21-21-1114285-01
Prakash Chand Saini Empowering people to
Vinayak Enclave Part-II, Near BSNL Tower, Girdharpur lead healthier lives
Sunarasi
Gali No- 5, H. No-132
Ghaziabad Up to 100%of your
UTTAR PRADESH Premium as Health
INDIA Returns*
201009
9540745679
22/02/2025
Cover from Day 1
for Chronic Illnesses*
Dear Prakash Chand Saini,
A relationship that stands the test of time only gets fruitful in the future. We’re glad
that you’ve chosen to continue your health and wellness journey with us. Cover on Modern
By offering you the best insurance advice and the finest health guidance, we will Treatment methods
ensure that we keep giving you more and more reasons to renew our relationship
year-on-year.
Excited? So are we! Get ready to make the most out of your new insurance plan Expert Health Coach
Activ Health - Platinum - Essential
We hope that you continue to stay healthy throughout your journey with us.
Double Sum Insured
Warm regards, in 2 years with
Cumulative Bonus^
Mayank Bathwal
Chief Executive Officer Scan the QR code to
Aditya Birla Health Insurance Co. Limited. Download the Activ Health
App
Your health
and your policy,
POLICY NUMBER: 21-21-1114285-01 all in one place
Name Membership No DOB
Khiladi Singh PT85713740 01/01/1969
*Not Applicable for Activ Health – Gold Enhanced
For assistance, connect with us via the following channels: ^Only Applicable for Activ Health – Platinum Enhanced and Premiere
Follow us to follow Activ Health UIN:ADIHLIP24102V052324
Activ Health - Policy Schedule
Unit no 1101 & 1104 11th floor, Unit no 1101 & 1104 11th floor,
Unit no 1501& 1502, 15th floor, Unit no 1501 & 1502 ,15th floor,
Policy Issuing Office G Corp Tech Park, Policy Servicing Office G Corp Tech Park
Kasarwadavali, Ghodbunder Kasarvadavali Mumbai
Road, Thane West-400615 MAHARASHTRA 400001
Intermediary POLICYBAZAAR INSURANCE Intermediary
5100357
Name BROKERS PRIVATE LIMITED Code
Intermediary Contact Details 18002585970 Intermediary E-mail ID adityabirla@[Link]
Toll Free Number 18002707000
I. Details of Policyholder
Policyholder Name Prakash Chand Saini
Vinayak Enclave Part-II, Near BSNL Tower, Girdharpur Sunarasi Gali No- 5, H. No-132
Policyholder Address
Ghaziabad, 201009, Ghaziabad, UTTAR PRADESH
Mobile Number: 9540745679
Contact Number Emergency/Alternate Contact Number: NA
WhatsApp No, if different from Mobile Number: 9540745679
Email ID saXXXXXXXXXX24@[Link]
II. Policy Details
Product Name Activ Health Plan Name Platinum - Essential
Policy Number 21-21-1114285-01
First Policy Start date with ABHI 22/02/2022
Start Date of Policy & Time 00:00 hrs on 22/02/2025 Expiry Date & Time of Policy 23:59 hrs on 21/02/2027
Policy Type Individual Policy Tenure (in years) 2
Policy Category Renewal
Mode of Premium payment Single
Portability No Previous Policy Number 21-21-1114285-00
GSTN Number NA GSTN Account Type Consumers
III. Insured Person's Details
Start date Start Date
of Policy of of First
Insured Relationship Pre-existing Policy with
Name of the Insured Person (in with Member ID Age Gender DOB Diseases (if US
person case of Policyholder applicable) (applicable
new at policy
member renewal)
Syncope - R55 -
PT8571374 ,Hypertension
Khiladi Singh NA Father 56 Male 01/01/1969 22/02/2022
0 (High Blood
Pressure) - I10 - 0
Continued ..................
Activ Health, Product UIN: ADIHLIP24102V052324.
Applicability of Chronic Management Program (Available for Eligible Room
Cumulative Bonus
Platinum, Essential ,Enhanced and Premiere Plan only) Category
Waiting Sum Zone
Period from Start date Insured Category ICU
Chronic Condition Room Type % Amount
Start Date of of coverage Charges
First Policy
Single
No 0 22/02/2025 500000 Zone I Private upto SI 10 40000
A/C Room
(for policies Renewed with Us, the Start date of the first Policy with Us will also be displayed against each Insured Person).
