ALL YOU NEED TO KNOW
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Features
Frequently Asked Questions
Yes, we provide you the option to select a Zone higher than that of the applicable Zone as per the city of residence on payment of relevant premium at the time of buying the policy or at the time of renewal.
A dependent child is an unmarried child between the age of 3 months and 18 years, or up to 21 years if in full time education, residing with the insured person.
You need to submit the duly filled claim form and all the necessary claims documents like
- Duly completed Claim Form
- Photo ID & Age Proof
- Original Discharge Card / Day Care Summary / Transfer Summary
- Original final Hospital Bill with all original Deposit & Final Payment Receipt
- Original Invoice with payment receipt & implant stickers for all Implants used during Surgeries I.e. Lens Sticker and Invoice in Cataract Surgery, Stent Invoice and Sticker in Angioplasty Surgery.
- Letter from treating Medical Practitioner stating:
- Present complaints with duration & past history
- Medical history of co-morbidities e.g. Hypertension, Heart ailment etc.
- Treatment detail with name of drugs and route of administration
- All previous consultation papers indicating history and treatment details for current ailment
- All original diagnostic reports (including imaging and laboratory) along with Medical Practitioner’s prescription and invoice / bill with receipt from diagnostic center
- All Original Medicine / Pharmacy Bills along with Medical Practitioner’s prescription
- MLC / FIR Copy – in Accidental Cases Only
- Copy of Death Summary and Copy Death Certificate (in Death Claims Only)
- Letter from treating Medical Practitioner stating – in Accidental Cases Only
- Details of Accident/trauma
- Whether patient was under the influence of alcohol or any intoxicating substance during incident / Accident
- Pre & Post-Operative Imaging reports – in Accidental Cases Only
- Copy of Indoor case papers with nursing sheet detailing medical history of the patient, treatment details, & patient’s progress
- KYC documents
- Additional documents may be required in case of contribution claims and as per coverage under certain covers or as may be required basis the specific claim.
No, medical expense for donor are covered if the organ is for the use of insured person, who is recipient for the organ.
The zones are as below:
Zone I: Bangalore, Gurgaon, Mumbai, Navi Mumbai, New Delhi, Thane
Zone II: Ahmedabad, Kolkata, Noida, Pune, Hyderabad, Chennai, Chandigarh, Mohali
Zone III: Rest of India excluding the locations mentioned under Zone I & Zone II
Under the Chronic Management Program, the Insured Person will be entitled to manage Medical Expenses for out-patient treatment of Diabetes, Hypertension, Hyperlipidemia and Asthma, as specified in the Policy Schedule. The program will cover the following: (i) Medical Practitioner’s consultations; (ii) Diagnostic test; (iii) Pharmacy expenses
No, any claim arising out of an event that occurs in grace period will not be covered. We suggest you to renew your policy on or before expiry date to continue to have an uninterrupted coverage.
In such case, a waiting period as per the opted plan shall be applicable for Chronic Management Program irrespective of your health status. After completion of the applicable waiting Period, if in case you are found to be suffering from a covered chronic condition (through results of Health Assessment™) then, we will activate Chronic Management Program for you.
The list of our network hospital is available on our website www.adityabirlahealth.com. Alternatively, you can also call at our toll free no. 1800 103 1033 to get this information.
Permanent Exclusions and Waiting Periods do not apply under HealthReturns™ Benefit.
Day Care Treatment means medical treatment, and/or surgical procedure which is:
I. Undertaken under General or Local Anaesthesia in a hospital/day care centre in less than 24 hrs because of technological advancement, and
ii. Which would have otherwise required hospitalization of more than 24 hours.
Second E-opinion is available for 11 Critical conditions namely: Cancer of specified severity, Myocardial Infarction, Open chest CABG, Open heart replacement or Repair of heart valves, Coma of specified severity, Kidney failure requiring regular dialysis, Stroke resulting in permanent symptoms, Major organ/ bone marrow transplant, Permanent paralysis of limbs, Motor neuron disease with permanent symptoms, Multiple sclerosis with persisting symptoms.
You can earn HealthReturns™ by way of (subject to plan opted):
• Percentage of Premium earned through Healthy Heart Score™ and Active Dayz™
• Benefit for Hospital Room Choice.
If the Policy is issued on a floater basis, the reload of Sum Insured will be available on a floater basis for all Insured Persons in the family.
The Insured Person shall be managed under the Chronic Management Program as applicable for the particular combination.
There is no co-payment for treatment if hospitalization is availed in lower zone (zone III in your case). For availing treatment in higher zone, a co-payment is applicable. In your case since applicable zone is II and if treatment is availed in Zone I, 10% co-payment will be applicable.
You can avail a 5% discount on covering 2 family members and a 10% on covering 3 or more family members in an Individual Policy type.
The reload of Sum Insured shall not apply to the first claim in the Policy Year unless related to an Injury due to a road traffic accident where the claim amount exceeds the Sum Insured.
Yes, we cover road Ambulance to a Hospital for treatment in an Emergency following an Illness or Injury, subject to limits, terms and conditions applicable as per your plan. Coverage shall also be provided under the below circumstances, if the Medical Practitioner certifies in writing that:
No. Is it important to do Health Assessment as well as Activ Dayz to earn HealthReturnsTM. If a you don’t track your Active DayzTM, the substitute is to take a fitness assessment.
Fitness Assessment is relevant for individuals that don’tgo to the gym or don’t track their steps through wearable devices or for people who do yoga/ swim. Fitness Assessment measures your cardiovascular endurance, flexibility, strength, height to weight ratio and body fat percentage. You can call and book a fitness assessment on our toll free number.
There may be instances where we may deny Cashless facility for Hospitalization due to any of the following reasons:
• insufficient Sum Insured
• insufficient information to determine admissibility
• Or because the treatment is not covered under the policy.
In such cases, you may be required to pay for the treatment and submit the Claim for reimbursement to Us which will be considered subject to the Policy Terms & Conditions.
Co pay means a cost sharing requirement under a health insurance policy that provides that the policyholder/insured will bear a specified percentage of the admissible claims amount. A co-payment does not reduce the Sum Insured.
Yes, health check-up program is available irrespective of claim status.
Yes, the claim is admissible even if treatment is availed in a room category higher than the eligible room category. However, a co-payment will be applicable as per the eligible room category and the room category at which treatment is taken. In your case, the co-payment applicable is 15%.
Fitness assessment is an overall assessment of a person’s physical ability and on a case to case basis, we will decide on the best route to measure their fitness.
All waiting periods, as applicable for your plan, shall apply afresh on the Sum insured to the extent of enhancement over the previous policy Sum insured from the effective date of such enhancement.
We shall settle a claim within 7 days of the receipt of the last necessary information and documentation as stated in Policy wordings.
No you cannot pay extra premium to reduce the Waiting Period.
Yes, the premium paid for health insurance policies qualifies for deduction under Section 80D of the Income Tax Act.
You are entitled to a deduction of up to Rs. 25000 as medical insurance premium paid for yourself, your spouse and children.
In addition to it, if you pay health insurance premium for your parents, you will be entitled to additional deduction of up to Rs. 25,000/- (if parents are not senior citizens) Or up to Rs. 30,000/- (if parents are senior citizens)
If the results of Health Assessment™ indicates that you suffer from any of the aforementioned chronic conditions then you shall be entitled to avail the benefits under the Chronic Management Program, after 24 months of waiting period, provided that the detected chronic condition was not a Pre-Existing Disease, no additional premium shall be required to activate the benefits under the Chronic Management Program.
We may apply a risk loading (additional premium) on the premium payable based on details and declarations on the Proposal Form and the results of the pre-Policy medical examination.
If the Sum Insured under the Policy has been increased at the time of Renewal, the Cumulative Bonus shall be calculated on the Sum Insured of the last completed Policy Year.
Full cost of all such pre policy medical examination tests will be borne by us for all accepted proposals. In case of rejected proposals or where a counter offer is not accepted by the customer, we will bear only 50% of the cost for such tests. In case of declined proposals, costs of the same will be borne by the Customer. We may also ask the member to undergo additional medical tests on a case to case basis; in case of such accepted proposals, full cost of such tests will be borne by us. In case of declined proposals, cost of the same will be borne by the customer.
