Insurance Terms and Conditions

Issued by Aditya Birla Health Insurance Co. Ltd.

DECLARATIONS

I declare that I am not suffering from or 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:

1. High Blood Pressure, Heart Attack or any other Heart Disease, abnormal lipid levels;
2. Stroke, Paralysis in any form, or any other Cerebrovascular Disease;
3. Diabetes or thyroid/parathyroid or any other Endocrinal Disease, Any Kidney Disease;
4. Acute / Chronic Liver (Failure/ Disease), Cirrhosis of Liver, Alcoholic liver disease; any pancreatic disease;
5. Any Lung Disease (e.g. Chronic Obstructive Pulmonary Diseases, Parenchymal lung Disease, Pulmonary Embolism etc.);
6. Blood Disorders, Gastro-Intestinal Diseases, Ulcer or any other disorder of the bones, spine or muscle;
7. Any Cancer or Cancerous growth;
8. Any Mental or Psychiatric condition, any Genetic Disease, autoimmune or any disease related to central nervous system (disease related to brain); Congenital conditions;
9. HIV / AIDS or AIDS related complications;
10. Covid positive in last 3 months;
11. Any h/o sudden loss of weight in last 1 yr.

TERMS & CONDITIONS

1. The insurance policy is only valid for Indian citizens.
2. All Insured should be 18-60 years of age at the time of policy inception. Policy will be issued for a tenure specified in the Policy Certificate.
3. This Policy will be 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, any application for insurance cover in respect of any Insured Person and any other information or details submitted in relation to the Proposal Form. This Policy is a contract of insurance between You and Aditya Birla Health Insurance Ltd which is subject to receipt of premium in full in respect of the Insured Persons and the terms, conditions and exclusions of this Policy.

COVERAGE DESCRIPTION - GROUP PERSONAL ACCIDENT

Per life rate (including GST)

LOSS OF JOB - GROUP ACTIV SECURE

If We have accepted a claim for Permanent Total Disablement or Permanent Partial Disablement in accordance with Section III.1.A.2 or III.1.A.3, then in addition to any amount payable under that Section We will pay the amount as specified in the Policy Schedule or Certificate of Insurance, provided that the Insured Person is disabled from engaging in his/her primary occupation and loses his/her source of income generation.

1. In case of salaried persons: A lump sum amount equal to 3 months salary, based on the last 3 months salary slip of the employer. Salary shall mean and include Basic Salary along with the Daily Allowance and any other allowance being paid by the Employer. It would not include overtime, Seasonal allowance, Bonus, variable pay, performance bonus etc., tips, commissions or any other special compensation or anything available in kind or in lieu of such items in whatever form. Also salary would exclude income from any other sources. In case of Insured is earning from more than one source, only the higher of two would be considered for the purpose of calculation of payout under this benefit.
2. In case of self-employed persons or where salary information is not available: 5% of Sum Insured under Permanent Total Disablement (Section III.1.A.2) or under Permanent Partial Disablement (Section III.3), whichever is higher, up to a maximum of Rs 75,000 shall be payable. This amount can be paid either lump sum or in three equated monthly instalments as specified in the Policy Schedule or Certificate of Insurance.

DOCUMENTS REQUIRED FOR SPECIFIC BENEFITS

If these details are not provided in full or are insufficient for Us to consider the request, We will request additional information or documentation in respect of that request.

1. Document pertaining to the section under which the following Benefit is payable i.e. Permanent Total Disablement / Permanent Partial Disablement.
2. Loss of employment/termination letter indicating the reason for termination.
3. Proof of employment (appointment letter / salary slips).

EXCLUSIONS

We shall not be liable to make any payment for any claim under any Benefit in respect of any Insured Person directly or indirectly caused by, based on, arising out of, relating to or howsoever attributable to any of the following:

A. Standard Exclusions

1. Investigation & Evaluation (Code - Excl04):
   1. Expenses related to any admission primarily for diagnostics and evaluation purposes only are excluded.
   2. Any diagnostic expenses which are not related or not incidental to the current diagnosis and treatment are excluded.
2. Rest Cure, rehabilitation and respite care (Code - Excl05): Expenses related to any admission primarily for enforced bed rest and not for receiving treatment. This also includes:
   1. Custodial care either at home or in a nursing facility for personal care such as help with activities of daily living such as bathing, dressing, moving around either by skilled nurses or assistant or non-skilled persons.
   2. Any services for people who are terminally ill to address physical, social, emotional and spiritual needs.
3. Obesity / Weight Control (Code - Excl06): Expenses related to the surgical treatment of obesity that does not fulfil all the below conditions:
   1. Surgery to be conducted is upon the advice of the Doctor
   2. The surgery/Procedure conducted should be supported by clinical protocols
   3. The member has to be 18 years of age or older and
   4. Body Mass Index (BMI):
      1. greater than or equal to 40 or
      2. greater than or equal to 35 in conjunction with any of the following severe comorbidities following failure of less invasive methods of weight loss:
         1. Obesity-related cardiomyopathy
         2. Coronary heart disease
         3. Severe Sleep Apnea
         4. Uncontrolled Type 2 Diabetes
4. Change-of-Gender treatments (Code - Excl07): Expenses related to any treatment, including surgical management, to change characteristics of the body to those of the opposite sex.
5. Cosmetic or plastic Surgery (Code - Excl08): Expenses for cosmetic or plastic surgery or any treatment to change appearance unless for reconstruction following an Accident, Burn(s) or Cancer or as part of medically necessary treatment to remove a direct and immediate health risk to the insured. For this to be considered a medical necessity, it must be certified by the attending Medical Practitioner.
6. Hazardous or Adventure sports (Code - Excl09): Expenses related to any treatment necessitated due to participation as a professional in hazardous or adventure sports, including but not limited to, para-jumping, rock climbing, mountaineering, rafting, motor racing, horse racing or scuba diving, hand gliding, sky diving, deepsea diving.
7. Breach of law (Code - Excl10): Expenses for treatment directly arising from or consequent upon any Insured Person committing or attempting to commit a breach of law with criminal intent.
8. Excluded Providers (Code - Excl11): Expenses incurred towards treatment in any hospital or by any Medical Practitioner or any other provider specifically excluded by the Insurer as per Annexure VI and as disclosed in website (www.adityabirlahealth.com/healthinsurance) / notified to the policyholders are not admissible. However, in case of life threatening situations or following an accident, expenses up to the stage of stabilization are payable but not the complete claim.
9. Treatment for Alcoholism, drug or substance abuse or any addictive condition and consequences thereof. (Code - Excl12)
10. Treatments received in health 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: Expenses related to the treatment for correction of eye sight due to refractive error less than 7.5 dioptres. (Code - Excl15)
13. Unproven Treatments (Code - Excl16): Expenses related to any unproven treatment, services and supplies for or in connection with any treatment. Unproven treatments are treatments, procedures or supplies that lack significant medical documentation to support their effectiveness.
14. Sterility and Infertility (Code - Excl17): Expenses related to sterility and infertility. This includes:
    1. Any type of contraception, sterilization
    2. Assisted Reproduction services including artificial insemination and advanced reproductive technologies such as IVF, ZIFT, GIFT, ICSI
    3. Gestational Surrogacy
    4. Reversal of sterilization
15. Maternity Expenses (Code - Excl18):
    1. Medical treatment expenses traceable to childbirth (including complicated deliveries and caesarean sections incurred during hospitalization) except ectopic pregnancy;
    2. Expenses towards miscarriage (unless due to an accident) and lawful medical termination of pregnancy during the policy period.

B. Specific Exclusions

16. Circumstantial Exclusion
    1. Treatment arising from or consequent upon war or any act of war, invasion, act of foreign enemy, war like operations (whether war be declared or not or caused during service in the armed forces of any country), civil war, public defence, rebellion, uprising, revolution, insurrection, military participation or involvement in naval, military or air force operation.
    2. Usurped acts, nuclear weapons / materials, chemical and biological weapons, ionizing radiation, contamination by radioactive material or radiation of any kind, nuclear fuel, nuclear waste.
    3. The Insured Person's direct participation in terrorist acts.
17. Behavioural Exclusions
    1. Suicide or attempted suicide, wilfully self-inflicted injury;
    2. Illegal act of the Insured Persons;
    3. Any treatment for Injury resulting from the consumption of alcohol or any intoxicating substance, its intake or abuse thereof, the use of drugs (other than drugs taken under treatment prescribed and directed by a Medical Practitioner but not for the treatment of drug addiction).
18. Medical Exclusions
    1. All routine examinations and preventive health check-ups.
    2. Circumcisions (unless necessitated by Illness or Injury and forming part of treatment).
    3. Unless "OPD Expenses" Benefit is opted under the Policy, all treatments that are availed as an out-patient basis (without any Hospitalization) shall be excluded.
    4. Preventive care, vaccination including inoculation and immunizations (except in case of post-bite treatment); any physical, psychiatric or psychological examinations or testing.
    5. Admission for nutritional and electrolyte supplements unless certified to be required by the attending Medical Practitioner as a direct consequence of an otherwise covered claim.
    6. External Congenital Anomalies, diseases or defects.
    7. Stem cell therapy or surgery (except Hematopoietic stem cells for bone marrow transplant for hematological conditions), or growth hormone therapy or Hormone Replacement Therapy.
    8. Dentures, implants and artificial teeth.
    9. Cost incurred for any health check-up or for the purpose of issuance of medical certificates and examinations required for employment or travel or any other such purpose.
19. Prosthesis and Devices
    1. Hearing aids, spectacles or contact lenses including optometric therapy, multifocal lens.
    2. Wigs, or toupees, and related expenses.
    3. Any expenses incurred on prosthesis, corrective devices, external durable medical equipments, wheelchairs, crutches, instruments used in treatment of sleep apnea syndrome / and other sleep disorders or continuous ambulatory peritoneal dialysis (C.A.P.D.), devices used for ambulatory monitoring of blood pressure, blood sugar, glucometers, nebulizers and oxygen concentrator for bronchial asthmatic condition / COPD conditions, cost of cochlear implant(s) unless necessitated by an Accident. Cost of artificial limbs, crutches, external appliance and/or device used for diagnosis or treatment.
20. Non-Medical expenses
    1. As mentioned under Annexure (V) List II, III & IV will be excluded unless forms a part of In-patient hospitalization.
21. Specific treatment Exclusion
    1. Treatment for Rotational Field Quantum Magnetic Resonance (RFQMR), External Counter Pulsation (ECP), Enhanced External Counter Pulsation (EECP), Hyperbaric Oxygen Therapy, KTP Laser Surgeries, cyber knife treatment, Femto laser surgeries, bioabsorbable stents, bioabsorbable valves, bioabsorbable implants, Use of Radio Frequency (RF) probe for ablation.
22. Activities and Profession Exclusions
    1. Treatment taken from a person not falling within the scope of definition of Medical Practitioner with any state medical council / medical council of India.
    2. Treatment charges or fees charged by any Medical Practitioner acting outside the scope of license or registration granted to him by any medical council.
    3. Treatments rendered by a Medical Practitioner who is a member of the Insured Person's family or stays with him in the same residence, except if pre-approved by Us.
23. Geographical Exclusion
    1. Treatment taken outside India.

