Quoted Generation Date 07-12-2024

Valid Till 22-12-2024

ADITYA BIRLA CAPITAL HEALTH INSURANCE CO. LTD.

BASIC DETAILS
Name of Corporate Ayika Sciences Private Limited Location Delhi
Business Type Fresh Product GHI
Segment SME_Inhouse Intermediary Other
Policy Start Date 31-12-1900 Relationship Manager Deep
Policy End Date 30-12-1901 UW name 0
Quotation Number Industry Telecom & Communication
POLICY DETAILS
Net Premium 8,51,185 No of Employees 72
GST 153213 Total No of Lives 141
Total gross premium 10,04,398 Premium calculation Per Life-Age Band wise
Brokerage % 7.50% Premium Payment Frequency One time
Rewards 7.50% Addition of member Pro Rata
TPA Name ABHI inhouse Deletion of member Pro Rata
TPA Fee (%) 2.50% Policy Category Floater
NGO/NPO NO Emoha No
Existing Insurer 0 Existing Insurer status #N/A
Facility No Wellness Not Covered
Paid Outstanding Total Incurred amount Claims Analysis Date
Incurred Amount
0 0 0 NA
Co-Insurance Details UNDERWRITER CONFIRMATION
Leader (Name of Insurance Company) ABHI (100%)

COVERAGE DESCRIPTION
Base Cover

Family Defination Employee, spouse, 4 dependent children upto 25 years

AGE LIMIT FOR SELF 70 Years

AGE LIMIT FOR SPOUSE 70 Years
AGE LIMIT FOR CHILDREN 25 Years
AGE LIMIT FOR PARENTS -
In-patient Hospitalization (Sum Insured) As Per demography
Parents SI restriction Parents SI is restricted to 50% of FSI

Hospital Room limit ( Available for NON-ICU and ICU) No room rent capping applicable.
Day Care Procedures Covered
Domicillary Hospitalization Covered
Pre-hospitalization Medical Expenses in days 60 Days
Post-hospitalization Medical Expenses in days 90 Days
Organ Donor Expenses Organ cost shall not be covered. Medical expenses shall be covered. Rest as per policy wordings
Road Ambulance Expenses Road ambulance charges are covered upto Rs. 3,000/- per incident in case of emergency.

OPD Expenses Not covered

AYUSH - We will cover the Medical Expenses for medically required AYUSH Treatments undergone as an In-patient upto 25% of SI Max upto Rs 25,000, where
treatment has been taken in a government Hospital or in any institute recognized by government and/ or in any institute recognized by government and/ or accredited
by Quality Council of India or National Accreditation Board on Health
Ayush treatment (In-patient Hospitalization)
Comfort treatment involving steam bath/sauna/oil massages are excluded. Such treatments being combined with any stay packages at resorts where the treatment
forms a part of an overall leisure package shall not be covered under this Benefit.

We will cover the Medical Expenses up to Rs. 30,000/- for In-patient treatment in a recognized psychiatric unit of a Hospital including consultations, diagnostics,
Psychatric In-patient Care counselling and/ or therapy and medication. The In-patient treatment under this Benefit must at all times be administered under the direct control of a registered
psychiatrist.

Sub-Limits for Specified Illness / Conditions No disease sublimits applicable

Optional Benefits

Infertility Treatment Not covered

If an Insured Person who is less than 3 years of Age is Hospitalized in an ICU or a Neo-natal ICU or a Cardiac Care Unit of a Hospital, then We will cover the Room
Wellmother cover Rent and other boarding expenses of the Insured Person’s mother to stay with the Insured Person in the same Hospital upto Rs. 5000 within the Maternity Limit if
Maternity is covered .

Covered for Expenses Incurred for a Normal baby after the birth till discharge. Automatic coverage for necessary expenses related to the newborn's wellbeing after
Well Baby Cover birth and before discharge. Expenses like doctors check up and any other check up / tests performed to ensure that the baby is well at birth, to be covered upto Rs.
5000 within the Maternity Limit if Maternity is covered .

Preferred Provider Network Not Applicable

Maternity limit Rs.50000/- for normal delivery & Rs.50000/- for C-Section.
Maternity Benefit
Maternity Benefit will be applicable for self and Spouse (if spouse is covered in the policy). Maternity benefit shall be applicable to first 2 deliveries (including
(Normal - C Sec Delivery)
twins) and/or 2 medically required and lawful termination of pregnancies.

Maternity Waiting Period Covered

 New Born Baby Expenses Covered

Corporate Buffer Not applicable

Wellness Coach(In case of facility need to selected as

Not covered
yes)Applicable for Employee only

Lasik surgery Covered if correction index is +/- 6.5D

Cyberknife/Robotic surgery/Stem cell therapy/ Stereotactic

Covered with 50% Co pay
radio surgeries

We Will Cover the below Specified Modern Treatment Upto 50% of SI on IPD basis
1. Oralchemotherapy
2. Uterine Artery Embolization and HIFU
3. Balloon SinuplastyDeep Brain stimulation
4. Immunotherapy- Monoclonal Antibody to be given as injection
Modern Treatment 5. Intra vitreal injections
6. BronchicalThermoplasty.
7. Cochlear Implant
8. Vaporisation of the prostrate (Green laser treatment or holmium laser treatment)

Covered upto Rs. 1,00,000/- Per Family. We will provide Emergency Medical Assistance in India as described below when an Insured Person, during the Policy
Domestic Emergency Medical assistance Period, is travelling 150 (one hundred and fifty) kilometres or more away from his/her residential address as mentioned in the Policy Schedule or Certificate of
Insurance for a period of less than 90 (ninety) days.

Dental Treatment Covered in case of hospitalization due to accident on IPD basis only
Terrorism Any Hospitalisation person suffer due to terrorism activities will be covered upto IPD Sum Insured

Waivers and Discounts

External congenital ailments covered Covered in case of life threatening conditions with overall policy limit is 10 lakhs.
Internal congenital ailments covered Covered
Co-payment No co-pay
Co-payment on Parents No Co-pay
Pre-existing disease Waiting Period Covered
Specified disease / procedure waiting period Not Applicable
Pre-Post Natal Pre-post natal covered upto Rs.5000/- within maternity limit
30 day waiting period Not Applicable

1. There should not be any addition or deletion to be allowed in parental policies, except in case of new joinees or employees getting relieved from the organization
Voluntary Parental Enrolment- Lock in Period
2. Lock-in for 3 years to be applicable in parental policies, if parental coverage is provided on selection basis.

Reasonable & Customary Charges Applicable

“We understand that as per applicable regulations for Group Insurance minimum 7 lives are required to be insured under the Group Policy. Accordingly we confirm
Special Condition 1 that we will insure atleast 7 lives during the course of the policy and in this context we are paying premium of 7 lives upfront. IN the event we fail to insure
minimum 7 lives then the Insurance Company shall book the entire premium of 7 lives and no refund shall be due to us”