Zone as per city of residence will be considered. As per our policy, Pune is a Zone II city and Jamshedpur is a Zone III city, so Zone II will be applicable for you. However, if you wish so, you can opt for a higher zone by paying the relevant premium applicable for that zone.
You can send a duly filled claim form along with all other claim documents to our registered office address, Or to your nearest Aditya Birla Health Insurance branch.
You can make a claim by calling our toll-free number 1800-226-226 (MTNL or BSNL) or 1800-2-700-700 (any line) or 022 6638 4800 (local/STD charges apply). We will then assist you with the submission of the documents required and the process will be completed within 7 working days, once all the required documents are submitted.
Yes, you can request for enhancement of Sum insured at the time of renewal. However, the enhancement is subject to underwriting decision and applicability of waiting periods such as first-30 days waiting period, two-years waiting period and pre-existing disease waiting period.
Your health insurance policy is issued on the basis of the Disclosure to information norm, including the information provided by You in respect of the Insured Persons in the Proposal Form and any other details submitted in relation to the Proposal Form.
No, certain diseases like Asthma are specifically excluded under domiciliary hospitalization. However, in-patient hospitalization expenses for Asthma is covered under the Policy.
HA is available for all members (above 18 years). Irrespective of whether it is an individual or family floater policy.
Health Assessment™ is a simple health exam that measures the Insured Person on the parameters of MER (including BP, BMI, HWR and smoking status), Fasting Blood Sugar and Total Cholesterol.
If the Insured Persons in the expiring Policy are covered on an individual basis and there is an accumulated Cumulative Bonus for each Insured Person under the expiring Policy, and such expiring Policy has been Renewed with Us on a Family Floater Policy basis then the Cumulative Bonus to be carried forward for credit in such Renewed Policy shall be the lowest among all the Insured Persons.
This is an annual policy where the premium can be made online via Credit Card, NetBanking or Cheque.
We offer lifetime renewability for this health plan, subject to payment of premium and fulfilment of other policy conditions.
Yes, you will be covered for CMP under this Policy if and when you develop such chronic conditions later.
You can call at the call centre toll free number to book an appointment. When a slots is available relevant communication will be sentwith date, time and venue.
You can contact us to avail Health Check-up at our network providers on cashless basis. You can also claim for reimbursement for defined health check-up tests up to defined limits as per age and plan as per terms and conditions of your policy.
Pre-Existing Disease or PED means any condition, ailment or injury or related condition(s) for which there were signs or symptoms, and / or were diagnosed, and / or for which medical advice / treatment was received within 48 months prior to the first policy issued by the insurer and renewed continuously thereafter.
Any treatment taken during the first 30 days of the commencement of the Policy shall not be covered under the Policy, unless the treatment is required as a result of an Accident that happened after policy start date.
We cover medical expenses that you incur after your discharge from the hospital. The no. of days for which this cover is applicable will be as per the plan chosen by you at the time of buying the policy. Please note such expenses will be covered subject to your hospitalization claim being admissible and subject to other terms and conditions of your policy.
You can download our App’, which can track and show how many Activ Days have been earnedin a month.
Funds under HealthReturns™ may be utilized for: • In-patient Medical Expenses and Day Care Treatment, provided that the Sum Insured, Cumulative Bonus and Reloaded Sum Insured (if applicable) are exhausted during the Policy Year. • Payment of Co-payment (wherever applicable). • For non-payable claims, in case of an In-patient Hospitalization or Day Care Treatment. • Non-Medical expenses, that would not otherwise be payable under the Policy. • Alternative Treatments
You can also utilize funds under HealthReturns™ to pay premium for Renewal of the Policy or to pay premium for adding a new member to a policy from 1st renewal onwards.
You can avail it from day 1 (without any waiting period).
If the Insured Person who has a covered chronic condition, has already undergone tests under Chronic Management Program within three months from date of availing this Benefit, then those specific tests will be covered under the Health Check-up Program in the same Policy Year.
