31-25-0590913-00

Arka Som
C/O: Uday Kumar Som,, India, Hooghly, 712611, Bhurkunda,
West Bengal, Goghat - II, Bhurkunda
NA .
Goghat
WEST BENGAL
INDIA
712611
8001669569

18/03/2026 Empowering people

Dear Arka Som,

Thank you for choosing us. In our journey together, we promise to offer you the Up to 100% of your
best insurance and assurance of good health. Premium as Health
ReturnsTM
Together, we will achieve our goals by making every small step count. Every ladder
you climb, every calorie you burn, every lap you swim, every song you dance on -
every little act will move the needle towards a healthier you. 90 days pre and
180 days post
Excited? So are we! Get ready to make the most out of your new insurance plan Hospitalization Coverage
Activ One - MAX

Thank you once again for partnering with us. With our purpose of Empowering You Any Room of your
To Lead A Healthier Life, we ensure you a fruitful and healthful journey. Choice up to
Base Sum Insured

Claims Protect: Avail

Claim coverage for listed
Non-Medical expenses

Super Reload: Unlimited

refil up to 100% Sum
Insured from 2nd claim
Onwards
Warm regards, Introducing The Activ Health

Mayank Bathwal
Chief Executive Officer
Aditya Birla Health Insurance Co. Limited.
Your health and your
For assistance, connect with us via the following channels: policy, all in one place

Follow us on: Product Name: Activ One, Product UIN: ADIHLIP24097V012324

 Activ One MAX
Policy Schedule
This document will serve as a quick guide for you to understand important information regarding your health insurance
policy including its key features, coverage limits, premium details and nominee details, among others.

Unit no 1101 & 1104 11th floor, Unit

no 1501& 1502, 15th floor, G Corp
2nd Floor, Bangur BFL Estate
Policy Issuing Office Tech Park, Kasarwadavali, Policy Servicing Office
Kolkata WEST BENGAL 700016
Ghodbunder Road, Thane
West-400615
Intermediary Name HDFC Bank - Virtual Sales Kolkata Intermediary Code 2113026
Intermediary Contact Details 02261606161 Intermediary E-mail ID NA
Toll Free Number 18002707000

Policyholder Name Arka Som

C/O: Uday Kumar Som,, India, Hooghly, 712611, Bhurkunda, West Bengal, Goghat - II, Bhurkunda .
Policyholder Address
Goghat, 712611, Hooghly, WEST BENGAL
Contact Number 8001669569
Email Id ARXXXXX48@[Link]
GSTIN NA

Product Name Activ One

Plan MAX
Policy Number 31-25-0590913-00
First Policy Start date 18/03/2026
Start Date of Policy & Time 00:00 hrs on 18/03/2026 Expiry Date & Time of Policy 23:59 hrs on 17/03/2028
Policy Type Individual Policy Tenure 2 Years
Enrollment for Automatic renewal
Policy Category New Business YES
premium payment facility
Mode of Premium payment Single
Portability/Migration No Previous Policy Number NA
GSTIN NA GSTIN Account Type Consumers
New Business

Start date of
Policy of
Insured Pre-Existing Start date of
Relationship Age
Person (only DOB Diseases first policy with
Name of Insured person with Member ID (completed Gender
in case of new (DD-MM-YYYY) (PED) us(applicable at
Proposer birthday)
member (if applicable) policy renewal)
additions mid
term)
Arka Som NA Self PT50771173 29 Male 05/10/1996 NA 18/03/2026

Continued and to be read in conjunction of the table above

Specific disease Waiting Pre-Existing Disease Super Credit

Base Sum Insured Initial Waiting Period Super Credit %
period Waiting Period Amount
1000000 30 Days 2 Years 3 Years 0 NA

Continued and to be read in conjunction of the table above optional cover opted.

Product Name: Activ One, Product UIN: ADIHLIP24097V012324

0 0
Name of Insured Person Room Rent Type Options Preferred Provider Network (PPN) Discount
1 0 10% discount applicable 10% co-payment will apply if
Arka Som Shared Accomodation
treatment taken outside PPN
1

Waiting Period from Start Date of Chronic Management Program

Name of the Insured Person Chronic Condition
Start Date of First Policy Coverage Applicability
Arka Som No NA NA No

Name of the Insured Person Special Condition (if applicable)

Arka Som No

Name of the Insured Person Pre-Existing Disease Details (if applicable)

Arka Som NA

HealthReturnsTM (Applicable for Renewal Policy)

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

Arka Som NA 0

Trademarks - HealthReturnsTM, Healthy Heart Score and Active Dayz are owned by MMI Group Limited and used under license by
Aditya Birla Health Insurance Co. Limited.

Nominee Name Nominee Relationship with Policyholder Nominee Contact Number

SABITA SOM Mother NA
Appointee Details: (Required only if Nominee is a Minor)
Appointee Name Relationship with Nominee
NA NA
Note - A Minor should not be declared as Appointee.

No

Product Name: Activ One, Product UIN: ADIHLIP24097V012324

 Product Name Activ One
Plan Variant MAX
Refer Base Sum Insured column under Insured Person’s
Base Sum Insured
details above
Basic Covers Hospitalization Room Rent Shared Accomodation
Treatment ICU Charges Actuals up to Sum Insured
Road Ambulance Cover (per
Actuals up to Sum Insured
hospitalization)
Day Care Treatments Actuals up to Sum Insured
Modern Procedures / Treatments Actuals up to Sum Insured for listed procedures
HIV / AIDS and STD Cover Actuals up to Sum Insured
Mental Illness Hospitalization Actuals up to Sum Insured
Obesity Treatment Actuals up to Sum Insured
Pre-Hospitalization Expenses (up to Sum Insured) 90 Days
Post-Hospitalization Expenses (up to Sum Insured) 180 Days
Claim Protect (Non-Medical Expense Waiver) Waiver of Non-Medical Expense Exclusion of Base Policy
List as per Annexure 1 (all 4 lists)

Domiciliary Hospitalization Actuals up to Sum Insured

Home Health Care Actuals up to Sum Insured
AYUSH Treatment Actuals up to Sum Insured
Organ Donor Expenses Actuals up to Sum Insured
Annual Health Check up (Listed & Cashless) Covered
Super Reload Unlimited Refill [2nd Claim onwards -
Unlimited Covered
Times (upto Base Sum Insured)]
Super Credit (increases irrespective of claim) 100% of SI per year, up to 500% of Base Sum Insured
(up to Max of 3 Cr under this benefit)
Health Management Program Health AssessmentTM Available once in a policy year undertaken at our
Network Providers / Empaneled Service Providers on a
cashless basis only / on digital basis

HealthReturnsTM Available up to 100% of the Premium

Premium for
Premium for
Other Optional Loading Discounts
Base and CGST SGST/UTGST IGST Other taxes/Cess Total Premium
Covers (if applicable) (if applicable)
Related Covers
(If Opted)

11075.58 1687.4 0 957.2186 0 0 0 0 11806.00

GST Registration No: 19AANCA4062G1ZK PAN Number :AANCA4062G Category: General Insurance SAC Code: 997133

We hereby declare that though our aggregate turnover in any preceding financial year from 2017-18 onwards is more than the aggregate turnover
notified under sub-rule (4) of rule 48, we are not required to prepare an invoice in terms of the provisions of the said sub-rule.

Consolidated Stamp Duty paid vide E-challan GRN no. MH015140071202526P dated 12/01/2026

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

Date : 18/03/2026

Location : Mumbai
Authorized Signatory

Product Name: Activ One, Product UIN: ADIHLIP24097V012324

 Premium Certificate
We confirm the receipt of premium amount of INR 11806.00 as per below details paid by Mr. Arka Som for Self and/or Family and/or
Parents:

Policy Number: 31-25-0590913-00 Plan Name: MAX

Type of Plan: Individual Proposer Name: Arka Som

Policy Start Date: 00:00 hrs on 18/03/2026 Policy End Date: 23:59 hrs on 17/03/2028

Premium Details:

Premium Date Net Premium Amount CGST SGST IGST Total Premium Total Premium Paid

18-03-2026 11805.76 0 0 0 11806.00 11806

Mode of Premium payment Single

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:
Financial Year Year wise proportionate Premium amount*
2025-26 5,903.00
2026-27 5,903.00

0 • Premium paid in cash(Rs. 0), premium paid using HealthReturnsTM, 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 don’t 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
declaration the liability shall be upon the policy holder.

For and on behalf of Aditya Birla Health Insurance Co.

Limited

Date : 18/03/2026
Authorized Signatory
Place : Mumbai

Product Name: Activ One, Product UIN: ADIHLIP24097V012324

 Health Booster
Annexure to Base Policy Schedule
(This needs to be read in conjunction with Base Policy Schedule)
0 0
I. Details of Add–on Covers
0 0
Add-on Insured Person
0 0 Add On Cover
Cover No Arka Som
0 1
Aggregate
Co-Payment
Sub-Limits*
Waiver
Sum
Removal
Modification
Unlimited
Insured
ofof
Co-Payment
Care
Deductible
Super
of
Multiplier
Super
Credit
1 0 One-time Unlimited Sum
0 0 • Insured for any one selected Yes
admissible claim in Policy
life
Air Ambulance (Domestic)
• Yes
Up to Base Sum Insured
Maternity Cover Services
Note:
. For more details on Add-on Covers risk factors, please read the terms and conditions carefully.
. All declarations / terms and conditions as per the base proposal form would apply.
. Deductions available under Section 80D of the Income Tax Act except Personal Accident Cover
. In case the base product undergoes revision, the existing Add-on form will be replaced with a subsequently revised version of the
product.

II. Premium Details:

Premium Details (Rs) (Total)

Premium for Other
Premium for Base and Loading (if Discounts (if Other taxes / Total
Optional Covers CGST SGST/UTGST IGST
Related Covers applicable) applicable) Cess Premium
(If Opted)
11075.58 1687.4 0 957.2186 0 0 0 0 11806.00

GST Registration No: 19AANCA4062G1ZK PAN Number :AANCA4062G Category: General Insurance SAC Code: 997133

Consolidated Stamp Duty paid vide E-challan GRN no. MH001265008202526E & 25/04/2025.

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

Date : 18/03/2026

Place : Mumbai
Authorized Signatory

Product Name: Health Booster, Product UIN: ADIHLIA25035V012425.

POLICY NO. 31-25-0590913-00
Name Membership No. DOB
Arka Som PT50771173 05/Oct/1996
 Activ One
Proposal Form

This document summarizes all relevant information about the person / people proposed to be insured under your health insurance policy including age,
medical history lifestyle habits, pre-existing diseases, if any, and the risks to be covered. As an insurer, it helps us to assess risks, determine premiums,
establish terms and conditions and to be relevant to you and your health needs. It is vital that you provide us with complete and accurate information.

1. Please choose suitable options wherever applicable and fill the form in BLOCK LETTERS. Application No.
2. The proposed policy holder will be referred to in this Proposal Form as “Proposer”, “You” or “Your”
3. Please disclose truthfully and accurately all facts and required information that is likely to impact / affect our decision
on issuing a health insurance policy or its terms, conditions and exclusions. Incorrect information may lead to policy
cancellation / claim rejection. In case of untrue / incorrect statements, misrepresentation, non-description or non-disclosure
of any relevant information or material information being withheld by the Proposer or anyone acting on their behalf,
particularly in the proposal form / personal statement, declaration and connected documents, the policy shall become void
at our discretion. If You are in any doubt, please seek the advice of your insurance advisor
4. In case of a portability proposal, the health insurance policy period will only begin after complete premium payments including loading premium (if applicable)
are submitted by You. This may result in a break in coverage period, in which case You may not be covered by any policy. It is therefore recommend that You
extend Your porting policy with existing insurer on short period basis until this proposal is accepted and issued by us in case of portability [Link]
Company’s liability does not commence until the acceptance of the proposal has been formally intimated to You and full premium has been realized by the
Company.
5. Any changes / cancellations in this form will have to be authenticated by the Proposer.

Customer ID PT50771173 Branch Stamp

Name Arka Som

Gender: Male Date of Birth: 05-10-1996 Marital Status: Single
Whether Employee of
NA
Aditya Birla Group
Whether Customer of
NA NA
Aditya Birla Group
Whether Corporate
NA NA
GMC Policy Holder
C/O: Uday Kumar Som,, India, Hooghly, 712611, Bhurkunda, West Bengal, Goghat - II, Bhurkunda
.
Correspondence Address
City: Goghat Town (District): Hooghly
State: WEST BENGAL Pincode: 712611
C/O: Uday Kumar Som,, India, Hooghly, 712611, Bhurkunda, West Bengal, Goghat - II, Bhurkunda
0
.
Permanent Address
City: Goghat Town (District): Hooghly
State: WEST BENGAL Pincode: 712611
Nationality Indian
Pan (Mandatory) XXXXXX395G Form 60 (only in case the customer does not have PAN) Yes
Aadhaar Number. ((last 4 digits) (By GST Registration Status
signing the Proposal form I give Consumers
my consent for using my Please specify GST identity Number: NA
Aadhaar No. for Authentication (mandatory for Registered dealer & Compounding dealer)
of my Aadhaar Details))
Proof of Address (POA - any one) PAN Card

Product Name: Activ One, Product UIN: ADIHLIP24097V012324

 Contact Details Mobile Number* 8001669569 Alternate Contact Number: NA
Email ID* ((All proposal/policy related
communications will be sent on ARXXXXX48@[Link]
this e-mail id))
Annual Income (INR) 500000
Occupation Government Employee
Are you a Politically Exposed
No
Persons (PEP)# or related to PEP# ?
WhatsApp consent^: Yes

Do you have ABHA No:?

Yes I would like to contribute in creating a healthier, greener and cleaner environment by authorizing Aditya Birla
Go Green consent Health Insurance Co. Limited to send all my policy & service related communication to the Email ID mentioned in this
application form.

*The registered mobile number will be enrolled for WhatsApp notifications related to your Health Insurance Policy. We respect your privacy and will ensure that promotional
content is not shared through this channel. ^If You don’t want to give consent and authorize Aditya Birla Health Insurance Co. Limited to send you communication via
WhatsApp please select ‘No’ in WhatsApp consent column.
#
Have you ever been entrusted with prominent public functions, for example, Heads of State or of Government, Senior Politicians, Senior Government, Judicial or
Militray Officials, Senior Executives of State Owned Corporations or Important Political Party Officials.

Would you like to opt for Electronic Policy Issuance through an e-Insurance Account (eIA) of an Insurance Repository? No
If you have an eIA, please provide following details

I) Name of Insurance Repository

III) EIA No NA

III) Name as appearing in EIA Arka Som

MAX If you do not have an eIA, would you like to open an account? Yes

Plan Type: Sum Insured Options (INR)

MAX 1000000
Cover: Individual Tenure: 2 Years Details for Hospital Cash Cover of Parents OR Parents-in-law

Details of Optional Cover(s) as per Annexure -I

PT50771173
Insured 1: Name: Arka Som IF PEP# No

Date of Birth: 05/10/1996 Marital Status: Annual Income: 500000

Gender: Male Aadhaar/PAN No: XXXXXX395G Height: 168 Weight: 62

Mobile No~ : 8001669569 Relationship with Proposer: $ Self City of Residence: Goghat
Email ID~ : ARXXXXX48@[Link] Sum Insured: %(INR) 1000000

Do you have ABHA No. NA If yes please provide ABHA Number (Optional)

$
In case of family floater maximum of 2 Adults and up to 4 Children are allowed (Relationship covered: Self, legally married spouse OR live-in partner (same or
opposite sex), Dependent Children (Natural / legally adopted), Parents and Parents-in-law) and In case of Multi-individual policy, relationship covered:
Self, legally married spouse OR live-in partner (same or opposite sex), son, daughter, brother, sister, grandson, granddaughter, son-in-law, daughter-in-law,
brother-in-law, sister-in-law, nephew, niece, parents and parents-in-law.
Mobile Number and E-Mail id is mandatory for each adult insured. Mention the Mobile Number / E-Mail id of the proposer ONLY in case any Insured’s Mobile Number is not
available.
%
In case of Multi Individual policy, Sum Insured opted to be filled separately for each Insured Person and in case of Family Floater, the Sum Insured opted in section II
Product / Plan details above shall be applicable to all members

Product Name: Activ One, Product UIN: ADIHLIP24097V012324

 Do you have Previous / Current policy or proposal applied for Life, Health, Hospital Daily Cash or Critical Illness or Cancer or Personal Accident Insurance?
No
If Yes, Please fill the following details with respect to insurance policies(s) currently held with us or any other insurance company.

[Link] Previous/Current Insurance Details: * Insured PT50771173

1 Name of the Insurerd Person Arka Som

2 Claim in previous policy(Yes/No)# NA
Was any proposal/policy declined/ deferred / withdrawn / accepted with modified terms/ cancelled, if
3 NA
“yes” please provide details in additional information (Yes/No)

4 Do you want to consider your health insurance policy for Portability # # (Yes / No) No

#
If Claims in Previous Policy is “Yes”, Please mention details of Claim in ‘Information On Health And Lifestyle’ section.
##
In case you want portability of your previous policy, kindly fill the portability form separately.

Nominee Name Nominee relationship with Proposer Nominee Contact Number

SABITA SOM Mother NA

Appointee Name Relationship with Nominee

NA NA

Note - A Minor should not be declared as Appointee.

In the event of death of the Proposer, any payment due under the policy shall become payable to the nominee and the receipt of the proceeds by such nominee would be
sufficient discharge to the Company. For all other persons covered under the Policy, the Proposer will be the nominee.

Product Name: Activ One, Product UIN: ADIHLIP24097V012324

Please answer the following questions in "Yes" OR "No" with respect to all persons proposed to be insured.
Note - Please answer all below mentioned questions for each Insured. Please attach discharge card / summary, all consultation papers, investigation reports,
histopathology reports, disability certificate from civil surgeon if any.

Insured 1

[Link] you ever been diagnosed with /advised / taken treatment or observation is suggested or
undergone any investigation or consulted a doctor or undergone or advised surgery for any one or
more from the following? If YES then please mention Details in the additional information section
below.
1. Cancer, Tumor, Polyp or Cyst No
2. Any Heart Disease or Disorder, Chest Pain or Discomfort, Irregular Heartbeats, Palpitations or
No
Heart Murmu
3. Hypertension / High Blood Pressure (BP) / High Cholesterol / Any other Lipid disorders No
4. Asthma / Tuberculosis (TB) / COPD / Pleural Effusion / Bronchitis / Emphysema or any other
No
Disease of Lungs, Pleura and Airway or Respirato Disease?
5. Thyroid Disease / Cushing's Disease / Parathyroid Disease / Addison's Disease / Pituita Tumor /
No
Disease or any other disorder of Endocrine System?
6. Diabetes Mellitus / High Blood Sugar / Diabetes on Insulin or Medication No
7. Motor Neuron Disease / Muscular Dystrophies / Myasthenia Gravis / Demyelinating Disease or
No
any other Disease of Neuromuscular System (Muscles and / or Nervous System)
8. Stroke / Paralysis / Transient Ischemic Attack / Multiple Sclerosis / Epilepsy / Mental-Psychiatric
Illness / Parkinsonism / Alzheimer's / Depression / Dementia or any other disease of Brain and No
Nervous System?

9. Cirrhosis / Hepatitis / Wilson's Disease / Pancreatitis / Liver Disease / Crohn's Disease /

Ulcerative Colitis / Inflammato Bowel Diseases / Piles or any other Disease of Mouth, Esophagus, No
Liver, Gall bladder, Stomach or Intestines or any other part of Digestive System?

10. Kidney Stones / Renal Failure / Dialysis / Chronic Kidney Disease / Prostate Disease or any
No
other Disease of Kidney, Urina Tract or Reproductive Organs?

11. HIV / SLE / Rheumatoid Arthiritis / Scleroderma / Sarcoidosis / Psoriasis / Bleeding or Clotting
No
Disorders or any other Diseases of Blood, Bone Marrow / Immunity or Skin

12. Disease or Disorder of Eye, Ear, Nose or Throat (except any sight related problems corrected by
No
prescription lenses)?

13. Disease of the Musculoskeletal System / Or Thopedic Disorders / Degeneration, Fracture or

No
Dislocation of Bones or Joints / Avascular Necrosis of Joints or any other Disorder related to it?

Product Name: Activ One, Product UIN: ADIHLIP24097V012324

 14. Any other Disease / Health Adversity / Injury / Condition / Treatment not mentioned above No
15. Has any of the Proposed to be Insured been hospitalized / recommended to take investigations / medication or has been under any
No
prolonged treatment / undergone surge for any illness / inju other than for childbirth / minor injuries?
16. Has any of the Proposed to be Insured have been suffering / suffered from Covid-19 disease? If yes, confirm if any complications arise
No
due to Covid-19
0 17. Do you consume any of the following substances? (if yes, please mention the quantity)
Alcohol [30ml (Number of pegs) of hard liquor/ pints of beer/ glasses of wine] per week No
Pan Masala / Guthaka (Number of small Pouches) per week No
Smoking (Number of Cigarette/bidi sticks) per week No

Any Other substance (Name & Quantity) per week No

Additional Information: Please attach extra sheets if required

Details Insured 1
Disease Name NA
Date of Diganosis NA
Last Consultation Date NA
Name of Surgery (if any) No
Details of Treatment given (Hospitalization / OPD, other) NA
Disability% No
Period of Hospitalization (if any) No

Any Other Information No

Mode of Premium Single

Payment By: Online Payment

Name of Premium Relationship of Payer Bank Details (Bank account Number,

Instrument Number Instrument Date Instrument Amount
Payer** with Proposer Bank name, IFSC code)
114370903410 18-03-2026 11806 Arka Som Self ,,

** Income Tax benefit u/s 80D of Income Tax Act 1961, is available to the person who pays the health insurance premium by other than cash payment mode
for himself and his family member (Spouse, dependent children & parent). Eligibilities u/s 80D are subject to Income Tax Act.

Mandatory details required to process all payment due in relation to your policy including refunds (if any) and / or claims directly to your bank account.

Name as in Bank Account: Arka Som

Bank Name: NA Account Number: NA
IFSC Code: NA
Account Type (Current / Saving) Savings

In case of payment through Debit Card, Credit Card and Online Mode of payment, the refund will go back to the same card or bank account as
the case may be. I agree and undertake to intimate in writing to Aditya Birla Health Insurance Co. Ltd. about any change in bank account details. I also
hereby certify that the particulars furnished above are correct to the best of my knowledge

Date: NA Place: MUMBAI Signature:

ECS (NACH) Mandate:

I would like to avail the renewal premium payment facility by mandating Aditya Birla Health Insurance Co. Ltd. to debit my premium through NACH.
For availing NACH, duly filled and signed physical NACH mandate to be submitted.
Note – You will be eligible for 2.5% renewal discount on the renewal premium, if the renewal premium is received through NACH / Standing instruction (where payment
is made either by direct debit of bank account or credit card)

Product Name: Activ One, Product UIN: ADIHLIP24097V012324

 I hereby declare that I have fully explained the contents of the proposal form and all other documents incidental to availing the health insurance
from Aditya Birla Health Insurance Co. Limited to the Proposer in the language understood by them. The same have been fully understood by
them and the replies have been recorded as per the information provided by the Proposer. Replies have been read out to, fully understood and
confirmed by the Proposer.

Declarant Name Arka Som Declarant Signature Date 18/03/2026

Proposer Name Arka Som Proposer Signature
Proposer Sign Date Place MUMBAI

I hereby declare, on my behalf and on behalf of all persons proposed to be insured, that the above statements, answers and/ or particulars given by me
are true and complete in all respects to the best of my knowledge and that I am authorized to propose on behalf of these other persons.

I understand that the information provided by me will form the basis of the insurance policy, is subject to the Board approved underwriting policy of the
insurer and that the policy will come into force only after full payment of the premium chargeable.

I further declare that I will notify in writing any change occurring in the occupation or general health of the life to be insured/proposer after the proposal
has been submitted but before communication of the risk acceptance by the company

I declare that I consent to the company seeking medical information from any doctor or hospital who/which at any time has attended on the person to be
insured/proposer or from any past or present employer concerning anything which affects the physical or mental health of the person to be
insured/proposer and seeking information from any insurer to whom an application for insurance on the person to be insured/proposer has been made
for the purpose of underwriting the proposal and/or claim settlement.
I authorize the company to share information pertaining to my proposal including the medical records of the insured/ proposer for the sole purpose of
underwriting the proposal and/or claims settlement and with any Governmental and/or Regulatory authority which includes sharing of my medical data
through ABHA.
NA

Declaration / Consent (AML / KYC): "You agree that the Company shall be entitled to share and store any personal information and documents shared by you
/ for the purpose of AML / KYC compliance with its Vendors and partners for the purpose of validation and AML / KYC compliance and who can store and
validate from the concerned authorities / agencies / portals. You also allow the Company to receive, maintain, save and store your AML / KYC related
information and documents from third party entities / intermediaries for the purpose of AML / KYC compliance in regard to processing your application for
insurance policy and / or its continuation, as the case may be in furtherance to the stipulated norms. In the event you have any concerns or you do not agree
to the same, you are requested to kindly visit the nearest Company branch in regards to your Application / Proposal / Policy."

Date: 18/03/2026 Place: MUMBAI

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The information we collect from cookies will not be used to create profiles of users and will only be used in aggregate form.

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Insurance Website or used in any way by Aditya Birla Health Insurance or its group companies/affiliates.

Product Name: Activ One, Product UIN: ADIHLIP24097V012324

 Business Source Channel: No
Intermediary Details
Intermediary Name HDFC Bank - Virtual Sales Kolkata
Intermediary Code 2113026
Ref Code 1 L3209
Ref Code 2 NA
SP Code (For Corporate Agency channel only) NA
RM/LG/Ref Code (For Corporate Agency channel only) No
Sales Manager Name (for All Channels) Bimal Gupta
Sales Manager Code (For All Channels) 271354
ABHI Branch Details (to be filled for all channels)
Intermediary Branch Name West Bengal - Kolkata
Intermediary Branch Code NA

I, HDFC Bank - Virtual Sales Kolkata in my capacity as an Insurance Advisor/ Specified Person of the Corporate Agent/Authorised employee of the
Broker/Relationship Officer, do hereby declare that I have explained all the contents of this Proposal Form and verified photograph of proposer,
including the nature of the questions contained in this Proposal Form to the Proposer and that any details sought herein will form the basis of the
Contract of Insurance between the Company and the Proposer,. I have further explained that if any untrue statement(s)/ information/response(s) is/are
contained in this Proposal Form/including addendum(s), affidavits, statements, submissions, furnished/to be furnished, or if there has been a
non-disclosure of any material fact, the policy issued in his/her favor pursuant to this Proposal may be treated as null and void by the Company and all
premiums paid under the Policy may be forfeited to the company. I confirm that the proposal form is filled accurately by the customer to the best of
my knowledge.

Date: 18/03/2026

Signature of Agent
(Insurance Advisor Signed date cannot be prior to Customer’s Signed date)

Section 41 of Insurance Act 1938 (Prohibition of rebates):

1)No person shall allow or offer to allow, either directly or indirectly, as an inducement to any person to take out or renew or continue an insurance in respect of
any kind of risk relating to lives or property in India, any rebate of the whole or part of the commission payable or any rebate of premium shown on the policy,
nor shall any person taking out or renewing or continuing a policy accept any rebate, except such rebate as may be allowed in accordance with the prospectus
or tables of the insurers.
2)Any person making default in complying with the provisions of this section shall be liable for a penalty which may extend to ten lakh rupees

Product Name: Activ One, Product UIN: ADIHLIP24097V012324

 1
0
0
Optional Covers: Insured 1

1 Note
1 1. Additional premium shall be applied for opting below Optional Covers
2. For Optional Covers,
0
• In case of family floater, if opted it is applicable for all insured persons on floater basis. Individiual basis (this will depend on nature of optional cover opted)
1
Please tick under Insure.
0 • In case of Individual policy, applicable for the Insured person on individual basis who has chosen the Optional Cover.
0 4. Room Rent Type Options
Yes
1 Shared Accomodation
6. Preferred Provider Network (PPN) Discount
0 Yes
No
0
0
0
0
0
0
0
0
0

0
0
0
0

Acknowledgement (this is perforated section, to be placed & created accordingly)

Application Number : QSP_250005804847

We acknowledge with thanks the receipt of your application and amount by Cash/Cheque/Demand Draft/ Others Online Payment of amount of INR 11806 dated
18/03/2026 drawn on 18-03-2026 Neither the submission to Us of a completed proposal for insurance nor any payment for any policy sought obliges Us to agree to
issue a policy, which decision is and always shall be in our sole and absolute [Link] We accept a proposal for insurance, it shall be subject to the policy terms
and conditions and We shall have no liability whatsoever if premium is not received by Us in full and in time or is not realized. If We do not accept the proposal, We
will inform you and refund the payment, post deduction of applicable pre-policy check up charges if any,received from you without interest.‘We do not have any
liability of claim until the proposal is accepted by us, counter offer if any accepted by you & policy is issued
Name of the Branch Official : Kolkata Signature of Branch Official : Date: 18/03/2026

Product Name: Activ One, Product UIN: ADIHLIP24097V012324

 Activ One MAX
CUSTOMER INFORMATION SHEET /
KNOW YOUR POLICY
This document provides key information about your policy. You are also advised to go through your policy document.

POLICY CLAUSE
SR. No. TITLE DESCRIPTION
NUMBER
01. Product Name Activ One MAX
02. Policy Number 31-25-0590913-00

Type of Insurance Both Indemnity and Benefit

03.
Product/Policy
04. Sum Insured (Basis) Individual Sum insured – Each member has separate sum
(Along with amount) Insured under the policy
Floater Sum Insured-where all member under the policy have a
single sum insured limit which may be utilized by any or all
members

Insured Person Individual Sum Insured

Arka Som 1000000

Individual
05. Policy Coverage I. Basic covers
(What the policy
1. Hospitalization Treatment C.1
covers?)
2. Pre-Hospitalization Expenses C.2
3. Post-Hospitalization Expenses C.3
4. Claim Protect (Non-Medical Expense Waiver) C.4
5. Domiciliary Hospitalization C.5
6. Home Health Care C.6
7. AYUSH Treatment C.7
8. Organ Donor Expenses C.8
9. Annual Health Check-up C.9
10. Super Reload C.10
11. Super Credit C.11
12. Health Management Program C. 12
II. Optional Covers: (Available if opted by paying C.13
additional premium)
13. Reduction in Specific Disease waiting period C.13.1
14. Reduction in Pre-Existing Disease waiting period C.13.2
15. Room Rent Type Options C.13.3
16. Per Claim Deductible C.13.4
17. Preferred Provider Network (PPN) Discount C.13.5
18. Critical Illness cover C.13.6

Product Name: Activ One, Product UIN: ADIHLIP24097V012324

 19. Personal Accident Cover (AD+PTD+PPD) C.13.7
20. Chronic Care (Day 1 In-patient Hospitalization) C.13.8
21. Chronic Management Program (OPD) C.13.9
22. Cancer Booster C.13.10
23. Durable Medical Equipment Cover C.13.11
24. Compassionate Visit C.13.12
25. Second Medical Opinion for listed Major Illness C.13.13
26. Annual Screening Package for Cancer Diagnosed Patients C.13.14
III. Optional Add-ons: (Available if opted by paying
additional premium) – Please refer to Policy Schedule

06. Exclusions Standard Exclusion: D.1.4 to D.1.18

(What the policy 1. Investigation & Evaluation (Code- Excl04)
does not cover) 2. Rest Cure, rehabilitation and respite care (Code- Excl05)
3. Obesity/ Weight Control (Code- Excl06)
4. Change-of-Gender treatments: (Code- Excl07)
5. Cosmetic or plastic Surgery: (Code- Excl08)
6. Hazardous or Adventure sports: (Code- Excl09) -.
7. Breach of law: (Code- Excl10)
8. Excluded Providers: (Code- Excl11)
9. Treatment for, Alcoholism, drug or substance abuse
or any addictive condition and consequences thereof.
(Code- Excl12).
10. Treatments received in heath hydros, nature cure clinics,
spas or similar establishments or private beds registered
as a nursing home attached to such establishments or
where admission is arranged wholly or partly for
domestic reasons. (Code- Excl13)
11. Dietary supplements and substances that can be
purchased without prescription, including but not l
imited to Vitamins, minerals and organic substances
unless prescribed by a medical practitioner as part of
hospitalization claim or day care procedure (Code- Excl14)
12. Refractive Error:(Code- Excl15)
13. Unproven Treatments:(Code- Excl16)
14. Sterility and Infertility: (Code- Excl17)
15. Maternity Expenses (Code - Excl18)

Specific Exclusions: D.2.1 to D.2.8

1. Circumstantial Exclusion
2. Behavioural Exclusions
3. Medical Exclusions
4. Prosthesis and Devices
5. Non-Medical expenses
6. Specific treatment Exclusion
7. Activities and Profession Exclusions
8. Geographical Exclusion

Product Name: Activ One, Product UIN: ADIHLIP24097V012324

07. Waiting • Initial waiting Period: 30 days for all illnesses (except D.1.3
period accident) in the first year and is not applicable in
subsequent renewals and policies accepted under
• Time period Portability
during which • For Personal Accident Cover (AD,PTD), no initial waiting
specified disease / period applicable.
treatment is not • For Critical Illness Cover, We shall not be liable to make C.13.6
covered any payment in respect of any Critical Illness whose signs
or symptoms first occur within 60 days from the Inception
• It is counted Date of cover.
from the beginning • Specific Waiting periods (Not applicable for claims arising D.1.2
of the policy due to an accident): 24 months for listed diseases/
coverage procedures
• Pre-Existing Diseases: Covered after 36 months D.1.1
Note: Waiting Periods in force for Insured Persons shall
be as per the plan opted or option selected

08. Financial limits of

coverage

i) Sub-limit (It is a Nil

pre-defined limit
and We will not pay
any amount in
excess of this limit)
ii) Co-payment (It Nil
is a specified
amount /
percentage of the
admissible claim
amount to be
paid by Insured)
iii) Deductible Nil
(It is a specified
amount: - up to
which an insurance
company will not
pay any claim, and -
which will be
deducted from
total claim amount
(if claim amount is
more than the
specified amount)
iv) Any other limit Nil

Product Name: Activ One, Product UIN: ADIHLIP24097V012324

09. Claims / Claims a. For Cashless Service: E.2.7
Procedure Kindly contact us 48 hrs prior for planned
hospitalisation or within 24 hours of
hospitalisation in case of emergency
hospitalisation.

Link for Hospital Network details:

[Link]
healthinsurance/locate-care/hospital-listing

b. For Reimbursement of Claim: E.2.7

Type of claim Prescribed Time Limit
Reimbursement of Within 30 days of
Hospitalization, Day Care date of discharge
Treatment or Pre from Hospital.
Hospitalization Expenses

Reimbursement of Post Within 15 days from

Hospitalization Expenses completion of post
Hospitalization
treatment.

c. For Personal Accident and Critical Illnessbenefits E.2.7.2

• We shall be given an intimation of the claim within 7
days from the date of Accident or diagnosis of the
critical illness or admission in the Hospital.
• The claims documents must be provided to Us within
30 days of occurrence of the event.

10. Policy Servicing ln case of any Policy Services the insured person may contact
the
• Website:
[Link]
• Toll- Free: 1800 270 7000
• E-mail: [Link]@[Link]
(Senior citizens may write to us at:
[Link]@[Link])
• In case you are not satisfied with the resolution you may
write to Head – Customer Care :
[Link]@[Link]
• Courier: Write to Us at below address
Unit no 1101 & 1104 11th floor, Unit no 1501 & 1502 15th
floor, G Corp Tech Park, Kasarwadavali, Ghodbunder
Road, Thane West - 400601

11. Grievances / ln case of any grievance the insured person may contact the E.1.8
Complaints • Website:
[Link]
• Toll- Free: 1800 270 7000
• E-mail: [Link]@[Link]
(Senior citizens may write to us at:
[Link]@[Link])
• In case you are not satisfied with the resolution you may
write to Head – Customer Care :
[Link]@[Link]

Product Name: Activ One, Product UIN: ADIHLIP24097V012324

 • Courier: Write to Us at below address
• Unit no 1101 & 1104 11th floor, Unit no 1501 & 1502 15th
floor, G Corp Tech Park, Kasarwadavali, Ghodbunder
Road,Thane West – 400601
lnsured person may also approach the grievance cell at
any of the company's branches with the details of
grievance.

If lnsured person is not satisfied with the Redressal of

grievance through one of the above methods, insured
person may contact the grievance officer at:
[Link]@[Link]

If Insured Person is not satisfied with the Redressal of

grievance through above methods, the Insured Person
may also approach the office of Insurance Ombudsman of
the respective area/region for Redressal of grievance as
per Insurance Ombudsman Rules 2017 (at the addresses
given in Annexure II of Policy terms and conditions).
Grievance may also be lodged at IRDAI Integrated
Grievance Management System-
[Link]

12. Things to a. Free Look period: The Free Look Period shall be applicable E.1.1
remember on new individual health insurance policies, except for
those policies with tenure of less than a year. Free-look
shall not be applicable on renewals or at the time of
porting / migrating the policy. The Insured Person shall be
allowed Free Look Period of thirty days from date of
receipt of the policy document, whether received
electronically or otherwise, to review the terms and
conditions of the policy, and to return the same if not
acceptable. A request received by insurer for cancellation
of the policy during free look period shall be processed
and premium shall be refunded within 7 days of receipt of
such request.

b. Policy Renewal: The policy shall ordinarily be renewable E.1.3

except on grounds of fraud, moral hazard,
misrepresentation by the insured person. Renewal shall
not be denied on the ground that the insured had made a
claim or claims in the preceding policy years.

c. Migration and Portability: The Insured Person will have E.1.12 & 13
the option to migrate the Policy to other health insurance
products / plans, offered by the Company or to port the
Policy to other insurers

Process for migration:

The Insured Person will have the option to migrate the
Policy to other health insurance products/plans offered
by the Company by applying for Migration of the policy
atleast 30 days before the policy renewal date as per
IRDAI guidelines on Migration.

Process for portability:

The Insured Person will have the option to port the Policy
to other insurers by applying to such Insurer to port the

Product Name: Activ One, Product UIN: ADIHLIP24097V012324

 entire policy along with all the members of the family, if
any, at least 30 days before, but not earlier than 60 days
from the policy renewal date as per IRDAI guidelines
related to Portability

In case the Insured Person wants to migrate or Port their

Health Insurance Policy, then contact Us with the details
through: E-mail ID:
[Link]@[Link]
Toll Free: 1800 270 7000
Address: Any of Our Branch office or Corporate office

d. Changes to Sum Insured on Renewal: You may opt for E.2.5.C

enhancement of Sum Insured at the time of Renewal,
subject to underwriting. All Waiting Periods as defined
in the Policy shall apply afresh for this enhanced limit
from the effective date of such enhancement.

e. Moratorium Period: After completion of sixty continuous E.1.10

months of coverage (including portability and migration)
in health insurance policy, no policy and claim shall be
contestable by the insurer on grounds of non-disclosure,
misrepresentation, except on grounds of established
fraud This period of sixty continuous months is called as
moratorium period. The moratorium would be applicable
for the sums insured of the first Policy. Wherever, the
sum insured is enhanced, completion of sixty continuous
months would be applicable from the date of
enhancement of sums insured only on the enhanced
limits. The accrued credits gained under the ported and
migrated policies shall be counted for the purpose of
calculating the Moratorium period.

13. Insured’s a. The Policy shall be void and all premium paid thereon E.1.14
Obligations shall be forfeited to the Company in the event of
misrepresentation, mis-description or non-disclosure
of any material fact by the policyholder.
b. During the Policy Term any material information
changes on Occupation and/ or Medical Conditions
shall be communicated to Us in a Change Request Form.
This form can be downloaded from Our website or
collected from Our branch office or can also be
obtained by contacting Us over the telephone.

Please refer Policy Schedule for the applicable benefits

Product Name: Activ One, Product UIN: ADIHLIP24097V012324

72

Declaration by the Policy Holder:

I have read the above and confirm having noted the details.

Arka Som authenticated via OTP for QSP_250005804847

Place : Goghat
On null at 00:00:01
Date :18-MAR-26

(Signature of the Policy Holder)

LEGAL DISCLAIMER NOTE:

The information must be read in conjunction with the product brochure and policy document. In case of any conflict between the
CIS and the policy document, the terms and conditions mentioned in the policy document shall prevail.

Please refer below link for Product related documents

Aditya Birla Health Insurance Download ([Link])
 Health Booster
CUSTOMER INFORMATION SHEET /
KNOW YOUR POLICY
This document provides key information about your policy. You are also advised to go through your policy document.

DESCRIPTION (Please refer to applicable Policy Clause Number in POLICY CLAUSE

SI. No. TITLE
next column) NUMBER
Name of Insurance Health Booster
01.
Product/Policy
02. Policy Number 31-25-0590913-00

Type of Insurance Indemnity basis

03.
Product/Policy
04. Sum Insured (Basis) Individual Sum insured – Each member has separate sum
(Along with amount) Insured under the policy
Floater Sum Insured-where all member under the policy have a
single sum insured limit which may be utilized by any or all
members

In Insured Person Individual Sum Insured

di As per Policy Schedule
 05. Policy Coverage (1) Sub-Limits Section
(What the policy On availing this option, if an Insured Person is Hospitalized during C.1
covers?) the Policy Period for any of the Specified Illnesses or Conditions
specified in Policy Schedule/Policy Schedule, then it is agreed that
our maximum cumulative liability for treatment of all ailments/
procedures listed in each section and made under the Policy year
will be limited to the amount as per the opted category as specified
against the applicable Benefit in the Policy Schedule of this Policy.

Category
Sub-limits
A B C (not applicable
for Zone 3 - if Base Policy
have zonal pricing)

Treatment of Cataract Up to INR 20,000 per eye Up to INR 20,000 per eye Up to INR 30,000 per eye

Treatment of Total Knee Replacement and Up to INR 70,000 per Up to INR 80,000 Up to INR 1,20,000
Treatment of Total Hip Replacement knee / per hip per knee/per hip per knee/per hip

Cumulative liability for treatment of all ailments/

procedures listed below:-
i. Surgery for treatment of all Up to INR 50,000/ Up to INR 75,000/ Up to INR 1,00,000/
types of Hernia Policy year Policy year Policy year
ii. Hysterectomy
iii. Surgeries for Benign Prostate
Hypertrophy (BPH)
iv. Treatment of all Renal Disorders
and complications

Cumulative liability for treatment of all ailments/ Up to INR 1,50,000/ Up to INR 2,25,000/ Up to INR 3,00,000/
procedures listed below:- Policy year Policy year Policy year
i. Treatment of Cerebrovascular
and Cardiovascular disorders
ii. Treatments/Surgeries for Cancer
iii. Treatment for breakage of bones

Product Name: Health Booster, Product UIN: ADIHLIA25035V012425.

(2) Co-Payment C.2
On availing this option, pre-determined percentage of Co-Payment
as opted and specified in the Policy Schedule, shall be applied on
each and every admissible claim under the Base Policy or this
Policy. Once the Co-Payment option is availed by the Insured
Person, it cannot be opted out of at subsequent Renewal. This
Co-payment will be additive to any other Co-payment in the Base
Policy or this Policy, if applicable

(3) Aggregate Deductible C.3

On availing this option, the Insured Person shall bear an amount
equal to the Aggregate Deductible specified on Policy Schedule
for all admissible claims made by the Insured Person and assessed
by the Company in a Policy Year. The liability of the Company to
pay the admissible claim under that Policy Year will commence only
once the specified Aggregate Deductible has been exhausted.

(4) Waiver of Co-Payment C.4

On availing this option, the Mandatory Co-payment applicable in
Base Policy shall not apply completely or partially on payable
claims under the Base Policy or this Policy as specified in the Policy
Schedule / Product Benefit Table.

(5) Sum Insured Multiplier C.5

On availing this option, Annual Base Sum Insured of the policy is
combined for the entire tenure opted (2 or 3 years). This combined
Base Sum Insured will be available for the entire policy tenure.

(6) Removal of Super Credit C.6

On availing this option, the Insured Person will not receive the
additional percentage of Base Sum Insured under Super Credit
benefit (if applicable) that is available under the Base Policy.

(7) Modification of Super Reload C.7

On availing this option and if the Base Sum Insured along with
accumulated Super Credit (if applicable) for the Policy Year in
respect of the Insured Person, is completely exhausted or is
insufficient for covering a claim, the Super Reload Benefit in the
Base Policy will be available only once during the policy year as
specified in the Policy Schedule/Product Benefit Table of this Policy.

(8) Unlimited Care C.8

On availing this option, Insured person will get coverage for the
Medical Expenses incurred in respect of Hospitalization under
In-Patient Treatment / AYUSH Treatment for any one claim during
the lifetime of the Policy without any limits on the Base Sum Insured

(9) Air Ambulance (Domestic) C.9

On availing this option, if an Insured Person requires emergency
care that necessitates immediate and rapid transportation via
airplane or helicopter, which ground transportation cannot provide,
the Company shall cover expenses incurred for ambulance
transportation from the site of the first occurrence of the illness or
accident to the nearest hospital during the policy year.

Product Name: Health Booster, Product UIN: ADIHLIA25035V012425.

 (10) Maternity Cover C.10
On availing this option, Insured Person will get a lump-sum amount
as Maternity Expenses as specified in the Policy Schedule / Product
Benefit Table.

(11) Maternity Care C.11

On availing this option, the Insured Person may avail wellness
services through empanelled service provider as mentioned in the
Policy Schedule / Product Benefit Table.

(12) NRI Discount C.12

On availing this option, if the Insured Person qualifies as an NRI as
per below mentioned condition (i) then the Insured Person will be
entitled for a pre-defined discount as specified in the Policy
Schedule.
I. An NRI or Non-Resident Indian is an Indian Citizen living outside
India for a minimum of 183 days in 1 financial year for the
purpose of employment, business, or vocation (occupation for
which an individual is trained).
II. Insured will have to make a declaration at the time of opting this
optional cover every year to avail the discount.
III. For Insured who have been offered NRI discount in a particular
policy year and at policy renewal makes further declaration of
his stay abroad for the forthcoming year the applicable NRI
discount would be offered on the renewal premium. If the
Insured would be based in India then no discount would be
applicable upon renewal.

06. Exclusions Permanent Exclusions Section D

(what the policy does As per the Exclusions mentioned in Base Policy and Health Booster
not cover)
terms and conditions

07. Waiting period There's no waiting period for the mentioned Add-on covers, except for Section D
the Maternity Cover, where the waiting period applies according to
Section Maternity Cover. However, this Policy shall follow waiting
periods applicable in Base Policy unless otherwise stated and covered
in Section C of this policy terms and conditions

08. Financial limits of

coverage

(i)Sub-limit (It is a As per Base Policy and Health Booster’s terms and conditions.
pre-defined limit, and
We will not pay any
amount in excess of
this limit

(ii)Co-payment (It is As per Base Policy and Health Booster’s terms and conditions.
a specified amount /
percentage of the
admissible claim
amount to be paid
by Insured)

(iii)Deductible As per Base Policy and Health Booster’s terms and conditions.

(iv)Any other limit As per Base Policy and Health Booster’s terms and conditions.

09. Claims / Claims All claims must be made in accordance with the procedure set out in Base Section F
Procedure
Policy unless otherwise stated and covered in Section C of the policy
terms and conditions

Product Name: Health Booster, Product UIN: ADIHLIA25035V012425.

10. Policy Servicing As per Base Policy E.1.16

11. Grievances/ As per Base Policy E.1.16

Complaints

12. Things to remember 1) Free Look period E.1.15

a. The Free Look Period shall be applicable on new individual health
insurance policies, except for those policies with tenure of less
than a year. Free-look is not applicable on renewals or at the time
of porting / migrating the policy.
b. The Insured Person shall be allowed free look period of thirty
days from date of receipt of the policy document, whether
received electronically or otherwise, to review the terms and
conditions of the policy, and to return the same if not acceptable.
c. lf the insured has not made any claim during the Free Look
Period, the insured shall be entitled to:
i. Refund of the premium paid, less any expenses incurred by
the Company on medical examination of the Insured Person,
if any and stamp duty charges or
ii. Where the risk has already commenced and the option of
return of the policy is exercised by the Insured Person, a
deduction towards the proportionate risk premium for period
of cover, any expenses incurred by the Company on medical
examination of the Insured Person, if any and stamp duty
charges or
iii. Where only a part of the insurance coverage has
commenced, such proportionate premium commensurate
with the insurance coverage during such period, any
expenses incurred by the Company on medical examination
of the Insured Person, if any and stamp duty charges.
iv. A request received by insurer for cancellation of the policy
during free look period shall be processed and premium
shall be refunded within 7 days of receipt of such request

2) Renewability E. 1.10
a. The Policy shall ordinarily be renewable provided the product is
not withdrawn, except on grounds of established fraud or
non-disclosure or misrepresentation by the Insured Person.
b. The Company shall endeavor to give notice for renewal.
However, the Company is not under obligation to give any
notice for renewal.
c. Renewal shall not be denied on the ground that the Insured
Person had made a claim or claims in the preceding Policy Years.
d. Request for renewal along with requisite premium shall be
received by the Company before the end of the Policy Period.
e. At the end of the Policy Period, the policy shall terminate and
can be renewed within the Grace Period of fifteen days where
premium payment mode is monthly and thirty days in all other
cases. to maintain continuity of benefits without break in policy.
Coverage is not available during the grace period.
f. No loading shall apply on renewals based on individual
claims experience
g. An Insurer shall not resort to fresh underwriting unless there is
an increase in sum insured. In case increase in sum insured is
requested by the policyholder, the Insurer may underwrite only
to the extent of increased sum insured.

Product Name: Health Booster, Product UIN: ADIHLIA25035V012425.

 3) Portability E.1.9
The Insured Person will have the option to port the Policy to other
insurers by applying to such Insurer to port the entire policy along
with all the members of the family, if any, at least 45 days before,
but not earlier than 60 days from the policy renewal date as per
IRDAI guidelines related to Portability. If such person is presently
covered and has been continuously covered without any lapses
under any health insurance policy (individual or group policy) with
an Indian General/Health insurer, the proposed Insured Person is
entitled to transfer the credits gained to the extent of the Sum
Insured, No Claim Bonus, specific waiting periods, waiting period
for pre-existing disease, Moratorium period etc from the Existing
Insurer to the Acquiring Insurer in the previous policy.

4) Migration E.1.8
The Insured Person (including all members under family cover and
group insurance policies)
will have the option to migrate the Policy to an alternative health
insurance product/ plans, offered by the Company policy, to the
extent of the sum insured and the benefits available in the previous
policy by applying for migration of the policy at least 30 days
before the policy renewal date as per IRDAI guidelines on Migration.
If such person is presently covered and has been continuously
covered without any lapses under any health insurance product /
plan offered by the Company, the Insured Person can transfer the
credits gained to the extent of the Sum Insured, No Claim Bonus,
Specific Waiting periods, waiting period for pre-existing diseases,
Moratorium period etc. in the previous policy to the migrated policy.

5) Moratorium Period E.1.12

After completion of sixty continuous months of coverage (including
portability and migration) in health insurance policy, no policy and
claim shall be contestable by the insurer on grounds of non-
disclosure, misrepresentation, except on grounds of established
fraud. This period of sixty continuous months is called as
moratorium period. The moratorium would be applicable for the
sums insured of the first policy. Wherever, the sum insured is
enhanced, completion of sixty continuous months would be
applicable from the date of enhancement of sums insured only
on the enhanced limits. The accrued credits gained under the
ported and migrated policies shall be counted for the purpose of
calculating the Moratorium period.

13. Insured’s Obligations 1) The policy shall be void and all premium paid thereon shall be E.1. 1
forfeited to the Company in the event of misrepresentation,
mis-description or non-disclosure of any material fact by
the policyholder.
2) During the Policy term any material information changes on
occupation and/ or medical conditions shall be communicated
to Us in a Change Request form. This form can be downloaded
from Our website or collected from Our branch office or can
also be obtained by contacting Us over the telephone.

Benefits and exclusion are applicable as per the plan chosen. Please refer Policy Schedule for the applicable benefits

Product Name: Health Booster, Product UIN: ADIHLIA25035V012425.

72

Declaration by the Policy Holder:

I have read the above and confirm having noted the details.

Arka Som authenticated via OTP for QSP_250005804847

Place : Goghat
On null at 00:00:01
Date :18-MAR-26

(Signature of the Policy Holder)

LEGAL DISCLAIMER NOTE:

The information must be read in conjunction with the product brochure and policy document. In case of any conflict between the
CIS and the policy document, the terms and conditions mentioned in the policy document shall prevail.

Please refer below link for Product related documents

Aditya Birla Health Insurance Download ([Link])

Product Name: Health Booster, Product UIN: ADIHLIA25035V012425