SI 0-25 26-35 36-45 46-55 56-65 66-70 71-75 76-80 Above 80 Total
50,000 - - - - - - - - - -
75,000 - - - - - - - - - -
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 55 55 26 5 - - - - - 141
5,50,000 - - - - - - - - - -
6,00,000 - - - - - - - - - -
7,00,000 - - - - - - - - - -
Total 55 55 26 5 - - - - - 141
2.626637522
Endorsement rates (Excluding GST)
Sum Insured 0-25 26-35 36-45 46-55 56-65 66-70 71-75 76-80 Above 80
50,000 0 0 0 0 0 0 0 0 0
75,000 0 0 0 0 0 0 0 0 0
1,00,000 0 0 0 0 0 0 0 0 0
1,50,000 0 0 0 0 0 0 0 0 0
2,00,000 0 0 0 0 0 0 0 0 0
2,50,000 0 0 0 0 0 0 0 0 0
3,00,000 0 0 0 0 0 0 0 0 0
3,50,000 0 0 0 0 0 0 0 0 0
4,00,000 0 0 0 0 0 0 0 0 0
4,50,000 0 0 0 0 0 0 0 0 0
5,00,000 5,143.00 5,765.16 7,278.84 12,397.29 20,712.55 31,657.21 44,902.87 56,414.60 61,594.87
5,50,000 0 0 0 0 0 0 0 0 0
6,00,000 0 0 0 0 0 0 0 0 0
 7,00,000 0 0 0 0 0 0 0 0 0
Total 0 0 0 0 0 0 0 0 0
*Rates for only those sum insured option which are opted in quote will be applicable. These rates may vary with any change in
demography, sum insured and coverages.

DISCLAIMER - WHEREEVER APPLICABLE

1. No Individual (Employee or Dependant) can be covered more than once in a policy.
2. Any change in demography/Sum Insured will warrant a revision in Quote/ Rates.
3. Data for new joinees - Employees and dependant’s data to reach by pre-decided mutually agreed timeline or 30 days.
4. In case of New Joinees names of all dependants to be submitted one time only along with the name of the employee.
5. Addition/ Deletion to be done on Prorate basis effective from date of joining/relieving subject to balance being available in CD account.
6. In case of deletions, there will be no refund for the members who have claimed.
7. Maximum age of entry in policy is 80 years for parents and 60 Yrs for Self and Spouse
8. Maximum age of entry for dependent children is 25 years.
9. No change of Sum insured allowed after commencement of the policy.
10. No addition of new slabs for Sum Insured allowed after commencement of the policy.
11. Midterm addition allowed only in case of New Born baby and Spouse (on account of marriage).Mid term addition of parents not allowed except for new joinees.
12. Natural additions for any existing employee must done within 30 days of marriage (for spouse) and date of birth (for child).
13. Additional premium to be collected for every new addition in the policy.
14. All insurable members in the group to be insured under GMC policy and there shall be no selection of members.
15. Members already employed but not declared by the employer at the time of providing the quote shall not be covered subsequently after commencement of the
16. We shall provide Per member Premium for addition and deletion in the policy.
17. The basis of selecting the sum insured for the members shall be communicated to the insurance company prior to inception of policy. No individual member shall
be allowed to choose his/her sum insured deviating from the basis provided.
18. The cover shall cease automatically for any member leaving the organization insured under our GMC policy.
19. In case of fresh proposal, the quote is released basis the conditions that, this is fresh case with no prior cover under Group Health Insurance. If information
changes, the quote needs to be re-approved.
20. Quote is valid for 15 days only.

EMOHA Offering
Emotional Wellbeing (Medium care Plan)
Dedicated Emoha Daughters offering personalized Telephonic Twice/Mont
Emoha Daughter
assistance for social and clinical needs. h
Access to online helpdesk offering support for getting medicines delivered, avail lab Tests,
Helpdesk Covered
accompany to hospital, booking holiday tours, help with technology and much more at discounted
prices.
Live interactive events online platform designed specifically for seniors Covered
Exclusive invitation to a Variety of co-sponsored online events. Covered
Online Engagement program
Online Monthly celebration of birthdays and anniversaries for all corporate policy holders parents. Covered
Access to exclusive senior online clubs. Covered
Healthcare benefits
Support from Geriatric experts via Teleconsultations to help manage chronic conditions Covered
(Upto
Teleconsultation 12/year
covered)

Access to online geriatric emergency coordination services which include but are not limited to
Emergency Coordination Covered
finding the nearest hospital, dispatching an ambulance (cost of one trip is included).
Seamlessly manage health records with EHR , Emoha Daughters will help with digitizing the existing
Digitized medical Records Covered
health record data for easy retrieval and sharing.
Our experts provide tailored guidance online on how to make your home safer, help reduce risk of
Home Elderization Counselling falls, improve accessibility and thereby enabling senior's independence. Covered

