Mr.
SHYAM SUNDER DASS
S/O MAHANANDA GIAN
GEETA BHAWAN ROAD
NEAR KUMAR OPTICAL, SUNAM, SANGRUR, PUNJAB
148028
Mobile No: XXXXXX5716
Certificate of Insurance (COI) - Health Plus
How to reach us?
Website Online Renewal
www.nivabupa.com It takes a few minutes to renew your policy Log on to
www.nivabupa.com/renew
Customer Helpline No. Like us on Facebook
1860-500-8888
Customer Services Follow us on twitter
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Important Terms & Conditions (T&C)
a. Niva Bupa requests you to refer to the detailed Terms and Conditions (T&C) available with the Group Master Policyholder.
You may also refer the T&C on our website.
b. Free Look Provision: You can review the T&C within the number of days specified overleaf and request cancellation of the
Certificate of Insurance in case of objections to any T&C. We will refund the premium as specified in the T&C provided that
no claim has been registered under the cover.
c. Grievances Redressal In case of any query or complaint/grievance, you may approach our office at the below mentioned
address. In case you are not satisfied with our resolution, You ,may register a complaint in the Integrated grievance
Management System (IGMS) of IROAI or approach the Insurance Ombudsman. Details about the IGMS and Ombudsman
are available on our website.
Certificate of Insurance (COI) - Health Plus
Group Master Policy Number 51148400202400 Group Master PolicyHolder's Name Bajaj Finance Ltd.
Group Master Policyholder's 4th Floor, Viman Nagar, Finserv Off Group Master Policy Issue date 30/12/2024
Address & Pincode Pune - Ahmed Nagar Road,
Pune – 411014, Maharashtra
Certificate Number 113014147713 Proposer’s Name Mr. SHYAM SUNDER DASS
Cover Inception Date and Time 01/07/2025 12:00 AM Proposer’s Address & Pincode S/O MAHANANDA GIAN GEETA
BHAWAN ROAD NEAR KUMAR
OPTICAL, SUNAM, SANGRUR,
PUNJAB SANGRUR PUNJAB -
148028
Cover Expiry Date and Time 30/06/2026 11:59 PM Contact Number XXXXXX5716
Policy Tenure 12 Months
Insured Name(s) Certificate no Date of Birth/ Age Gender Relationship with proposer Sum Insured (in Rs)
Mr. SHYAM SUNDER DASS 113014147713 01/05/1972 M Self 74,000
Nominee Name Relationship Nominee Address (if different) Nominee Contact Details Appointee Details (if nominee is minor)
Moumita maty Sister Same as insured Same as insured NA
1 In-patient treatment
(i) Surgical operations, including pre and post-operative care
(ii) Nursing care, drugs and surgical dressings
(iii) Doctors’ fees
(iv) Operation theatre charges Covered up to Sum Insured
(v) Diagnostic Procedures and therapies
Prosthetic and other devices or equipment if implanted internally
(vi)
during a surgical operation
2 Hospital Accommodation
(i) Hospital Accommodation (Room Rent/per day) 2% of Sum Insured
(ii) Hospital Accommodation (ICU/per day) Double of Room rent/day
Pre and Post Hospitalization Medical Expenses (including Medical
3 Practitioner's consultation, diagnostics tests, medicines, drugs and Covered up to Sum Insured (30 days/60 days)
consumables)
4 All Day Care Treatments Covered up to Sum Insured
5 Organ Transplant when medically necessary Covered up to Sum Insured
6 Emergency Ground Ambulance Up to Rs 1,000 per hospitalization
10 Sub-limit on specified illness/conditions Applicable
11 Co-payment 20% on each claim
12 Domiciliary Treatment up to 10% of Sum Insured
Waiting Period
Initial Waiting Period 30 Days
Specific Disease Waiting Period Waived
Pre-Existing Disease (PED) Waiting Period 36 Months
Free Look Period 30 Days
Intermediary Details
Intermediary Name Intermediary Code Intermediary Contact No
Bajaj Finance Ltd. CA00070001 02039575152
GST Details:
GSTI No.: 09AAFCM7916H1Z6 SAC Code / Type of Service : 997133 / General Insurance Services
Niva Bupa State Code : 09 Customer State Code / Customer GSTI No. : 03 / NA
Premium Details:
Net CGST SGST/UTGST IGST Gross Gross Premium (Rs.) (in words) Premium
Premium (0.00%) (0.00%) (18.00%) Premium frequency
(Rs.) (Rs.)
678.00 0.00 0.00 122.03 800.00 Eight Hundred Only Single
Income tax benefit u/s 80D is available as per the existing Income Tax Laws. Please consult your tax advisor for more details.
This Policy is subject to the terms, conditions and exclusions mentioned in the HEALTH PLUS, UIN: NBHHLGP22157V032122
The contract will be cancelled ab intio in case; the consideration under the policy is not realized.
Policy issuing office : Delhi , Consolidated Stamp Duty deposited on the Master Policy.
Goods and Service Tax Registration No.: 09AAFCM7916H1Z6
Pursuant to Notification no 13/2020– Central Tax and Notification no 14/2020– Central Tax both dated 21st March 2020 read with rule 54 (2) of
CGST Rules 2017, the provisions of E Invoicing & QR code are not applicable to an Insurance company, hence E Invoice number and QR code has
not been printed on this document. GST under RCM: NIL
The cover may be renewed on sole discretion of Niva Bupa Health Insurance Co Ltd subject to member being the part of the group at the time of
renewal also. In case You cease to be a member of the group, the cover will stand cancelled as per T&C of the policy
Where the proposal form is not received, information obtained from insured, whether orally or otherwise, is captured in the policy document.
Discrepancies, if any, in the information contained in the policy document may be pointed out by an insured within 30 days from the policy issue
date after which information contained in the policy document shall be deemed to have been accepted as correct.
For registration of claims You may contact us at:
Claims Department, Niva Bupa Health Insurance Company Limited, 2nd Floor, Plot No D-5, Sector 59, Noida, Gautam Budhnagar – 201301 Fax No.:
011-3090-2010 Or Email us through our service platform https://rules.nivabupa.com/customer-service/com
For the list of recognized / un-recognized hospitals, kindly refer to the link https://rules.nivabupa.com/hospital-network/
Location: Noida, Uttar Pradesh
Director - Operations & Customer Service
Date: 02/07/2025
For and on behalf of Niva Bupa Health Insurance Co. Ltd.
(Formerly known as Max Bupa Health Insurance Co. Ltd.)
Procedure Amount
Appendicectomy 32000
Cataract per eye including Cost of Lens 18000
Cholecystectomy 26000
Hernioplasty/Herniorraphy- Unilateral including cost of mesh and tacker 32000
Hernioplasty/Herniorraphy- Bilateral including Cost of mesh and tacker 37000
Hydrocele 18000
Hysterectomy (Abdominal/Vaginal) 40000
Total Knee Replacement (Unilateral) including cost of implants 72000
Total Knee Replacement (Bilateral) including cost of implants 109000
Hip Replacement (Unilateral) including cost of implants 72000
Hip Replacement (Bilateral) including cost of implants 109000
Arthroscopic Surgery ( Other Than ACL / Menisectomy) 29000
Haemorrhoidectomy including Cost of stapler 29000
PCNL- Unilateral 37000
PCNL- Bilateral 43000
Valve Replacement including cost of implants 145000
Temporary Pacemaker Implantation including cost of temporary pacemaker 14000
Angioplasty including cost of implants and angiography 109000
CABG 1,45,000
Terms & Conditions
Some key features applicable for persons covered by the Policy (“Primary 2. For cashless Hospitalization We will make the payment of the amounts
Insured”) are provided herein. Niva Bupa Health Insurance Company Limited assessed to be due directly to the Network Hospital. In case the
(“We/Us/Our”) requests You to refer to the detailed terms and conditions of Primary Insured is covered under the Co-payment clause, We would
the Policy provided in Policy Document available with Bajaj Finance. In the pay the final bill as assessed and approved by Us, to the Network
event of any conflict between the features mentioned herein and the terms Hospital, net of the applicable Co-payment applied to the approved
and conditions of the Policy Document, the later shall prevail. amount. The balance amount and other inadmissible costs will be borne
by the Primary Insured and paid directly by the Primary Insured to the
Benefits Network Hospital.
a. In-patient Treatment: Medical Expenses for Doctor’s fees, diagnostic
b. Out-Of-Network Hospitals & All Other Claims for Reimbursement:
procedures, medicines, drugs and consumables, operation theatre
1. In all Hospitalizations which have not been pre-authorized, We
charges, intensive care unit, intravenous fluids, blood transfusion,
must be notified in writing within 48 hours of the Primary
injection administration charges, the cost of prosthetics and other
Insured’s admission to the Hospital or before the Primary
devices or equipment if implanted internally during a Surgical
Insured’s discharge from the Hospital, whichever is earlier. The
Procedure.
notification should be provided by the Primary Insured. In the
b. Hospital Accommodation: Reasonable charges for Hospital and
event the Primary Insured is unable to provide the notification due
Intensive Care Unit accommodation.
to ill health, then the notification should be provided by an
c. Pre & Post Hospitalization Medical Expenses: Medical Expenses
immediate adult member of the Primary Insured’s family.
incurred due to Illness immediately before Primary Insured’s
2. For any Illness or Accident or medical condition that requires
admission and after an Primary Insured’s discharge from a Hospital.
