23-21-9543089-01

MADHUKAR GANPAT CHACHAD

Empowering people to
3/11, Kamana society
lead healthier lives
S.K.Bole Marg, Prabhadevi

Mumbai Up to 30% of
MAHARASHTRA your premium as
INDIA HealthReturnsTM*
400028
7718030738 Compprehensive
20/01/2023 Health Check-up
at no additional cost
Dear MADHUKAR GANPAT CHACHAD,
A relationship that stands the test of time only gets fruitful in the future. We’re glad
Cover on Modern
that you’ve chosen to continue your health and wellness journey with us.
Treatmentmethods
By offering you the best insurance advice and the finest health guidance, we will
ensure that we keep giving you more and more reasons to renew our relationship
year-on-year. Coverage for
Excited? So are we! Get ready to make the most out of your new insurance plan Domiciliary
Active Assure - Diamond Hospitalization
We hope that you continue to stay healthy throughout your journey with us.
Worldwide
Warm regards, emergency assistance
services

Mayank Bathwal
Chief Executive Officer Scan the QR code to
Download the Activ Health App
Aditya Birla Health Insurance Co. Limited.

Your health
and your policy,
POLICY NUMBER: 23-21-9543089-01
all in one place
Name Membership No DOB
MADHUKAR GANPAT
PT85356432 28/Apr/1927
CHACHAD

For assistance, connect with us via the following channels: *Not Applicable for Activ Assure – Silver

Follow us to follow your Activ Assure, Product UIN: ADIHLIP23130V042223

 Activ Assure Policy Schedule
Policy Issuing Office
Intermediary Name
Intermediary Contact Details
Toll Free Number
Unit no 1101 & 1104 11th
floor, Unit no 1501& 1502, MBC Park, 07th Floor, C Building,
15th floor, G Corp Tech Park, Policy Servicing Office Kasarvadavali Thane
Kasarwadavali, Ghodbunder MAHARASHTRA 400615
Road, Thane West-400615
POLICYBAZAAR INSURANCE
Intermediary Code 5100357
BROKERS PRIVATE LIMITED
18002585970 Intermediary E-mail ID crthealth@policybazaar.com
18002707000

I.Details of Policy Holder

Policyholder Name MADHUKAR GANPAT CHACHAD
3/11, Kamana society S.K.Bole Marg, Prabhadevi Mumbai, 400028, Mumbai,
Policyholder Address
MAHARASHTRA
Contact Number 7718030738
Email Id siXXXXXXXXXXXXad@gmail.com

II .Policy Details
Product Name Activ Assure Plan Name Active Assure - Diamond
Policy Number 23-21-9543089-01
First Policy Start date 20/01/2022
Start Date of Policy & Time 00:00 hrs on 20/01/2023 Expiry Date & Time of Policy 23:59 hrs on 19/01/2024
Policy Type Individual Policy Tenure (in years) 1
Policy Category Renewal
Mode of Premium payment Single
Portability No Previous Policy Number 23-21-9543089-00
GSTN Number NA GSTN Account Type Consumers

III.Insured Person's Details

Start
date of
Policy of
Start date of
Insured
Relationship Pre-existing first policy with
Name Of Insured Person (in
with Member ID Age Gender DOB Diseases (if us (applicable
person case of
Policyholder applicable) at policy
new
renewal)
member
additions
mid term)
MADHUKAR GANPAT
NA Self PT85356432 95 Male 28/04/1927 NA 20/01/2022
CHACHAD

Activ Assure, Product UIN: ADIHLIP21250V032021

 Super No Claim
No Claim Bonus*
Bonus*
Co-Payment ICU
Sum Insured Room Type
^ Charges
% Amount % Amount

1000000 NA Any Room Up to S.I 10 100000 50 500000

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

Optional Covers
Any Room
Accidental Cancer
Upgrade(Av Preferred
Reduction in Pre Unlimited Hospitalisation Hospitalisatio
Name Of Insured Super No Claim ailable with Provider
Existing Disease re-load of Booster (not n Booster (not
Person Bonus Sum Network(PPN
Waiting Period* Sum Insured available in SI available in SI
Insured Rs ) Discount
above 1 Cr) above 1 Cr)
5 Lac)
MADHUKAR
No No Yes No No No NA
GANPAT CHACHAD

*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)
MADHUKAR GANPAT CHACHAD No

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

MADHUKAR GANPAT CHACHAD NA

HealthReturnsTM1 (Applicable for Renewal Policy)

Name of the Insured Person HealthReturnsTM carried forward from Total HealthReturnsTM available for utilization
Previous Year
MADHUKAR GANPAT CHACHAD 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

PRADIPKUMAR CHACHAD Son NA

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

Total Ported
Sum Insured
Date of first Previous Type of Waiting period
Name of Insured Person Previous Insurer (Sum Insured +
enrollment Policy Number Cover waived off
Cumulative
Bonus)
MADHUKAR GANPAT CHACHAD NA NA NA NA NA NA

Activ Assure, Product UIN: ADIHLIP21250V032021

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
Sum Insured
Covers Lac, 100 Lac, 150 Lac, 200 Lacs
In-patient Covered
Hospitalization
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
30 days
Medical Expenses
Post–hospitalization
60 days
Medical Expenses
Day Care Treatment 586 listed Procedures, Covered up to S.I.
Domiciliary
Hospitalization (Home Upto 10% of S.I
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 10% of S.I. per annum, Max upto 50% of

No Claim Bonus 10% of S.I. per annum, Max upto 50% of S.I
Benefits S.I
Health Check-up
Annual Annual
Program
Second E-Opinion on
Available for 15 listed Critical Illnesses Available for 15 listed Critical Illnesses
Critical Illnesses
Domestic Emergency
Assistance Services
Available Available
(including Air
Ambulance)
International Emergency
Assistance Services
Available Available
(including Air
Ambulance)
Health AssessmentTM Available Not Available

Activ Assure, Product UIN: ADIHLIP21250V032021

 HealthReturnsTM Available, Earned by ways of - Percentage Not Available
of Premium earned through Healthy Heart
Score™ and Active Days
Value
Added Health Coach Available Not Available
Services

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 Additional 50% of S.I. per annum, Max upto
Super NCB
Optional upto 100% of S.I 100% of S.I
Covers
Accidental 100% of S.I. 100% of S.I.

Cancer Hospitalization
Booster (not available 100% of S.I. 100% of S.I.
above 1Cr S.I)
Any Room Upgrade Available with S.I. 5L Available with S.I. 5L
Preferred Provider
10% Discount Available 10% Discount Available
Network (PPN) Discount

VII. Premium Details (Rs)

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

61465.0 12293 0 0 6638.22 6638.22 NA NA 87034.00

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

The stamp duty of Re. 1 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

For and on behalf of Aditya Birla Health Insurance Co.

Ltd

Date : 20/01/2023

Place : Mumbai Authorized Signatory

Activ Assure, Product UIN: ADIHLIP21250V032021

 Premium Certificate
We confirm the receipt of premium amount of INR 87034.00 as per below details paid by MADHUKAR GANPAT CHACHAD for Self and/or
Family and/or Parents:

Policy Number: 23-21-9543089-01 Plan Name: Active Assure - Diamond

Type of Plan: Individual Proposer Name: MADHUKAR GANPAT CHACHAD

Policy Start Date: 00:00 hrs on 20/01/2023 Policy End Date: 23:59 hrs on 19/01/2024

Receipt Instrument
Receipt Number Dated Relationship Payment Mode Bank Name
Amount Number
pay_KsagqOuIIGO Online
RR-22-23-0367872 87034.00 18-12-2022 Self NA
SYk Payment
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 87,034.00
* 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 : 20/01/2023

Location: Mumbai
Authorized Signatory

Activ Assure, Product UIN: ADIHLIP21250V032021

 23-21-9543089-01

Membership Blood
Name DOB
No. Group
MADHUKAR GANPAT
CHACHAD PT85356432 28/Apr/1927