31-24-0030822-00

RAM BRIKSHA PRASAD

SO SYA RAM SAW
RVER SIDE KARANGDJ JARANGDIH
JARANGDIH COLLIERY,BOKARO
Bermo
JHARKHAND
INDIA
829113
9431509677 Empowering people to
24/05/2024 lead healthier lives
Dear RAM BRIKSHA PRASAD,
Thank you for choosing us. In our journey together, we promise to offer you the Up to 100% of your
best insurance and assurance of good health. Premium as Health
ReturnsTM
Together, we will achieve our goals by making every small step count. Every ladder
you climb, every calorie you burn, every lap you swim, every song you dance on -
every little act will move the needle towards a healthier you. 90 days pre and
180 days post
Excited? So are we! Get ready to make the most out of your new insurance plan Hospitalization Coverage
Activ One - MAX

Thank you once again for partnering with us. With our purpose of Empowering You Any Room of your
To Lead A Healthier Life, we ensure you a fruitful and healthful journey. Choice up to
Base Sum Insured
Warm regards,

Claims Protect: Avail

Mayank Bathwal Claim coverage for listed
Chief Executive Officer Non-Medical expenses
Aditya Birla Health Insurance Co. Limited.

Super Reload: Unlimited

refil up to 100% Sum
POLICY NUMBER: 31-24-0030822-00 Insured from 2nd claim
Name Membership No DOB Onwards
RAM BRIKSHA PRASAD PT06297964 20/Sep/1966
MANJU DEVI PT06297979 01/Jan/1969 Introducing The Activ Health App

Your health and your

policy, all in one place
For assistance, connect with us via the following channels:

Follow us on: Product Name: Activ One, Product UIN: ADIHLIP24097V012324

 Activ One MAX
Policy Schedule
This document will serve as a quick guide for you to understand important information regarding your health insurance
policy including its key features, coverage limits, premium details and nominee details, among others.

Unit no 1101 & 1104 11th floor,

Unit no 1501& 1502, 15th floor,
304 - 305, Third Floor, Ozone Plaza
Policy Issuing Office G Corp Tech Park, Kasarwadavali, Policy Servicing Office
Dhanbad JHARKHAND 826001
Ghodbunder Road, Thane
West-400615
Intermediary Name Anil Kumar Thakur Intermediary Code ABH1175840
Intermediary Contact Details 8789039218 Intermediary E-mail ID [email protected]
Toll Free Number 18002707000

Policyholder Name RAM BRIKSHA PRASAD

Policyholder Address SO SYA RAM SAW RVER SIDE KARANGDJ JARANGDIH Bermo, 829113, Bokaro, JHARKHAND
Contact Number 9431509677
Email Id [email protected]
GSTIN NA

Product Name Activ One

Plan MAX
Policy Number 31-24-0030822-00
First Policy Start date 24/05/2024
Start Date of Policy & Time 00:00 hrs on 24/05/2024 Expiry Date & Time of Policy 23:59 hrs on 23/05/2025
Policy Type Family Floater Policy Tenure 1 Year
Enrollment for Automatic renewal
Policy Category New Business NO
premium payment facility
Mode of Premium payment Single
Portability/Migration No Previous Policy Number NA
GSTIN NA GSTIN Account Type Consumers
New Business

Start date of
Policy of Pre-Existing
Start date of first
Insured Relationship Age Diseases
DOB policy with
Name of Insured person Person (only with Member ID (completed Gender (PED)
(DD-MM-YYYY) us(applicable at
in case of new Proposer birthday) (if applicable)
policy renewal)
member

Diabetes
Mellitus - E11
-0
,High BMI -
E66 -
RAM BRIKSHA PRASAD NA Self PT06297964 57 Male 20/09/1966 ,Hepatomegal 24/05/2024
y - R16 -
,Benign
Prostate
Enlargement -
N40 - 5

Hyperlipidemi
MANJU DEVI NA Spouse PT06297979 55 Female 01/01/1969 24/05/2024
a - E78 - 0

Continued and to be read in conjunction of the table above

Product Name: Activ One, Product UIN: ADIHLIP24097V012324

 Specific disease Waiting Pre-Existing Disease Super Credit
Base Sum Insured Initial Waiting Period Super Credit %
period Waiting Period Amount
30 Days 2 Years 3 Years NA NA
1000000
30 Days 2 Years 3 Years NA NA
Continued and to be read in conjunction of the table above optional cover opted.

0 0
Name of Insured Person
0 0 RAM BRIKSHA PRASAD
MANJU DEVI
0
Personal Accident (Fixed Benefit) Chronic Care (Day 1 In-Patient Hospitalization)
0 2
PED Waiting Period and initial Waiting Period will be waived for the listed chronic conditions
2 0 AD+PTD+PPD Sum Insured INR 1000000

PED Waiting Period and initial Waiting Period will be waived for the listed chronic conditions
0 0 AD+PTD+PPD Sum Insured INR 1000000

Waiting Period from Start Start Date of Chronic Management Program

Name of the Insured Person Chronic Condition
Date of First Policy Coverage Applicability
Diabetes Mellitus - 0
RAM BRIKSHA PRASAD Not Applicable 24-MAY-24 No
,High BMI -
MANJU DEVI Hyperlipidemia - 0 Not Applicable 24-MAY-24 No

Name of the Insured Person Special Condition (if applicable)

RAM BRIKSHA PRASAD No
MANJU DEVI No

Name of the Insured Person Pre-Existing Disease Details (if applicable)

Diabetes Mellitus - E11 - 0
,High BMI - E66 -
RAM BRIKSHA PRASAD
,Hepatomegaly - R16 -
,Benign Prostate Enlargement - N40 - 5
MANJU DEVI Hyperlipidemia - E78 - 0

HealthReturnsTM (Applicable for Renewal Policy)

Name of the Insured Person HealthReturnsTM carried forward from Previous Year -Total HealthReturnsTM available for utilization

RAM BRIKSHA PRASAD NA 0

MANJU DEVI NA 0

Trademarks - HealthReturnsTM, Healthy Heart Score and Active Dayz are owned by MMI Group Limited and used under license by
Aditya Birla Health Insurance Co. Limited.

Nominee Name Nominee Relationship with Policyholder Nominee Contact Number

MANJU DEVI Spouse 9431509677
Appointee Details: (Required only if Nominee is a Minor)
Appointee Name Relationship with Nominee
NA NA
Note - A Minor should not be declared as Appointee.

