Group Activ Health - Certificate of Insurance

Policy Issuing Office Aditya Birla Health Policy Servicing Aditya Birla Health Insurance Co.
Insurance Company Limited, Office Limited, 7th Floor, C building,
10th Floor, R- Tech Park, Modi Business Centre,
Nirlon Compound, Kasarvadavali, Thane (W) -
Goregaon-East, Mumbai- 400615
400063
Master Policy 71-22-00081-00-00 Certificate Number GHI-TB3-OL-21-IN6189952
Number
Master Policy Holder Bajaj Finance Limited
Name
Product Name Group Activ Health Member ID BF-0000053067-01
Name of Insured R Suryakanth Unique Identification IN6189952
Person and H NO 2-66, Number
Residential
Jajapur,
Address of
Narayanpet
Insured person
TELANGANA - 500094

Contact Details 9440028630

Start date & Time of Master Policy 00:01 hrs on 10/07/2023

Expiry Date & Time of Master Policy 23:59 hrs on 30/07/2024
Period of Insurance
Inception Date 00:01 hrs on 21/01/2023
End Date 23:59 hrs on 20/01/2024

Insured Person Detail

Insured Person Date of Gender Nominee Relationsh Sum Insured
Birth ip

Benefit Description
Group Mediclaim Refer Coverage Details below

Group Activ Health, Product UIN:

IRDAI/HLT/ABHI/P-H(G)/V.1/19/2016-17
 Policy Exclusions
Group Mediclaim As per Annexure 1

Premium Details
Particulars Amount (Rs.)
Net Premium 17,441.53
IGST(18.00%) 1,339.48
Gross Premium 18,781.00
Premium Payment Mode Annual
GST Registration No. 27AANCA4062G1ZN Category: General
Insurance SAC Code:997133

Claim Process
Please contact Address for Correspondence Aditya Birla Health Insurance Company Limited,
us through any Claims Dept. 5th floor, C building, Modi Business Centre,
of these Kasarvadavali,Mumbai,
Modes Thane West 400 615
Contact Number 1800 270 7000
Email ID [email protected]

Note- At the time of claim, dependent member need to establish relationship with the Insured Person by
submitting relevant documents as a relationship proof.

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.

Group Activ Health, Product UIN:

IRDAI/HLT/ABHI/P-H(G)/V.1/19/2016-17
 PREMIUM CERTIFICATE

Premium Certificate is for the purpose of deduction under Section 80-(D) of Income Tax (Amendment) Act
1986.

This is to certify that KUNCHI PRASANNA DINESH paid INR 8,781.00 (In words Eight Thousand Seven
Hundred And Eighty- One Only) towards Premium for Health Insurance for the Period From 00:01 hrs on
(21/01/2022) to midnight (20/01/2023).
Instrument Number Instrument Date Amount Name of the Bank
- - - -

Stamp Duty- The stamp duty of Rs. 1 paid vide MH008239866202122E & 30/10/2021, received from
Stamp Duty Authorities vide Receipt No./GRASS DEFACE NO '0004071843202122 & 10/11/2021,
payment has been made vide Letter of Authorisation No. CSD/186/2021/4609 Dated 11/11/2021 from
Main Stamp Duty Office

Master Policy Number: 71-21-00081- Certificate Number: GHI-TB3-OL-21-

00-00 IN6189952

Date: 21/01/2022
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.
Annexure-1 Basic coverage
Coverage Details
Plan Type Mother( Divya Nair)

Section II : Base Covers

Base Covers Coverage
1.1 In-patient Hospitalization 500,000.00

Room rent – Single Private AC Room (All other

charges like professional fees, OT charges,
investigation charges/ lab reports will be in
accordance with the room rent restriction). ICU
at actuals
1.2 Day Care Treatment 527 listed procedures

Group Activ Health, Product UIN:

IRDAI/HLT/ABHI/P-H(G)/V.1/19/2016-17
1.3 Domiciliary Hospitalization Covered up to full Sum Insured
1.4 Pre – hospitalization Medical Expenses 30 days

1.5 Post-hospitalization Medical Expenses 60 days

1.6 Organ Donor Expenses Covered
1.7 Road Ambulance Expenses Rs.3000 per incident in case of emergency.
1.8 Reload Benefit No

Section IV : Waivers and Discounts

37 Co-payment No Co-payment
41 Pre-Existing Disease Waiting Period 2 years, applicable from first COI start date
42 Specified Disease / Procedure Waiting 2 years, applicable from first COI start date
Period
43 30 Days Waiting Period and 15 days Applicable for first COI
COVID waiting period

