Group Activ Health - Certificate of Insurance

Aditya Birla Health Insurance Aditya Birla Health Insurance

Company Limited, 7th floor, C Company Limited, 7th floor, C
Policy Issuing Office building, Modi Business Policy Servicing Office building, Modi Business
Centre, Kasarv adav a li , Centre, Kasarv adav a li ,
Mu mb ai , Tha ne W est 400 6 15 Mu mb ai , Tha ne W est 400 6 15
Master Policy Numb er 71-2 0-0 009 9-0 1-0 1 Certificate Number GHI -7 1-2 3-3 960 803 -00 0
Master Pol icyh ol de r
Axis Bank Limited
Name
P roduct Nam e Group Activ Health Memb er I d P T9 7 24 62 0 6
GA NE S H S UB R AM ANI Y AN
S/O RA MA R A J U
Name of Insured
P erson and R esi den tial NO: 2/1529 9 TH STREET, Unique Ide ntificati on
OMSAKTHI NAGAR, 5003 689
Address of Insured Number
Person RAMANATHAPURAM INDIA, TAMIL
NADU, 623503

Mob ile Nu mb er 9543 228 833 Email Id ganeshra maraju @gma il .co m

Start date & Time of Master Policy 00:01 hrs 0 5/ 0 3/ 20 23

Expiry Date & Time of Master Policy 23:59 on 04 /0 3/ 20 2 4
Incep tion Dat e 00:01 hrs 1 8/ 0 7/ 20 23
End Dat e 23: 59 on 1 7/07 /20 24
Coverage Typ e Float er

Insured Person Detai l

Nomine e Sum
Insured Person Date of Birth Gender Nomine e
R el at ion sh ip Ins ur e d
GANESH SUBRAMANIYAN.R
15/06/1990 Male Mallika R Mother 5000000

MALLIKA. R 12/11/1964 Female 5000000

RAMARAJU. M 15/06/1954 Male 5000000

Benefit Descripti on
Group M ediclaim Refer Coverage D etails

Policy Exclusions
Group M ediclaim As per Annexure I

Premium Detai ls
Particu lars Amount
Net P remium 19050.0
CGST (9%) NA
SGST / UTGST (9%) NA
IGST (18%) 4249.0
G ross P remium 23299.0
P remium p ayment mo d e Online P a y m ent

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

Authorized Signatory

Group Activ Health, Product UIN: IRDAI/HLT/ABHI/P-H(G)/V

Claim Process
Address for Aditya Birla Health Insurance Company Limited, 5th floor, C building, Modi
Please contact us
Correspond ence Business Centre, Kasarvadavali, Mumbai, Thane West - 400615
through any of the se
Contact Numb er 1800 390 7000
Modes
Email ID care.healthinsurance@adityabirlacapital.com

Grievance Redressa l

In case of a grievance, the Insured Person/ P olicyholder can contact Us with the details through
our website:https://www.adityabirlacapital.com/healthinsurance
Email:care.healthinsurance@adityabirlacapital.com
or Toll Free : 1800 390 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 P erson can also walk-in and approach the grievance cell at any of Our branches. If in case the Insured P erson 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, h e /sh e
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

 PR EMI UM C E R T I F I C A T E

Premium Certificate is for the purpose of deduction under Section 80-(D) of Income Tax (Amendment) Act 1 986.
This is to certify that ARUL GAJENDRA BOOPATHY CHELLAKKANNU paid INR. 23299.00 (In words Twenty T h r e e Thousand Two
Hundred Ninety Nine Only) towards Premium for Health Insurance for the Period From 00:01 hrs 18/07 /2023 to midnight
23:59 on 17/07/2024.

Instrument Number Instrument Date Amount Name of the Bank

pay_MFGIQz8fpga33q -1807202317
18/07/2023 23299 NA
51383300

Stamp Duty - The stamp duty has been paid vide MH016945204202223E & 18/03/2023, received from Stamp Duty Authorities vide
Receipt No. 0008817681202223 & 31/03/2023, payment has been made vide Letter of Authorization No. LOA/CSD/678/2023/2013 &
10/04/2023 from Main Stamp Duty Office.

Master Policy Number: 71-20-00099-01-01 Certificate Number: GHI-71-23-3960803-000

Date: 18/07/2023 Place: Mumba i

Authorized Signatory

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 Deta ils

Base Covers
Sr N o Cover Name Cov erag e
No Of Day Care Procedures Covered 5 2 7
1 Day Care Treatment

5000000
2 Domiciliary Hospitalization

Room Type: Any Room

ICU Coverage : Upto SI
3 In Patient Hospitalisation
5000000

500000
4 Organ Donor Exp en s es

60 days
5 Post hospitalization Medical Exp enses

30 days
6 Pre hospitalization Medical Exp enses

2500 INR
7 Road Amb ulance Exp enses 2500

Optional Covers
Frequency per Policy Year : TWICE
1 F itness Assessment

Blood pressure check, Body Mass Index, Hip to waist Ratio, MER, Serum
2 Health Assessm ent Cholesterol and Fasting Blood Sugar
Once in a year.
30 %
3 HealthReturns TM Self and Sp ouse will earn He althReturns @ 30% based on their Healthy, Heart
Score and their number of Active Days recorded in a month.
Waivers and Discoun ts
1 30 day waiting p eriod Yes
2 Pre Existing Diseases W aiting P eriod 2 Years

Riders
Riders Lim it / Optio ns
1 Sup er Reload Rid er NA
2 Super No Claim Bonus Rider NA

Group Activ Health, Product UIN: IRDAI/HLT/ABHI/P-H(G)/V

3 Tele – OPD consultation Rider NA
Additional S.I. for Pandemic and
4 NA
epid emic R id er

Pre Existing Dise ase

Member Name Re lat ionsh ip Pre Existing Dise ase
GANESH SUBRAMANIYAN R Self NA
MALLIKA R MOTHER NA
RAMARAJU M FATHE R NA

Group Activ Health, Product UIN: IRDAI/HLT/ABHI/P-H(G)/V

Policy No: 71-20-00099-01-01 COI No. GHI-71-23-3960803-000
Coverage Start Date: 18/07/2023 Coverage End Date: 17/07/2024

Name Membership No. Relationship DOB

GANESH SUBRAMANIYIAN
PT97246206 Self 15/06/1990

MALLIKA R PT97246208 Mother 12/11/1964

RAMARAJU M PT97246210 Father 15/06/1954

• This card is onl y i dentificati on and is not a n aut horizati on t o proc eed wit h t he treatm ent or guar ant ee for pay ment .
• In c ase phot o less identity c ar ds iss ued to beneficiaries , acc eptabl e pr oof of identity s uc h as Aadhar C ar d/ Passport/ Dri ve r
License / Rati on C ar d/V oters I D/ PAN Car d s houl d be pr esent ed at the hos pit al.
• This non-transferabl e i dentificati on car d is v ali d at sel ected Netw or k Hos pit als & will enabl e Car d Holder t o av ail c ashl ess
hospit alizati on onl y on pr e-aut horizati on by A dity a Birla Healt h I ns ur anc e C o. Lt d
• For l at est updated net w ork hos pital list , log on t o https: // www .aditya birl ahealt h.com/ healt hi nsuranc e/#! / provi der -searc h