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MAHABANK SWASTHYA YOJNA PROPOSAL FORM

(Group Mediclaim Cum Personal Accident Insurance for Bank of Maharashtra Account Holders)

1. Name & Address of the Account Holder (In Capital Letters)
Mobile No:
2. SUM INSURED PER FAMILY (please tick)
Rs Lacs
0.50
1.00
1.50
2.00
2.50
Rs Lacs
3.00
3.50
4.00
4.50
5.00
FRESH PROPOSAL / RENEWAL PROPOSAL(Please tick) (Attach copy of existing Mahabank Swasthya Yojna Policy in case of renewal) (Attach copy of any other medical insurance held, if any)
(To be filled in by Bank) 3(a) Branch Name/City:
(b) BIC Code :
(c)IFS Code
(d ) Proposal From: Rural/Urban/Semi-Urban 4. Account No.
SB/CA/FD/Others (please specify) Date of Credit to United India Insurance Co. Ltd A/c No. 60032280062, Bank of Maharashtra Main Branch, Pune Journal Number:
Teller’s Signature
5 DETAILS OF PERSONS TO BE COVERED: PLAN A (1+3) ( ) / PLAN B (1 + 5) ( ) please tick
NAME OF THE INSURED PERSON (in capital letters)
Date of Birth
SEX
RELATIONSHIP
EXISTING DISEASE/ILLNESS/INJURY *
1
2
3
4
5
6
* Additional sheets may be used wherever necessary 6 TWO STAMP SIZE PHOTOGRAPH OF THE INSURED PERSONS: (seal in envelop with names on reverse of photographs) 7. Name of Nominee with relationship: 8.I hereby declare and agree that the above statements are true and complete. Myself and my family members are maintaining good health except the existing diseases/illness/injury as per Serial No. 5 above. I have read the salient features of the policy and willing to accept the cover subject to the terms, conditions, and exceptions prescribed by the Insurance Company. Enclosed, copy of existing medical insurance of account holder or other family members (Yes / No ) I/we agree that Bank of Maharashtra is no way responsible for claims under Mahabank Swasthya Yojna and the same have to be pursued with the TPA/Insurance Company. Place: Date: SIGNATURE OF PROPOSER BANK BRANCH SEAL SIGNATURE OF BRANCH MANAGER
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PREMIUM CHART – PLAN A (Family Size: 1+ 3 – Account Holder, Spouse, 2 Dependent Children) including Service Tax of 12.36%
Sum Insured
0.50 Lacs
1.00 Lac
1.50 Lacs
2.00 Lacs
2.50 Lacs
3.00 Lacs
3.50 Lacs
4.00 Lacs
4.50 Lacs
5.00 Lacs
Premium
956
1,848
2,709
,3488
4,181
4,875
5,484
6,094
6,706
7,316
PREMIUM CHART – PLAN B (Family Size: 1+ 5 – Account Holder, Spouse, 2 Dependent Children, Parents) including Service Tax of 12.36%
Sum Insured
0.50 Lacs
1.00 Lac
1.50 Lacs
2.00 Lacs
2.50 Lacs
3.00 Lacs
3.50 Lacs
4.00 Lacs
4.50 Lacs
5.00 Lacs
Premium
1,597
3,085
4,519
5,815
6,967
8,120
9,131
10,143
11,156
12,167
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 medical policy taken from any Indian Insurance Companies shall be taken provided the renewals have been continuous and without any break. However, this exclusion will be deleted after three consecutive continuous claim free policy years, provided, there was no hospitalization for the pre-existing ailment during these three years of insurance
2. Any disease other than those stated in clause 3 under exclusions, contracted by the insured person during the first 30 days from the commencement date of policy. The condition shall not, however, apply in case of the insured person having been covered under this scheme or any group insurance scheme with any 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 for Menorrhagia or Fibromyoma, Hernia, Hydrocele, Fistula in anus, Sinusitis and related disorders are not payable. If these diseases (other than congenital internal disease) are pre-existing at the time of proposal they will not be covered even during subsequent period of renewal. If the insured is aware of the existence of congenital internal disease before inception of the policy, the same will be treated as pre-existing and, however, subject to exclusion No.1;
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 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 and contact lenses, hearing aids;
7. Dental treatment or surgery of any kind including hospitalization either due to accident/disease
8. Convalescence, general debility, rundown condition or rest cure. Congenital external disease or defects or anomalies, sterility, venereal disease, intentional self injury and use of intoxicating 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 Lympadinopathy Associated Virus(LAV) or the Mutants Derivative or Variation Deficiency Syndrome or any syndrome or condition of a similar kind commonly known referred to as AIDS;
10. Charges incurred at hospital or nursing home primarily for diagnosis, x-ray or laboratory examinations other diagnostic studies not consistent with or incidental to the diagnosis and treatment of positive existence of 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/disease as certified by the attending physician;
12. Injury or disease directly caused by or contributed to by nuclear weapon/ materials;
13. Treatment arising from or traceable to pregnancy (including voluntary termination of pregnancy) and child birth (including caesarean section);
14. Naturopathy
Three sets of application are to be obtained. The 1st& 2nd Copy to be sent to United India Insurance Co. Ltd, Bancassurance Office, Sawarkar Bhawan, 2nd Floor, Near Balgandharv Rangmandir, Shivajinagar, Pune – 411005; Tel: 020-25533306/4038/5621). 3rd Copy is to be retained at the Bank Branch. Stamp size photograph to be affixed on the 1st copy only or seal photographs (name written on reverse) in an envelope & staple properly to 1st& 2nd Copy