Group Activ Health - Certificate of Insurance
Aditya Birla Health Insurance Company Aditya Birla Health Insurance Company
Limited,10th Floor,R-Tech Park,Nirlon Limited,10th Floor,R-Tech Park,Nirlon
Policy Issuing Office Compound,Next To HUB Mall,Off Policy Servicing Office Compound,Next To HUB Mall,Off
Western Express Highway,Goregaon Western Express Highway,Goregaon
East,Mumbai-400063 East,Mumbai-400063
Master Policy Number 61-19-00250-00-00 Certificate Number GHI-HD-20-2010582
Product Name Group Activ Health Member Id HDFCGP20200021752
K A S SUNDARA SRIHARI
49-9-25, RAMANUJA KUTEERAM,
Name of Insured Person LALITHA NAGAR,
Unique Identification HDFCGP20200024945
Residential Address of VISAKHAPATNAM,
Number
Insured Person ANDHRA PRADESH, 530016
Start date & Time of Master Policy 00:01 hrs 07-02-2024
Expiry Date & Time of Master Policy 23:59 on 06-02-2025
Period of Insurance 1 Year
Inception Date 00:01 hrs 06-05-2024
End Date 23:59 on 06-05-2025
Individual/Family Floater Individual Floater
Insured Person Detail
Insured Person Date of Birth Gender Nominee Relationship Sum Insured
K SRIHARI 06-08-1992 F K SRUTI Spouse 500000
Benefit Description
Group Mediclaim Refer Coverage Details
Policy Exclusions
Group Mediclaim As per Annexure I
Premium Details
Perticulars Amount (Rs.)
Net Premium 38,387.29
CGST (9%)
SGST / UTGST (9%)
IGST (18%) 6909.71
Gross Premium 45,297.00
Premium payment mode Annual
Gst Registration No :27AANCA4062G1ZN Category: General Insurance SAC Code: 997133
Claim Process
Aditya Birla Health Insurance Company Limited, 10th Floor, R-Tech Park, Nirlon
Address for Correspondence
Please contact us through Compound, Off Western Express Highway, Goregaon East, Mumbai – 400063
any of these Modes Contact Number 1800 270 7000
Email ID [email protected]
Grievance Redressal
In case of a grievance, the Insured Person/ Policyholder can contact Us with the details through our website: www.adityabirlacapital.com,Email:[email protected] or Toll Free : 1800 270 7000. Address: Any of Our Branch office or Corporate
office. For senior citizens, please contact respective branch office of the Company or call at 1800 270 7000 or write an e- mail at [email protected]. The Insured Person can also walk-in and approach the grievance cell at any of Our
branches. If in case the Insured Person is not satisfied with the response, then they can contact Our Head of Customer Service at the following email [email protected]. If the Insured Person is still not satisfied with Our redressal, he/she may
approach the nearest Insurance Ombudsman. The contact details of the Ombudsman offices are provided on Our website and in the Policy.
Product UIN IRDAI/HLT/ABHI/P-H(G)/V.I/19/2016-17
PREMIUM CERTIFICATE
Premium Certificate for the purpose of deduction under Section 80-(D) of Income Tax (Amendment) Act 1986.
This is to certify that K V S CHARI paid Rs. 45,297.00 (In words Forty Five Thousand Two Hundred Ninety Seven) towards
Premium for Health Insurance for the Period From 00:01 hrs 00:01 hrs 11-07-2024 to midnight 23:59 on 10-07-2025.
Instrument Number Instrument Date Amount Name Of the Bank
HDFCGP20200021752 06-05-2024 45,297.00 HDFC Bank Ltd
Stamp Duty - The stamp duty of INR 1/- paid vide MH008619098201920M dated 21/03/2024, received from Stamp Duty Authorities vide
Receipt No./GRASS DEFACE NO 0004549315201920 dated 28/03/2024, payment has been made vide Letter of Authorisation No.
CSD/235/2019/5742/19 dated 29/03/2024 from Main Stamp Duty Office
Master Policy Number: 61-19-00250-00-00 Certificate Number: GHI-HD-20-2010582
Date: 06-05-2024 Place: Mumbai
Note: Amount is inclusive of all taxes and cesses as applicable. This certificate must be surrendered to the Insurance Company for issuance of fresh
certificate in case of cancellation of Master Policy or any alteration in the insurance affecting the premium.
Coverage Details
Section II : Base Covers
Base Covers Coverage
1000000.00
Single Private AC Room (All other charges like professional fees, OT
1.1 In-patient Hospitalization
charges, investigation charges/ lab reports will be in accordance with
the room rent restriction). ICU – Actuals
1.2 Day Care Treatment 527 Day Care procedures are covered
1.4 Pre – hospitalization Medical Expenses 60 days
1.5 Post-hospitalization Medical Expenses 90 days
1.6 Organ Donor Expenses 1000000.00
1.7 Road Ambulance Expenses INR 5000 /-
Section III : Optional Covers
29 Reload of Sum Insured Up to 100% of sum insured
Section IV : Waivers and Discounts
41 Pre-Existing Disease Waiting Period 4 years
42 Two Year Waiting Period Applicable
43 First 30 Days Waiting Period Applicable
Product UIN IRDAI/HLT/ABHI/P-H(G)/V.I/19/2016-17
Annexure I - Permanent Exclusion
We shall not be liable to make any payment for any claim under any Benefit in respect of any Insured 25.Venereal disease, all sexually transmitted disease or Illness including but not limited to genital
Person directly or indirectly caused by, based on, arising out of, relating to or howsoever attributable to warts, Syphilis, Gonorrhea, Genital Herpes, Chlamydia, Pubic Lice and Trichomoniasis.
any of the following: 26.“AIDS” (Acquired Immune Deficiency Syndrome) and/or infection with HIV (Human
1.Treatment directly or indirectly arising from or consequent upon war or any act of war, invasion, act Immunodeficiency Virus) including but not limited to conditions related to or arising out of HIV/AIDS
of foreign enemy, war like operations (whether war be declared or not or caused during service in the such as ARC (AIDS Related Complex), Lymphomas in brain, Kaposi’s sarcoma, tuberculosis.
armed forces of any country), civil war, public defense, rebellion, uprising, revolution, insurrection, 27.Complications arising out of pregnancy (including voluntary termination), miscarriage (except as a
military or usurped acts, nuclear weapons / materials, chemical and biological weapons, ionizing result of an Accident or Illness), maternity or birth (including caesarean section) except in the case of
radiation, contamination by radioactive material or radiation of any kind, nuclear fuel, nuclear waste. ectopic pregnancy for In-patient only.
2.Committing or attempting to commit a breach of law with criminal intent, intentional self- Injury or 28.Treatment for sterility, infertility, sub-fertility or other related conditions and complications arising
attempted suicide while Insured Person is sane or insane. out of the same, assisted conception, surrogate or vicarious pregnancy, birth control, and similar
3.Willful or deliberate exposure to danger, intentional self- Injury, non- adherence to Medical Advice, procedures contraceptive supplies or services including complications arising due to supplying services.
participation or involvement in naval, military or air force operation, circus personnel, racing in 29.Expenses for organ donor screening, or save as and to the extent provided for in the treatment of the
wheels or horseback, diving, aviation, scuba diving, parachuting, hang-gliding, rock or mountain donor (including Surgery to remove organs from a donor in the case of transplant Surgery).
climbing, bungee jumping, parasailing, ballooning, skydiving, river rafting, polo, snow and ice sports in 30.Admission for Organ Transplant but not compliant under the Transplantation of Human Organs Act,
a professional or semi- professional nature. 1994 (amended).
4.Abuse or the consequences of the abuse of intoxicants or hallucinogenic substances such as 31.Treatment and supplies for analysis and adjustments of spinal subluxation, diagnosis and treatment
intoxicating drugs and alcohol, including smoking cessation programs and the treatment of nicotine by manipulation of the skeletal structure; muscle stimulation by any means except treatment of
addiction or any other substance abuse treatment or services, or supplies. fractures (excluding hairline fractures) and dislocations of the mandible and extremities.
5.Weight management programs or treatment in relation to the same including vitamins and tonics, 32.Dentures and artificial teeth, Dental Treatment and Surgery of any kind, unless requiring
treatment of obesity (including morbid obesity). Hospitalization due to an Accident.
6.Treatment for correction of eye sight due to refractive error including routine examination. 33.Cost incurred for any health check-up or for the purpose of issuance of medical certificates and
7.All routine examinations and preventive health check-ups. examinations required for employment or travel or any other such purpose.
8.Cosmetic, aesthetic and re-shaping treatments and Surgeries: 34.Artificial life maintenance, including life support machine used to sustain a person, who has been
9.Plastic Surgery or cosmetic Surgery or treatments to change appearance unless medically required and declared brain dead, as demonstrated by: 1. Deep coma and unresponsiveness to all forms of
certified by the attending Medical Practitioner for reconstruction following an Accident, cancer or stimulation; or 2. Absent pupillary light reaction; or 3. Absent oculovestibular and corneal reflexes; or
burns. 4. Complete apnea.
10.Circumcisions (unless necessitated by Illness or Injury and forming part of treatment); aesthetic or 35.Treatment for developmental problems, learning difficulties e.g. Dyslexia, behavioral problems
change-of-life treatments of any description such as sex transformation operations. including attention deficit hyperactivity disorder (ADHD).
11.Non- allopathic treatment, except as per coverage of AYUSH Treatment. 35.Treatment for Age Related Macular Degeneration (ARMD), treatments such as Rotational Field
12.Conditions for which treatment could have been done on an out-patient basis without any Quantum Magnetic Resonance (RFQMR), External Counter Pulsation (ECP), Enhanced External
Hospitalization. Counter Pulsation (EECP), Hyperbaric Oxygen Therapy.
13.Unproven/Experimental treatment, investigational treatment, devices and pharmacological 36. Expenses which are medically not required such as items of personal comfort and convenience
regimens. including but not limited to television (if specifically charged), charges for access to telephone and
14.Admission primarily for diagnostic purposes not related to Illness for which Hospitalization has been telephone calls (if specifically charged), food stuffs (save for patient’s diet), cosmetics, hygiene
done. articles, body care products and bath additives, barber expenses, beauty service, guest service as well
15.Convalescence (except as per the coverage as coverage defined in Section 11 - Recovery Benefit), as similar incidental services and supplies, vitamins and tonics unless certified to be required by the
cure, rest cure, sanatorium treatment, rehabilitation measures, private duty nursing, respite care, attending Medical Practitioner as a direct consequence of an otherwise covered claim.
long-term nursing care or custodial care. 37.Treatment taken from a person not falling within the scope of definition of Medical Practitioner.
16.Preventive care, vaccination including inoculation and immunizations (except in case of post-bite 38.Treatment charges or fees charged by any Medical Practitioner acting outside the scope of license
treatment); any physical, psychiatric or psychological examinations or testing or registration granted to him by any medical council.
17.Admission for enteral feedings (infusion formulas via a tube into the upper gastrointestinal tract) and 39.Treatments rendered by a Medical Practitioner who is a member of the Insured Person’s family or
other nutritional and electrolyte supplements unless certified to be required by the attending Medical stays with him, save for the proven material costs are eligible for reimbursement as per the applicable
Practitioner as a direct consequence of an otherwise covered claim. cover.
18. Hearing aids, spectacles or contact lenses including optometric therapy, multifocal lens. 40.Any treatment or part of a treatment that is not of a reasonable charge, is not a Medically
19.Treatment for alopecia, baldness, wigs, or toupees, and all treatment related to the same. Necessary Treatment; drugs or treatments which are not supported by a prescription.
20.Medical supplies including elastic stockings, diabetic test strips, and similar products. 41.Charges related to a Hospital stay not expressly mentioned as being covered, including but not
21.Any expenses incurred on prosthesis, corrective devices external durable medical equipment of any limited to charges for admission, discharge, administration, registration, documentation and filing,
kind, like wheelchairs crutches, instruments used in treatment of sleep apnea syndrome or continuous including MRD charges (medical records department charges).
ambulatory peritoneal dialysis (C.A.P.D.) and oxygen concentrator for bronchial asthmatic condition, 42.Non-medical expenses including but not limited to RMO charges, surcharges, night charges, service
cost of cochlear implant(s) unless necessitated by an Accident or required intra-operatively. Cost of charges levied by the Hospital under any head and as specified in the Annexure V for non- medical
artificial limbs, crutches or any other external appliance and/or device used for diagnosis or treatment expenses.
(except when used intra-operatively). 43.Treatment taken outside India.
22.Psychiatric or psychological disorders, mental disorders (including mental health treatments), 44.Insured Person whilst flying or taking part in aerial activities except as a fare-paying passenger in a
Parkinson and Alzheimer’s disease, general debility or exhaustion (“rundown condition”), sleep-apnea, regular scheduled airline or air charter company.
stress.
23.External Congenital Anomalies, diseases or defects, genetic disorders.
24.Stem cell therapy or surgery, or growth hormone therapy
* This is a computer generated document and does not need a signature
Product UIN IRDAI/HLT/ABHI/P-H(G)/V.I/19/2016-17
Policy No: 61-19-00250-00-00 COI No.GHI-HD-20-2010582
Coverage Start Date: 06/05/2024 Coverage End Date: 05/05/2025
Name Membership No. Relationship DOB
K A S SUNDARA SRIHARI HDFCGP20200021752 Self 06/08/1992
• This card is only identification and is not an authorization to proceed with the treatment or guarantee for payment.
• In case photo less identity cards issued to beneficiaries, acceptable proof of identity such as Aadhar Card/Passport/Driver
License /Ration Card/Voters ID/ PAN Card should be presented at the hospital.
• This non-transferable identification card is valid at selected Network Hospitals & will enable Card Holder to avail cashless
hospitalization only on pre-authorization by Aditya Birla Health Insurance Co. Ltd
• For latest updated network hospital list, log on to https://www.adityabirlahealth.com/healthinsurance/#!/provider-search