C. Permanent Exclusions Specific to Personal Accident

We shall not be liable to make any payment for any claim under any Benefit under Personal Accident, in respect of any Insured Person, directly or indirectly for, caused by or arising from or in any way attributable to any of the following:

1. Any Pre-Existing Disease or Injury or disability arising out of a Pre-Existing Disease which is not direct cause of accident.
2. Any payment in case of more than one claim under the Policy during any one Policy Period by which Our maximum liability in that period would exceed the Sum Insured. This would not apply to payments made under the Additional Covers.
3. Suicide or attempted suicide, intentional self-inflicted Injury, acts of self-destruction whether the Insured Person is medically sane or insane.
4. Strokes, fits or convulsions which affect the entire body.
5. Certification by a Medical Practitioner who shares the same residence as the Insured Person or who is a member of the Insured Person's family.
6. Death or disablement arising out of or attributable to foreign invasion, act of foreign enemies, hostilities, warlike operations (whether war be declared or not or while performing duties in the armed forces of any country during war or at peace time), participation in any naval, military or air-force operation, civil war, public defence, rebellion, revolution, insurrection, military or usurped power.
7. Congenital external diseases, defects or anomalies or in consequence thereof.
8. Bacterial infections (except pyogenic infection which occurs through a cut or wound due to Accident).
9. Medical or surgical treatment except as necessary solely and directly as a result of an Accident.
10. Any change of profession after inception of the Policy which results in the enhancement of Our risk under the Policy, if not accepted and endorsed by Us on the Policy Schedule or Certificate of Insurance.
11. Death or disablement arising or resulting from the Insured Person committing any breach of law or participating in an actual or attempted felony, riot, crime, misdemeanour or civil commotion with criminal intent.
12. Death or disablement arising from or caused due to use, abuse or a consequence or influence of an abuse of any substance, intoxicant, drug, alcohol or hallucinogen.
13. Death or disablement resulting directly or indirectly, contributed or aggravated or prolonged by childbirth or from pregnancy or a consequence thereof including ectopic pregnancy unless specifically arising due to Accident.
14. Death or disablement caused by participation of the Insured Person in any flying activity, except as a bona fide, fare-paying passenger of a recognized airline on regular routes and on a scheduled timetable.
15. Insured Persons whilst engaging in a speed contest or racing of any kind (other than on foot), bungee jumping, parasailing, ballooning, parachuting, skydiving, paragliding, hang gliding, mountain or rock climbing necessitating the use of guides or ropes, potholing, abseiling, deep sea diving using hard helmet and breathing apparatus, polo, snow and ice sports in so far as they involve the training for or participation in competitions or professional sports and specified in the Policy Schedule.
16. Insured Persons involved in naval, military or air force operations.
17. Working in underground mines, tunnelling or explosives, or involving electrical installation with high tension supply, or as jockeys or circus personnel, or engaged in Hazardous Activities.
18. Accidental death or Injury occurring after twelve calendar months from the date of the Accident.
19. Death or disablement unless directly caused by an Accident.
20. Death or disablement or Injury arising from or caused by ionizing radiation or contamination by radioactivity from any nuclear fuel (explosive or hazardous form) or resulting from or from any other cause or event contributing concurrently or in any other sequence to the loss, claim or expense from any nuclear waste from the combustion of nuclear fuel, nuclear, chemical or biological attack.
    1. Chemical attack or weapons means the emission, discharge, dispersal, release or escape of any solid, liquid or gaseous chemical compound which, when suitably distributed, is capable of causing any Illness, incapacitating disablement or death.
    2. Biological attack or weapons means the emission, discharge, dispersal, release or escape of any pathogenic (disease producing) microorganisms and/or biologically produced toxins (including genetically modified organisms and chemically synthesized toxins) which are capable of causing any Illness, incapacitating disablement or death.

CONTACT

For any further queries, the policy holder should reach out to Aditya Birla Health Insurance Ltd. on their toll free number, official email ID or offices as mentioned in the policy document.

The insurance policy is a contract between Aditya Birla Health Insurance Ltd. and the customer.