Your Policy is valid for the duration mentioned in your Policy schedule. We offer you an option of buying our health policy for a term of 1 year, 2 years or 3 years. You can renew your policy at the end of the policy term.
To get the benefit under Chronic Management Program, the you must undergo a Health Assessment™ within 3 months from the Start date.
We provide you cashless facility at our Network hospitals. We must be contacted to pre-authorise Cashless Facility for planned treatment at least 72 hours prior to the proposed treatment. For emergency treatment, you must contact us for pre authorization within 24 hours of the Insured Person’s Hospitalization.
You can email us at customercare.abh@adityabirla.com
or You can call our toll free no. 1800 103 1033
or You can visit our website www.healthinsurance.adityabirlahealth.com
or You can visit any of our Branch offices or Corporate office
The following conditions are covered under Chronic Management Program: - Diabetes Mellitus - Hypertension - Hyperlipidaemia - Asthma
Each Insured Person above 18 years of Age on the Start date may avail a comprehensive health check-up in a Policy Year as defined in Policy wordings
Completed claim forms and documents must be furnished to Us within the stipulated timelines. Failure to furnish such evidence within the time required will not invalidate nor reduce any claim if You can satisfy Us that it was not reasonably possible for You to submit / give proof within such time. If there are any deficiencies in the necessary, claim documents which are not met or partially met. We will send a maximum of 3 (three) reminders following which we will either: • send a rejection letter • Or, make a part-payment if we have not received the deficiency documents after 45 days from the date of the initial request for such documents.
Yes, you can include your spouse and up to 2 children in the policy.
In such case, if you eventually get detected with a Chronic condition after 6 months of the Start date of the Policy or after 6 months of the Policy anniversary, then the benefits under Chronic Management Program will be pro-rated to such effect as specified in the Policy Schedule or Endorsement Schedule. You will be intimated about the same.
In case of cashless hospitalization, you will be required to settle all non-admissible expenses, co-payment (if applicable), directly with the Hospital).
In case of reimbursement of claim, admissible claim amount (after adjusting for Co-pay or earned HealthReturns™) will be paid by Us to you.
Please refer to Permanent exclusion section in the policy wordings to know the diseases/ conditions/ treatment that are not covered in this health policy.
The policy can be cancelled with a notice period of 30 days. The premium paid by you will be returned on a pro-rata basis or 25% of the annual premium, whichever is higher will be retained. Any cancellation request sent after 30 days of commencement of the policy will be refunded on a pro-rata basis.
We provide the Emergency medical assistance when an Insured Person is travelling 150 (one hundred and fifty) kilometres or more away from his/her residential address as mentioned in the Policy Schedule for a period of less than 90 (ninety) days. Emergency assistance services are provided for emergency medical evacuation and medical repatriation, subject to terms and conditions in your policy wordings.
As many as 527 listed Day Care procedures are covered under Activ Health policy
We cover medical expenses that you incur before your admission to hospital within the policy period. The number of days for which this cover is applicable will be as per plan chosen by you at the time of buying the policy. Please note such expenses will be covered subject to your hospitalization claim being admissible and subject to other terms and conditions of your policy.
Based on your age and selected Sum insured option and a declared medical condition (if any) we may require you to undergo a medical examination. Medical tests will be facilitated by us and conducted at our network of diagnostic centres.
No, any earned Cumulative Bonus will not be reduced for claims made in the future, unless utilised. If utilized, we will reduce only to the utilized value.
We offer cashless facility at our Network hospitals. For non-network hospitals and claims as per covers like pre and post hospitalization cover, we settle claims on reimbursement basis.
If the Insured Persons in the expiring Policy are covered on a Family Floater Policy basis and such Insured Persons renew their expiring Policy with Us by splitting the Sum Insured in to two or more Family Floater Policies/Individual Policies, then the Cumulative Bonus of the expiring Policy shall be apportioned to such Renewed Policies in the proportion of the Sum Insured of each Renewed Policy.
You should submit all the necessary information and documentation in respect of all claims within 30 days of the Insured Person’s discharge from Hospital. Claims for Pre-hospitalisation Medical Expenses and Post Hospitalisation Medical Expenses should be submitted to us within 30 days of the completion of the post hospitalisation treatment.