Pre Existing Disease:

Member Name Relationship Pre Existing Disease

* This is a computer generated document and does not need a signature

Terms & Conditions
(i)The donation conforms to The
Transplantation of Human Organs Act
1.1In-patient Hospitalization 1994 and the organ is for the use of the
We will cover the Medical Expenses incurred towards Insured Person;
one or more of the following arising out of an (ii) The organ transplant is medically
Insured Person’s Hospitalization during the Policy required for the Insured Person as
Period following an Illness or Injury that occurs certified in writing by a Medical
during the Policy Period provided that: Practitioner;
(iii) We will not cover:
(i)The Hospitalization is for Medically (1)Pre-hospitalization Medical
Necessary Treatment and follows written Expenses or Post-hospitalization
Medical Advice; (ii)The Medical Expenses Medical Expenses of the organ
incurred are Reasonable and Customary donor;
Charges for one or more of the following: (2)Screening expenses of the
(1)Room Rent and other organ donor;
boarding charges; (3)Any other Medical Expenses as
(2)ICU Charges; a result of the harvesting from the
(3)Operation theatre expenses; organ donor;
(4)Medical Practitioner’s fees (4)Costs directly or indirectly
including fees of specialists and associated with the acquisition of the
anaesthetists treating the donor’s organ;
Insured Person; (5)Transplant of any organ/tissue

Group Activ Health, Product UIN:

IRDAI/HLT/ABHI/P-H(G)/V.1/19/2016-17
 (5)Qualified Nurses’ charges; where the transplant is
(6)Medicines, drugs and other experimental or investigational;
allowable consumables prescribed by (6)Expenses related to
the treating Medical Practitioner; organ transportation or
preservation;
(7)Any other medical treatment
or complication in respect of the
donor, consequent to
harvesting.

(7)Investigative tests or Permanent Exclusions -

diagnostic procedures directly
related to the Injury/Illness for We shall not be liable to make any payment for any
which the Insured Person is claim under any Benefit in respect of any Insured
Hospitalized and conducted within Person directly or indirectly caused by, based on,
the same Hospital where the arising out of, relating to or howsoever
Insured Person is admitted; attributable to any of the following:
(8)Anaesthesia, blood, oxygen and
blood transfusion charges; 1. Treatment directly or indirectly arising from
(9)Surgical appliances and or consequent upon war or any act of war,
prosthetic devices recommended invasion, act of foreign enemy, war like
by the attending Medical Practitioner operations (whether war be declared or not
that are used intra operatively or caused during service in the armed forces
during a Surgical Procedure. of any country), civil war, public defense,
(iii)If the Insured Person is admitted in rebellion, uprising, revolution, insurrection,
the Hospital in a room category/Room military or usurped acts, nuclear weapons /
Rent higher than the eligibility as materials, chemical and biological weapons,
specified in the Policy Schedule/Certificate ionizing radiation, contamination by
of Insurance, then We shall be liable to pay radioactive material or radiation of any kind,
only a pro-rated proportion of the total nuclear fuel, nuclear waste.
Associated Medical Expenses (including 2. Committing or attempting to commit a
surcharge or taxes thereon) in the proportion breach of law with criminal intent, intentional
of the difference between the Room Rent self- Injury or attempted suicide while Insured
actually incurred and the entitled room Person is sane or insane.
category/eligible Room Rent to the Room 3. Willful or deliberate exposure to danger,
Rent actually incurred. intentional self- Injury, non- adherence to
Medical Advice, participation or involvement
Family Eligibility- Self, lawfully wedded in naval, military or air force operation, circus
spouse/ Partner (including same sex partners), son personnel, racing in wheels or horseback,
(biological/ adopted), daughter(biological/ adopted) diving, aviation, scuba diving, parachuting,
hang-gliding, rock or mountain climbing,
Sum Insured means- For a Family Floater bungee jumping, parasailing, ballooning,
Policy, the amount specified in the Policy Schedule skydiving, river rafting, polo, snow and ice
or Certificate of Insurance which is Our maximum, sports in a professional or semi-
total and cumulative liability for any and all claims professional nature.
arising during a Policy Year in respect of any and 4. Abuse or the consequences of the
all Insured Persons. abuse of intoxicants or hallucinogenic
substances such as intoxicating drugs and
Pre – hospitalization Medical Expenses- alcohol, including smoking cessation
We will cover, on a reimbursement basis, the programs and the treatment of nicotine

Group Activ Health, Product UIN:

IRDAI/HLT/ABHI/P-H(G)/V.1/19/2016-17
Insured Person’s Pre-hospitalization Medical Expenses addiction or any other substance abuse
incurred in respect of an Illness or Injury that occurs treatment or services, or supplies.
during the Policy Period upto 30 days provided 5. Weight management programs or
that: treatment in relation to the same
including vitamins and tonics, treatment
(i) We have accepted a claim for In- of obesity (including morbid obesity).
patient Hospitalization; 6. Treatment for correction of eye sight
(ii) The date of admission to the Hospital due to refractive error including routine
for the purpose of this Benefit shall be the examination.
date of the Insured Person’s first admission to 7. All routine examinations and preventive
the Hospital in relation to the same Illness health check-ups.
for which We have accepted an In-patient 8. Cosmetic, aesthetic and re-shaping
Hospitalization claim. treatments and Surgeries:
Plastic Surgery or cosmetic Surgery or
Post – hospitalization Medical Expenses- treatments
We will cover, on a reimbursement basis, the Insured

Person’s Post-hospitalization Medical Expenses to change appearance unless medically

incurred following an Illness or Injury that occurs required and certified by the attending
during the Policy Period upto 60 days, provided Medical Practitioner for reconstruction
that: following an Accident, cancer or burns.
9. Circumcisions (unless necessitated by
(i) We have accepted a claim for In- Illness or Injury and forming part of treatment);
patient Hospitalization; aesthetic or change-of-life treatments of
(ii) The date of discharge from the Hospital any description such as sex
for the purpose of this Benefit shall be the transformation operations.
date of the Insured Person’s last discharge 10. Non- allopathic treatment.
from the Hospital in relation to the same 11.Conditions for which treatment could
Illness for which We have accepted an In- have been done on an out-patient basis
patient Hospitalization claim. without any Hospitalization.
12.Unproven/Experimental
Day Care Treatment- Day Care Treatment treatment, investigational
means medical treatment, and/or surgical procedure treatment, devices and
which is: pharmacological regimens.
13.Admission primarily for diagnostic
(i)undertaken under General or Local purposes not related to Illness for which
Anaesthesia in a hospital/day care centre Hospitalization has been done.
in less than 24 hrs because of 14.Convalescence, cure, rest cure,
technological advancement, and sanatorium treatment, rehabilitation
(ii)Which would have otherwise required measures, private duty nursing, respite care,
hospitalization of more than 24 hours. long-term nursing care or custodial care.
15.Preventive care, vaccination
Treatment normally taken on an out-patient basis is including inoculation and immunizations
not included in the scope of this definition. (except in case of post-bite treatment); any
physical, psychiatric or psychological
We will cover the Medical Expenses incurred on examinations or testing
the Insured Person’s Day Care Treatment during 16.Admission for enteral feedings
the Policy Period following an Illness or Injury that (infusion formulas via a tube into the upper
occurs during the Policy Period provided that: gastrointestinal tract) and other nutritional
and electrolyte supplements unless

Group Activ Health, Product UIN:

IRDAI/HLT/ABHI/P-H(G)/V.1/19/2016-17
 (i) The Medical Expenses are incurred, certified to be required by the attending
including for any procedure which Medical Practitioner as a direct
requires a period of specialized observation consequence of an otherwise covered
or care after completion of the procedure claim.
undertaken by an Insured Person as Day 17.Hearing aids, spectacles or contact
Care Treatment and such list of 527 Day lenses including optometric therapy,
Care Treatment is listed in Annexure I; multifocal lens.
(ii) The Day Care Treatment is for 18.Treatment for alopecia, baldness, wigs,
Medically Necessary Treatment and or toupees, and all treatment related to the
follows the written Medical Advice; same.
(iii) We will not cover any OPD Treatment 19.Medical supplies including elastic
under this Benefit. stockings, diabetic test strips, and similar
products.
Domiciliary Hospitalization- 20.Any expenses incurred on prosthesis,
Domiciliary Hospitalization means medical treatment corrective devices external durable
for an illness/disease/ injury which in the medical equipment of any kind, like
normal course would require care and treatment wheelchairs crutches, instruments used in
at a hospital but is actually taken while confined at treatment of sleep apnea syndrome or
home under any of the following circumstances: continuous ambulatory peritoneal dialysis
(C.A.P.D.) and oxygen concentrator for
(i) The condition of the patient is such that bronchial asthmatic condition, cost of
cochlear implant(s) unless necessitated by
an Accident or required intra-operatively. Cost
of artificial limbs, crutches or any other
external appliance and/or device used for
diagnosis or treatment (except

Group Activ Health, Product UIN:

IRDAI/HLT/ABHI/P-H(G)/V.1/19/2016-17
 he/she is not in a condition to be removed to a when used intra-operatively).
hospital, or 21.Psychiatric or psychological disorders,
(ii)The patient takes treatment at home mental disorders (including mental health
on account of non-availability of room in a treatments), Parkinson and Alzheimer’s
hospital. disease, general debility or exhaustion
(“rundown condition”), sleepapnea, stress.
We will cover Medical Expenses upto full Sum 22.External Congenital Anomalies,
Insured incurred for the Insured Person’s diseases or defects, genetic disorders.
Domiciliary Hospitalization during the Policy Period 23.Stem cell therapy or surgery, or
following an Illness or Injury that occurs during the growth hormone therapy
Policy Period provided that: 24.Venereal disease, all sexually transmitted
disease or Illness including but not
(i) The Domiciliary Hospitalisation limited to genital warts, Syphilis, Gonorrhea,
continues for at least 3 consecutive days Genital Herpes, Chlamydia, Pubic Lice and
in which case We will make payment Trichomoniasis.
under this Benefit in respect of Medical 25.“AIDS” (Acquired Immune Deficiency
Expenses incurred from the first day of Syndrome) and/or infection with HIV
Domiciliary Hospitalisation; (Human Immunodeficiency Virus) including
(ii) The treating Medical Practitioner but not limited to conditions related to or
confirms in writing that Domiciliary arising out of HIV/AIDS such as ARC
Hospitalization was medically required (AIDS Related Complex), Lymphomas in
and the Insured Person’s condition was brain, Kaposi’s sarcoma, tuberculosis.
such that the Insured Person could not be 26.Complications arising out of
transferred to a Hospital or the Insured pregnancy (including voluntary
Person satisfies Us that a Hospital bed termination), miscarriage (except as a
was unavailable; result of an Accident or Illness),
(iii) If a claim is accepted under this Benefit maternity or birth (including caesarean
then We shall not pay any Post-hospitalization section) except in the case of ectopic
Medical Expenses, but We will accept a pregnancy for In- patient only.
claim for Pre- hospitalization Medical 27.Treatment for sterility, infertility, sub-fertility
Expenses subject to the terms and or other related conditions and
conditions of pre hospitalization; complications arising out of the same,
(iv) We shall not be liable to pay for any assisted conception, surrogate or vicarious
claim in connection with: pregnancy, birth control, and similar
(1)Asthma, bronchitis, tonsillitis procedures contraceptive supplies or
and upper respiratory tract infection services including complications arising
including laryngitis and pharyngitis, due to supplying services.
cough and cold, influenza; 28.Expenses for organ donor screening,
(2)Arthritis, gout and rheumatism; or save as and to the extent provided for in
(3)Chronic nephritis and the treatment of the donor (including Surgery
nephritic syndrome; to remove organs from a donor in the case
(4)Diarrhea and all type of of transplant Surgery).
dysenteries, including 29.Admission for Organ Transplant but
gastroenteritis; not compliant under the Transplantation of
(5)Diabetes mellitus and insipidus; Human Organs Act, 1994 (amended).
(6)Epilepsy; 30.Treatment and supplies for analysis
(7)Hypertension; and adjustments of spinal subluxation,
(8)Psychiatric or diagnosis and treatment by manipulation
psychosomatic disorders of of the skeletal structure; muscle
all kinds; stimulation by any means except

Group Activ Health, Product UIN:

IRDAI/HLT/ABHI/P-H(G)/V.1/19/2016-17
 (9)Pyrexia of unknown origin. treatment of fractures (excluding hairline
fractures) and dislocations of the mandible
Room Rent- and extremities.
Room Rent means the amount charged by a 31. Dentures and artificial teeth, Dental
Hospital towards Room and Boarding expenses and
shall include