Hospitalization, the Primary Insured shall deliver to Niva Bupa the
d. Day-Care Procedures: Medical Expenses for Day-Care Procedures
claims documents, at his own expense, within 15 days of the
where such procedures are undertaken by an Primary Insured in a
Primary Insured's discharge from Hospital (when the claim is only
Hospital requiring stay for a continuous period of less than 24 hours.
in respect of post-hospitalization, within 15 days of the completion
Any procedure undertaken on an out-patient basis in a Hospital will not
of the post-hospitalization)
be covered
3. For any medical treatment taken from an Out-Of-Network Hospital
e. Organ Donor: Medical Expenses for an organ donor’s treatment for
We will only pay Medical Expenses which are Reasonable
harvesting of the organ.
Charges. Delayed payments shall attract interest as per
f. Emergency Ground Ambulance: Ambulance expenses incurred to
applicable regulations.
transfer the Primary Insured following an Emergency to the nearest
c. In all cases:
Hospital by surface transport.
1. We reserve the right to call for:
g. Sub-limit on specified illness or conditions: If opted, coverage for
i. Any other documentation or information that We believe
specified illness or conditions would be restricted to specified sub-
may be required; and
limits.
ii. A medical examination by Our doctor or for an investigation
h. Domiciliary Hospitalization: Medical Expenses upto the limit specified in
as often as We believe this to be necessary. Any expenses
Certificate of Insurance for Medically Necessary treatment taken at
related to such examinations or investigations shall be borne
home if the condition for which treatment is taken would otherwise have
by Us.
necessitated Hospitalisation as long as either (i) the attending Medical
2. In the event of the Primary Insured's death during Hospitalization,
Practitioner confirms that the Insured Person could not be transferred
written notice accompanied by a copy of the post mortem report
to a Hospital or (ii) the Insured Person takes treatment at home on
(if any) shall be given to Us within 14 days regardless of whether
account of non availability of room in a hospital. Secondly, the
any other notice has been given to Us. We reserve the right to
treatment continues for at least 3 consecutive days.
seek an autopsy.
Copayment d. All claims are to be notified to Us within timelines as mentioned above.
a. For all Primary Insureds, We will pay only the balanced proportionate In case where the delay in intimation is proved to be genuine and for
percentage of any amount We assess for payment or reimbursement in reasons beyond the control of the Primary Insured or Nominee
respect of any claim under the Policy made by a Primary Insured. specified in the Schedule of Insurance Certificate, We may condone
such delay and process the claim, We reserve the right to decline such
Waiting Periods requests for claim process where there is no merit for a delayed claim.
a. Pre-Existing Diseases: Benefits will not be available for Pre-Existing e. If You hold an indemnity policy with Us, a single notification for claim
Diseases until 36 months months of continuous coverage have elapsed will apply to both the indemnity plan as well as any other Policy.
from the date of commencement of coverage for the Primary Insured. f. For registration of claims You may contact us at:
b. Waiting Period : 30 days We will not cover any treatment taken during Claims Department
the first 30 days since the date of commencement of coverage for the Niva Bupa Health Insurance Company Limited,Logix Infotech Park, Plot
Primary Insured, unless the treatment needed is the result of an no D-5, Sector 59, Noida, Gautam Budh Nagar, Uttar Pradesh 201301
Accident or Cardio or Neurological Emergency. Fax: +91 11 30902010
Claims Procedure
In respect of any claim helpline no :1860-500-8888
a. Cashless Hospitalization Facility for Network Hospitals: Or Email us through our service platform
1. The Primary Insured should notify Niva Bupa in writing at https://rules.nivabupa.com/customer-service/
least 72 Hours before a planned Hospitalization. In an
Emergency the Primary Insured (or person on behalf of the
Primary Insured) should notify Us in writing within 48 hours
of Hospitalization; and
Disclaimer - We would like to inform you that the name of Max Bupa Health Insurance Company Limited (“Our Company”) has changed to Niva Bupa
Health Insurance Company Limited effective from 5th July 2021. In this context, the name of the product bought by you has changed from “Max Health
Plus” to “Health Plus” (“Product”). We further state that the changes in name of Our Company along with Product name does not alter any Product
benefits. We would like to reiterate that our core ideology and brand ethos remain unchanged. As we progress on our brand transition journey, we will
stand by the promises made to you at all times and you will continue to enjoy all benefits.
