Group Activ Health - Certificate of Insurance

Unit no 1101 & 1104 11th Unit no 1101 & 1104 11th
floor, Unit no 1501& 1502, floor, Unit no 1501& 1502,
Policy Issuing Office 15th floor, G Corp Tech Park, Policy Servicing Office 15th floor, G Corp Tech Park,
Kasarwadavali, Ghodbunder Kasarwadavali, Ghodbunder
Road, Thane West-400615 Road, Thane West-400615
Master Policy Number 71-20-00040-01-01 Certificate Number GHI-HB-22-2105515-003
Master Policyholder
HDFC Bank Limited
Name
Product Name Group Activ Health Member Id 000738026601
DINESH G .
Name of Insured 24 Kvvempu Nagar 2Nd
Person and Residential Stage,Behind Rama Unique Identification
1861155
Address of Insured Temple,Jallahalli Po Number
Person Jalahalli,Bengaluru,Bangalore,I
NDIA,KARNATAKA,560014
Mobile Number 8618624006 Email Id Dineshshekar21@Gmail.Com

Start date & Time of Master Policy 00:01 hrs 04/04/2023

Expiry Date & Time of Master Policy 23:59 on 03/04/2024
Inception Date 00:01 hrs 04/12/2023
End Date 23:59 on 03/12/2024
Coverage Type Floater
First Coverage Start date 04/12/2022

Insured Person Detail

Nominee Sum
Insured Person Date of Birth Gender Nominee
Relationship Insured
DINESH G . 21/01/1998 Male Rani Mother 1000000

Benefit Description
Group Mediclaim Refer Coverage Details

Policy Exclusions
Group Mediclaim As per Annexure I

Premium Details
Particulars Amount
Net Premium 7412.97
CGST (9%) 667.17
SGST / UTGST (9%) 667.17
IGST (18%) NA
Gross Premium 8747.31
Premium payment mode Online Payment

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

Authorized Signatory

Group Activ Health, Product UIN: IRDAI/HLT/ABHI/P-H(G)/V.I/19/2

Claim Process
Address for Unit no 1101 & 1104 11th floor, Unit no 1501& 1502, 15th floor, G Corp Tech
Please contact us
Correspondence Park, Kasarwadavali, Ghodbunder Road, Thane West-400615
through any of these
Contact Number 1800 270 7000
Modes
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:https://www.adityabirlacapital.com/healthinsurance
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
of the the nearest
Ombudsman offices Insurance Ombudsman.
are provided The contact
on Our website and in details of the Ombudsman offices are provided on Our website and
the Policy.

Group Activ Health, Product UIN: IRDAI/HLT/ABHI/P-H(G)/V.I/19/2

 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 DINESH G . paid INR. 8747.31 (In words Eight Thousand Seven Hundred Fourty Seven and Three One
Paisa Only) towards Premium for Health Insurance for the Period From 00:01 hrs 04/12/2023 to midnight 23:59 on
03/12/2024.

Instrument Number Instrument Date Amount Name of the Bank

45717291701411985 01/12/2023 8747.31 NA

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: 71-20-00040-01-01 Certificate Number: GHI-HB-22-2105515-003

Date: 01-DEC-23 Place: Mumbai

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 Details

Base Covers
Sr No Cover Name Coverage
25000
Comfort treatment involving steam bath/sauna/oil massages are excluded.
Ayush treatment (In-patient
1 Such treatments being combined with any stay packages at,resorts where the
Hospitalization)
treatment forms a part of an overall leisure package shall not be covered
under this Benefit.
No Of Day Care Procedures Covered 527
2 Day Care Treatment

1000000
3 Domiciliary Hospitalization

SI Limit Per Day : INR 1000

Deductible in Days : 1 days.
4 Hospital Cash Limit Per Hospitalization Event :10 days.
Limit per Policy Year :30 days

Room Type: Single Private A/c Room

ICU Coverage : Upto SI
1000000
5 In Patient Hospitalisation
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)
1000000
6 Organ Donor Expenses

90 days
7 Post hospitalization Medical Expenses

60 days
8 Pre hospitalization Medical Expenses

5000 INR
9 Road Ambulance Expenses Covered up to 1% of the sum insured maximum Rs. 5000 in case of
emergency

Group Activ Health, Product UIN: IRDAI/HLT/ABHI/P-H(G)/V.I/19/2

Optional Covers
Frequency per Policy Year : TWICE
1 Fitness Assessment

Blood pressure check, Body Mass Index, Hip to waist Ratio, MER, Serum
2 Health Assessment Cholesterol and Fasting Blood Sugar

Health check up (defined tests) for 1 person in a family,on 100% cashless

3 Health Check-up Program
basis.
30 %
4 HealthReturns TM

Once per Policy Year, subject to 1 E-opinion per Critical Illness/ medical
5 Second E - Opinion
condition per policy year
6 reload of sum insured Reload available upto 100% of Sum Insured
Waivers and Discounts
1 30 day waiting period Yes
2 Pre Existing Diseases Waiting Period 4 Years
Specified Disease Procedure Waiting
3 Applicable
Period
Riders
Riders Limit / Options
Super no claim bonus - 10% increase
1 Super No Claim Bonus 1000000
Max up to 100%
Pre Existing Disease
Member Name Relationship Pre Existing Disease
DINESH G . Self NA

Group Activ Health, Product UIN: IRDAI/HLT/ABHI/P-H(G)/V.I/19/2

Policy No: 71-20-00040-01-01 COI No. GHI-HB-22-2105515-003
Coverage Start Date: 04/12/2023 Coverage End Date: 03/12/2024

Name Membership No. Relationship DOB

DINESH G . 000738026601 Self 21/01/1998

• 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
Unit no 1101 & 1104 11th
Unit no 1101 & 1104 11th floor,
floor, Unit no 1501& 1502,
Unit no 1501& 1502, 15th floor,
15th floor, G Corp Tech
Policy Issuing Office Policy Servicing Office G Corp Tech Park, Kasarwadavali,
Park, Kasarwadavali,
Ghodbunder Road, Thane
Ghodbunder Road, Thane
West-400615
West-400615
Master Policy Number 62-20-00216-01-01 Certificate Number GFB-HB-22-2063610-003
Master Policyholder
HDFC Bank Limited
Name
Product Name Group Activ Secure Member Id 00073802672
Plan Name Plan A
DINESH G .
Name of Insured 24 Kvvempu Nagar 2Nd
Person and Residential Stage,Behind Rama Unique Identification
1861155
Address of Insured Temple,Jallahalli Po Number
Person Jalahalli,Bengaluru,Bangalore
,INDIA,KARNATAKA,560014
Mobile Number 8618624006 Email Id Dineshshekar21@Gmail.Com

Inception date & Time of Master Policy 00:01 hrs 04/04/2023

Expiry Date & Time of Master Policy 23:59 on 03/04/2024
Period of Insurance 1 Year
Start Date 00:01 hrs 04/12/2023
End Date 23:59 on 03/12/2024
First Certificate Number & First Coverage Start
GFB-HB-22-2063610 & 00:01 hrs 04/12/2022
date
Insured Person Detail

Nominee
Insured Person Date of Birth Gender Nominee Sum Insured
Relationship
As Per Coverage
Dinesh G . 21/01/1998 Male Rani Mother
Details

Coverage Details

Group Activ Secure -

Capital Sum Insured/ Sum Insured (Rs)
Personal Accident
Section A: Basic Covers
Accidental Death Cover (AD)+
Permanent Partial Disablement (PPD) 1000000
+ Permanent Total Disablement
(PTD)
10000
Road Ambulance Cover

Section B: Optional Covers

100000
Education Fund for Children

10000
Funeral Expenses

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.

Policy Exclusions
Plan A <As per Quote & Policy Wordings>

Premium Details
Particulars Amount
Net Premium 600.0
CGST (9%) 54.0
SGST / UTGST (9%) 54.0
IGST (18%) NA
Total Premium 708.0
Premium payment mode Online Payment
GST Registration No.: 27AANCA4062G1ZN Category: General Insurance SAC Code: 997133

Authorized Signatory

Claim Process
Address for Unit no 1101 & 1104 11th floor, Unit no 1501& 1502, 15th floor, G Corp Tech
Please contact us
Correspondence Park, Kasarwadavali, Ghodbunder Road, Thane West-400615
through any of these
Contact Number 1800 270 7000
Modes
Email ID care.healthinsurance@adityabirlacapital.com
 PREMIUM CERTIFICATE
(Only for Premium contributed towards Group Critical Illness and Group Hospital Cash)
Premium Certificate is for the purpose of deduction under Section 80-(D) of Income Tax (Amendment) Act 1986.
This is to certify that DINESH G . paid INR. 708 (In words Seven Hundred Eight Only) towards Premium for Health Insurance for
the Period from null to midnight null.

Instrument Number Instrument Date Amount Name of the Bank

45717291701411985 01/12/2023 708 NA

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: 62-20-00216-01-01 Certificate GFB-HB-22-2063610-003

Date 04-12-2023 Place: Mumbai

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.