THE NEW INDIA ASSURANCE CO. LTD.
(Government of India Undertaking)
New India Mediclaim Policy
NIAHLIP25040V082425
Policy Schedule
Policy No 17010034249500003452 Policy Period From:28/03/2025 05:03:21 PM
To:27/03/2026 11:59:59 PM
Policy Term(Duration) 1 Previous Policy Period 24-MAR-24 to 23-MAR-25
Previous Policy No 17010034239500003653
Policyholder's Details
Policyholder Name MR. SANJAY BALKRISHNA GAWALI Customer ID 1H3406219
PAN Card No AIZPG0499E
Zone ZONE I - Maharashtra and Gujarat Mobile No/Phone No XXXXXX8723
Policyholder's address FLAT NO. A-3, CHABHAIYYA CHS., Email id
[email protected],
KAPUR BAWDI, OPP-BALKUM FIRE
STATION, THANE DIST. : THANE,
MAHARASHTR
SANDOZBAUG ,MAHARASHTRA,
400607
Name of the Nominee MRS VENU GAWALI
Relation with the Policy SPOUSE
holder
GSTIN NA
Policy Issuing Office and Intermediary Details
Office Name and Code THE NEW INDIA ASSURANCE CO. LTD. Office Contact No 25496403 / 25408770
(DO) (170100)
Office Email Id [email protected] Development Officer Mrs. MRS. VAISHALI KONDAJI
(2D5612657)
Name of the MS. SADHANA SHAH
Agent/Intermediary (NIA2D5612479)
Office Address B/201, PINAK GALAXY, Contact No. of 9819466356 / 9930998535
OPP. BIG BAZAR, KAPURBAWDI Agent/Intermediary
JUNCTION,
MAJIWADE, THANE (W.),400607
E-mail id of Intermediary [email protected],
[email protected],
Regional Office MUMBAI RO-V (170000) GSTIN 27AAACN4165C3ZP
Regional Contact No NA SAC 997133 (Accident and health insurance
services)
Details Of TPA (Notice or Communication to be given in respect of claim)
Name of the TPA MEDI ASSIST INSURANCE TPA PVT.
LTD.
Email-id of the TPA Address of the TPA MEDI ASSIST INDIA TPA PVT. LTD.,
[email protected] TOWER D, FOURTH FLOOR,,IBC
KNOWLEDGE PARK, 4/1,
BANNERGHATTA ROAD,,BANGALORE
Toll Free / Contact No of
the TPA / 8049698000
Fax of TPA 18004259559
Highlights of New India Mediclaim Policy*
* Automatic reinstatement of Sum Insured for 5 Lakhs Sum Insured & above. * Room rent and ICU Charges at 1% and 2% of Sum Insured per day
respectively.
* Health Check Up for every block of 3 claim free years up to a * Hospital Cash up to 1% of Sum Insured.
maximum of ` 5,000/-.
* Day one baby cover. * Ambulance charges up to 1% of Sum Insured.
* Cumulative Bonus 25% SI for claim free year. * Midterm inclusion of newly married spouse.
* Optional Cover I: No Proportionate Deduction. * Cataract claims, up to 20% of Sum Insured or ` 50,000 whichever
less, for each eye.
Signature Not
Verified
Digitally signed
by DHIRAJ
KUMAR
Date: 2025.03.28 Policy
No. : 17010034249500003452Document generated by QR_RENEWAL at 28/03/2025 18:01:39 Hours.
18:01:13 IST
Regd. & Head Office: New India Assurance Bldg., 87 M.G. Road, Fort, Mumbai - 400 001. TOLL FREE No. 1 800 209 1415.
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Page 1 of 7
THE NEW INDIA ASSURANCE CO. LTD.
(Government of India Undertaking)
* Optional Cover II: Maternity Expenses Benefit for Sum Insured 5 * Ayurveda/ Yoga and Naturopathy/ Unani/Siddha and Homeopathy
Lakhs and Above. system of medicines are covered up to 100 % of the Sum Insured.
* Optional Cover III: Revision in Limit of Cataract (For 8 Lakhs & above * For Pre Existing Diseases Waiting period is 36 Months
Sum Insured).
* Optional Cover IV: For a Voluntary Co-Pay of 20% - (15% discount on * For specified diseases waiting period is 24 months
premium).
* Optional Cover V: For Non-Payable Items * Please refer to policy document for detailed terms and conditions.
Important
*1.Date of Inception of first policy is the date from which the policyholder has been continuously obtaining health insurance cover in
India from any of the insurers without break subject to portability guidelines.
2.Enhanced Sum Insured under the policy will be subject to policy clauses 4.1,4.2 and 4.3
3. PED and specified diseases waiting periods for each of the merged policy shall be reckoned as per its date of inception of first policy.
* Please visit https://www.newindia.co.in for the list of network hospitals providing cashless facility. If network hospital is not
available in your city/location, please contact the concerned TPA." You are also requested to share your policy details when
you visit the network hospital.
Insured Persons details (Cumulative Bonus is applicable for more than 1 L Sum Insured persons.)
S. No Name of the insued Date of Gender Relation ABHA ID(if any) Sum Cumu *Date of inception Pre Existing Disease
(Member ID) birth(Age) insured lative of first policy
Bonus
1 Mr. Sanjay 05/01/196 M Proposer NA 300000 750 24/03/2009 ( NA ),NA
Balkrishna 2(63) 00
Gawali(1H3406
219)
2 Mrs. Venu 26/12/196 F Spouse NA 200000 100 24/03/2009 ( NA ),NA
Gawali(1H3475 9(55) 000
564)
3 Miss. Aishwarya 06/08/199 F Children NA 200000 100 24/03/2009 ( NA ),NA
Gawali(1H3441 7(27) 000
563)
Cumulative Bonus Details
S. No Member ID Sum Insured CB percentage CB Amount
1 1H3406219 300000 25 75000
2 1H3475564 200000 50 100000
3 1H3441563 100000 50 50000
3 1H3441563 100000 50 50000
Any claim arising out of illness contracted or injury sustained or Hospitalization commencing in the break period i.e. from 23-
MAR-25 to 28-MAR-25 will not be admissible under this policy.
Optional Cover Table
Policy Level - Optional Cover - 1 Not Opted Member Level - Optional Cover - III Not Opted
(No Proportionate Deduction) for 2L SI & (Revision in Cataract Limit)
above
Member Level - Optional Not Opted Policy Level - Optional Not Opted Member Level - Optional Not Opted
Cover - II Cover - IV Cover V (For Non-Medical
(Maternity Benefit) (Voluntary Co-pay of 20%) Items)
Modern Treatment Rider Not Opted
Premium Details
Sl. No. Name of Basic Premium Premium Premium Discount Premium Premium Discount Total
Insured Premium for for for for for for Premium
Optional Optional Optional Optional Optional Modern
Cover I Cover II Cover III Cover IV Cover V Treatment
Rider
1 MR. 27682 0 0 0 0 0 0 0 27682
SANJAY
BALKRIS
HNA
GAWALI
Policy No. : 17010034249500003452Document generated by QR_RENEWAL at 28/03/2025 18:01:39 Hours.
Regd. & Head Office: New India Assurance Bldg., 87 M.G. Road, Fort, Mumbai - 400 001. TOLL FREE No. 1 800 209 1415.
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Page 2 of 7
THE NEW INDIA ASSURANCE CO. LTD.
(Government of India Undertaking)
2 MRS. 15884 0 0 0 0 0 0 0 15884
VENU
GAWALI
3 MISS. 5516 0 0 0 0 0 0 0 5516
AISHWAR
YA
GAWALI
Total Gross 49082
Premium(Without
GST)
CGST(@9%) 4417
SGST(@9%) 4417
Net Premium in Words(RUPEES FIFTY-SEVEN THOUSAND NINE HUNDRED SIXTEEN ONLY) IGST 0
Total GST 8834
Net Premium(With 57916
GST)
Previous Year Policy Details
Sl. No. Previous Policy Name of From Date To Date Sum Insured CB Amount Pre-existing
No Insured Diseases
1 170100342295 MR. SANJAY 24/03/2023 23/03/2024 300000 150000 N
00004181 BALKRISHNA
GAWALI
2 170100342295 MRS. VENU 24/03/2023 23/03/2024 200000 100000 N
00004181 GAWALI
3 170100342295 MISS. 24/03/2023 23/03/2024 200000 100000 N
00004181 AISHWARYA
GAWALI
4 170100342395 MR. SANJAY 24/03/2024 23/03/2025 300000 150000 N
00003653 BALKRISHNA
GAWALI
5 170100342395 MRS. VENU 24/03/2024 23/03/2025 200000 100000 N
00003653 GAWALI
6 170100342395 MISS. 24/03/2024 23/03/2025 200000 100000 N
00003653 AISHWARYA
GAWALI
*This Policy is subject to terms and conditions of New India Mediclaim.
In WITNESS WHEREOF,the undersigned being duly authorized by the Insurers and on behalf of the Insurers has(have) hereunder set
his/her(their) hand(s) on this 28th day of March 2025.
at ______________ this _______________ day of _______________ 20
Date of Issue: 28/03/2025
(Mr. Kaustubh M. Kulkarni)
[Chief Business Mgr.]
FOR AND ON BEHALF OF
THE NEW INDIA ASSURANCE COMPANY LIMITED
DULY CONSTITUTED ATTORNEY(S)
Policy No. : 17010034249500003452Document generated by QR_RENEWAL at 28/03/2025 18:01:39 Hours.
Regd. & Head Office: New India Assurance Bldg., 87 M.G. Road, Fort, Mumbai - 400 001. TOLL FREE No. 1 800 209 1415.
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Page 3 of 7
THE NEW INDIA ASSURANCE CO. LTD.
(Government of India Undertaking)
Policy No. : 17010034249500003452Document generated by QR_RENEWAL at 28/03/2025 18:01:39 Hours.
Regd. & Head Office: New India Assurance Bldg., 87 M.G. Road, Fort, Mumbai - 400 001. TOLL FREE No. 1 800 209 1415.
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Page 4 of 7
THE NEW INDIA ASSURANCE CO. LTD.
(Government of India Undertaking)
Insurer Office Code : THE NEW INDIA ASSURANCE CO. LTD. (DO)
(170100)
Address : B/201, PINAK GALAXY,
OPP. BIG BAZAR, KAPURBAWDI JUNCTION,
MAJIWADE, THANE (W.),400607
Telephone : 25496403 / 25408770
Fax : 25423121
New India Mediclaim
PREMIUM CERTIFICATE FOR THE PURPOSE OF DEDUCTION UNDER SECTION 80 D OF INCOME TAX ( AMENDMENT ) ACT 1986
This is to certify that Mr./Mrs. MR. SANJAY BALKRISHNA GAWALI has paid ` 57916 towards premium for New India Mediclaim
for the period 28/03/2025 05:03:21 PM to 27/03/2026 11:59:59 PM
Policy no. : 17010034249500003452
Receipt no. & date : 10000089240301141005
28/03/2025
Date of Issue: 28/03/2025
(Mr. Kaustubh M. Kulkarni)
[Chief Business Mgr.]
Authorized Signatory For and on behalf of
The New India Assurance Company
Limited
(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)
Policy No. : 17010034249500003452Document generated by QR_RENEWAL at 28/03/2025 18:01:39 Hours.
Regd. & Head Office: New India Assurance Bldg., 87 M.G. Road, Fort, Mumbai - 400 001. TOLL FREE No. 1 800 209 1415.
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Page 5 of 7
THE NEW INDIA ASSURANCE CO. LTD.
(Government of India Undertaking)
IMPORTANT
This policy is subject to the terms and conditions contained in the policy document (Clauses).
This policy is governed by Health Insurance Regulations 2024 issued by Insurance Regulatory
Development Authority of India on 20.03.2024.
This policy is also governed by IRDAI (Protection of Policyholders' Interest) Regulations, 2024 and Master
Circular on Health Insurance Business 2024 by IRDAI.
This Schedule comes attached with the policy document (Clauses). If not attached, please ask for the
same.
Health Insurance Regulation 2024, IRDAI (Protection of Policyholders' Interest) Regulations, 2024 and
Master Circular on Health Insurance Business 2024 are available on the website of IRDAI.
Beware of spurious calls offering alluring benefits. Never share any policy details with unknown callers.
Call 1800-209-1415 for any enquiry or contact the nearest operating office of New India Assurance Co Ltd.
QR code for PPN HOSPITAL QR CODE FOR TERMS AND CONDITIONS
List of PPN Hospitals In case of requirement of printed copy of terms and
conditions, please contact our business office
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.
Tax Invoice No : 17010024P0021716
Policy No. : 17010034249500003452Document generated by QR_RENEWAL at 28/03/2025 18:01:39 Hours.
Regd. & Head Office: New India Assurance Bldg., 87 M.G. Road, Fort, Mumbai - 400 001. TOLL FREE No. 1 800 209 1415.
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Page 6 of 7
THE NEW INDIA ASSURANCE CO. LTD.
(Government of India Undertaking)
IRDA Registration Number: 190
NIA PAN NUMBER: AAACN4165C
Policy No. : 17010034249500003452Document generated by QR_RENEWAL at 28/03/2025 18:01:39 Hours.
Regd. & Head Office: New India Assurance Bldg., 87 M.G. Road, Fort, Mumbai - 400 001. TOLL FREE No. 1 800 209 1415.
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Page 7 of 7
