AB AROGYADAAN

Simple 4 Step Process 1. Print this proposal form front & back sides in quadruplicate 2. Fill up the proposal form completely 3. Affix photograph of each member on the Original Proposal form 4. Handover the Proposal Form at the branch along with the premium amount.

United India Insurance Co.Ltd Bancassurance Division 3-5-817& 818, United India Towers Basheerbagh, Hyderabad 500 029.

Andhra Bank Head Office 5-9-11, Saifabad Hyderabad 500 004

AB AROGYADAAN GROUP MEDICLAIM INSURANCE PROPOSAL FORM FOR ANDHRA BANK ACCOUNT HOLDERS 1) Name of the Branch & Zone Branch Code No. _____________________ 2) Account Number_____________________ 3) Name of the Proposer (Main A/c holder only) ___________________________________________________________ 4) Postal Address __________________________________________________________________________________ _________________________________________________________________________________________________ E.mail Id __________________________________ Mobile Number _____________________ Telephone No._________ 5) Name and Address of Medical Practitioner / Family Doctor ________________________________________________ 6) Period of Insurance : From ____________ To _________________ (It starts from the day of BA Number for the premium paid / Debited / and it will be in force for one year) 7) a) Sum Insured per family Rs. 1,00,000 / 1,50,000 / 2,00,000 / 2,50,000 / 3,00,000 / 3,50,000 / 4,00,000 / 4,50,000 / 5,00,000 b) Plan opted : Plan I / Plan II (Parents of the proposer are covered under Plan II only) 8) Premium Rs. ________________ Paid by Cheque / Cash / Debited to A/c No ___________________ Date _________ 9) Member Details:Name of the Insured Person Existing Disease / Illness / Injury Treatment received for the past 3 years Age Signature of the proposer / Member

S. No 1 2 3 4 5 6

Relation

Sex

10) Photographs of the Insured Persons (Photo to be pasted on Original only) Account Holder Spouse Child 1 Child 2 Father Required to be affixed only if opted for Plan II Mother Required to be affixed only if opted for Plan II

I hereby declare and warrant that the above statements are true and complete. I & my family members are maintaining good health subject to item no. 9. I have read the salient features of the policy overleaf and willing to accept the coverage subject to the terms, conditions and exclusions prescribed by the Insurance Company as per the Agreement between Andhra Bank and United India Insurance Company Limited. I / We understood that in case of any claim under the Policy Andhra Bank will not undertake any responsibility or will not accept any correspondence and the same have to be pursued with the Insurance Company / Specified TPA only. I request you to renew the policy every year on due date duly debiting my account until further notice in writing to the contrary. I am aware that the Policy will be renewed basing on premium rates, terms & conditions prevailing at the time of renewal effective from the date of payment of premium. Place: Date: Signature of Proposer

For Office Use Only

Premium remitted by BA ________________ Dated _____________________ for Rs. ____________________________

Date _______________

Signature of the Branch Manager

Original with Photos & 1st copy along with BA Number to be sent to United India Ins. Co. Ltd., 2nd Copy to be with Branch, 3rd Copy to Account holder.

SALIENT FEATURES OF AB AROGYADAAN MEDICLAIM POLICY 1. The policy covers reimbursement of Hospitalisation expenses for the illness / diseases contracted or injury sustained by the Insured Person. In the event of any claim becoming admissible under policy, the company will pay through TPA to the Hospital / Nursing Home or the insured person the amount of such expenses as would fall under different heads mentioned below, as are reasonably and necessarily incurred thereof by or on behalf of such Insured Person, but not exceeding the Sum Insured in aggregate mentioned in the schedule during one period of Insurance towards the following expenses :
a) Room, Boarding and Nursing Expenses : Not exceeding 1% of Sum Insured per day or actual amount incurred whichever is less

b) ICU expenses : Not exceeding 2% of Sum Insured per day or actual amount incurred whichever is less.

c)

Hospitalization Expenses : Expenses in respect of specified illnesses to be restricted as detailed below:

LIMITS FOR EACH HOSPITALISATION 10% of SI subject to maximum of Rs.25,000/15% of the SI subject to maximum of Rs.30,000/20% of the SI subject to maximum of Rs.50,000/80% of the SI subject to maximum of Rs.4 Lac

Hospitalisation Benefits
a. b. c. d. Cataract Hernia Hysterectomy / Myomectomy Following Specified major surgeries i. Cardiac Surgeries ii. Cancer Surgeries iii. Brain Tumor Surgeries iv. Pacemaker implantation For sick, sinus syndrome v. Hip replacement vi. Knee joint replacement Pre & Post Hospitalization in respect of any illness In respect of persons above 60 years a. b. c. d.

--Actual expenses subject to maximum of 10% of Sum Insured. 20% will be deductible on all admissible claims

d) Surgeon, Anesthetist, Medical Practitioner, Consultants, Specialists Fees e) Anesthetist, Blood, Oxygen, Operation Theatre Charges, surgical appliances, Medicines & Drugs, Diagnostic Materials and X-ray, Dialysis, Chemotherapy, Radiotherapy, Artificial Limbs, cost of prosthetic devices implanted during surgical procedure like Pacemaker, relevant laboratory diagnostic tests, etc & similar expenses.
2. Insured can visit Corporate Hospitals only in case of Critical illness (like Coronary artery disease, Cerebro Vascular Accident, Chronic renal failure, Multiple Sclerosis, Multiple Fractures, Knee and Hip replacement) or Surgery. For other aliments facilities at non-corporate hospitals only may be utilized. However, the policyholder can visit any hospital in which case claims will be restricted to 70% in respect of hospitalization for normal aliments in Corporate Hospital. 3. Expenses on Hospitalization less than a minimum period of 24 hrs are not admissible. However, this time limit is not applied to specific treatment ie. Dialysis, Chemotherapy, Radiotherapy; Eye Surgery, Dental Surgery, Lithotripsy (Kidney Stone removal), D & C, Tonsillectomy taken in the Hospital / Nursing Home where the Insured is discharged on the same day, the treatment will be considered to be taken under hospitalization Benefit. This condition will also not apply in case of stay in hospital of less than 24 hours provided a) The treatment is such that it necessitates hospitalization and the procedure involves specialized infrastructure facilities available in hospitals. b) Due to technological advances hospitalization is required for less than 24 hours only.

4. ANY ONE ILLNESS : It will be deemed to mean continuous period of illness and it includes relapse within 105 days from the date of discharge from hospital / nursing home from where the treatment was taken. Occurrence of same illness after a lapse of 105 days as stated above will be considered as fresh illness for the purpose of this policy. 5. PRE HOSPITALIZATION : Relevant medical expenses incurred up to 30 days prior to hospitalization on diseases / illness / injury sustained will be considered as part of the claim. Post hospitalization are relevant medical expenses incurred up to 60 days prior to hospitalization on diseases / illness / injury sustained will be considered as part of the claim. Both Pre hospitalization and Post hospitalization expenses are limited to actual subject to a maximum of 10% of Sum Insured. 6. TPA means Third Party Administrator who, for the time being, is licensed by the Insurance Regulatory and Development Authority, and engaged for a fee of remuneration, by whatever name called as per the provisions of health services. 7. In case of enhancement of Sum Insured during subsequent renewals, the additional sum insured will be treated as fresh policy and no renewal benefits will accrue for additional sum insured. The benefits of the enhanced Sum Insurd will accrue from the 4 th year of enhancement of Sum Insured. 8. Age Limit : Age limit for the first time coverage is 5 years to 60 years and for renewal age limit applicable up to 80 yrs. Children between the age group of 3 months to 5 years can be covered provided one or both parents are covered concurrently. 9. In patient facility I Corporate Hospitals is limited to Ciritcal Illness / Surgery. For other aliments non corporate hospitals only may be utilized. However, Policy holder is at liberty to go to any hospital, in which case, claims will be restricted to 70% in respect to hospitalization for normal aliments in Corporate Hospitals. EXCLUSIONS : 1. All diseases / injuries which are pre- existing when the cover incepts for the first time. For the purpose of applying this condition, the date of inception of the initial Mediclaim Policy taken from any of the Indian Insurance Companies shall be taken, provided the renewals have been continuous and without any break. However, this exclusion will be deleted after 3 consecutive continuous claim free policy years, provided, there was no hospitalization of the pre-existing ailment during these 3 years of Insurance. It is the responsibility of the Policyholder to ensure that renewal premium is remitted to Insurance Company on or before the expiry of the due date irrespective of giving standing instructions to branches to avoid break in policy. 2. Any disease other than those stated in clause 3) below, contracted by the Insured person during the first 30 days from the commencement date of the policy. This condition shall not however, apply in case of the Insured person having been covered under this scheme or Group Insurance Scheme with any of the Public Sector Indian Insurance Companies for a continuous period of preceding 12 months without any break.

