Group Activ Health - Certificate of Insurance

Aditya Birla Health Insurance Company Aditya Birla Health Insurance Co.
Limited, 10th Floor, R-Tech Park, Nirlon Limited, 7th Floor, Modi Business
Policy Issuing Office Policy Servicing Office
Compound, Goregaon-East, Centre, Kasarvadavali, Thane (W) -
Mumbai-400063 400615

Master Policy Number 61-20-00054-00-00 Certificate Number GHI-CM-21-2000390

Master Policy Holder Name Axis Bank Limited.
Product Name Group Activ Health Member Id 000611659501

LHAWANG NEDUP ETHENPA

Name of Insured Person and
C/O UGEN TASHI ETHENPA H NO Unique Identification
Residential Address of 418352119
173|PO PAKYONG|- ,East Number
Insured Person
Sikkim,Pakyong,SIKKIM - 737106

Contact Details xxxxxxxxxx LHAWANGNEDUPETHENPA@gmail.com

Start date & Time of Master Policy 00:01 hrs 13-08-2020

Expiry Date & Time of Master Policy 23:59 on 12-08-2021
Period of Insurance 1 year/s
Inception Date 00:01 hrs 13-04-2021
End Date 23:59 on 12-04-2022
Insured Person Detail
Insured Person Date of Birth Gender Nominee Relationship Sum Insured
LHAWANG NEDUP ETHENPA 08-10-1973 M Pema Doma Bhutia Spouse 500000
PEMA DOMA BHUTIA 12-03-1980 F
TSHERING CHODEN ETHENPA 17-10-2005 F
SAMTEN LHAMU ETHENPA 02-02-2009 F

Benefit Description
Group Mediclaim Refer Coverage Details

Policy Exclusions
Group Mediclaim As per Annexure I

Premium Details
Particulars Amount
Net Premium 14,406.78
CGST (9%)
SGST / UTGST (9%)
IGST (18%) 2593.22
Gross Premium 17,000.00
Premium payment mode Annual
GST Registration No. :27AANCA4062G1ZN Category: General Insurance SAC Code: 997133
Claim Process

Aditya Birla Health Insurance Co. Limited, 5th Floor, Modi Business Centre,
Address for Correspondence
Please contact us through Kasarvadavali, Near Hipercity Mall, Thane, Maharashtra - 400615
any of these Modes Contact Number 1800 270 7000
Email ID care.healthinsurance@adityabirlacapital.com

Grievance Redressal
In case of a grievance, the Insured Person/ Policyholder can contact Us with the details through our website: www.adityabirlacapital.com.
Email:care.healthinsurance@adityabirlacapital.com 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
seniorcitizen.healthinsurance@adityabirlacapital.com. 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
carehead.healthinsurance@adityabirlacapital.com. 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.
 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 LHAWANG NEDUP ETHENPA paid INR. 17,000.00 towards Premium for Health Insurance for the Period from 00:01 hrs
13-04-2021 to midnight 23:59 on 12-04-2022.

Instrument Number Instrument Date Amount Name of the Bank

81170313 13-04-2021 17,000.00 Axis Bank Limited

Stamp Duty - The stamp duty of INR 1/- paid vide MH011444489201920M dated 01/02/2020, received from Stamp Duty Authorities vide
Receipt No./GRASS DEFACE NO 0006038796201920 dated 05/02/2020, payment has been made vide Letter of Authorisation No.
CSD/315/2020/862/2020 dated 27/02/2020 from Main Stamp Duty Office.

Master Policy Number: 61-20-00054-00-00 Certificate Number: GHI-CM-21-2000390

Date: 13-04-2021 Place: Mumbai

Note: Amount is inclusive of all taxes and cesses as applicable. This certificate must be surrendered to the Insurance Company for issuance of fresh
certificate in case of cancellation of Master Policy or any alteration in the insurance affecting the premium.

