Aditya Birla Activ Care Standard

Key Features

In-patient Hospitalization

In case of a hospitalization of more than 24 hours due to a planned treatment or an unforeseen emergency, we will cover expenses like room rent, doctor’s fee, operation theatre expenses, medicines, drugs and other consumables under the policy as per your eligibility.

Pre-hospitalization medical expenses

You may incur expenses as per your plan’s eligibility for consultations or diagnostic tests before your hospitalization, such costs will be covered up to 30 days before your hospitalization where a claim under In-patient hospitalisation / Domiciliary hospitalization / day care treatment is accepted.

Post-hospitalization medical expenses

You may incur expenses as per your plan’s eligibility for medicines, diagnostic tests or physiotherapy such costs will be covered up to 60 days after your discharge from the hospital where a claim under In-patient hospitalisation / Domiciliary hospitalization / day care treatment is accepted.

Day care treatment

Due to advancements in medical science, certain medical procedures like a dialysis may not require a 24-hour hospitalization, we will cover you for such 586 procedures as well.

Domiciliary Hospitalization

We will cover your medical expenses as per your plan’s eligibility in case you need to get treated at home, if your health condition did not allow hospital transfer as recommended by a doctor or due to unavailability of a bed at the hospital

Road Ambulance Cover

In case of an emergency, we will cover costs incurred on transportation to a hospital by a road ambulance as per your plan’s eligibility.

Organ Donor Expenses

In case of organ transplants to you, we not only cover you, we also cover the medical expenses of the organ donor for harvesting the organ for your use, as per your plan’s eligibility.

Reload of Sum Insured

In case the sum insured along with no claim bonus (if any) is insufficient as a result of previous claims in that policy year, then you get upto an additional 100% of sum insured as per your plan’s eligibility, for hospitalization due to an illness unrelated to previous claims in that policy year.

AYUSH In-patient hospitalisation

We will pay you as per your plan’s eligibility, for medical expenses incurred by you towards your in-patient hospitalization under AYUSH (Ayurveda, Yoga and Naturopathy, Unani, Siddha, and Homeopathy) treatment.

Home Treatment

We shall cover the treatment expenses at your home for Illnesses such as chemotherapy, dengue, gastroenteritis, hepatitis on a cashless basis as per your plan’s eligibility

Home Treatment : The limit specified in the benefit table is a per Policy Year Limit. Applicable on a floater basis for a floater policy and applicable per life basis for an Individual policy

We do not assume any liability towards any additional or incidental charges/expenses, including but not limited to any charges towards breakage, damage, deposit for equipment, and equipment transportation . All such charges/expenses shall be borne by the Insured Person

The maximum number of days , of covered services per Insured Person, for each Policy Year, covered under this section shall not exceed 15 days.

We do not assume any liability towards, and shall not be responsible for any actual or alleged errors, omissions or representations made by any Medical Practitioner and/or Network Service Provider / Empanelled Service Provider or in any service under this Benefit or for any consequences of actions taken or not taken in reliance thereon.

Home Treatment services are provided through Network Service Provider / Empanelled Service Provider in select cities for select treatment procedures only. Please contact Us or refer to Our website for updated list of treatment procedures and cities where Home Treatment service is provided.

No Claim Bonus

With our policy, you get benefits even if you do not claim. We will provide you with a No Claim Bonus which is 10% of Sum Insured for each year that you do not claim. Whenever there is a claim, No Claim Bonus reduces by the same rate at which it increased, which is 10% of Sum Insured. The Maximum limit for No Claim Bonus is 50% of Sum Insured.

Domestic / International Emergency Assistance Services (Including Air Ambulance)

We travel on work or sometimes to get away from our busy lives and sometimes we may end up going to places that are remote. In such cases where an adequate medical facility is not available and you need medical help, we will help you reach such a medical facility and then take you back to your home.-This service is available in all 3 plans

OPD treatment

We shall cover medically required consultations, visit(s) to a Medical Practitioner who is a qualified doctor and diagnostic tests which are incurred on an out-patient basis on cashless basis as per your plan’s eligibility.

Health Assessment

We provide Health Assessment for each and every insured member once in a policy year on renewal of your policy

Comprehensive Health Check-up

We provide Comprehensive Health Check-up for each and every insured member once in a policy year on renewal of your policy

Reference
CBC - Complete Blood Count
ECG – Electrocardiogram,
Hba1c - glycated haemoglobin test
PSA- Prostate-Specific Antigen

Health Coach

At times when we are suffering from any of the chronic conditions, a coaching session with a specialist may help. We give you a personalized coaching by a medical expert who will guide you through your health journey when you are suffering from Asthma, Hypertension, Hyperlipidemia or Diabetes mellitus. These coaching session shall be provided on telephonic discussion with You to help you become healthier version of yourself

Personal Health Coach

At times when we are suffering from any of the chronic conditions, a coaching session with a specialist may help. We give you a personalized coaching by a medical expert who will guide you through your health journey when you are suffering from Asthma, Hypertension, Hyperlipidemia or Diabetes mellitus. You can also avail Health coaching session for nutritional, medical and wellness counselling. These coaching session shall be provided on telephonic discussion with You to help you become healthier version of yourself.

Difference between Personal Health Coach and Health Coach:

HealthReturnsTM - Available in all 3 Plans

Earn HealthReturnsTM upto 21% of your premium by earning Active Dayz and staying healthy. You can start earning HealthReturnsTM by completing the following steps

• Complete a health assessment which as a result provides you a healthy heart score
• Start exercising to earn Activ Dayz. Active Dayz can be earned through plethora of options like running, walking, yoga and many more
• Earn HealthReturns monthly based on the accumulated Activ DayzTM and your Healthy Heart Score.
• Earn HealthReturnsTM by talking to your Health Coach/Personal Health Coach

Grid:

In order to achieve a particular level of HealthReturns™ the Insured Person must achieve either the required number of Active Dayz™ or achieve a level (as shown in table above) under Fitness Assessment.

The grid above is calculated on the Monthly Premium. The Insured Person can earn up to 20% of their Monthly Premium as HealthReturnsTM based on the grid above.

All Insured Person(s) in the Policy will be credited with an additional 1% HealthReturnsTM annually on successful completion of following conditions

1. Successful completion Health AssessmentTM (in case of Standard Plan)/ Comprehensive Health Check-up(in case of Classic and Premier plan) as specified in the Policy Schedule / Product benefit Table and successful generation of Healthy Heart Score TM.

2. First Successful interaction in a Policy Year with Health Coach / Personal Health Coach as specified in the Policy Schedule / Product benefit Table.

How it works for an Individual Policy

In case of an Individual Policy, each Insured Person would be tracked separately and shall earn HealthReturnsTM based on individual performance as per grid of Healthy Heart ScoreTM and Active DayzTM.

How it works for a Family Floater Policy

In case of a Family Floater Policy, each Insured Person would be tracked separately and shall earn HealthReturnsTM based on individual performance as per grid of Healthy Heart ScoreTM and Active DayzTM. For the purpose of calculating HealthReturnsTM, We will allocate the overall premium to the adults in the Policy. Weightages for allowed family combinations are as described in the table below.

Earned HealthReturns can be utilized by any covered Insured Person under a Policy.

How can one spend HealthReturnsTM:

Funds under HealthReturnsTM may be utilized towards the following expenses:

1. In-patient Medical Expenses and Day Care Treatment, provided that the Sum Insured, No Claim Bonus (if any) and Reloaded Sum Insured (if any) are exhausted during the Policy Year as specified in section C(Y) .

2. Payment of Co-payment (wherever applicable).

3. For non-payable claims, in case of an In-patient Hospitalization or Day Care Treatment.

4. Non-Medical Expenses listed in Annexure I ‘Non-Medical Expenses’ that would not otherwise be payable under the Policy.

5. Out-patient expenses up to the value of accrued funds.

6. Ayush Treatments in excess of the limits as specified in Policy Schedule / Product Benefit Table of this Policy.

Alternatively, funds can also be utilized to pay Renewal Premium. Funds earned as HealthReturnsTM, once earned can be carried forward each month/ each Policy Year (as applicable) and as long as the Policy is Renewed with Us in accordance with the Renewal Terms under the Policy.

Permanent Exclusions and Waiting Periods do not apply under this Benefit.

The claim for accumulated HealthReturnsTM can be made a maximum 4 times in a Policy Year. If You /Insured Person wish to know the present value of the funds earned as HealthReturnsTM, then You may contact Us at our toll free number or through Our website

Second E-Opinion on major Illness- -Available in all 3 Plans

When it comes to detection of a major illnesses such a cancer, kidney failure or heart attack, then a second opinion is always helpful. We understand that and provide you with a second e-opinion through a consortium of well qualified specialists. The service is available once per policy year

Health and Wellness discount- -Available in all 3 Plans

You get discounts on the OPD consultations, Diagnostics and Pharmacy offered through our Network Service Providers and / or Empanelled Service Providers

Optional Care Benefits:

Nursing at Home

We Cover expenses of qualified nurse at home as per written recommendation of your doctor subsequent to hospitalisation.

Nursing at Home : The limit specified in the benefit table is a per Policy Year Limit. Applicable on a floater basis for a floater policy and applicable per life basis for an Individual policy

Lifestyle support equipment

We Cover expenses of Lifestyle support equipment like ICU bed, wheelchair, walker, belts, collars etc as per written recommendation of your doctor subsequent to hospitalisation.

Reference

PAP- Papanicolaou

2D ECHO - Two-Dimensional Echocardiography

TMT – Tread Mill Test

ENT – Ear Nose Throat

OPG - Orthopantomogram

Optional Covers:

Room Upgrade

You have the option to upgrade to a higher category of hospital room as per your plan’s eligibility.

Co-payment

Standard and Classic : 20% co pay for all Inpatient Hospitalisation, Domiciliary, Ayush, Home Treatment and Day care claims

Premier : 10% co pay for all Inpatient Hospitalisation, Domiciliary, Ayush, Home Treatment and Day care claims

In case a Sub-Limit is applicable along with Co-Payment as specified in the Policy Schedule/ Product Benefit Table, the claim payout would be adjudicated in following sequence:

1.1 Step 1: Co-payment would be first applied on the total admissible claim amount.

Step 2: Sub-Limit shall be applied on the amount arrived from the Step 1

Sub limits:

1. Standard Plan : Cataract (per eye): upto Rs 25000

2.

Waiting Period

initial waiting period (not applicable in case of accident and subsequent renewal) : 30 days for all plans

24 months Specific illness waiting period applicable for Classic Plan and Premier Plan
For Standard Plan 24 month specific illness waiting period except 48 month waiting period for Joint Replacement Surgery

Pre - Existing Illness waiting period: 24 months (For all Plans)

​​​​​​​Location present for cashless options in care benefits: