Mrs.

SONAM MAHAJAN
T 17/521 OPP GHORA PEER DARGAH
INSIDEGATE KHAZANA - 143001
Mobile No: ******3736

Certificate of Insurance(COI) -Health Plus

Certificate of Insurance(COI) - Health Plus

Policy Number 50455600202401 PolicyHolder Name Bandhan Bank
Policyholder Address & DN 32 Salt Lake City Sector V Kolkata Policy Issue date 30/06/2024
Pincode WEST BENGAL 700091
Certificate Number 203500265601
Proposer Name Mrs. SONAM MAHAJAN
Current Policy Start Date and Time 03/08/2024 12:00 AM
Proposer Address & Pincode T 17/521 OPP GHORA PEER
DARGAH INSIDEGATE
KHAZANA - 143001
Current Policy End Date and Time 02/08/2025 11:59 PM Contact Number ******3736
Previous Year Policy Policy Inception Date Jul 24 2019 12:00AM
2809204805903900
Insured details

Certificate No. Salutation Insured Name Date of Birth/ Age Gender Relationship Sum Insured NCB
203500265601 Mrs. SONAM MAHAJAN 16/06/1989 F Self
203500265604 Miss SUNISHTHA MAHAJAN 22/09/2013 F Daughter INR 500000 With INR 0 Deductible 50000
203500265603 Mr. SATVIK MAHAJAN 12/02/2015 M Son
203500265602 Mr. SAZZID MAHAJAN 29/11/1987 M Spouse
Nominee details

Nominee Name Relationship Nominee Address (if different) Appointee Details(if nominee is minor)
SAZZID MAHAJAN Spouse

Benefit Structure

Base Sum Insured 500000

In-patient Treatment Up to Base Sum Insured

Hospital accommodation- Room Rent/day 1% of base sum insured

Hospital accommodation- ICU/day 2% of base sum insured

Day Care Treatments Listed 536 treatments Covered up to Base Sum Insured

Pre-Hospitalization Medical expenses Up to Base Sum Insured 90 Days

Post-Hospitalization Medical expenses Up to Base Sum Insured 180 Days

e-Consultation Within Network Provider only

Domiciliary Hospitalization Up to Base Sum Insured

Organ Transplant Up to Base Sum Insured

Modern Treatment Up to Base Sum Insured as per T&C

Alternative treatments Up to Base Sum Insured

No Claim Bonus/ Cumulative Bonus 10% per annum for every claim free year Up to 100% of Base Sum Insured

Emergency Ground Ambulance- Within India (one transfer per Hospitalization) INR 2000 per Hospitalization
Up to 4.5L: Up to INR 10,000 per delivery , Maximum 2 delivery/termination (36 months
waiting period)
Maternity 5L and Above: Up to INR 25,000 per delivery , Maximum 2 delivery/termination (36
months waiting period)

With Copay
Plan Type

Co-Payment 15% co-payment on each claim if plan type opted as "With Copay"

Waiting Periods
[Waiting period is applicable since the inception of the original policy and not from date of porting]

Initial Waiting Period Waved

Waiting Period for Disease Specific Exclusions 12 months

Pre-Existing Disease (PED) Waiting Period 24 Months

Free Look Period 30 days

Intermediary Details
Intermediary Name Bandhan Bank Ltd
 Intermediary Code BNK0180001

Intermediary Contact No 018002588181

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. :

Premium Details

Net Gross Premium(Rs.) CGST(0.00%) SGST/UTGST(0.00%) Premium

IGST(18.00%) Premium(Rs.) Gross Premium(Rs.) (in words) frequency

12610.00 0.00 0.00 2269.83 14880 Fourteen Thousand Eight Hundred Eighty 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 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 Policy.
Goods and Service Tax Registration No.: 09AAFCM7916H1Z6
The cover may be renewed on sole discretion of Niva Bupa Health Insurance Co Ltd subject to member being the part of renewal also.
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 reach Us on Insta Assist
Policy member with "Self" relationship type is the proposer of the policy. All other member or Nominee relationship type are w.r.t. the buyer of the policy. This will not have any implication in exercising the policy for claims

Location: Noida, Uttar Pradesh

Date: 09/07/2025

Director - Operations & Customer Service

For and on behalf of Niva Bupa Health Insurance Co.Ltd.
(Formerly known as Max Bupa Health Insurance Co.Ltd.)