Coverage Details

Section II : Base Covers

Base Covers Coverage
1.1 In-patient Hospitalization INR 5 Lakhs
1.2 Day Care Treatment 527 listed procedures
1.3 Domiciliary hospitalization Covered upto full Sum Insured
1.4 Pre – hospitalization Medical Expenses 30 days
1.5 Post-hospitalization Medical Expenses 60 days
1.7 Road Ambulance Expenses INR 2,500
Section III : Optional Covers
13 Fitness Assessment Covered twice in a policy year
Self and Spouse will earn HealthReturns @ 30% based on their
Healthy Heart Score and their number of Active Dayz recorded in a
month.
14 Health Returns (Apply on GHI premium)
*Unique mobile no. & email id of each member will be required for
implementation of services.
Blood pressure check, Body Mass Index, Hip to waist Ratio, MER,
Serum Cholesterol and Fasting Blood Sugar.
Email id is mandatory, Soft copy of report will be shared through
21 Health Assessment e-mail.
Health Assessment for adults only
Service available in network DC
Customer to be fixed appointment through calls(1800 270 7000)
29 Reload of Sum Insured Up to 100% of sum insured
Section IV : Waivers and Discounts
41 Pre - Existing Disease Waiting Period 2 years
42 Two Year Waiting Period Applicable
43 First 30 Days Waiting Period Applicable
Annexure I - Permanent Exclusion
We shall not be liable to make any payment for any claim under any Benefit in respect of any Insured
Person directly or indirectly caused by, based on, arising out of, relating to or howsoever attributable to
any of the following:
1.Treatment directly or indirectly arising from or consequent upon war or any act of war, invasion, act
of foreign enemy, war like operations (whether war be declared or not or caused during service in the
armed forces of any country), civil war, public defense, rebellion, uprising, revolution, insurrection,
military or usurped acts, nuclear weapons / materials, chemical and biological weapons, ionizing
radiation, contamination by radioactive material or radiation of any kind, nuclear fuel, nuclear waste.
2.Committing or attempting to commit a breach of law with criminal intent, intentional self- Injury or
attempted suicide while Insured Person is sane or insane.
3.Willful or deliberate exposure to danger, intentional self- Injury, non- adherence to Medical Advice,
participation or involvement in naval, military or air force operation, circus personnel, racing in
wheels or horseback, diving, aviation, scuba diving, parachuting, hang-gliding, rock or mountain
climbing, bungee jumping, parasailing, ballooning, skydiving, river rafting, polo, snow and ice sports in
a professional or semi- professional nature.
4.Abuse or the consequences of the abuse of intoxicants or hallucinogenic substances such as
intoxicating drugs and alcohol, including smoking cessation programs and the treatment of nicotine
addiction or any other substance abuse treatment or services, or supplies.
5.Weight management programs or treatment in relation to the same including vitamins and tonics,
treatment of obesity (including morbid obesity).
6.Treatment for correction of eye sight due to refractive error including routine examination.
7.All routine examinations and preventive health check-ups.
8.Cosmetic, aesthetic and re-shaping treatments and Surgeries:
9.Plastic Surgery or cosmetic Surgery or treatments to change appearance unless medically required and
certified by the attending Medical Practitioner for reconstruction following an Accident, cancer or
burns.
10.Circumcisions (unless necessitated by Illness or Injury and forming part of treatment); aesthetic or
change-of-life treatments of any description such as sex transformation operations.
11.Non- allopathic treatment, except as per coverage of AYUSH Treatment.
12.Conditions for which treatment could have been done on an out-patient basis without any
Hospitalization.
13.Unproven/Experimental treatment, investigational treatment, devices and pharmacological
regimens.
14.Admission primarily for diagnostic purposes not related to Illness for which Hospitalization has been
done.
15.Convalescence (except as per the coverage as coverage defined in Section 11 - Recovery Benefit),
cure, rest cure, sanatorium treatment, rehabilitation measures, private duty nursing, respite care,
long-term nursing care or custodial care.
16.Preventive care, vaccination including inoculation and immunizations (except in case of post-bite
treatment); any physical, psychiatric or psychological examinations or testing
17.Admission for enteral feedings (infusion formulas via a tube into the upper gastrointestinal tract) and
other nutritional and electrolyte supplements unless certified to be required by the attending Medical
Practitioner as a direct consequence of an otherwise covered claim.
18. Hearing aids, spectacles or contact lenses including optometric therapy, multifocal lens.
19.Treatment for alopecia, baldness, wigs, or toupees, and all treatment related to the same.
20.Medical supplies including elastic stockings, diabetic test strips, and similar products.
21.Any expenses incurred on prosthesis, corrective devices external durable medical equipment of any
kind, like wheelchairs crutches, instruments used in treatment of sleep apnea syndrome or continuous
ambulatory peritoneal dialysis (C.A.P.D.) and oxygen concentrator for 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 when used intra-operatively).
22.Psychiatric or psychological disorders, mental disorders (including mental health treatments),
Parkinson and Alzheimer’s disease, general debility or exhaustion (“rundown condition”), sleep-apnea,
stress.
23.External Congenital Anomalies, diseases or defects, genetic disorders.
24.Stem cell therapy or surgery, or growth hormone therapy
* This is a computer generated document and does not need a signature
25.Venereal disease, all sexually transmitted disease or Illness including but not limited to genital
warts, Syphilis, Gonorrhea, Genital Herpes, Chlamydia, Pubic Lice and Trichomoniasis.
26.“AIDS” (Acquired Immune Deficiency Syndrome) and/or infection with HIV (Human
Immunodeficiency Virus) including but not limited to conditions related to or arising out of HIV/AIDS
such as ARC (AIDS Related Complex), Lymphomas in brain, Kaposi’s sarcoma, tuberculosis.
27.Complications arising out of pregnancy (including voluntary termination), miscarriage (except as a
result of an Accident or Illness), maternity or birth (including caesarean section) except in the case of
ectopic pregnancy for In-patient only.
28.Treatment for sterility, infertility, sub-fertility or other related conditions and complications arising
out of the same, assisted conception, surrogate or vicarious pregnancy, birth control, and similar
procedures contraceptive supplies or services including complications arising due to supplying services.
29.Expenses for organ donor screening, or save as and to the extent provided for in the treatment of the
donor (including Surgery to remove organs from a donor in the case of transplant Surgery).
30.Admission for Organ Transplant but not compliant under the Transplantation of Human Organs Act,
1994 (amended).
31.Treatment and supplies for analysis and adjustments of spinal subluxation, diagnosis and treatment
by manipulation of the skeletal structure; muscle stimulation by any means except treatment of
fractures (excluding hairline fractures) and dislocations of the mandible and extremities.
32.Dentures and artificial teeth, Dental Treatment and Surgery of any kind, unless requiring
Hospitalization due to an Accident.
33.Cost incurred for any health check-up or for the purpose of issuance of medical certificates and
examinations required for employment or travel or any other such purpose.
34.Artificial life maintenance, including life support machine used to sustain a person, who has been
declared brain dead, as demonstrated by: 1. Deep coma and unresponsiveness to all forms of
stimulation; or 2. Absent pupillary light reaction; or 3. Absent oculovestibular and corneal reflexes; or
4. Complete apnea.
Treatment for developmental problems, learning difficulties e.g. Dyslexia, behavioral problems
including attention deficit hyperactivity disorder (ADHD).
36.Treatment for Age Related Macular Degeneration (ARMD), treatments such as Rotational Field
Quantum Magnetic Resonance (RFQMR), External Counter Pulsation (ECP), Enhanced External
Counter Pulsation (EECP), Hyperbaric Oxygen Therapy.
37. Expenses which are medically not required such as items of personal comfort and convenience
including but not limited to television (if specifically charged), charges for access to telephone and
telephone calls (if specifically charged), food stuffs (save for patient’s diet), cosmetics, hygiene
articles, body care products and bath additives, barber expenses, beauty service, guest service as well
as similar incidental services and supplies, vitamins and tonics unless certified to be required by the
attending Medical Practitioner as a direct consequence of an otherwise covered claim.
38.Treatment taken from a person not falling within the scope of definition of Medical Practitioner.
39.Treatment charges or fees charged by any Medical Practitioner acting outside the scope of license
or registration granted to him by any medical council.
40.Treatments rendered by a Medical Practitioner who is a member of the Insured Person’s family or
stays with him, save for the proven material costs are eligible for reimbursement as per the applicable
cover.
41.Any treatment or part of a treatment that is not of a reasonable charge, is not a Medically
Necessary Treatment; drugs or treatments which are not supported by a prescription.
42.Charges related to a Hospital stay not expressly mentioned as being covered, including but not
limited to charges for admission, discharge, administration, registration, documentation and filing,
including MRD charges (medical records department charges).
43.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.
44.Treatment taken outside India.
45.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.
For detailed policy wordings regarding the above please visit our website
https://www.adityabirlahealth.com/healthinsurance/#!/downloads
Policy No: 61-20-00054-00-00 COI No. GHI-CM-21-2000390
Coverage Start Date: 13/04/2021 Coverage End Date: 12/04/2022

Name Membership No. DOB Relationship

LHAWANG NEDUP ETHENPA 000611659501 08/10/1973 Self

PEMA DOMA BHUTIA 000611659502 12/03/1980 Spouse

Dependent
TSHERING CHODEN ETHENPA 000611659503 17/10/2005 Daughter

• This card is only identification and is not an authorization to proceed with the treatment or guarantee for payment.
• In case photo less identity cards issued to beneficiaries, acceptable proof of identity such as Aadhar Card/Passport/Driver
License /Ration Card/Voters ID/ PAN Card should be presented at the hospital.
• This non-transferable identification card is valid at selected Network Hospitals & will enable Card Holder to avail cashless
hospitalization only on pre-authorization by Aditya Birla Health Insurance Co. Ltd
• For latest updated network hospital list, log on to https://www.adityabirlahealth.com/healthinsurance/#!/provider-search
Policy No: 61-20-00054-00-00 COI No. GHI-CM-21-2000390
Coverage Start Date: 13/04/2021 Coverage End Date: 12/04/2022
Name Membership No. DOB Relationship
Dependent
SAMTEN LHAMU ETHENPA 000611659504 02/02/2009 Daughter

• This card is only identification and is not an authorization to proceed with the treatment or guarantee for payment.
• In case photo less identity cards issued to beneficiaries, acceptable proof of identity such as Aadhar Card/Passport/Driver
License /Ration Card/Voters ID/ PAN Card should be presented at the hospital.
• This non-transferable identification card is valid at selected Network Hospitals & will enable Card Holder to avail cashless
hospitalization only on pre-authorization by Aditya Birla Health Insurance Co. Ltd
• For latest updated network hospital list, log on to https://www.adityabirlahealth.com/healthinsurance/#!/provider-search
Group Activ Secure - Certificate of Insurance

Aditya Birla Health Insurance Company
Limited, 10th Floor, R-Tech Park, Nirlon
Policy Issuing Office
Compound, Goregaon-East, Mumbai -
400063
Aditya Birla Health Insurance Co.
Limited, 7th Floor, Modi Business
Policy Servicing Office
Centre, Kasarvadavali, Thane (W) -
400615

Master Policy Holder Number 62-20-00065-00-00 Certificate Number GFB-CM-21-2000538

Master Policy Holder Name Axis Bank Limited.
Product Name Group Activ Secure Member Id 000611659801
Plan Name Group Activ Secure - Personal Accident
Mr LHAWANG NEDUP ETHENPA
Name of Insured Person &
C/O UGEN TASHI ETHENPA H NO Unique Identification
Residential Address of Insured 418352119
173|PO PAKYONG|- ,East Number
Person
Sikkim,Pakyong,SIKKIM - 737106
Contact Details xxxxxxxxxx LHAWANGNEDUPETHENPA@gmail.com

Inception date & Time of Master Policy 00:01 hrs 13/08/2020

Expiry Date & Time of Master Policy 23:59 on 12/08/2021
Period of Insurance 1 Year
Start Date 00:01 hrs 13/04/2021
End Date 23:59 on 12/04/2022

Insured Detail

Insured Person Date of Birth Gender Nominee Sum Insured Certificate Number
PEMA DOMA BHUTIA 12-03-1980 F Pema Doma Bhutia 500000 GFB-CM-21-2000538

Coverage Details
Group Activ Secure - Personal Accident Capital Sum Insured / Sum Insured (Rs)
Section A : Basic Covers
Accidental Death
Permanent Total Disablement INR 500000
Permanent Partial Disablement
Recovery Benefit INR 100000
Section B: Optional Covers
Education Benefit INR 10000 per child
Coma Benefit INR 100000

Grievance Redressal
In case of a grievance, You can contact Us with the
details through: Our website: adityabirlacapital.com/health
insurance Email: care.healthinsurance@adityabirlacapital.com
Toll Free: 1800 270 7000
Address: Any of Our Branch office or Corporate office For senior citizens, please contact the respective branch office of the Company or call at
1800 270
7000 or may write an e- mail at seniorcitizen.healthinsurance@adityabirlacapital.com
You can also walk-in and approach the grievance cell at any of Our
branches.If in case You are not satisfied with the response then You can contact Our Head of Customer Service at the following email
carehead.healthinsurance@adityabirlacapital.com
If You are still not satisfied with Our redressal, You may approach the nearest Insurance Ombudsman. The
Contact details of the Ombudsman offices are provided on Our Website and in the policy.

Policy Exclusions
Group Personal Accident As per Annexure I
Premium Details
Particulars Amount (Rs.)
Net Premium 254.24
CGST (9%)
SGST / UTGST (9%)
IGST (18%) 45.76
Total Premium 300

GST Registration No.:27AANCA4062G1ZN Category: General Insurance SAC Code: 997133

Claim Process

Aditya Birla Health Insurance Co. Limited, 5th Floor, Modi

Address for Correspondence Business Centre, Kasarvadavali, Near Hipercity Mall, Thane,
Please contact us Maharashtra - 400615
through any of these Modes
Contact Number 1800 270 7000
Email ID care.healthinsurance@adityabirlacapital.com

Stamp Duty:The stamp duty of INR 1…/- paid vide MH011444489201920M dated 01/02/2020, received from Stamp Duty Authorities
vide Receipt No./GRASS DEFACE NO 0006038796201920 dated 05/02/2020, payment has been made vide Letter of Authorisation No.
CSD/315/2020/862/2020 dated 27/02/2020 from Main Stamp Duty Office.
Master Policy Number: 62-20-00065-00-00 Certificate Number: GFB-CM-21-2000538

Date: 13/04/2021 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 I – PERMANENT EXCLUSIONS (Personal Accident)
We shall not be liable to make any payment for any claim under any Benefit under Section II.A. or
Section II.B., in respect of any Insured Person, directly or indirectly for, caused by or arising from or
in any way attributable to any of the following:
1. Any Pre-Existing Disease or Injury or disability arising out of a Pre-Existing Diseases or any
complication arising therefrom.
2. Any payment in case of more than one claim under the Policy during any one Policy Period by
which Our maximum liability in that period would exceed the Sum Insured. This would not apply to
payments made under the Additional Covers.
3. Suicide or attempted suicide, intentional self-inflicted Injury, acts of self-destruction whether the
Insured Person is medically sane or insane.
4. Mental Illness or sickness or disease including a psychiatric condition, mental disorders of or
disturbances of consciousness, strokes, fits or convulsions which affect the entire body and pathological
disturbances caused by mental reaction to the same.
5. Certification by a Medical Practitioner who shares the same residence as the Insured Person or who
is a member of the Insured Person’s family.
6. Death or disablement arising out of or attributable to foreign invasion, act of foreign enemies,
hostilities, warlike operations (whether war be declared or not or while performing duties in the armed
forces of any country during war or at peace time), participation in any naval, military or air-force
operation, civil war, public defence, rebellion, revolution, insurrection, military or usurped power.
7. Death or disablement directly or indirectly caused by or associated with any venereal disease or
sexually transmitted disease.
8. Congenital internal or external diseases, defects or anomalies or in consequence thereof.
9. Bacterial infections (except pyogenic infection which occurs through a cut or wound due to
Accident).
10. Medical or surgical treatment except as necessary solely and directly as a result of an Accident.
11. Death or disablement directly or indirectly caused due to or associated with human T-call Lymph
tropic virus type III (HTLV-III or IITLB-III) or Lymphadinopathy Associated Virus (LAV) and its
variants or mutants, Acquired Immune Deficiency Syndrome (AIDS) whether or not arising out of HIV,
AIDS related complex syndrome (ARCS) and any injury caused by and/or related to HIV.
12. Any change of profession after inception of the Policy which results in the enhancement of Our risk
under the Policy, if not accepted and endorsed by Us on the Policy Schedule or Certificate of
Insurance.
13. Death or disablement arising or resulting from the Insured Person committing any breach of law or
participating in an actual or attempted felony, riot, crime, misdemeanour or civil commotion with
criminal intent.
14. Death or disablement arising from or caused due to use, abuse or a consequence or influence of an
abuse of any substance, intoxicant, drug, alcohol or hallucinogen.
15. Death or disablement resulting directly or indirectly, contributed or aggravated or prolonged by
childbirth or from pregnancy or a consequence thereof including ectopic pregnancy unless specifically
arising due to Accident;
*This is a computer generated statement doesn’t need any signature
16. Death or disablement caused by participation of the Insured Person in any flying activity, except as a bona
fide, fare-paying passenger of a recognized airline on regular routes and on a scheduled timetable.
17. Insured Persons whilst engaging in a speed contest or racing of any kind (other than on foot), bungee jumping,
parasailing, ballooning, parachuting, skydiving, paragliding, hang gliding, mountain or rock climbing
necessitating the use of guides or ropes, potholing, abseiling, deep sea diving using hard helmet and breathing
apparatus, polo, snow and ice sports in so far as they involve the training for or participation in competitions or
professional sports and specified in the Policy Schedule.
18. Insured Persons involved in naval, military or air force operations.
19. Working in underground mines, tunnelling or explosives, or involving electrical installation with high tension
supply, or as jockeys or circus personnel, or engaged in Hazardous Activities.
20. Accidental death or Injury occurring after twelve calendar months from the date of the Accident.
21. Death or disablement unless directly caused by an Accident.
22. Death or disablement or Injury arising from or caused by ionizing radiation or contamination by radioactivity
from any nuclear fuel (explosive or hazardous form) or resulting from or from any other cause or event
contributing concurrently or in any other sequence to the loss, claim or expense from any nuclear waste from the
combustion of nuclear fuel, nuclear, chemical or biological attack.
a) Chemical attack or weapons means the emission, discharge, dispersal, release or escape of any solid, liquid or
gaseous chemical compound which, when suitably distributed, is capable of causing any Illness, incapacitating
disablement or death.
b) Biological attack or weapons means the emission, discharge, dispersal, release or escape of any pathogenic
(disease producing) microorganisms and/or biologically produced toxins (including genetically modified organisms
and chemically synthesized toxins) which are capable of causing any Illness, incapacitating disablement or death.
23. Any physical, medical or mental condition or treatment or service that is specifically excluded in the Policy.
24. Any Injury which shall result in Hernia
25. Any Benefit under the policy arising from Hernia.
For detailed policy wordings regarding the above please visit our website
https://www.adityabirlahealth.com/healthinsurance/#!/downloads
Group Activ Secure - Certificate of Insurance

Aditya Birla Health Insurance Company
Limited, 10th Floor, R-Tech Park, Nirlon
Policy Issuing Office
Compound, Goregaon-East, Mumbai -
400063
Aditya Birla Health Insurance Co.
Limited, 7th Floor, Modi Business
Policy Servicing Office
Centre, Kasarvadavali, Thane (W) -
400615

Master Policy Holder Number 62-20-00065-00-00 Certificate Number GFB-CM-21-2000537

Master Policy Holder Name Axis Bank Limited.
Product Name Group Activ Secure Member Id 000611659601
Plan Name Group Activ Secure - Personal Accident
LHAWANG NEDUP ETHENPA
Name of Insured Person &
C/O UGEN TASHI ETHENPA H NO Unique Identification
Residential Address of Insured 418352119
173|PO PAKYONG|- ,East Number
Person
Sikkim,Pakyong,SIKKIM - 737106
Contact Details xxxxxxxxxx LHAWANGNEDUPETHENPA@gmail.com

Inception date & Time of Master Policy 00:01 hrs 13/08/2020

Expiry Date & Time of Master Policy 23:59 on 12/08/2021
Period of Insurance 1 Year
Start Date 00:01 hrs 13/04/2021
End Date 23:59 on 12/04/2022

Insured Detail

Insured Person Date of Birth Gender Nominee Sum Insured Certificate Number
LHAWANG NEDUP ETHENPA 08-10-1973 M Pema Doma Bhutia 500000 GFB-CM-21-2000537

Coverage Details
Group Activ Secure - Personal Accident Capital Sum Insured / Sum Insured (Rs)
Section A : Basic Covers
Accidental Death
Permanent Total Disablement INR 500000
Permanent Partial Disablement
Recovery Benefit INR 100000
Section B: Optional Covers
Education Benefit INR 10000 per child
Coma Benefit INR 100000

Grievance Redressal
In case of a grievance, You can contact Us with the
details through: Our website: adityabirlacapital.com/health
insurance Email: care.healthinsurance@adityabirlacapital.com
Toll Free: 1800 270 7000
Address: Any of Our Branch office or Corporate office For senior citizens, please contact the respective branch office of the Company or call at
1800 270
7000 or may write an e- mail at seniorcitizen.healthinsurance@adityabirlacapital.com
You can also walk-in and approach the grievance cell at any of Our
branches.If in case You are not satisfied with the response then You can contact Our Head of Customer Service at the following email
carehead.healthinsurance@adityabirlacapital.com
If You are still not satisfied with Our redressal, You may approach the nearest Insurance Ombudsman. The
Contact details of the Ombudsman offices are provided on Our Website and in the policy.

Policy Exclusions
Group Personal Accident As per Annexure I
Premium Details
Particulars Amount (Rs.)
Net Premium 254.24
CGST (9%)
SGST / UTGST (9%)
IGST (18%) 45.76
Total Premium 300

GST Registration No.:27AANCA4062G1ZN Category: General Insurance SAC Code: 997133

Claim Process

Aditya Birla Health Insurance Co. Limited, 5th Floor, Modi

Address for Correspondence Business Centre, Kasarvadavali, Near Hipercity Mall, Thane,
Please contact us Maharashtra - 400615
through any of these Modes
Contact Number 1800 270 7000
Email ID care.healthinsurance@adityabirlacapital.com

Stamp Duty:The stamp duty of INR 1…/- paid vide MH011444489201920M dated 01/02/2020, received from Stamp Duty Authorities
vide Receipt No./GRASS DEFACE NO 0006038796201920 dated 05/02/2020, payment has been made vide Letter of Authorisation No.
CSD/315/2020/862/2020 dated 27/02/2020 from Main Stamp Duty Office.
Master Policy Number: 62-20-00065-00-00 Certificate Number: GFB-CM-21-2000537

Date: 13/04/2021 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 I – PERMANENT EXCLUSIONS (Personal Accident)
We shall not be liable to make any payment for any claim under any Benefit under Section II.A. or
Section II.B., in respect of any Insured Person, directly or indirectly for, caused by or arising from or
in any way attributable to any of the following:
1. Any Pre-Existing Disease or Injury or disability arising out of a Pre-Existing Diseases or any
complication arising therefrom.
2. Any payment in case of more than one claim under the Policy during any one Policy Period by
which Our maximum liability in that period would exceed the Sum Insured. This would not apply to
payments made under the Additional Covers.
3. Suicide or attempted suicide, intentional self-inflicted Injury, acts of self-destruction whether the
Insured Person is medically sane or insane.
4. Mental Illness or sickness or disease including a psychiatric condition, mental disorders of or
disturbances of consciousness, strokes, fits or convulsions which affect the entire body and pathological
disturbances caused by mental reaction to the same.
5. Certification by a Medical Practitioner who shares the same residence as the Insured Person or who
is a member of the Insured Person’s family.
6. Death or disablement arising out of or attributable to foreign invasion, act of foreign enemies,
hostilities, warlike operations (whether war be declared or not or while performing duties in the armed
forces of any country during war or at peace time), participation in any naval, military or air-force
operation, civil war, public defence, rebellion, revolution, insurrection, military or usurped power.
7. Death or disablement directly or indirectly caused by or associated with any venereal disease or
sexually transmitted disease.
8. Congenital internal or external diseases, defects or anomalies or in consequence thereof.
9. Bacterial infections (except pyogenic infection which occurs through a cut or wound due to
Accident).
10. Medical or surgical treatment except as necessary solely and directly as a result of an Accident.
11. Death or disablement directly or indirectly caused due to or associated with human T-call Lymph
tropic virus type III (HTLV-III or IITLB-III) or Lymphadinopathy Associated Virus (LAV) and its
variants or mutants, Acquired Immune Deficiency Syndrome (AIDS) whether or not arising out of HIV,
AIDS related complex syndrome (ARCS) and any injury caused by and/or related to HIV.
12. Any change of profession after inception of the Policy which results in the enhancement of Our risk
under the Policy, if not accepted and endorsed by Us on the Policy Schedule or Certificate of
Insurance.
13. Death or disablement arising or resulting from the Insured Person committing any breach of law or
participating in an actual or attempted felony, riot, crime, misdemeanour or civil commotion with
criminal intent.
14. Death or disablement arising from or caused due to use, abuse or a consequence or influence of an
abuse of any substance, intoxicant, drug, alcohol or hallucinogen.
15. Death or disablement resulting directly or indirectly, contributed or aggravated or prolonged by
childbirth or from pregnancy or a consequence thereof including ectopic pregnancy unless specifically
arising due to Accident;
*This is a computer generated statement doesn’t need any signature
16. Death or disablement caused by participation of the Insured Person in any flying activity, except as a bona
fide, fare-paying passenger of a recognized airline on regular routes and on a scheduled timetable.
17. Insured Persons whilst engaging in a speed contest or racing of any kind (other than on foot), bungee jumping,
parasailing, ballooning, parachuting, skydiving, paragliding, hang gliding, mountain or rock climbing
necessitating the use of guides or ropes, potholing, abseiling, deep sea diving using hard helmet and breathing
apparatus, polo, snow and ice sports in so far as they involve the training for or participation in competitions or
professional sports and specified in the Policy Schedule.
18. Insured Persons involved in naval, military or air force operations.
19. Working in underground mines, tunnelling or explosives, or involving electrical installation with high tension
supply, or as jockeys or circus personnel, or engaged in Hazardous Activities.
20. Accidental death or Injury occurring after twelve calendar months from the date of the Accident.
21. Death or disablement unless directly caused by an Accident.
22. Death or disablement or Injury arising from or caused by ionizing radiation or contamination by radioactivity
from any nuclear fuel (explosive or hazardous form) or resulting from or from any other cause or event
contributing concurrently or in any other sequence to the loss, claim or expense from any nuclear waste from the
combustion of nuclear fuel, nuclear, chemical or biological attack.
a) Chemical attack or weapons means the emission, discharge, dispersal, release or escape of any solid, liquid or
gaseous chemical compound which, when suitably distributed, is capable of causing any Illness, incapacitating
disablement or death.
b) Biological attack or weapons means the emission, discharge, dispersal, release or escape of any pathogenic
(disease producing) microorganisms and/or biologically produced toxins (including genetically modified organisms
and chemically synthesized toxins) which are capable of causing any Illness, incapacitating disablement or death.
23. Any physical, medical or mental condition or treatment or service that is specifically excluded in the Policy.
24. Any Injury which shall result in Hernia
25. Any Benefit under the policy arising from Hernia.
For detailed policy wordings regarding the above please visit our website
https://www.adityabirlahealth.com/healthinsurance/#!/downloads