Inbuilt Premiere Benefit (Applicable only to Platinum – Premiere Plan)
Personal Accident Cover International Coverage for major
Name of the Insured Person Critical Illness Cover
(AD,PTD) illnesses
Khiladi Singh NA NA NA
Optional Covers*
Name of the Personal Critical Illness International PPN Discount Waiver of Maternity OPD Hospital Cash
Insured Person Accident Cover Cover Coverage for major mandatory Expenses Expenses Benefit
(AD,PTD) illnesses (available co-payment**
with base Sum
Insured of 10L &
above only)
Khiladi Singh NA NA No NA Yes NA No No
* Personal Accident Cover (AD,PTD), Critical Illness Cover, International Coverage for Major Illnesses, Waiver of mandatory
co-payment, Maternity
Expenses, OPD Expenses, Hospital Cash Benefit as Optional covers are not applicable for Platinum Premiere Plan.
** Waiver of co-payment is applicable for base benefit and not optional covers except PPN discount, if opted.
Name of the Insured Person Special condition (if applicable)
Khiladi Singh No
Name of the Insured Person Pre existing details (if applicable)
Khiladi Singh Syncope - R55 - ,Hypertension (High Blood Pressure) - I10 - 0
HealthReturnsTM1 (Applicable for Renewal Policy)
Name of the Insured Person HealthReturnsTM carried forward from Total HealthReturnsTM available for
Previous Year utilization
Khiladi Singh NA 0
1
Trademarks- Health Returns, Healthy Heart Score and Active Dayz are owned by MMI Group Limited and used under license
by Aditya Birla Health Insurance Co. Limited.
IV. Nominee Details
Nominee Name Nominee Relationship with Policyholder Nominee Contact Number
Khiladi Singh Father NA
V. Assignment clause
Assignment: This Policy has been assigned to: NA
Relationship with the Assignee: NA
Reason for Assignment: NA
VI . Previous Insurer Details (Only applicable for Portability policies)
Total Ported
Date of Previous Sum Insured Waiting
Type of
Name of Insured Person first Previous Insurer Policy (Sum Insured + period waived
Cover
enrollment Number Cumulative off
Bonus)
NA NA NA NA NA NA NA
Activ Health, Product UIN: ADIHLIP24102V052324.
[Link] under the Policy (shall be displayed as applicable under the Plan in force)
Product Name Activ Health
Product Features / Platinum
Product Variants Essential
50,000, 75,000, 1 Lac, 2 Lac, 3 Lac, 4 Lac, 5 Lac, 6 Lac, 7 Lac, 8 Lac, 9 Lac, 10 Lacs, 15
Sum Insured (Rs.)
Lac, 20 Lac, 25 Lac, 30 Lac, 40 Lac, 50 Lac, 100 Lac
I. Basic Room Options
Covers upto S.I. - 3 L
1. Shared Room
2. Single Private A/C Room
In-patient Room Options
Hospitalization S.I. 4L and above
1. Shared Room
2. Single Private A/C Room
3. Any Room
ICU Charges Upto S.I.
Pre-hospitalization
30 days
Medical Expenses
Post-hospitalization
60 days
Medical Expenses
Day Care Treatment Covered up to Sum Insured
Domiciliary
Covered up to Sum Insured
Hospitalization
Covered up to Actual Expenses per event in case of Network Providers
Road Ambulance Cover
Reimbursed up to Rs.3,000 per Hospitalization for Non-Network Providers
Organ Donor Expenses Not Available
Reload of Sum Insured Not Available
Super Reload Not Available
AYUSH Cover Covered up to Sum Insured
Mental Illness Sum Insured - Upto 4L:Rs. 50,000
Hospitalisation Sum Insured 5L & above:Rs. 1,00,000
Obesity Treatment Covered up to Sum Insured
S.I. Upto 4L - Rs. 25,000
Home Treatment
S.I. 5L and above -Rs. 50,000
Modern Treatment
Methods and Upto S.I. for listed procedures
Advancement in Co-Payment of 50% for Robotic surgeries
Technologies
Domestic Emergency
Assistance Services
Not Available
(including Air
Ambulance)
International Emergency
Assistance Services
Not Available
(including Air
Ambulance)
OPD Cover Not Available
Post-hospitalisation
Not Available
Physiotherapy cover
Premium Waiver Not Available
For SI 3 Lac and below
Zone II to Zone I: 10%
Co-payment for
Zone III to Zone II: 15%
treatment in a Higher
Zone III to Zone I: 25%
Zone
For S.I. 4L and above –
Not Applicable
Mandatory Co-payment 20% for all S.I options
Activ Health, Product UIN: ADIHLIP24102V052324.