Total Ported Sum

Date of first Previous Policy Type of Insured (Sum Waiting period
Name of Insured Person Previous Insurer
enrollment Number Cover Insured + waived off
Cumulative Bonus)
MANJU DEVI NA NA NA NA NA NA
RAM BRIKSHA PRASAD NA NA NA NA NA NA

Product Name: Activ One, Product UIN: ADIHLIP24097V012324

 Product Name Activ One
Plan Variant MAX
Refer Base Sum Insured column under Insured Person’s
Base Sum Insured
details above
Basic Covers Hospitalization Room Rent Any Room - Actuals up to Sum Insured
Treatment ICU Charges Actuals up to Sum Insured
Road Ambulance Cover (per
Actuals up to Sum Insured
hospitalization)
Day Care Treatments Actuals up to Sum Insured
Modern Procedures / Treatments Actuals up to Sum Insured for listed procedures
HIV / AIDS and STD Cover Actuals up to Sum Insured
Mental Illness Hospitalization Actuals up to Sum Insured
Obesity Treatment Actuals up to Sum Insured
Pre-Hospitalization Expenses (up to Sum Insured) 90 Days
Post-Hospitalization Expenses (up to Sum Insured) 180 Days
Claim Protect (Non-Medical Expense Waiver) Waiver of Non-Medical Expense Exclusion of Base
Policy List as per Annexure 1 (all 4 lists)

Domiciliary Hospitalization Actuals up to Sum Insured

Home Health Care Actuals up to Sum Insured
AYUSH Treatment Actuals up to Sum Insured
Organ Donor Expenses Actuals up to Sum Insured
Annual Health Check up (Listed & Cashless) Covered
Super Reload Unlimited Refill [2nd Claim onwards -
Unlimited Covered
Times (upto Base Sum Insured)]
Super Credit (increases irrespective of claim) 100% of SI per year, up to 500% of Base Sum Insured (up
to Max of 3 Cr under this benefit)
Health Management Program Health AssessmentTM Available once in a policy year undertaken at our
Network Providers / Empaneled Service Providers on a
cashless basis only / on digital basis

HealthReturnsTM Available up to 100% of the Premium

Product Name: Activ One, Product UIN: ADIHLIP24097V012324

 Loading Discounts CGST SGST/UTGST IGST Other taxes/Cess
Basic Premium Total Premium
(if applicable) (if applicable) (9%) (9%) (18%) (1%)

37232.14 949.8 0 3520.97 3520.97 NA NA 46164.00

GST Registration No: 20AANCA4062G1Z1 PAN Number :AANCA4062G Category: General Insurance SAC Code: 997133

Consolidated Stamp Duty paid vide E-challan turnover

GRN no. in
MH015093118202324E datedfrom
05/02/2024
We hereby declare that though our aggregate any preceding financial year 2017-18 onwards is more than the aggregate turnover
notified under sub-rule (4) of rule 48, we are not required to prepare an invoice in terms of the provisions of the said sub-rule.

For and on behalf of Aditya Birla Health Insurance Co. Ltd

Date : 24/05/2024

Location : Mumbai
Authorized Signatory

Product Name: Activ One, Product UIN: ADIHLIP24097V012324

 Premium Certificate
We confirm the receipt of premium amount of INR 46164.00 as per below details paid by Mr. RAM BRIKSHA PRASAD for Self and/or Family and/or
Parents:
Policy Number: 31-24-0030822-00 Plan Name: MAX

Type of Plan: Family Floater Proposer Name: RAM BRIKSHA PRASAD

Policy Start Date: 00:00 hrs on 24/05/2024 Policy End Date: 23:59 hrs on 23/05/2025

Receipt Details:
CGST SGST/UTGST IGST
Receipt Date Base Premium Amount Total Premium (incl. of taxes)
(9%) (9%) (18%)
10-05-2024 37232.14 3520.97 3520.97 0.00 46164.00
24-05-2024 37232.14 3520.97 3520.97 0.00 46164.00

Mode of Premium payment Single

Year wise breakup of premium for the purpose of claiming Income Tax deduction u/s 80D (subject provisions of Income Tax Act) is provided
as under:
Financial Year Year wise proportionate Premium amount*
2024-25 46,164.00

* Premium paid in cash and premium paid towards Personal Accident, Wellness Coach do not qualify for deduction u/s 80D. Further premium
paid for person other than family member & parents (as defined under Income Tax Act) also don’t qualify for deduction under section 80D.

Amount is rounded off to nearest rupee and is inclusive of all taxes and cesses as applicable. For exact premium, please refer to Section VII
of Policy schedule
Note:
1. The year wise deductions as mentioned above are as per provision of Section 80D and this would be subjected to the specified annual
limits and other provisions as applicable for respective years as per applicable provisions of Income Tax Act.
2. Deduction under section 80D of the Act is allowed to the person who pays premium out of his/her income chargeable to tax.
3. Deduction under section 80D of the Act is available on realization of premium paid by Policyholder.
4. Tax laws are subject to change and any such change could have a retrospective effect. This letter should not be construed as tax, legal or
investment opinion from us. For specific suitability, you are requested to consult your tax advisor.
5. This receipt must be surrendered to the company, in case of cancellation of this policy. In event of incorrect representation of this
declaration the liability shall be upon the policy holder.

For and on behalf of Aditya Birla Health Insurance Co. Limited

Date : 24/05/2024

Place : Mumbai
Authorized Signatory

Product Name: Activ One, Product UIN: ADIHLIP24097V012324

 31-24-0030822-00

Membership
Name DOB
No.
RAM BRIKSHA PRASAD PT06297964 20/Sep/1966
MANJU DEVI PT06297979 01/Jan/1969
 Medical Examination Report
Transcript of the Digital Medical Verification Report

This is the transcript of the answers provided by individual health to be insured to the questions asked in a in digital verification for the underwriting of

the Proposal received by the Underwriting team of Aditya Birla Health Insurance Company Ltd. The answers provided by the health to be insured would

form a part of the application and basis for insurance.

We request you to go through the transcript carefully. In case of any disagreement, you are requested to highlight the same within 15 days of the receipt

of this transcript; otherwise the same shall be considered as accepted by you and thereby binding on you. Please retain this transcript for future

reference.

Proposal No. QSP_2400002092 Date 2024-05-12

94

Proposer Name RAM BRIKSHA DOB of Proposer 1966-09-20

PRASAD

Name Of Member RAM BRIKSH Member ID PT06297964

PRASAD

DOB Of Member 1966-09-20 Gender Of Member Male

Relationship With Self Contact Number 9431509677

Proposer

These are the following questions, along with their answers, that were asked during the verification :

YES NO IF YES, please give details

Height yes 172.72cm

Weight yes 65.5kgs

Diabetes yes yes

Medication type- oral? Insulin? yes Oral

Please mention the medicines you yes Ayurvedic Churna 1 tablespoon

are taking (name of medicine and
dosages)?

Are you aware whether it is ‘Type 1 yes Do not Know

Diabetes’ or ‘Type 2 Diabetes’? If
yes, please state
(disclaimer should be shown –
Company will decide basis
information shared)
Since when you are suffering from yes 03 2023
Diabetes?

Whether any hospitalization in past yes No

for Diabetes or related complication

Multiple Hospitalization History yes No

When was last blood sugar level yes 03 2024

reading (fasting blood sugar/
random blood sugar/ HBA1C)
checked

Latest blood sugar level reading yes 6.8

(fasting blood sugar/ random blood
sugar / HBA1C)

hypertension no no

Do you ever had/have recorded yes yes

blood pressure in the past? Routine
or due to any complain or Physician
advice if yes please share complete
details

When was last blood pressure yes 04 2024

reading checked?

Latest Blood pressure measurement yes 120/70

?

High Cholesterol or High no no

Triglycerides

Asthma no no

Current or past history of COVID no no

Epilepsy/Fits/Seizure/Convulsion no no

Heart Problem like Heart Attack, no no

Heart Disease (Ischemic /
Coronary), Heart Valve disease, or
any heart disease or procedure /
surgery like Angioplasty / PTCA or
By Pass Surgery (CABG)
Heart Problem like Heart Attack, no no
Heart Disease (Ischemic /
Coronary), Heart Valve disease, or
any heart disease or procedure /
surgery like Angioplasty / PTCA or
By Pass Surgery (CABG)

Blood disorder or Blood Vessel no no

disease like obstruction of artery/
occlusion of arteries of limbs
including Varicose Vein

Do you ever had/have or currently no no

suffering from any Respiratory
disease? If Yes , Conrm from list of
disease Tuberculosis (TB),
Bronchitis, COPD, or any other lung
/ respiratory disease/ Obstructive
sleep apnoea (OSA)

Do you ever had/have or currently yes yes

suffering from any?
Gastrointestinal or Digestive
disease. Genito urninary ? If Yes,
Confirm from list of disease
Ulcer (Stomach/Duodenal), Reflux
Disease (GERD), Anal
fissure, fistula, Piles, Gall Bladder
Stone, Alcoholic Liver disease,
Liver cirrhosis or any other digestive
tract disease, Prostate related
disease, hernia, hydrocele,
varicocele

Name of Disease/Illness/Condition yes Prostate related disease

Date of Diagnosis yes 03 2024

Last Consultation Date yes 04 2024

Name of Surgery if any yes N/A

Details of Management yes OPD

(hospitalized/OPD)

Name of medicines yes Prostagard 8

Do you ever had/have or currently no no
suffering from Kidney/Urinary Tract
related disorders? If yes list of
disease Kidney problem like
Renal Failure, Stone in kidney or
urinary tract, or any other kidney
/urinary tract disease

Do you ever had/have or currently no no

suffering from any Nervous
system/Neurological/Brain/Spinal
cord related disorders? If Yes

Nervous system disorders like Brain

Stroke, Paralysis, Brain
Tumor, Parkinsonism, Alzheimer’s
Disease, Multiple sclerosis, Down
Syndrome or any other Brain /
Spinal Cord or nervous system
disease/ Polio

Do you ever had/have or currently no no

suffering from Arthritis of any type,
Spondylosis, Slipped Disc, or any
disease of the muscles, bones or
joints or any history of fracture

Psychiatric /Mental illnesses no no

Disability or deformity whether no no

physical / mental

Autism no no

Do you ever had/have or currently no no

suffering from any Tumor - benign or
malignant, Cancer, ulcer, growth,
cyst, Lump or mass in the body.

Do you ever had/have or currently no no

suffering from Cataract, Deviated
Nasal Septum, Nasal Polyps, or any
disease of the Ear, Nose, Throat,
Thyroid, Teeth, Eye, speech

HIV/AIDS, sexually transmitted no no

diseases (STD)
Genetic Disorder, Birth defects no no

Any other condition no no

Fibroid (Uterus), Breast Lumps, no no

Polycystic Ovary Disease (PCOD) or
any other Gynecological disease
(only for female)

Under any regular medication yes yes

prescribed by the Doctor other than
vitamin pills and tonics ?

Name of Disease/Illness/Condition yes Non Alcoholic fatty liver grade 2

Date of Diagnosis yes 03 2024

Last Consultation Date yes 04 2024

Name of Surgery if any yes N/A

Details of Management yes OPD

(hospitalized/OPD)

Name of medicines yes Uprise D3 60k. xonin 100mg.

Esopam plus. Ensule plus.

Blood tests, X-Ray/USG/Scan/MRI no no

other than routine or pre-
employment health check? Reason
for undergoing the test and the
findings of the report? Any adversity
noted

Surgery done or advised and still no no

pending for the surgery to be done?

Does any person proposed to be no no

insured Smoke or consume tobacco
in any form, or alcohol? If yes,
please indicate the Quantity (Qty)
consumed. If not, please indicate No
 Whether lady is pregnant <Only for no no
Married lady – Only if relationship
with proposer is Self/ Spouse &
Marital status of Proposer is
mentioned as ‘Married’> - Whether
insured currently pregnant (for
female only)

Whether lady is pregnant <Only for no no

Married lady – Only if relationship
with proposer is Self/ Spouse &
Marital status of Proposer is
mentioned as ‘Married’> -
Pregnancy related complications
(Past pregnancy - for Female only)

DECLARATION GIVEN BY THE PROSPECT DURING VERIFICATION :

You, RAM BRIKSH PRASAD, declared that, you have fully understood the questions asked to you and have furnished
complete, true and accurate information after fully understanding the same

Sir/Mam' are you in agreement with the declaration provided by you during medical verification

We thank you for having taken the time to conrm the details. We will process your proposal based on the information
provided

Dated Time of Medical 2024-05-12 10:19:05

Verification

I am the Proposer yes

I am the Insured Member

 Medical Examination Report
Transcript of the Digital Medical Verification Report

This is the transcript of the answers provided by individual health to be insured to the questions asked in a in digital verification for the underwriting of

the Proposal received by the Underwriting team of Aditya Birla Health Insurance Company Ltd. The answers provided by the health to be insured would

form a part of the application and basis for insurance.