3. During the first year of the operation of the policy, the expenses on treatment of diseases such as Cataract, Benign Prostatic Hypertrophy, Hysterectomy/ Myomectomy for Menorrhagia or Fibromyoma, Hernia, Hydrocele, Congenital internal disease, Fistula in anus, piles, Sinusitis and related disorders, Gall Bladder Stone removal, Gout & Rheumatism, Calculus Diseases, Joint Replacement due to Degenerative Condition and age-related Osteoarthritis & Osteoporosis are not payable.
4. Injury / disease directly or indirectly caused by or arising from or attributable to invasion, Act of Foreign enemy, War like operations (whether war be declared or not). 5. Circumcision unless necessary for treatment of a disease not excluded hereunder or as may be necessitated due to an accident. Vaccination or Inoculation or change of life or Cosmetic or Aesthetic treatment of any description, Plastic surgery other than as may be necessitated due to an accident or as a part of any illness. 6. Cost of spectacles, contact lenses and hearing aids. 7. Dental treatment or surgery of any kind including hospitalization. 8. Convalescence, general debility; run-down condition or rest cure; Congenital external disease or defects or anomalies, Sterility, Venereal disease, intentional self injury and use of intoxication drugs / alcohol. 9. All expenses arising out of any condition directly or indirectly caused to or associated with Human T-Cell Lymphotropic Virus Type III (HTLB - III) or lymphadinopathy Associated Virus (LAV) or the Mutants Derivative or Variation Deficiency Syndrome or any syndrome or condition of a similar kind commonly referred to as AIDS. 10. Charges incurred at Hospital or Nursing Home primarily for diagnosis, x-ray or Laboratory examinations or other diagnostic studies not consistent with or incidental to the diagnosis and treatment of positive existence or presence of any ailment, sickness or injury, for which confinement is required at a Hospital / Nursing Home. 11. Expenses on vitamins and tonics unless forming part of treatment for injury or diseases as certified by the attending physician.

12. Injury or Disease directly or indirectly caused by or contributed to by nuclear weapon / materials. 13. Treatment arising from or traceable to pregnancy (including voluntary Termination of pregnancy) and childbirth (including caesarean section). 14. Magneto Therapy, Naturopathy, Acupuncture, Acupressure, Homeopathy, Ayurveda and other such types of treatments.

15. Any kind of Service charges, Surcharges, Admission Fees/Registration Charges levied by the hospital. 16. All non-Medical expenses of any kind whatsoever.
Claim Procedure: In case of Hospitalization in non networking hospitals intimation has to be given to TPA within 24 hours of hospitalization. For any information / non receipt of ID Cards / Queries regarding claims TPA may be contacted at the address given below : M/s Good Health Plan Ltd. Plot No.49, Nagarjuna Hills, Panjagutta, Hyderabad 500 082 Toll Free Nos. 1800-102-9919, 1800-103-9919, Tel. 040 44765000 Extn Nos. 31/32/56/21/22/61/62/63/64/47/48/49 Arogyadaan help desk : Ms. Neeraja 9885119961, Mr. Chalapathi Rao 9966993316, Mrs. Naidu : 9000140325 Email : arogyadaan@ghpltpa.com, mail@ghpltpa.com