31-25-0411350-00

VAISHNAVI V PANDITH
71,46-45, 6th Cross Road, 3rd Stage
4th Block, Shakti Ganapathi Nagar, Basaweshwar Nagar
NA Bengaluru
KARNATAKA
INDIA
560079
9731182158

24/12/2025
Empowering people

Dear VAISHNAVI V PANDITH,

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 - NXT

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
Warm regards,

Cashless Home
Mayank Bathwal Healthcare
Chief Executive Officer Coverage
Aditya Birla Health Insurance Co. Limited.

Super Reload: 2x Cover

From day 1 and unlimited refill
POLICY NUMBER: 31-25-0411350-00
up to 100% Sum Insured
Name Membership No DOB from 2nd Claim onwards
Venkatramana Pandith PT43277657 22/Sep/1959
Introducing The Activ Health

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 NXT
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
10th Floor, R Tech Park Goregaon
Policy Issuing Office Tech Park, Kasarwadavali, Policy Servicing Office
Mumbai MAHARASHTRA 400063
Ghodbunder Road, Thane
West-400615
POLICYBAZAAR INSURANCE
Intermediary Name Intermediary Code 5100357
BROKERS PRIVATE LIMITED
Intermediary Contact Details 18002585970 Intermediary E-mail ID adityabirla@[Link]
Toll Free Number 18002707000

Policyholder Name VAISHNAVI V PANDITH

71,46-45, 6th Cross Road, 3rd Stage 4th Block, Shakti Ganapathi Nagar, Basaweshwar Nagar
Policyholder Address
Bengaluru, 560079, Bangalore, KARNATAKA
Contact Number 9731182158
Email Id vaXXXXXXXXXXXXth@[Link]
GSTIN NA

Product Name Activ One

Plan NXT
Policy Number 31-25-0411350-00
First Policy Start date 24/12/2025
Start Date of Policy & Time 00:00 hrs on 24/12/2025 Expiry Date & Time of Policy 23:59 hrs on 23/12/2028
Policy Type Individual Policy Tenure 3 Years
Enrollment for Automatic renewal
Policy Category Portability NO
premium payment facility
Mode of Premium payment Single
Refer Section V. Previous Insurer
Portability/Migration Yes Previous Policy Number
Details
GSTIN NA GSTIN Account Type NA
Portability

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)
Diabetes
Mellitus - E11
-0
,Hypertension
(High Blood
Pressure) -
Venkatramana Pandith NA Father PT43277657 66 Male 22/09/1959 24/12/2025
I10 - 0
,Carbuncle -
L0293 -
,Thyroid
disorder -
E079 -
Continued and to be read in conjunction of the table above

Product Name: Activ One, Product UIN: ADIHLIP24097V012324

 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.
For applicability of Waiting period on Base Sum Insured please refer Section V - Previous policy details

0 0
1 1 Name of Insured Person Claim Protect (Non-Medical Expense Waiver) Room Rent Type Options
Non-payable items will be covered (all 4 lists of
0 0 Venkatramana Pandith
Annexure I)
Single Private Room

0 0 Super Credit (increases irrespective of claim)

100% of Base Sum Insured per year, up to 500% of Base Sum
1 0 Insured (up to Max of 3 Cr under this benefit)

0 0

1 0 Durable equipment cover

A combined Sum Insured of INR 5 Lacs or up to Base Sum
0 0 0 Insured, whichever is lower

Waiting Period from Start Date of Chronic Management Program

Name of the Insured Person Chronic Condition
Start Date of First Policy Coverage Applicability
Refer Section V.
Refer Section V.
Venkatramana Pandith No Previous Insurer No
Previous Insurer Details
Details

Name of the Insured Person Special Condition (if applicable)

Venkatramana Pandith No

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

Diabetes Mellitus - E11 - 0 ,Hypertension (High Blood Pressure) - I10 - 0 ,Carbuncle - L0293 - ,Thyroid
Venkatramana Pandith
disorder - E079 -

HealthReturnsTM (Applicable for Renewal Policy)

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

Venkatramana Pandith 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

Venkatramana Pandith Father 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.

Yes

Product Name: Activ One, Product UIN: ADIHLIP24097V012324

 Total Ported Sum
Insured (Sum
Date of first Previous Policy Type of Waiting period
Name of Insured Person Previous Insurer Insured +
enrollment Number Cover waived off
Cumulative
Bonus)
No waiting
period for SI
Aditya Birla Health Insurance Co. 31-25-0411350-0 600000;0
Venkatramana Pandith 24-12-2025 Individual 1000000
Ltd. 0 Months waived
off on SI
400000;
ICICI LOMBARD GENERAL 4177i/ISECA/2741
Venkatramana Pandith 24-12-2022 Floater NA NA
INSURANCE CO. LTD. 35816/02/000

Product Name: Activ One, Product UIN: ADIHLIP24097V012324

 Product Name Activ One
Plan Variant NXT
Base Sum Insured Refer Base Sum Insured column under Insured
Basic Covers Hospitalization Room Rent Single Private Room
Treatment ICU Charges Actuals up to Sum Insured
Road Ambulance Cover (per hospitalization) Actuals up to Sum Insured
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
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
Super Reload 2X Cover Covered from Day 1
Unlimited Refill [2nd Claim onwards - 2nd Claim Onwards - unlimited times (up to Base
Unlimited Times (upto Base Sum Insured)] Sum Insured)
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)

143498.28 0 0 20807.25 0 0 0 0 122691.00

GST Registration No: 27AANCA4062G1ZN 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. MH001265008202526E & 25/04/2025

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

Date : 24/12/2025

Location : Mumbai
Authorized Signatory

Product Name: Activ One, Product UIN: ADIHLIP24097V012324

 Premium Certificate
We confirm the receipt of premium amount of INR 122691.00 as per below details paid by Mrs. VAISHNAVI V PANDITH for Self and/or Family
and/or Parents:

Policy Number: 31-25-0411350-00 Plan Name: NXT

Type of Plan: Individual Proposer Name: VAISHNAVI V PANDITH

Policy Start Date: 00:00 hrs on 24/12/2025 Policy End Date: 23:59 hrs on 23/12/2028

Premium Details:

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

11-12-2025 122691.03 0 0 0 122691.00 122691

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 40,897.00
2026-27 40,897.00
2027-28 40,897.00

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 : 24/12/2025

Place : Mumbai
Authorized Signatory

Product Name: Activ One, Product UIN: ADIHLIP24097V012324

POLICY NO. 31-25-0411350-00
Name Membership No. DOB
Venkatramana Pandith PT43277657 22/Sep/1959
 Activ One NXT
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 NXT
02. Policy Number 31-25-0411350-00

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

Venkatramana Pandith 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. Domiciliary Hospitalization C.4
5. Home Health Care C.5
6. AYUSH Treatment C.6
7. Organ Donor Expenses C.7
8. Super Reload C.8
9. Health Management Program (In-built) C. 9
II. Optional Covers: (Available if opted by paying additional C.10
premium)
10. Reduction in Specific Disease waiting period C.10.1
11. Reduction in Pre-Existing Disease waiting period C.10.2
12. Claims Protect (Non-Medical Expense Waiver) C.10.3
13. Room Rent Type Options C.10.4
14. Per Claim Deductible C.10.5
15. Preferred Provider Network (PPN) Discount C.10.6
16. Critical Illness cover C.10.7
17. Personal Accident Cover(AD+ PTD+PPD) C.10.8
18. Super Credit C.10.9

Product Name: Activ One, Product UIN: ADIHLIP24097V012324

 19 Chronic Care (Day 1 In-patient Hospitalization) C.10.10
20. Chronic Management Program (OPD) C.10.11
21. Cancer Booster C.10.12
22. Durable Medical Equipment Cover C.10.13
23. Compassionate Visit C.10.14
24. Second Medical Opinion for listed Major Illness C.10.15
25. Annual Screening Package for Cancer Diagnosed Patients C.10.16
26. Annual Health Check-up C.10.17
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
limited 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 period 1. Initial waiting Period: 30 days for all illnesses (except D.1.3
• Time period accident) in the first year and is not applicable in
during which subsequent renewals and policies accepted under
specified disease / Portability
treatment is not 2. For Personal Accident Cover (AD,PTD), no initial waiting C.10.6
covered period applicable.
3. For Critical Illness Cover, We shall not be liable to make
• It is counted from any payment in respect of any Critical Illness whose
the beginning of signs or symptoms first occur within 60 days from the
the policy coverage Inception Date of cover.
4. Specific Waiting periods (Not applicable for claims D.1.2
arising due to an accident): 24 months for listed
diseases/procedures
5. 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]
locate-care/hospital-listing

b. For Reimbursement of Claim: E.2.7

Type of claim Prescribed Time Limit

Reimbursement of Within 30 days of date of
Hospitalization, Day Care discharge from Hospital.
Treatment or Pre
Hospitalization Expenses
Reimbursement of Post Within 15 days from completion
Hospitalization Expenses of post Hospitalization treatment.

c. For Personal Accident and Critical Illness benefits 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.

ln case of any Policy Services the insured person may

10. Policy Servicing
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]
• 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.

Product Name: Activ One, Product UIN: ADIHLIP24097V012324

 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: E.1.1

Remember 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 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 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
Product Name: Activ One, Product UIN: ADIHLIP24097V012324
 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 E.1.10

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 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.

Product Name: Activ One, Product UIN: ADIHLIP24097V012324

72

Declaration by the Policy Holder:

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

VAISHNAVI V PANDITH authenticated via OTP for

Place : Bengaluru QE1039906432512
On null at 00:00:01
Date :24-DEC-25

(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])