We request you to go through the transcript carefully. In case of any disagreement, you are requested to highlight the same within 15 days of the receipt

of this transcript; otherwise the same shall be considered as accepted by you and thereby binding on you. Please retain this transcript for future

reference.

Proposal No. QSP_2400002092 Date 2024-05-12

94

Proposer Name RAM BRIKSHA DOB of Proposer 1966-09-20

PRASAD

Name Of Member MANJU DEVI Member ID PT06297979

DOB Of Member 1969-01-01 Gender Of Member female

Relationship With Spouse Contact Number 9431509677

Proposer

These are the following questions, along with their answers, that were asked during the verification :

YES NO IF YES, please give details

Height yes 157.48cm

Weight yes 63kgs

Diabetes no no

hypertension no no

Do you ever had/have recorded no no

blood pressure in the past? Routine
or due to any complain or Physician
advice if yes please share complete
details

High Cholesterol or High yes yes

Triglycerides

When were you first diagnosed with yes 01 2024

High Cholesterol/ High
Triglycerides?
Please mention the medicines you yes N/A
are taking (name of medicine and
dosages)? Or suffers from any
complication

When was last blood lipid profile yes 01 2024

(Total Cholesterol/ Triglyceride)
done.

Latest Total Cholesterol/ Triglyceride yes 238

level

Asthma no no

Current or past history of COVID no no

Epilepsy/Fits/Seizure/Convulsion no no

Heart Problem like Heart Attack, no no

Heart Disease (Ischemic /
Coronary), Heart Valve disease, or
any heart disease or procedure /
surgery like Angioplasty / PTCA or
By Pass Surgery (CABG)

Heart Problem like Heart Attack, no no

Heart Disease (Ischemic /
Coronary), Heart Valve disease, or
any heart disease or procedure /
surgery like Angioplasty / PTCA or
By Pass Surgery (CABG)

Blood disorder or Blood Vessel no no

disease like obstruction of artery/
occlusion of arteries of limbs
including Varicose Vein

Do you ever had/have or currently no no

suffering from any Respiratory
disease? If Yes , Conrm from list of
disease Tuberculosis (TB),
Bronchitis, COPD, or any other lung
/ respiratory disease/ Obstructive
sleep apnoea (OSA)
Do you ever had/have or currently no no
suffering from any?
Gastrointestinal or Digestive
disease. Genito urninary ? If Yes,
Confirm from list of disease
Ulcer (Stomach/Duodenal), Reflux
Disease (GERD), Anal
fissure, fistula, Piles, Gall Bladder
Stone, Alcoholic Liver disease,
Liver cirrhosis or any other digestive
tract disease, Prostate related
disease, hernia, hydrocele,
varicocele

Do you ever had/have or currently no no

suffering from Kidney/Urinary Tract
related disorders? If yes list of
disease Kidney problem like
Renal Failure, Stone in kidney or
urinary tract, or any other kidney
/urinary tract disease

Do you ever had/have or currently no no

suffering from any Nervous
system/Neurological/Brain/Spinal
cord related disorders? If Yes

Nervous system disorders like Brain

Stroke, Paralysis, Brain
Tumor, Parkinsonism, Alzheimer’s
Disease, Multiple sclerosis, Down
Syndrome or any other Brain /
Spinal Cord or nervous system
disease/ Polio

Do you ever had/have or currently no no

suffering from Arthritis of any type,
Spondylosis, Slipped Disc, or any
disease of the muscles, bones or
joints or any history of fracture

Psychiatric /Mental illnesses no no

Disability or deformity whether no no

physical / mental
Autism no no

Do you ever had/have or currently no no

suffering from any Tumor - benign or
malignant, Cancer, ulcer, growth,
cyst, Lump or mass in the body.

Do you ever had/have or currently no no

suffering from Cataract, Deviated
Nasal Septum, Nasal Polyps, or any
disease of the Ear, Nose, Throat,
Thyroid, Teeth, Eye, speech

HIV/AIDS, sexually transmitted no no

diseases (STD)

Genetic Disorder, Birth defects no no

Any other condition no no

Fibroid (Uterus), Breast Lumps, no no

Polycystic Ovary Disease (PCOD) or
any other Gynecological disease
(only for female)

Under any regular medication no no

prescribed by the Doctor other than
vitamin pills and tonics ?

Blood tests, X-Ray/USG/Scan/MRI no no

other than routine or pre-
employment health check? Reason
for undergoing the test and the
findings of the report? Any adversity
noted

Surgery done or advised and still no no

pending for the surgery to be done?

Does any person proposed to be no no

insured Smoke or consume tobacco
in any form, or alcohol? If yes,
please indicate the Quantity (Qty)
consumed. If not, please indicate No
 Whether lady is pregnant <Only for no no
Married lady – Only if relationship
with proposer is Self/ Spouse &
Marital status of Proposer is
mentioned as ‘Married’> - Whether
insured currently pregnant (for
female only)

Whether lady is pregnant <Only for no no

Married lady – Only if relationship
with proposer is Self/ Spouse &
Marital status of Proposer is
mentioned as ‘Married’> -
Pregnancy related complications
(Past pregnancy - for Female only)

DECLARATION GIVEN BY THE PROSPECT DURING VERIFICATION :

You, MANJU DEVI, declared that, you have fully understood the questions asked to you and have furnished complete,
true and accurate information after fully understanding the same

Sir/Mam' are you in agreement with the declaration provided by you during medical verification

We thank you for having taken the time to conrm the details. We will process your proposal based on the information
provided

Dated Time of Medical 2024-05-12 14:11:52

Verification

I am the Proposer yes

I am the Insured Member

 Activ One MAX
CUSTOMER INFORMATION SHEET /
KNOW YOUR POLICY
This document provides key information about your policy. You are also advised to go through your policy document.

SR. POLICY CLAUSE

TITLE DESCRIPTION
01. Product Name Activ One MAX
02. Policy Number 31-24-0030822-00

Type of Insurance Indemnity basis:

Product/Policy 1. Hospitalization Treatment
2. Pre-Hospitalization Expenses
3. Post-Hospitalization Expenses
4. Claim Protect (Non-Medical Expense Waiver)
5. Domiciliary Hospitalization
6. Home Health Care
7. AYUSH Treatment
8. Organ Donor Expenses
9. Annual Health Check-up
10. Super Reload
11. Super Credit
12. Health AssessmentTM
13. Health ReturnsTM
03. 14. Reduction in Specific Disease Waiting Period
15. Reduction in Pre-Existing Disease Waiting Period
16. Room Rent Type Options
17. Per Claim Deductible
18. Preferred Provider Network (PPN) Discoun
19. Chronic Care (Day 1 In-patient Hospitalization)
20. Chronic Management Program (OPD)
21. Cancer Booster
22. Durable Medical Equipment Cover
Family Floater 23. Compassionate Visit
24. Second Medical Opinion for listed Major Illness
25. Annual Screening Package for Cancer Diagnosed Patients
Fixed Benefit basis for all claims under:
1. Critical Illness cover
2. Personal Accident Cover

04. Sum Insured (Basis) Individual Sum insured – Each member has separate sum
(Along with amount) Insured under the policy
Floater Sum Insured-where all member under the policy have a
single sum insured limit which may be utilized by any or all
members
Insured Person Family Floater Sum Insured
MANJU DEVI
1000000
RAM BRIKSHA PRASAD
05. Policy Coverage I. Basic covers C.1
(What the policy 1. Hospitalization Treatment C.1
covers?) 1.a. In-Patient Treatment C.1.1
1.b. Other expenses covered C.1.1.1
1.b.1. Road Ambulance (domestic only) C.1.1.1.a
1.b.2. Dental Treatment C.1.1.1.b
1.b.3. Plastic Surgery C.1.1.1.c
1.b.4. All Day Care Treatments C.1.1.1.d
1.b.5. Modern Procedures/Treatments C.1.1.1.e
1.b.6. HIV / AIDS and STD Cover C.1.1.1.f
1.b.7. Mental Illness Hospitalization C.1.1.1.g
1.b.8. Obesity Treatment C.1.1.1.h
2. Pre-Hospitalization Expenses C.2
3. Post-Hospitalization Expenses C.3
4. Claim Protect (Non-Medical Expense Waiver) C.4
5. Domiciliary Hospitalization C.5
6. Home Health Care C.6
7. AYUSH Treatment C.7
8. Organ Donor Expenses C.8
9. Annual Health Check-up C.9
10. Super Reload C.10
11. Super Credit C.11
12. Health Management Program C. 12
12.1. Health Assessment TM
C.12.1
12.2. HealthReturns TM
C.12.2

II. Optional Covers: (Available if opted by paying additional C.13

premium)
13. Reduction in Specific Disease waiting period C.13.1
14. Reduction in Pre-Existing Disease waiting period C.13.2
15. Room Rent Type Options C.13.3
16. Per Claim Deductible C.13.4
17. Preferred Provider Network (PPN) Discount C.13.5
18. Critical Illness cover C.13.6
19. Personal Accident Cover (AD+PTD+PPD) C.13.7
20. Chronic Care (Day 1 In-patient Hospitalization) C.13.8
21. Chronic Management Program (OPD) C.13.9
22. Cancer Booster C.13.10
23. Durable Medical Equipment Cover C.13.11
24. Compassionate Visit C.13.12
25. Second Medical Opinion for listed Major Illness C.13.13
26. Annual Screening Package for Cancer Diagnosed Patients C.13.14

06. Exclusions Standard Exclusion:

(What the policy 1. Investigation & Evaluation (Code- Excl04) D.1.4

does not cover) a) Expenses related to any admission primarily for diagnostics
and evaluation purposes only are excluded.

Product Name: Activ One, Product UIN: ADIHLIP24097V012324

 b) Any diagnostic expenses which are not related or not
incidental to the current diagnosis and treatment are
excluded.

2. Rest Cure, rehabilitation and respite care (Code- Excl05) D.1.5

a) Expenses related to any admission primarily for enforced bed
rest and not for receiving treatment. This also includes:
i. Custodial care either at home or in a nursing facility for
personal care such as help with activities of daily living
such as bathing, dressing, moving around either by skilled
nurses or assistant or non-skilled persons.
ii. Any services for people who are terminally ill to address
physical, social, emotional and spiritual needs.

3. Obesity/ Weight Control (Code- Excl06) D.1.6

Expenses related to the surgical treatment of obesity that does
not fulfil all the below conditions:
1) Surgery to be conducted is upon the advice of the Doctor
2) The surgery/Procedure conducted should be supported by
clinical protocols
3) The member has to be 18 years of age or older and
4) Body Mass Index (BMI);
a) greater than or equal to 40 or
b) greater than or equal to 35 in conjunction with any of the
following severe co-morbidities following failure of less
invasive methods of weight loss:
i. Obesity-related cardiomyopathy
ii. Coronary heart disease
iii. Severe Sleep Apnea
iv. Uncontrolled Type2 Diabetes

4. Change-of-Gender treatments: (Code- Excl07) D.1.7

Expenses related to any treatment, including surgical management,
to change characteristics of the body to those of the opposite sex.

5. Cosmetic or plastic Surgery: (Code- Excl08) D.1.8

Expenses for cosmetic or plastic surgery or any treatment to
change appearance unless for reconstruction following an Accident,
Burn(s) or Cancer or as part of medically necessary treatment to
remove a direct and immediate health risk to the insured. For this
to be considered a medical necessity, it must be certified by the
attending Medical Practitioner.

6. Hazardous or Adventure sports: (Code- Excl09) - Expenses D.1.9

related to any treatment necessitated due to participation as a
professional in hazardous or adventure sports, including but not
limited to, para-jumping, rock climbing, mountaineering, rafting,
motor racing, horse racing or scuba diving, hand gliding,
sky diving, deep-sea diving.

Product Name: Activ One, Product UIN: ADIHLIP24097V012324

7. Breach of law: (Code- Excl10) - Expenses for treatment directly D.1.10
arising from or consequent upon any Insured Person committing
or attempting to commit a breach of law with criminal intent.

8. Excluded Providers: (Code- Excl11) D.1.11

Expenses incurred towards treatment in any hospital or by any
Medical Practitioner or any other provider specifically excluded by
the Insurer as per Annexure IV of this policy and as disclosed in
website (www.adityabirlahealth.com/healthinsurance) / notified to
the policyholders are not admissible. However, in case of life
threatening situations or following an accident, expenses up to
the stage of stabilization are payable but not the complete claim.

9. Treatment for, Alcoholism, drug or substance abuse or any D.1.12

addictive condition and consequences thereof. (Code- Excl12).

10. Treatments received in heath hydros, nature cure clinics, spas D.1.13
or similar establishments or private beds registered as a nursing
home attached to such establishments or where admission is
arranged wholly or partly for domestic reasons. (Code- Excl13)

11. Dietary supplements and substances that can be purchased D.1.14

without prescription, including but not limited to Vitamins,
minerals and organic substances unless prescribed by a medical
practitioner as part of hospitalization claim or day care procedure
(Code- Excl14)

12. Refractive Error:(Code- Excl15) - Expenses related to the D.1.15

treatment for correction of eye sight due to refractive error less
than 7 .5 dioptres.

13. Unproven Treatments:(Code- Excl16) D.1.16

Expenses related to any unproven treatment, services and
supplies for or in connection with any treatment. Unproven
treatments are treatments, procedures or supplies that lack
significant medical documentation to support their effectiveness.

14. Sterility and Infertility: (Code- Excl17) D.1.17

Expenses related to sterility and infertility. This includes:
i. Any type of contraception, sterilization
ii. Assisted Reproduction services including artificial insemination
and advanced reproductive technologies such as IVF, ZIFT,
GIFT, ICSI
iii. Gestational Surrogacy
iv. Reversal of sterilization

Product Name: Activ One, Product UIN: ADIHLIP24097V012324

15. Maternity Expenses (Code - Excl18): D.1.18
i. Medical treatment expenses traceable to childbirth (including
complicated deliveries and caesarean sections incurred during
hospitalization) except ectopic pregnancy;
ii. Expenses towards miscarriage (unless due to an accident) and
lawful medical termination of pregnancy during the policy period.

Specific Exclusions

1. Circumstantial Exclusion D.2.1

a) Treatment resulting from war, invasion, civil war, revolt, or
military involvement: Medical treatment that arises from
or is related to acts of war, military operations, or
involvement in armed forces activities
b) Exclusion of certain acts and substances: Treatment or
consequences related to unlawful acts, nuclear weapons /
materials, chemical and biological weapons, radiation
exposure, or contamination by radioactive materials or
substances.
c) The Insured Person’s direct participation in terrorist acts;

2. Behavioural Exclusions D.2.2

a) Suicide or attempted suicide, intentionally hurting oneself
on purpose;
b) Illegal act of the Insured Persons
c) Any treatment for Injury resulting from the consumption of
alcohol or any intoxicating substance, its intake or abuse
thereof
d) the use of drugs (other than drugs taken under
treatment prescribed and directed by a Medical Practitioner
but not for the treatment of drug addiction);

3. Medical Exclusions D.2.3

a) All routine examinations and Health Check-ups except
as per terms and conditions mentioned under Section
C.9 – Annual Health Check-up
b) Circumcisions (unless required for medical reasons
or as part of a treatment plan for an illness or injury);
c) Conditions for which treatment could have been done
on an outpatient basis without any Hospitalization
d) Preventive care, vaccinations and immunizations (except in
case of post-bite treatment); any physical, psychiatric or
psychological examinations or testing
e) Admission for nutritional and electrolyte supplements
unless certified by the attending medical practitioner that
they are necessary as a direct result of a covered claim
f) Any conditions or abnormalities that are present at birth
and are visible on the outside of the body, as well as any
related diseases or defects,

Product Name: Activ One, Product UIN: ADIHLIP24097V012324

 g) Stem cell therapy except Hematopoietic stem cells for
bone marrow transplant for haematological conditions) or
Surgery, or growth hormone therapy or Hormone
Replacement Therapy.
h) Dental/oral treatment: Treatment, procedures and
preventive, diagnostic, restorative, cosmetic services
related to disease, disorder and conditions related to
natural teeth and gingiva except if required by an Insured
Person while Hospitalized due to an Accident
i) AYUSH Treatment Any form of AYUSH Treatments,
except as mentioned under Section C.7

4. Prosthesis and Devices D.2.4

a) Hearing aids, spectacles or contact lenses including
optometric therapy, multifocal lens
b) Wigs, or toupees, and related expenses.
c) Expenses for prosthesis (artificial body parts), corrective
devices, external durable medical equipment, wheelchairs,
crutches, or instruments used in the diagnosis / treatment
of sleep apnea syndrome and other sleep disorders or
continuous ambulatory peritoneal dialysis (C.A.P.D.),
Devices used for ambulatory monitoring of blood pressure,
blood sugar, glucometers, nebulizers and oxygen
concentrator for bronchial asthma/ COPD conditions, cost
of cochlear implant(s) unless necessitated by an Accident.

5. Non-Medical expenses D.2.5

As mentioned under Annexure (I), items in List I II, III & IV will
be excluded unless forms a part of In-patient hospitalization.

6. Specific treatment Exclusion D.2.6

Treatment involving Rotational Field Quantum Magnetic
Resonance (RFQMR), External Counter Pulsation (ECP),
Enhanced External Counter Pulsation (EECP), Hyperbaric
Oxygen Therapy, KTP Laser Surgeries, cyber knife treatment,
Femto laser surgeries, bioabsorbable stents, bioabsorbable
valves, bioabsorbable implants, use of Infliximab, rituximab,
avastin, lucentis, Use of Radio Frequency (RF) probe for
ablation.Treatments provided by a Medical Practitioner who
is a family member of the Insured Person or resides in the
same household, unless pre-approval is obtained from Us.

7. Activities and Profession Exclusions D.2.7

a) Treatment received from a person who is not recognized
as a registered Medical Practitioner by any state medical
council or the medical council of India.
b) Medical or treatment fees charged by unlicensed and
unauthorized practitioners are not covered

Product Name: Activ One, Product UIN: ADIHLIP24097V012324

 8. Geographical Exclusion D.2.8
Treatment taken outside India, unless specified to be covered
in the Policy Schedule.

07. Waiting period 1. Pre-Existing Diseases (Code- Excl01): D.1.1

• Time period during Pre-existing Diseases shall be covered after a waiting period
which specified of 36/48 months as specified in Product Benefit Table / Policy
disease / treatment
is not covered Schedule

• It is counted from 2. Specified disease / procedure waiting period (Code- Excl02): D.1.2
the beginning of the (Not applicable for Personal Accident Cover (AD,PTD) and
policy coverage
Critical Illness Cover)

24 months for specific illness/conditions and their complications

in the first two years and is not applicable in subsequent renewals

Body System Illness Treatment/ Surgery

1. Eye Cataract Cataract Surgery
Glaucoma Glaucoma Surgery
Refractive Error Correction Correction Surgery
2. Ear Nose Throat Sinusitis Medical & Surgical Treatment
Rhinitis Medical & Surgical Treatment
Tonsillitis & Adenitis Medical & Surgical Treatment
Tympanitis & Non Traumatic Perforation Medical & Surgical Treatment
Deviated Nasal Septum Medical & Surgical Treatment
Otitis Media Medical & Surgical Treatment
Adenoiditis Medical & Surgical Treatment
Mastoiditis Medical & Surgical Treatment
Cholesteatoma Medical & Surgical Treatment
3. Gynecology All Cysts, Mass, Swelling, Lump, Granulomas, Polyps, Fibroids & Medical & Surgical treatment
Benign Tumour of the female genito urinary system
Polycystic Ovarian Disease Medical & Surgical treatment
Uterine Prolapse Medical & Surgical treatment
Fibroids (Fibromyoma) Medical & Surgical treatment
Breast lumps (excluding Malignant) Medical & Surgical treatment
Dysfunctional Uterine Bleeding (DUB) Medical & Surgical treatment
Endometriosis Medical & Surgical treatment
Menorrhagia Medical & Surgical treatment
Pelvic Inflammatory Disease Medical & Surgical treatment
4. Orthopedic / Gout Medical & Surgical treatment
Rheumatological Rheumatism, Rheumatoid Arthritis Medical & Surgical treatment
Non infective arthritis Medical & Surgical treatment
Osteoarthritis Medical & Surgical treatment
Osteoporosis Medical & Surgical treatment
Prolapse of the intervertebral disc Medical & Surgical treatment
Spondilosis, Spondioarthritis, Spondylopathies Medical & Surgical treatment
Ankylosing Spondilitis / Spondylopathies Medical & Surgical treatment
Psoriatic Arthritis / Arthropathy Medical & Surgical treatment
Internal Derangement of Knee / Ligament or Tendon or Meniscus Tear Medical & Surgical treatment
Joint Replacement Surgery Medical & Surgical treatment
Non Specific Arthritis Medical & Surgical treatment
Product Name: Activ One, Product UIN: ADIHLIP24097V012324
 5. Gastroenterology Stone in Gall Bladder, Bile duct & other parts of Biliary System Medical & Surgical treatment

(Alimentary Canal Cholecystitis Surgical treatment

and related Pancreatitis Surgical treatment

Organs) Fissure, Fistula in ano, hemorrhoids (piles), Pilonidal Sinus, Medical & Surgical treatment
Ano-rectal & Perianal Abscess
Rectal Prolapse Medical & Surgical treatment
Gastric or Duodenal Erosions or Ulcers + Gastritis & Duodenitis & Colitis Medical & Surgical treatment
Gastro Esophageal Reflux Disease (GERD) Medical & Surgical treatment
Cirrhosis Medical & Surgical treatment
Chronic Appendicitis Surgical treatment
Appendicular lump, Appendicular abscess Medical & Surgical treatment
6. Gastroenterology Stones in Urinary system (Stone in the Kidney, Ureter, Urinary Bladder) Medical & Surgical treatment
(Alimentary Canal Benign Hypertrophy / Enlargement of Prostate (BHP / BEP) Medical & Surgical treatment
and related Organs)
Hernia, Hydrocele Medical & Surgical treatment
Varicocoele / Spermatocoele Medical & Surgical treatment
7. Skin Skin tumour (unless malignant) Medical & Surgical treatment
All skin diseases
8. General Surgery Any swelling, tumour, cyst, nodule, ulcer, polyp Mass , Swelling, Lump, Medical & Surgical treatment
Granulomas, Benign Tumour anywhere in the body (unless malignant)
Varicose veins, Varicose ulcers Medical & Surgical treatment
Internal Congenital Anomaly or internal congenital diseases Medical & Surgical treatment
3. 30-day waiting period (Code- Excl03): D.1.3
30 days for all illnesses (except accident) in the first year and is
not applicable in subsequent renewals and policies accepted
under Portability

4. Initial waiting period (Applicable for Personal Accident Cover

(AD,PTD) and Critical Illness Cover)
• For Personal Accident Cover (AD,PTD), no initial waiting period C.13.7
applicable.
• For Critical Illness Cover, We shall not be liable to make any C.13.6
payment in respect of any Critical Illness whose signs or
symptoms first occur within 90 days from the Inception Date
of cover.

08. Financial limits of

coverage

(i) Sub-limit (It is a Nil

pre-defined limit
and We will not pay
any amount in
excess of this limit)

(ii) Co-payment (It Nil

is a specified
amount / percentage
of the admissible
claim amount to be
paid by Insured)

(iii) Deductible Nil

(iv) Any other limit Nil

Product Name: Activ One, Product UIN: ADIHLIP24097V012324

09. Claims / Claims a. For Cashless Service: E.2.7.1.a
Procedure Kindly contact us 48 hrs prior for planned hospitalisation or within
24 hours of hospitalisation in case of emergency hospitalisation.

Link for Hospital Network details:

https://www.adityabirlacapital.com/healthinsurance/locate-care/hospital-listing

b. For Reimbursement of Claim: E.2.7.1.d

Type of claim Prescribed Time Limit

Reimbursement of Within 30 days of date of

Hospitalization, Day Care discharge from Hospital.
Treatment or Pre Hospitalization
Expenses

Reimbursement of Post Within 15 days from completion

Hospitalization Expenses of post Hospitalization treatment.

c. For Personal Accident: We shall be given an intimation of the E.2.7.2

claim along with the following details within 7 days from the date
of Accident.
d. For Critical Illness: We shall be given intimation of the claim E.2.7.2
along with the following details within 30 days of the diagnosis
of the Critical Illness.

10. Policy Servicing ln case of any Policy services the insured person may contact the
Website: https://www.adityabirlacapital.com/healthinsurance/faqs
Toll- Free: 1800 270 7000
E-mail: [email protected]
(Senior citizens may write to us at:
[email protected])
In case you are not satisfied with the resolution you may write to Head –
Customer Care : [email protected]
Courier:
Write to our HO at below address
Unit no 1101 & 1104 11th floor, Unit no 1501 & 1502 15th floor, G Corp
Tech Park, Kasarwadavali, Ghodbunder Road,Thane West - 400601
lnsured person may also approach the grievance cell at any of the
company's branches with the details of grievance.

If lnsured person is not satisfied with the Redressal of grievance

through one of the above methods, insured person may contact the
grievance officer at: [email protected]
If Insured Person is not satisfied with the Redressal of grievance
through above methods, the Insured Person may also approach the
office of Insurance Ombudsman of the respective area/region for
Redressal of grievance as per Insurance Ombudsman Rules 2017
(at the addresses given in Annexure II)

Grievance may also be lodged at IRDAI Integrated Grievance

Management System-https://bimabharosa.irdai.gov.in/

Product Name: Activ One, Product UIN: ADIHLIP24097V012324

11. Grievances / ln case of any grievance the insured person may contact the E.1.8
Complaints Website: https://www.adityabirlacapital.com/healthinsurance/faqs
Toll- Free: 1800 270 7000
E-mail: [email protected]
(Senior citizens may write to us at:
[email protected])
In case you are not satisfied with the resolution you may write to Head –
Customer Care : [email protected]

Courier:
Write to our HO at below address
ln case of any grievance the insured person may contact the Website:
https://www.adityabirlacapital.com/healthinsurance/faqs
Toll- Free: 1800 270 7000
E-mail: [email protected]
(Senior citizens may write to us at:
[email protected])

In case you are not satisfied with the resolution you may write to Head –
Customer Care : [email protected]
Courier:
Write to our HO at below address
Unit no 1101 & 1104 11th floor, Unit no 1501 & 1502 15th floor, G Corp
Tech Park, Kasarwadavali, Ghodbunder Road,Thane West - 400601
lnsured person may also approach the grievance cell at any of the
company's branches with the details of grievance.

If lnsured person is not satisfied with the Redressal of grievance through

one of the above methods, insured person may contact the grievance
officer at: [email protected]

If Insured Person is not satisfied with the Redressal of grievance

through above methods, the Insured Person may also approach the
office of Insurance Ombudsman of the respective area/region for
Redressal of grievance as per Insurance Ombudsman Rules 2017
(at the addresses given in Annexure II)
Grievance may also be lodged at IRDAI Integrated Grievance
Management System-https://bimabharosa.irdai.gov.in/

Grievance may also be lodged at IRDAI Integrated Grievance

Management System-https://bimabharosa.irdai.gov.in/

12. Things to a. Free Look period: The Free Look Period shall be applicable on E.1.1
remember new individual health insurance policies and not on renewals or
at the time of porting/migrating the policy.

The insured person shall be allowed free look period of fifteen

days (thirty days for policies with a term of 3 years, if sold
through distance marketing) from date of receipt of the policy

Product Name: Activ One, Product UIN: ADIHLIP24097V012324

 document to review the terms and conditions of the policy, and
to return the same if not acceptable.

lf the insured has not made any claim during the Free Look Period,
the insured shall be entitled to:
i. refund of the premium paid, less any expenses incurred by
the Company on medical examination of the insured person or
ii. where the risk has already commenced and the option of return
of the policy is exercised by the insured person, a deduction

towards the proportionate risk premium for period of cover or

iii. where only a part of the insurance coverage has commenced,
such proportionate premium commensurate with the insurance
coverage during such period.

b. Policy Renewal: The policy shall ordinarily be renewable except E.1.3

on grounds of fraud, moral hazard, misrepresentation by the
insured person. Renewal shall not be denied on the ground
that the insured had made a claim or claims in the preceding
policy years.

c. Migration: The Insured Person will have the option to migrate E.1.12
the Policy to other health insurance products / plans offered by
the Company policy by applying for migration of the policy at
least 30 days before the policy renewal date as per IRDAI
guidelines on Migration. If such person is presently covered
and has been continuously covered without any lapses under
any health insurance product / plan offered by the Company,
the insured person will get the accrued continuity benefits in
waiting periods as per IRDAI guidelines on migration.

In case the Insured Person wants to migrate their Health Insurance

Policy, then contact Us with the details through:
E-mail ID: [email protected]
Toll Free: 1800 270 7000
Address: Any of Our Branch office or Corporate office

d. Portability: The Insured Person will have the option to port the E.1.13
Policy to other insurers by applying to such Insurer to port the
entire policy along with all the members of the family, if any, at
least 45 days before, but not earlier than 60 days from the policy
renewal date as per IRDAI guidelines related to Portability. If such
person is presently covered and has been continuously covered
without any lapses under any health insurance policy with an
Indian General/Health insurer, the proposed Insured Person will
get the accrued continuity benefits in waiting periods as per
IRDAI guidelines on portability.

Product Name: Activ One, Product UIN: ADIHLIP24097V012324

 In case the Insured Person wants to port their Health Insurance
Policy, then contact Us with the details through:
E-mail ID: [email protected]
Toll Free: 1800 270 7000
Address: Any of Our Branch office or Corporate office

e. Changes to Sum Insured on Renewal: You may opt for E.2.5.C

enhancement of Sum Insured at the time of Renewal, subject to
underwriting. All Waiting Periods as defined in the Policy shall
apply afresh for this enhanced limit from the effective date of
such enhancement.

f. Moratorium Period: After completion of eight continuous years E.1.10

under the Policy, no look back would be applied. This period of
eight years is called as ‘Moratorium Period’. The moratorium
would be applicable for the Sums Insured of the first Policy with
Us and subsequently completion of eight continuous years
would be applicable from date of enhancement of Sum Insured
only on the enhanced limits. After the expiry of Moratorium
Period, no health insurance claim shall be contestable except
for proven fraud and permanent exclusions specified in the
Policy contract. The Policy would however be subject to all limits,
sub limits, co-payments as per the terms and conditions of the
Policy contract.

13. Insured’s a. The Policy shall be void and all premium paid thereon shall be E.1.14
Obligations forfeited to the Company in the event of misrepresentation,
mis-description or non-disclosure of any material fact by the
policyholder.

b. During the Policy Term any material information changes on

Occupation and/ or Medical Conditions shall be communicated
to Us in a Change Request Form. This form can be downloaded
from Our website or collected from Our branch office or can
also be obtained by contacting Us over the telephone.

Benefits and exclusion are applicable as per the plan chosen. Please refer Policy Schedule for the applicable benefits

Product Name: Activ One, Product UIN: ADIHLIP24097V012324

72

Declaration by the Policy Holder:

I have read the above and confirm having noted the details.

RAM BRIKSHA PRASAD authenticated via OTP for

Place : Bermo QSP_240000209294
On 24/05/2024 at 15:56:17
Date :24-MAY-24

(Signature of the Policy Holder)

LEGAL DISCLAIMER NOTE:

The information must be read in conjunction with the product brochure and policy document. In case of any conflict between the
CIS and the policy document, the terms and conditions mentioned in the policy document shall prevail.

Please refer below link for Product related documents

Aditya Birla Health Insurance Download (adityabirlacapital.com)