UNITED INSURANCE COMPANY LIMITED Divisional Office : 010500 Catholic Centre, 64, Armenian Street, Chennai 600001 POLICY-CUM-CERTIFICATE FOR AROGYA RAKSHA UIN NO. UIIHLGP22008V032122 Policy Particulars Policy Number 0105002020484100000919503 Bank Reference Number 17307674 Policy Validity Period From Date To Date 3/9/2020 31/8/2021 Policy Plan B Sum Insured 200000

Bank Details Branch Code Branch Name Account Number Voucher Date K086 KALLUMKADAVU null 20200903 Previous Insurance history Previous Policy From Date To Date SUM INSURED 2019/01050020194841000009/73667 18/09/2019 31/08/2020 `null null null ` null null null `null null null Premium Overview Proposer Details Mediclaim PA Premium GST Total Amount (Incl. Premium GST ) GOPAKUMAR R 4658 117 IGST@18% : 859 5636 THEKKEDATHU VEEDU; MANCHALLOOR; ,, Pin:689695, Mob : 9497481493 / Phone: - Mail: [email protected] In case you have a policy other than Arogya Raksha, the onus is on you to give the copy of the previous year policy details as well as the claim details. NOMINEE DETAILS: Name:BINDHU GOPAN, Relation: SPOUSE Third Party Administrator Details Vidal Health TPA Vidal Health Insurance TPA Pvt. Ltd (Formerly TTK Health care Limited) 'ANMOLPALANI', NO:88, G. N. Chetty Road, T. Nagar, Chennai 600017 E-mail:[email protected],Contact: 080-46267018 TOLL FREE: 18604250251 | Web:www.vidalhealthtpa.com Policy Issuing Office Details United India Insurance Company Ltd., DO CATHOLIC CENTRE , Office Code 010500 , Catholic Centre, NO.64, Armenian street, ChennaI - 600001, OFFICE GST No.: 33AAACU5552C1ZQ,Phone: 044- 25389793/25389794/25386298 ,E-mail: [email protected] Download policies/ provisional e-cards at:http://portal.uiic.in/ArogyaSuraksha/renewLandingCustomer.jsp Details of family members covered (* Pre-Existing Diseases within 36 months prior to the first policy are not covered.) Sl. Name Birth Date Sex Relation Medical History Treatment Taken No 1 GOPAKUMAR R 10/5/1967 M SELF 2 BINDHU GOPAN 10/3/1976 F SPOUSE DIABETES,BP 3 ARCHA GOPAN 13/03/2000 F DAUGHTER

Declaration Policy subject to terms, conditions, exclusion and definitions.Terms and Conditions of the policy can be downloaded from http://portal.uiic.in/ArogyaSuraksha/renewLandingCustomer.jsp or www.indianbank.net.in. The detailed terms and conditions can be obtained from Indian Bank branch or United Inda Insurance Company Office . The proposal and declaration by the insured is the basis of this contract and deemed to be incorporated. Policy Created on: 20200903 Specified Person: GEO JOSSY S.P Code: SP0108239620 Authorized signatory

Policy Re-Printed on:20/09/2021 07:54:36 Page 1/4 UNITED INDIA INSURANCE COMPANY LIMITED Divisional Office : 010500 Catholic Centre, 64, Armenian Street, Chennai 600001 CERTIFICATE OF MEDICAL INSURANCE PREMIUM PAID (for the purpose of deduction u/s 80 D of the Income Tax Act, 1986)

This is to certify that Mr.GOPAKUMAR R having account number null with Indian Bank, has paid Rs 5636/- at Indian Bank branch KALLUMKADAVU for Medical Insurance as premium for policy no: 0105002020484100000919503 on 20200903 for Indian Bank Arogya Raksha Policy under PLAN B

20200903 For United India Insurance

Date Co.Ltd.

Authorized signatory Page 2/4 United India Insurance Company Limited Regd. Office: 24 Whites Road, Chennai – 600 014 Arogya Raksha (Group Health Insurance Scheme) TABLE OF BENEFITS (Details mentioned below are indicative and brief in nature. Please refer to Policy Wordings for complete information on your coverage)

BASE COVER Coverage Details ▪ Room Rent, Boarding & Nursing expenses up to Rs. (1.5% of Sum Insured) per day (In case of admission to a room at rates exceeding the aforesaid limits the reimbursement/payment of all associated medical expenses incurred at the Hospital shall be effected in the same proportion as the admissible rate per day bears to the actual rate per day of Room Rent). ▪ ICU/ICCU expenses up to Rs. (3% of Sum Insured) per day. ▪ Surgeon, Anaesthetist, Specialist Fees, Blood, Oxygen, Operation Theatre Charges, medicines and drugs, diagnostic tests, (For detailed list of covered expenses, please refer to Policy Terms & Conditions). ▪ Hospitalisation expenses (excluding cost of organ) incurred for donor in respect of organ transplant to the Insured Person. Hospitalisation ▪ Expenses for the following illnesses/surgeries shall be restricted as follows subject to waiting period: • Cataract: Up to Rs. (10% of Sum Insured) or Rs. 40,000/- for policies purchased on or after 01.07.2021 and Up to Rs. (10% of Sum Insured) or Rs. 25,000/- for policies purchased before 01.07.2021. (12 months waiting period) • Hernia: Up to Rs. (15% of Sum Insured) or Rs. 50,000/- for policies purchased on or after 01.07.2021 and Up to Rs. (15% of Sum Insured) or Rs. 30,000/- for policies purchased before 01.07.2021. (12 months waiting period) • Hysterectomy: Up to Rs. (20% of Sum Insured) or Rs. 50,000/- (12 months waiting period) • Major Surgeries: Up to Rs. (80% of Sum Insured) (Co-Payment) Day Care All medical treatments and/or surgical procedures which fall under the definition of Day Care Treatment, under Treatment Section 3 (Definitions) of the Policy Wordings, are covered. Pre & Post We will cover your medical expenses up to 30 days before hospitalisation & up to 60 days after your discharge Hospitalisation from hospital, subject to a maximum of Rs. (Not exceeding 10% of Sum Insured under both). Ayurvedic We will cover reasonable & customary medical expenses incurred for inpatient care treatment under Ayurvedic Treatment system of medicine in an AYUSH hospital/AYUSH Day Care Centre The below mentioned advanced medical procedures shall covered up to the following limits:

▪ Uterine Artery Embolization and HIFU up to Rs. (20% of Sum Insured), subject to a maximum of Rs. 2 Lakhs per Policy Period ▪ Balloon Sinuplasty up to Rs. (10% of Sum Insured), subject to a maximum of Rs. 1 Lakh per Policy Period ▪ Deep Brain stimulation up to Rs. (70% of Sum Insured) per Policy Period Modern ▪ Oral Chemotherapy up to Rs. (20% of Sum Insured) per Policy Period, subject to a maximum of Rs. 2 Lakhs per Treatment Policy Period (Applicable for ▪ Immunotherapy – Monoclonal Antibody to be given as injection up to Rs. (20% of Sum Insured), subject to a policy maximum of Rs. 2 Lakhs per Policy Period purchased on ▪ Intra vitreal injections up to Rs. (10% of Sum Insured), subject to a maximum of Rs. 1 Lakh per Policy Period or after ▪ Robotic Surgeries up to:Rs. (75% of Sum Insured) per Policy Period for claims involving Robotic Surgeries for (i) 01.10.2020) the treatment of any disease involving Central Nervous System irrespective of aetiology; (ii) Malignancies. Rs. (50% of Sum Insured) per Policy Period for claims involving Robotic Surgeries for other diseases ▪ Stereotactic radio surgeries up to Rs. (50% of Sum Insured) per Policy Period ▪ Bronchial Thermoplasty up to Rs. (30% of Sum Insured), subject to a maximum of Rs. 3 Lakhs per Policy Period ▪ Vaporization of the Prostate up to Rs. (30% of Sum Insured), subject to a maximum of Rs. 2 Lakhs per Policy Period. ▪ IONM (Intra Operative Neuro Monitoring) up to Rs. (15% ofSum Insured), subject to a maximum of Rs. 1 Lakh per Policy Period. Maternity A waiting period of 9 months is applicable for payment of any claim relating to normal delivery or caesarean. The waiting Expenses period may be relaxed only in case of delivery, miscarriage or abortion induced by accident or other medical emergency. We will cover Medical expenses up to Rs. (5% of Sum Insured) in respect of female Insured Person above 18 years during (Applicable only the Policy Period for the delivery of a child in a Hospital/Nursing home arising from or traceale to Pregnancy childbirth for first two including normal caesarean section during the Policiy Period or for medically required and lawful medical termination of childbirth) pregnancy.The hospitalisation expenses in respect of treatment given to the new-born baby in the Hospital as an in-patinet page 3/4 Arogya Raksha (Group Health Insurance Scheme) UIN: UIIHLGP22008V032122 from 02/07/2021 UIN: UIIHLGP21444V022021 from 01/10/2020 to 01/07/2021 UIN: IRDA/NL-HLT/UII/P-H/V.1/386/13-14 from 05/02/2014 to 30/09/2020 United India Insurance Company Limited Regd. Office: 24 Whites Road, Chennai – 600 014 for a maximum period of 90 days from the date of its birth shall be covred within the Mother's Maternity expenses. Health Check-Up We will reimburse expenses incurred towards cost of health check-up up to Rs. (1% of average Sum Insured) of in lieu of No preceding 4 claim-free years for a block of every three claim-free years. Claim Bonus ▪ Account Holder: 100% of Sum Insured (SI) Personal ▪ Spouse: 50% of Sum Insured (Total claim should not exceed Sum Insured) Accident ▪ Children: 25% of Sum Insured for each child (Death) Cover ▪ Total Claim should not exceed Sum Insured A co-payment of 10% shall be applicable on each and every claim of Insured Person who is above 65 years of Co-Payment age under the policy only for policies purchased on or before 30.06.2021. Mental Illness - In case of following mental illnesses the actual In-patient Hospitalization expenses will be covered upto 25% of Sum Insured (Applicable for subject to a maximum of Rs.3,00,000 per policy year; (Schizophrenia,Bipolar Affective Disorders,Depression,Obsessive policy purchased on Compulsive Disorders and Psychosis. For full details please refer policy wordings. or after 01.10.2020)

