contract
Please disclose all pre-existing disease/s or condi tion/s.
Policyholder is required to disclose all material information such as, but not
limited to, pre-existing diseases/conditions, medical history, etc. as sought Clause I
in the Proposal form and other connected documents. Non-disclosure, &
misrepresentation or misdescription of such information may result in claim Clause
13 Your Obligations
not being paid and shall make the policy void and all premium paid thereon V.A.5 &
shall be forfeited to UIIC. Clause
Nomination: Policyholder is required at the inception of the policy to V.A.11
make a nomination for the purpose of payment of claims under the policy in
the event of death of the Policyholder.
(Description is illustrative and not exhaustive)
Declaration by the Policy Holder

I have read the above and confirm having noted the details.

Place:
Date:
Signature of Policy Holder

Legal Disclaimer Note:The information must be read in conjunction with the policy document. In case of any
conflict between the CIS and the policy document, the terms and conditions mentioned in the policy shall prevail.

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 Benefit/Premium Illustration

Please note:
1. Premium rates specified in the illustrations below are standard premium rates exclusive of any loadings and
GST.
2. Rates shown below are for Zone A of FMP.

ILLUSTRATION

Illustration 1: Self, Spouse and 2 Dependent Children

Coverage opted
on Individual basis Coverage opted on Individual basis
Coverage opted on family floater
covering each covering multiple members of the family
basis with overall Sum Insured (Only
member of the under a single policy (Sum Insured is
one Sum Insured is available for the
Age of family separately available for each member of the
entire family)
Insured (at a single point in family)
Member time)
Premium
Sum Premium Sum Floater Sum
Premium Premium Discount, Premium after
Insured after Insured Discount Insured
(Rs.) (Rs.) if any (Rs.) discount
(Rs.) discount (Rs.) if any (Rs.)
(Rs.)
45 9,560 3,00,000 9,560 5% 9,082 3,00,000 9,560 25% 7,170
40 8,221 3,00,000 8,221 5% 7,810 3,00,000 8,221 25% 6,166
3,00,000
21 5,073 3,00,000 5,073 5% 4,820 3,00,000 5,073 25% 3,805
18 5,073 3,00,000 5,073 5% 4,819 3,00,000 5,073 25% 3,805
Total Premium for all
Total Premium for all members of the
members of the family is Rs. Total Premium when policy is opted
family is Rs. 26,531, when they are
27,927, when each member on floater basis is Rs. 20,945.
covered under a single policy.
is covered separately.
Sum Insured available for
Sum Insured available for each Sum Insured of Rs. 3,00,000 is
each individual is Rs.
individual is Rs. 3,00,000/- available for the entire family.
3,00,000/-

Illustration 2: Self and Spouse

Coverage opted
on Individual basis Coverage opted on Individual basis
Coverage opted on family floater
covering each covering multiple members of the family
basis with overall Sum Insured (Only
member of the under a single policy (Sum Insured is
one Sum Insured is available for the
Age of family separately available for each member of the
entire family)
Insured (at a single point in family)
Member time)
Premium
Sum Premium Sum Floater Sum
Premium Premium Discount, Premium after
Insured after Insured Discount Insured
(Rs.) (Rs.) if any (Rs.) discount
(Rs.) discount (Rs.) if any (Rs.)
(Rs.)
62 39,852 5,00,000 39,852 5% 37,859 39,852 25% 29,889
5,00,000 5,00,000
56 29,596 5,00,000 29,596 5% 28,116 29,596 25% 22,197
Total Premium for all
members of the family is Rs. Total Premium for all members of the
Total Premium when policy is opted
69,448, when each member family is Rs. 65,976, when they are
on floater basis is Rs. 52,086.
is covered separately. covered under a single policy.
Sum Insured of Rs. 5,00,000 is
Sum Insured available for Sum Insured available for each
available for the entire family.
each individual is Rs. individual is Rs. 5,00,000/-

10 / 12
 5,00,000/-

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 Policy No:0304812824P104565555
UIN. UIIHLIP20013V032021

UNITED INDIA INSURANCE COMPANY LIMITED

11/1 , FEEDER ROAD , MONDAL PARA, PO : TALPUKUR, BARACKPORE ,
NORTH TWENTY FOUR PARGANAS - 700123 WEST BENGAL
PH: (033) 25922405 FAX: EMAIL:
Premium Certificate for the purpose of deduction under Section 80-D of Income Tax (Amendment) Act,
1986.

This is to certify that MR SHAUKAT ALI has paid 18,485.00 ( Eighteen thousand four hundred eighty-five rupees only) towards Premium for FAMILY MEDICARE
POLICY for the period from 00:00 hrs On 01/07/2024 To Midnight of 30/06/2025

Policy No: 0304812824P104565555

For and On behalf of

United IndiaInsurance Co. Ltd.

Place: MO BARACKPORE 030481

Date:28/06/2024 3:03:38 PM

Authorised Signatory

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.

REGD. & HEAD OFFICE, 24, WHITES ROAD, CHENNAI - 600014

Website: http://www.uiic.co.in, Email - info@uiic.co.in

This is a system generated document and any manual alteration / correction / overwriting in the document will make it invalid.

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