You can avail of a long term discount of 7.5% and 10% on selecting a 2 and 3-year policy respectively
Yes, your newly wedded Spouse and new born baby can be added in the Policy during the term of Policy by paying premium as applicable.
Health Assessment and Fitness Assessment are two different benefits which will be done by different service providers. Health Assessment will be done by a diagnostic centres. Fitness Assessment will be done by our network of physiotherapists and physical trainers at gyms.
We provide you a benefit as a percentage of payable hospitalization claims, if treatment is availed at a room category lower than the eligible room category, as per your policy schedule. The benefit percentage is as per the room category and zone. It is defined in the Policy wordings. The benefit is credited as HealthReturns™ in respect of the Insured Person.
In case of Family Floater Policies, children up to 25 years’ age can be covered under floater plan. After that, at the time of Renewal, such children will be considered as an Adult and have to be moved out of the floater into an individual cover, which they can avail on payment of applicable premium. However, continuity benefits in terms of waiting periods for such Insured Person on the Policy will remain intact.
If the Insured Person is Hospitalized during the Policy Period for treatment of an Injury suffered due to an Accident where Hospitalisation continues for at least 10 consecutive days, then We will pay the lump sum amount specified in the Policy Schedule. This Benefit amount will not reduce the Sum Insured.
Yes, If HA is done of 20th Dec, then also Active days completed and tracked from 5th Dec onwards will be used to calculate HealthReturnsTM for the month.
For calculation of Healthy Heart Score™, tests under Health Assessment™ namely - MER (including BP, BMI, HWR and smoking status), Fasting Blood Sugar, Total Cholesterol will have to be carried out at one go (together) and at least once every Policy Year.
No. You can only be covered under individual Sum insured policy if you are suffering from chronic conditions such as Asthma, Diabetes, Hypertension and/or Hyperlipidaemia.
Step 1 – Complete Health questionnaire & Health Assessment™ (applicable for each individual Insured Person)
Step 2 – Comply with Chronic Management program
Step 3 – Earn Active Dayz™ by being physically active on an ongoing basis, or earn HealthReturns™ based on your results of fitness assessment and Healthy Heart Score™
Please refer to Policy wordings for detailed explanation of each of these steps.
No, OPD treatment is not covered under Day Care benefit.
In an individual policy, each person is covered for separate Sum insured as selected at the time of buying the policy. In a Family Floater plan, all insured members are covered under a floater sum insured. The sum insured for a Family Floater is our maximum liability for any and all claims made by all the insured members (a single Sum Insured which is shared by all members).
You will have to accept the offer for both chronic conditions.
During a Policy Year, the aggregate claim amount payable, subject to admissibility of the claim, shall not exceed the sum of:
(1) The Sum Insured
(2) Cumulative Bonus (if earned)
(3) Reloaded Sum Insured (if applicable)
chronic management program is over and above this.
Additionally, if you have fund under HealthReturns™, you may choose to reimburse this against the medical expenses.
We provide for a 100% reload of the Sum Insured specified in the Policy Schedule, in case, the available Sum Insured inclusive of earned Cumulative Bonus (if any) is insufficient as a result of previous claims in that Policy Year.
The reload of Sum Insured is available only for future claims and not in relation to any Illness/ Injury (including its complications) for which a claim has been admitted for the Insured Person during that Policy Year
Premium for your Activ Health policy depend on following factors:
- Your age
- Gender (for individual plan)
- Plan type (individual/ floater)
- No. of member covered (in individual policy, you get discount for covering 2 or more members under same policy)
- Selected term for policy (You get 7.5% and 10% discount respectively for buying 2yrs and 3yrs term policy)
- Selected SI
- Selected Room category
- Any pre-existing condition that you may have at the time of first buying this policy or detected at the time of pre policy medical check up
You also get additional discount on premium, if you are an employee of Aditya Birla Group.
We will provide a bonus as specified in the Policy Schedule at the end of the Policy Year, if the Policy is renewed with Us provided that there are no claims paid or outstanding in the expiring Policy Year. This is calculated as a percentage on the Sum Insured.