Policy Holding elders will get a priority in waitlist at Epoch centres in case they need to secure a
Assisted living Care Covered
room at one of the Epoch Centers (online support).
Specialized Caregiver Access to Online Counseling to help caregivers manage dementia, Parkinson’s and other chronic
conditions at home at discounted rates. Covered
Counselling

Declaration :-
We do hereby declare that all information provided by us under the present Offer, are true and correct and also complete in all respects and there is nothing material,
which is concealed by us in any manner whatsoever.
In the event of any change in information pertaining to any aspect of the quotation at a later date, Aditya Birla Capital Health Insurance Co Ltd reserves the right to
revise the premium and recover the same from customer or invoke cancellation of the policy, as may be deemed fit, without refund. We have also carefully read and
understood the entire terms, coverage and exclusions agreed in the Offer, and further accept the same, which shall be binding on both of us as a contract between us
and Aditya Birla Capital Health Insurance Co Ltd.
We accept the above quote and terms & condition as mentioned above.

Authorized Signatory(To be Signed by

HR)
Date-
OPD exclusion
 Exclusions:
1 Food, Food Supplements or Dietary Pills (Example – Horlicks, Glucose, Whey Protein, etc.)
2 Dietary supplements and substances that can be purchased without prescription, including but not limited to Vitamins, minerals and organic substances unless
prescribed by a medical practitioner as part of treatment
3 All non-medical expense or standard deductions incurred during inpatient hospitalization or day-care treatments will not be covered under OPD Policy.
4 Any ailment with sublimit in Group medical plan coverage cannot be claimed under OPD Policy. For. Ex. Mental health related treatment is covered Upto INR 1Lac in
Group medical plan. Any expenses incurred beyond INR 1Lac cannot be claimed in OPD policy.
5 Procedure fee or any type of procedures fees paid during an OP consultation are not covered. Example - wound cleaning/dressing
6 Over the counter (OTC)Medicines are not covered. Medicines purchased without doctor’s prescriptions are not covered.
7 Diagnostics/Investigations done without doctor’s prescriptions are not covered.
8 All cosmetic related consultations or diagnostics, and medicines (unless called out in inclusion) are not covered. Cosmetic Surgery or Treatment means surgery or
medical treatment solely or primarily to improve or preserve physical appearance, but not physical function or treatment of an underlying ailment/conditions (Example -
Chemical peel treatment, Laser hair removal and others. The exact nature of the procedure will be determined by program administrators at the time of processing the
claim.
9 Pre & Post-natal expenses or any maternity related expense will not be covered under OP as the same is covered under group medical plan.
10 Naturopathy and related treatments/expenses are not covered.
11 Treatment for alopecia, baldness, wigs, or toupees, and all treatment related to the same and all treatment related to the same are not mentioned.
12 Expenses related to any treatment necessitated due to participation in hazardous or adventure sports not covered
13 Treatments received in heath hydros, nature cure clinics, spas or similar establishments . 14 Treatment for, Alcoholism, drug or substance abuse. 15 Consultations for
General advise. 16 Consultations, treatment & expenses related to Change of Gender. 17 Pre Post Hospitalization expenses are excluded

Other Exclusions:
1 Cost of Frames / Spectacles. 2 Cosmetic lenses and procedures excluded. 3 Any cosmetic procedures. 4 Any kind of pharmacy expenses. 5 Protein shakes and other
supplements even if prescribed. 6 Hearing Aid. 7 Consultations & Treatment related to Obesity. 8 IVF, infertility related treatment. 9 Cataract / Lasix Surgery .10 Day care
treatment list of IPD cover. 11 Advance receipt/co-pay/Day -care/IPD deductions. 12 AYUSH treatments. 13 Physiotherapy expenses. 14 Any claim for dependents
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