KEY EXCLUSIONS: Expenses related to the treatment of a pre-existing disease (PED) and its direct complications shall be excluded until the expiry of 36 months of continuous coverage after the date of inception of the first policy with us. Expenses related to the treatment of any illness within 30 days from the first policy commencement date shall be excluded except claims arising due to an accident, provided the same are covered. Dental treatment or dental surgery of any kind unless necessitated by disease or injury and requiring hospitalization.

Expenses related to the treatment of the listed Conditions, surgeries/treatments as per Table A and Table B below, shall be excluded until the expiry of 12 months and 36 months (specific waiting period) respectively of continuous coverage after the date of inception of the first policy with us. This exclusion shall not be applicable for claims arising due to an accident. TableA:12 Months’ Specific Waiting Period: Cataract,Benign Prostatic Hypertrophy,Hysterectomy for Menorrhagia/Fibromyoma,Hernia of all types,Hydrocele,Piles, Fistula-in-Ano,Sinusitis and related disorders,Gout and Rheumatism,Calculus diseases and Congenital Internal diseases Table B: 36 Months’ Specific Waiting Period Treatment for joint replacement unless arising from accident, Age-related Macular Degeneration (ARMD),Age-related Osteo-arthritis & Osteoporosis, All Neuro degenerative disorders You will not be covered for the following also: ▪ Change of Life Treatments,Refractive Error ▪ Vaccination or Inoculation of any kind ▪ Cosmetic or Plastic Surgery ▪ Cost of Spectacles,Contact Lenses, Hearing Aids ▪ Rest Cure, Rehabilitation and Respite Care ▪ Congenital External diseases or anomalies ▪ Sterility & Infertility ▪ Hospitalisation not necessary ▪ Alcoholism, Drug or Substance Abuse, Breach of law ▪ Unproven Treatments, OPD, Domiciliary & less than ▪ Any item(s) or treatment specified in ‘List of Non-Medical 24 hours hospitalization Expenses– Payable/Non-Payable’ as per Annexure – 1 ▪ Obesity/Weight Control and available on Company web site also, unless specifically ▪ Nuclear, chemical, or biological attacks,War and war covered under the Policy. like occurrences (This list is only indicative and not exhaustive. For full list of exclusions, please refer to Policy Wordings) Redressal of Grievance : In case of any grievance the Insured Person may contact the company through United India Office-in- charge of Policy Issuing Office in person/through post at Divisional Office 010500, #64, Catholic Centre, Armenian Street, Chennai 600 001; Telephone : 044-25389793/94 or 25386298; Email: [email protected]. If not resolved the grievance may be escalated to our Chennai Regional Office Customer Care department at [email protected]

Policy subject to terms, conditions, exclusions, and definitions. Summary of terms and conditions of the policy can be downloaded from https://portal.uiic.in/ArogyaSuraksha/renewLandingCustomer.jsp or www.indianbank.net.in.The detailed terms and conditions can be obtained from Indian Bank branch or United India Insurance Company Office. The proposal and declaration by the Insured is the basis of this contract and deemed to be incorporated. page 4/4

Arogya Raksha (Group Health Insurance Scheme) UIN: UIIHLGP22008V032122 from 02/07/2021 UIN: UIIHLGP21444V022021 from 01/10/2020 to 01/07/2021 UIN: IRDA/NL-HLT/UII/P-H/V.1/386/13-14 from 05/02/2014 to 30/09/2020