31-24-0135267-00
NITISH UMESH SHARMA
Kailash Sadan Popatpara sheri no 16 Popatpara Near
Central Jail Rajkot Rajkot Gujarat
null
Rajkot
GUJARAT
INDIA
360001
9601002710 Empowering people to
08/10/2024 lead healthier lives
Dear NITISH UMESH SHARMA,
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 - NXT
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,
Cashless Home
Mayank Bathwal Healthcare
Chief Executive Officer Coverage
Aditya Birla Health Insurance Co. Limited.
Super Reload: 2x Cover
From day 1 and unlimited refill
POLICY NUMBER: 31-24-0135267-00 up to 100% Sum Insured
Name Membership No DOB from 2nd Claim onwards
NITISH UMESH SHARMA PT13226322 27/Oct/1995
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 NXT
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,
2nd Floor, 317 - A, 9th Main Road
Policy Issuing Office G Corp Tech Park, Kasarwadavali, Policy Servicing Office
Bengaluru KARNATAKA 560041
Ghodbunder Road, Thane
West-400615
Intermediary Name Direct . Intermediary Code 5100003
care.healthinsurance@adityabirlacapi
Intermediary Contact Details 18002707000 Intermediary E-mail ID
tal.com.
Toll Free Number 18002707000
Policyholder Name NITISH UMESH SHARMA
Kailash Sadan Popatpara sheri no 16 Popatpara Near Central Jail Rajkot Rajkot Gujarat Rajkot,
Policyholder Address
360001, Rajkot, GUJARAT
Contact Number 9601002710
Email Id
[email protected] GSTIN NA
Product Name Activ One
Plan NXT
Policy Number 31-24-0135267-00
First Policy Start date 08/10/2024
Start Date of Policy & Time 00:00 hrs on 08/10/2024 Expiry Date & Time of Policy 23:59 hrs on 07/10/2025
Policy Type Individual 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
Insured Start date of first
Relationship Age Diseases
Person (only DOB policy with
Name of Insured person with Member ID (completed Gender (PED)
in case of new (DD-MM-YYYY) us(applicable at
Proposer birthday) (if applicable)
member policy renewal)
additions mid
term)
NITISH UMESH SHARMA NA Self PT13226322 28 Male 27/10/1995 NA 08/10/2024
Continued and to be read in conjunction of the table above
Specific disease Waiting Pre-Existing Disease Super Credit
Base Sum Insured Initial Waiting Period Super Credit %
period Waiting Period Amount
1000000 30 Days 2 Years 4 Years NA NA
Continued and to be read in conjunction of the table above optional cover opted.
Product Name: Activ One, Product UIN: ADIHLIP24097V012324
0 0
1 0 Name of Insured Person Claim Protect (Non-Medical Expense Waiver)
Non-payable items will be covered (all 4 lists of
0 0 NITISH UMESH SHARMA
Annexure I)
Super Credit (increases irrespective of claim)
0 0
100% of Base Sum Insured per year, up to 500% of Base Sum
1 0 Insured (up to Max of 3 Cr under this benefit)
0 0
Waiting Period from Start Start Date of Chronic Management Program
Name of the Insured Person Chronic Condition
Date of First Policy Coverage Applicability
NITISH UMESH SHARMA No NA NA No
Name of the Insured Person Special Condition (if applicable)
NITISH UMESH SHARMA No
Name of the Insured Person Pre-Existing Disease Details (if applicable)
NITISH UMESH SHARMA NA
HealthReturnsTM (Applicable for Renewal Policy)
Name of the Insured Person HealthReturnsTM carried forward from Previous Year -Total HealthReturnsTM available for utilization
NITISH UMESH SHARMA 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
Umesh Sharma Father 9913227770
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.
No
Product Name: Activ One, Product UIN: ADIHLIP24097V012324
Product Name Activ One
Plan Variant NXT
Base Sum Insured Refer Base Sum Insured column under Insured
Basic Covers Hospitalization Room Rent Any Room - Actuals up to Sum Insured
Treatment ICU Charges Actuals up to Sum Insured
Road Ambulance Cover (per hospitalization) Actuals up to Sum Insured
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
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
Super Reload 2X Cover Covered from Day 1
Unlimited Refill [2nd Claim onwards - 2nd Claim Onwards - unlimited times (up to Base Sum
Unlimited Times (upto Base Sum Insured)] Insured)
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
Premium for
Premium for
Other Optional Loading Discounts CGST SGST/UTGST IGST Other taxes/Cess
Base and Related Total Premium
Covers (if applicable) (if applicable) (9%) (9%) (18%) (1%)
Covers
(If Opted)
8870.17 0 0 887.02 NA NA 1436.97 NA 9420.00
GST Registration No: 29AANCA4062G1ZJ 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. MH015093118202324E dated 05/02/2024
For and on behalf of Aditya Birla Health Insurance Co. Ltd
Date : 08/10/2024
Location : Mumbai
Authorized Signatory
Product Name: Activ One, Product UIN: ADIHLIP24097V012324
Premium Certificate
We confirm the receipt of premium amount of INR 9420.00 as per below details paid by MR. NITISH UMESH SHARMA for Self and/or Family and/or
Parents:
Policy Number: 31-24-0135267-00 Plan Name: NXT
Type of Plan: Individual Proposer Name: NITISH UMESH SHARMA
Policy Start Date: 00:00 hrs on 08/10/2024 Policy End Date: 23:59 hrs on 07/10/2025
Receipt Details:
CGST SGST/UTGST IGST
Receipt Date Base Premium Amount Total Premium (incl. of taxes)
(9%) (9%) (18%)
08-10-2024 7983.15 0.00 0.00 1436.97 9420.00
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 9,420.00
* 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 : 08/10/2024
Place : Mumbai
Authorized Signatory
Product Name: Activ One, Product UIN: ADIHLIP24097V012324
31-24-0135267-00
Membership
Name DOB
No.
NITISH UMESH SHARMA PT13226322 27/Oct/1995