II. Applicable on Sum Insured
Additional Cumulative Bonus 10% increase, Max up to 100% (up to maximum of 50 Lacs )/
Benefits /No Claim Discount No Claim Discount -Applicable on the premium of the expiring policy year provided no
claim under the policy
Dental Consultation &
Not Available
Investigations
Health Check- up
Available, Once in a policy year
Program
Second E-Opinion for
Available
Major Illnesses
Recovery Benefit Not Available
III. Value Chronic Management Available, As per Annexure 1
Added Program (OPD)
Benefit
Health AssessmentTM Available
HealthReturnsTM Available, upto 50% of Premium
Expert Health Coach Available - Medical, Nutritional, Mental & Fitness.
IV. Inbuilt
International Coverage
Premiere Not Available
for major illnesses
Benefit
(Applicable
only to Personal Accident Cover
Platinum – Not Available
(AD, PTD)
Premiere
Plan)
Critical Illness Cover Not Available
V. Optional Personal Accident Cover
S.I.- 5L,10L,15L,20L,30L
Covers (AD, PTD)
S.I.- 3L,5L,10L,15L,20L
Critical Illness Cover
Survival Period - 15 days
International Coverage
S.I.- 3 Cr/6 Cr, available with base S.I. of 10L & above only
for major illnesses
Preferred Provider
10% discount available
Network (PPN) Discount
Waiver of mandatory
Available for all S.I. options
co-payment
Maternity Expenses Available
Normal delivery –
i Maternity Expenses Rs. 75,000 C section
delivery Rs. 1,00,000
New Born Baby
ii Covered upto Maternity Sum Insured
Expenses
Vaccination
iii Covered upto Maternity Sum Insured
Expenses
Stem Cell
iv Rs. 35,000, over and above Maternity Sum Insured
Preservation
OPD Limit : Rs. 5,000 to Rs. 20,000, in multiples of Rs. 1,000
General Medical Practitioner/ Specialist Medical Practitioner: 10% of OPD Limit per
visit,Medicine and Diagnostic: 50% of OPD Limit
OPD Expenses Road Traffic Accident Diagnostic (over and above OPD Limit):Rs. 10,000
Cumulative Bonus applicable on Unutilized OPD Expenses*: 5% increase carry forward
available for 12 months from the completion of policy year, up to No limit, No
reduction on claim.*Not applicable for OPD limit for Road Traffic Accident diagnostics
Rs. 500 to Rs. 5,000 in multiples of Rs. 500 A deductible of 24 hours shall apply under
Hospital Cash Benefit
this Benefit.
Activ Health, Product UIN: ADIHLIP24102V052324.
[Link] Details (Rs)
Premium for Premium for Loading Discounts CGST SGST/UTGST IGST Other Total Premium
Base and Other Optional (if applicable) (if applicable) (9%) (9%) (18%) taxes/Cess(
Related Covers Covers 1%))
(If Opted)
29794.0 5958.8 0 2681.46 NA NA 5952.84 NA 39024.00
GST Registration No: 27AANCA4062G1ZN PAN Number :AANCA4062G Category: General Insurance SAC Code: 997133+
We hereby declare that though our aggregate turnover in any preceding financial year from 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.
Consolidated Stamp Duty paid vide E-challan GRN no. MH007197522202425E & 23/08/2024
For and on behalf of Aditya Birla Health Insurance
Co. Limited
Date : 22/02/2025
Place : Mumbai
Authorized Signatory
Activ Health, Product UIN: ADIHLIP24102V052324.
Premium Certificate
We confirm the receipt of premium amount of INR 39024.00 as per below details paid by Mr. Prakash Chand Saini for Self and/or Family and/or Parents:
Policy Number: 21-21-1114285-01 Plan Name: Platinum - Essential
Type of Plan: Individual Proposer Name: Prakash Chand Saini
Policy Start Date: 00:00 hrs on 22/02/2025 Policy End Date: 23:59 hrs on 21/02/2027
Receipt Number Receipt Amount Instrument Number Dated Relationship Payment Mode Bank Name
PB117010447_397362
RR-24-25-0751151 39024.00 03-02-2025 Self Online Payment NA
008
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:
Mode of Premium payment Single
Deduction under section 80D:
Financial Year Year wise proportionate Premium amount*
2024-25 19,512.00
2025-26 19,512.00
* 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 do not qualify for deduction under section 80D.
“The tax benefit u/s 80D is applicable only on the amount of the health insurance premium paid under the base policy. However, the amount paid towards HLTH
Meter will not qualify for deduction u/s 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 declarationthe liability shall
be upon the policy holder.
Any amount paid in cash towards premium will not qualify for tax benefits.
For and on behalf of Aditya Birla Health Insurance Co. Ltd
Date : 22/02/2025
Location: Mumbai
Authorized Signatory
Activ Health, Product UIN: ADIHLIP24102V052324
Activ Health, Product UIN: ADIHLIP24102V052324
21-21-1114285-01
Name Membership No. DOB
Khiladi Singh PT85713740 01/Jan/1969
