23-21-0007842-01

Rekha Raghav
A11 chandra vihar, palam extenstion
Dwarka sector 7
null
Delhi
DELHI
INDIA
110075
8826700368
04/05/2022

Dear Rekha Raghav,

Welcome to the journey of Health and Wellness with Aditya Birla Health Insurance.

We thank you for entrusting us with your Health Insurance needs and choosing Activ Health plan as your preferred choice.
It is our pleasure to have you as a valued customer.

With a vision and commitment to put our customers’ ‘Health First’, we have created this plan that would help you gain
more out of your health journey. Here are some of the important features that come as part of your plan:
Hospitalisation expenses covered for illnesses and medically required procedures such as Covid-19 and Bariatric Surgery.
TM
Earn up to 30% of your premium as HealthReturns .
Get 150% Reload of Sum Insured.
Modern Treatment Methods like Robotic Surgeries, Oral Chemotherapy, Balloon Sinuplasty covered.
Avail Annual Health Check-up benefit from Day 1.

For more benefits and details, read further. In case of any assistance, you can connect with us via the following channels:
WhatsApp: Call: Email:
Send ‘Hi’ on 1800-270-7000 to care.healthinsurance@adityabirlacapital.com
+91 8828800035 speak
to an executive

We assure you of the best customer service always.

Looking forward to a long and successful journey ahead!
Warm Regards,

Mayank Bathwal
Scan QR Code
Chief Executive Officer
to download the App
Aditya Birla Health Insurance Co. Limited.
Activ Assure Policy Schedule
Policy Issuing Office
Aditya Birla Health Insurance
MBC InfoTech Park, 07th Floor, C
Co.Limited, 7th Floor, Modi
Building, Kasarvadavali, Ghodbunder
Business Policy Servicing Office
Road Thane West, Mumbai (W) Thane
Centre,Kasarvadavali,Thane(W)-40
MAHARASHTRA 400615
0615

POLICYBAZAAR
INSURANCE
Intermediary Name Intermediary Code 5100357
BROKERS PRIVATE
LIMITED
Intermediary Contact Intermediary E-mail crthealth@policybazaar
18002585970
Details ID .com
Toll Free Number 18002707000

I. Details of Policy Holder

Policyholder Name Rekha Raghav
Policyholder Address A11 chandra vihar, palam extenstion Dwarka sector 7 Delhi, 110075, South West Delhi, DELHI
Contact Number 8826700368
Email Id TuXXXXXXXXXXXX25@gmail.com

II . Policy Details
Product Name Activ Assure Plan Name Active Assure - Diamond
Policy Number 23-21-0007842-01
First Policy Start date 04/05/2021
Start Date of Policy & Time 00:00 hrs on 04/05/2022 Expiry Date & Time of Policy 23:59 hrs on 03/05/2023
Policy Type Family Floater Policy Tenure (in years) 1
Policy Category Renewal
Mode of Premium payment Single
Portability No Previous Policy Number 23-21-0007842-00
GSTN Number NA GSTN Account Type Consumers

III. Insured Person's Details

Start date of
Policy of
Insured Start date of first
Pre-existing
Person (in Relationship with policy with us
Name Of Insured person Member ID Age Gender DOB Diseases (if
case of new Policyholder (applicable at policy
applicable)
member renewal)
additions mid
term)
000615417
Rekha Raghav NA Self 44 Female 01/07/1977 - - 04/05/2021
411
000615417
Tushar Raghav NA Son 19 Male 05/11/2002 - - 04/05/2021
412
000615417
Pragya Rahhav NA Daughter 13 Female 17/05/2008 - - 04/05/2021
413

No Claim Bonus* Super No Claim Bonus*

Sum Insured Co-Payment^ Room Type ICU Charges

% Amount % Amount

Single Private
500000 NA Up to S.I 10 50000 0 0
Room

Activ Assure, Product UIN: ADIHLIP21250V032021

^A mandatory co-payment of 20% applicable for Age at entry 61 years & above

Optional Covers

Cancer Any Room

Accidental
Hospitalisatio Upgrade(A Preferred
Reduction in Pre Unlimited Hospitalisation
Name Of Insured Super No Claim n Booster vailable Provider
Existing Disease re-load of Sum Booster (not
Person Bonus (not available with Sum Network(PPN)
Waiting Period* Insured available in SI
in SI above 1 Insured Rs Discount
above 1 Cr)
Cr) 5 Lac)

Rekha Raghav

Tushar Raghav No No No No No No No

Pragya Rahhav

*If opted Pre Existing Disease waiting period will reduce to 24 Months

(for policies Renewed with Us, the Start date of the first Policy with Us will also be displayed against each Insured Person)
Name of the Insured Person Special condition (if applicable)
Rekha Raghav No
Tushar Raghav No
Pragya Rahhav No

Name of the Insured Person *Pre existing details (if applicable)

Rekha Raghav - -
Tushar Raghav - -
Pragya Rahhav - -

-HealthReturnsTM1 (Applicable for Renewal Policy)

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

Rekha Raghav NA 0
Tushar Raghav NA 0
Pragya Rahhav 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
Tushar Raghav Son 9999999999

Activ Assure, Product UIN: ADIHLIP21250V032021

 V . Previous Insurer Details (Only applicable for Portability policies)
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)
Pragya Rahhav NA NA NA NA NA NA

Pragya Rahhav NA NA NA NA NA NA

Pragya Rahhav NA NA NA NA NA NA

Rekha Raghav NA NA NA NA NA NA

Rekha Raghav NA NA NA NA NA NA

Rekha Raghav NA NA NA NA NA NA

Tushar Raghav NA NA NA NA NA NA

Tushar Raghav NA NA NA NA NA NA

Tushar Raghav NA NA NA NA NA NA

VI . Product Benefit Table (shall be displayed as applicable under the Plan in force)

Product Name Activ Assure

Product Features / Diamond

Product Variants

Basic Rs 2 Lac, 3 Lac, 4 Lac, 5 Lac, 7 Lac, 10 Lac, 15 Lac, 20 Lac, 25 Lac, 30 Lac, 40 Lac, 50 Lac, 75 Lac,
Sum Insured
Covers 100 Lac, 150 Lac, 200 Lacs

In-patient Hospitalization Covered

2L, 3L, 4L S.I. – 1% of S.I.

Room Type 5L S.I. - Single Private A/C Room
7L S.I and above – Upto S.I

ICU Charges 2L, 3L, 4L S.I. – 2% of S.I. 5L and above S.I.- Upto S.I

Pre-hospitalization Medical
30 days
Expenses

Post–hospitalization Medical
60 days
Expenses

Day Care Treatment 586 listed Procedures, Covered up to S.I.

Domiciliary Hospitalization
Upto 10% of S.I
(Home Care)

S.I upto 4L – Rs.1500

S.I 5L – 10L – Rs.2000
Road Ambulance Cover S.I 15L – 40L – Rs.2500
S.I 50L – 75L – Rs.3000
S.I 1Cr – 2Cr – Rs.5000

Organ Donor Expenses Covered up to S.I

Reload of Sum Insured Upto 150% of S.I, Max up to 50 Lacs

S.I upto 4L – Rs. 15,000

S.I 5L – 10L – Rs. 20,000
Ayush (In-patient
S.I 15L – 40L – Rs. 30,000
hospitalization)
S.I 50L – 75L – Rs. 40,000
S.I 1Cr – 2Cr – Rs. 50,000

Daily Allowance 2L, 3L, 4L S.I. – Rs.500/day, Max 5 day per hospitalization

Upto Rs. 10,000

Vaccination Cover
(Applicable for SI 1Cr and above)

Additional No Claim Bonus 10% of S.I. per annum, Max upto 50% of S.I 10% of S.I. per annum, Max upto 50% of S.I
Benefits
Health Check-up Program Annual Annual

Second E-Opinion on Critical

Available for 15 listed Critical Illnesses Available for 15 listed Critical Illnesses
Illnesses

Domestic Emergency
Assistance Services Available Available
(including Air Ambulance)

Activ Assure, Product UIN: ADIHLIP21250V032021

 International Emergency
Assistance Services Available Available
(including Air Ambulance)
Health AssessmentTM Available Not Available
TM
HealthReturns Available, Earned by ways of - Percentage of
Premium earned through Healthy Heart Score™ Not Available
and Active Days
Value
Health Coach
Added
Services
Available Not Available

Reduction in PED Waiting

Option to reduce to 24 Months Not Available
Period

Unlimited Reload of Sum

100% of S.I (Unlimited times) x100% of S.I (Unlimited times)
Insured

Additional 50% of S.I. per annum, Max upto Additional 50% of S.I. per annum, Max upto 100% of
Super NCB
100% of S.I S.I
Optional
Covers Accidental Hospitalization
100% of S.I. 100% of S.I.
Booster (not available above

Cancer Hospitalization
Booster (not available above 100% of S.I. 100% of S.I.
1Cr S.I)

Any Room Upgrade Available with S.I. 5L Available with S.I. 5L

Preferred Provider Network

10% Discount Available 10% Discount Available
(PPN) Discount

VII . Premium Details (Rs)

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

10844.0 0.00 0 0 NA NA 1951.92 NA 12796

GST Registration No: 27AANCA4062G1ZN PAN Number :AANCA4062G Category: General Insurance SAC Code: 997133

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.

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

Date : 04/05/2022

Place : Mumbai
Authorized Signatory

Activ Assure, Product UIN: ADIHLIP21250V032021

 Premium Certificate
We confirm the receipt of premium amount of INR 12796.0 as per below details paid by Rekha Raghav for Self and/or Family and/or Parents:

Policy Number: 23-21-0007842-01 Plan Name: Active Assure - Diamond

Type of Plan: Family Floater Proposer Name: Rekha Raghav

Policy Start Date: 00:00 hrs on 04/05/2022 Policy End Date: 23:59 hrs on 03/05/2023

Receipt Number Receipt Amount Instrument Number Dated Relationship Payment Mode Bank Name
RR-22-23-047
12796 41950412 29-04-2022 Self Online Payment NA
470

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*

2022-23 12,796.00

* 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.
* 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 : 04/05/2022

Location: Mumbai
Authorized Signatory

Activ Assure, Product UIN: ADIHLIP21250V032021

 23-21-0007842-01

Membership Blood
Name DOB
No. Group
Rekha Raghav 000615417411 01/Jul/1977 No
Tushar Raghav 000615417412 05/Nov/2002 No
Pragya Rahhav 000615417413 17/May/2008 No