Group Activ Secure - Certificate of Insurance

Aditya Birla Health Insurance Aditya Birla Health Insurance

Company Limited, 10th Company Limited, 7th floor, C
Policy Issuing Office Floor, R-Tech Park, Nirlon Policy Servicing Office building, Modi Business Centre,
Compound, Goregaon-East, Kasarvadavali, Mumbai, Thane
Mumbai-400063 West 400 615
Master Policy Number 4-62-23-0000128-000 Certificate Number GFB-62-23-2925667-000
Master Policyholder
HDFC Bank Limited
Name
Product Name Group Activ Secure Member Id PT96004988
Plan Name Plan A
Haider Abbasbhai Basuwala
Ali Mill Stores 2Nd Floor
Name of Insured
Room No-C2,71A Netaji
Person and Residential Unique Identification
Subhas Road 1339591
Address of Insured Number
Burrabazar,Kolkata,West
Person
Bengal,Kolkata,Kolkata,INDI
A,WEST BENGAL,700001
Mobile Number 9830156602 Email Id amscal59@rediffmail.com

Inception date & Time of Master Policy 00:01 hrs 10/04/2023

Expiry Date & Time of Master Policy 23:59 on 04/04/2028
Period of Insurance 60 Months
Start Date 00:01 hrs 03/08/2023
End Date 23:59 on 02/08/2028
Insured Person Detail

Nominee
Insured Person Date of Birth Gender Nominee Sum Insured
Relationship
Hussain Haider As Per Coverage
Haider Basuwala 14/11/1964 Male Son
Basuwala Details

Group Activ Secure -

Capital Sum Insured/ Sum Insured (Rs)
Personal Accident
Section A: Basic Covers
2000000
Accidental Death Cover (AD)

100000
Shared Room
Accidental In-patient Hospitalization
Accidental hospitalization is covered upto Rs 100,000/ on indemnity basis or actual claims
(limited to India)
whichever is lower. minimum 24
hrs hospitalization is required
25000
Burns Benefit

2000000
Permanent Total Disablement (PTD)

25000
Recovery Benefit

5000
Road Ambulance Cover

Section B: Optional Covers

500
Chauffeur Benefit (Per day)
For maximum up-to 7 days.
250000
Coma Benefit
Section B: Optional Covers
5000
Cost of Support Items

1000000
Disappearance Benefit

10000
Funeral Expenses

99999
Loss of Job Salaried
For Salaried class, Cover-Rs.100,000.
10000
Modification Benefit (Residence)

10000
Modification Benefit (Vehicle)

10000
Repatriation of Mortal Remains

Group Activ Secure -

Sum Insured (Rs)
Critical Illness
100000
Group 11 CIs
Critical Illness Benefit
Initial Waiting Period -90 DAYS
Pre-Existing Diseases : Not covered
15 days
Survival Period

Group Activ Secure -

Daily Cash Benefit (Rs)
Hospital Cash
Section A: Basic Covers
3000
Accidental Hospital Cash Benefit

2 days
Deductible

Applicable
First 30 Days Waiting Period

30D
Limit per Policy year

10 days
Limits Per Hospitalization Claim

Applicable
One Year Waiting Period

APPLICABLE
Pre- Existing Diseases Waiting Period

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 10270.36
CGST (9%) 924.33
SGST / UTGST (9%) 924.33
IGST (18%) NA
Total Premium 12119.02
Premium payment mode CD-Customer
GST Registration No.: 27AANCA4062G1ZN Category: General Insurance SAC Code: 997133

Authorized Signatory

Claim Process
Address for Aditya Birla Health Insurance Company Limited, 5th floor, C building, Modi
Please contact us
Correspondence Business Centre, Kasarvadavali, Mumbai, 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 Haider Abbasbhai Basuwala paid INR. 12119.00 (In wordsTwelve Thousand One Hundred Nineteen Only)
towards Premium for Health Insurance for the Period from 03/08/2023 to midnight 02/08/2028.

Instrument Number Instrument Date Amount Name of the Bank

NA 07/08/2023 12119 HDFC

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: 4-62-23-0000128-000 Certificate GFB-62-23-2925667-000

Date 03/08/2023 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.

Important –
1) In case of payment by cheque, in the event of dishonour of cheque for any reason whatsoever, insurance provided under
this document automatically stands cancelled from the inception irrespective of whether a separate communication is sent or

Pre Existing Disease

Member Name Relationship Pre Existing Disease
Haider Basuwala Self NA
Policy No: 4-62-23-0000128-000 COI No. GFB-62-23-2925667-000
Coverage Start Date: 03/08/2023 Coverage End Date: 02/08/2028

Name Membership No. Relationship DOB

Haider Basuwala PT96004988 Self 14/11/1964

• 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