the associated Medical Expenses. Single Private Treatment and Surgery of any kind, unless
Room means a basic (cheapest) category of single requiring Hospitalization due to an Accident.
room in a Hospital with/without airconditioning 32.Cost incurred for any health check-up or
facility where a single patient is accommodated for the purpose of issuance of medical
and which has an attached toilet (lavatory and certificates and examinations required for
bath). employment or travel or any other such
purpose.
41.Pre-Existing Disease Waiting Period 33.Artificial life maintenance, including life
We will not make any payment for any claim in support machine used to sustain a person,
respect of any Insured Person directly or indirectly who has been declared brain dead, as
caused by, based on, arising out of, relating to or demonstrated by:
howsoever attributable to any Pre-Existing 1. Deep coma and
Diseases or any complication arising from the unresponsiveness to all forms of
same, until the time period of 3 Years has stimulation; or
elapsed since the Start Date of the first Policy 2. Absent pupillary light reaction; or
with Us. 3. Absent oculovestibular and
corneal reflexes; or
42.Specified Disease / Procedure Waiting 4. Complete apnea.
Period 34.Treatment for developmental
A waiting period of 24 months from the Start problems, learning difficulties eg. Dyslexia,
Date shall apply to the treatment, whether medical behavioral problems including attention deficit
or surgical and of the Illness/conditions and their hyperactivity disorder (ADHD).
complications mentioned in Annexure-II 35.Treatment for Age Related Macular
Degeneration (ARMD) , treatments
43.30 Days Waiting Period such as Rotational Field Quantum
Any treatment taken during the first 30 days of the Magnetic Resonance (RFQMR), External
Start Date shall not be covered under the Policy, Counter Pulsation (ECP), Enhanced
unless the treatment is required as a result of an External Counter Pulsation (EECP),
Accident that occurs during the Policy Period. Hyperbaric Oxygen Therapy.
36.Expenses which are medically not
If any of the Illness/conditions listed above are required such as items of personal
Pre - Existing Diseases, then they will be covered only comfort and convenience including but
after the completion of the Pre-Existing Disease not limited to television (if specifically
Waiting Period. charged), charges for access to telephone
and telephone calls (if specifically
Road Ambulance Expenses - charged), food stuffs (save for patient’s
diet), cosmetics, hygiene articles, body care
products and bath additives, barber
We will cover the costs incurred up to Rs. 3000 expenses, beauty service, guest service as
on transportation of the Insured Person by road well as similar incidental services and
Ambulance to a Hospital for treatment in an supplies, vitamins and tonics unless
Emergency following an Illness or Injury which certified to be required by the attending
occurs during the Policy Period. We will also cover Medical Practitioner as a direct

Group Activ Health, Product UIN:

IRDAI/HLT/ABHI/P-H(G)/V.1/19/2016-17
the costs incurred on transportation of the Insured consequence of an otherwise covered
Person by road Ambulance in the following claim.
circumstances up to the limits specified in the 37.Treatment taken from a person not
Policy Schedule or Certificate of Insurance: falling within the scope of definition of
Medical Practitioner.
i) it is medically required to transfer the 38.Treatment charges or fees charged
Insured Person to another Hospital or by any Medical Practitioner acting outside
diagnostic centre during the course of the scope of license or registration
Hospitalization for advanced diagnostic granted to him by any medical council.
treatment in circumstances where such 39.Treatments rendered by a Medical
facility is not available in the existing Practitioner who is a member of the
Hospital; Insured Person’s family or stays with him,
(ii) it is medically required to transfer the save for material
the
Person to another Hospital during the course of proven costs are eligible for
Hospitalization due to lack of super speciality reimbursement as per the applicable cover.
treatment in the existing Hospital. 40.Any treatment or part of a treatment that
is not of a reasonable charge, is not a
Organ Donor Expenses- Medically Necessary Treatment; drugs or
treatments which are not supported by a
We will cover the Medical Expenses incurred for an prescription.
organ donor’s treatment for the harvesting of the 41.Charges related to a Hospital stay not
organ donated up to the family sum insured expressly mentioned as being covered,
provided that: including but not limited to charges for
admission, discharge, administration,
registration, documentation and filing,
including MRD charges (medical records
department charges).
42.Non-medical expenses including but
not limited to RMO charges, surcharges,
night charges, service charges levied by
the Hospital under any head and as
specified in the Annexure V for non-
medical expenses.
43. Treatment taken outside India.
44.Insured Person whilst flying or taking
part in aerial activities except as a fare-
paying passenger in a regular scheduled
airline or air charter company.

Group Activ Health, Product UIN:

IRDAI/HLT/ABHI/P-H(G)/V.1/19/2016-17
 POLICY NO : 71-21-00081-00-00
Certificate Number : GHI-TB3-OL-21- Plan Type :
IN6189952 COVERAGE START DATE : COVERAGE
Self END DATE :
21/01/2022
Name Membership No. 20/01/2023
DOB Relationship

Company Name: Bajaj Finance

Limited
Toll Free No: 1800 270 7000

Website: www.adityabirlacapital.com
Email: