Group Personal Accident Policy
Health Insurance
1. Declarations
The proposer declares that they are not suffering from, have not been diagnosed with, and have not undergone treatment, investigation, or advised surgery for any of the following:
- High Blood Pressure, Heart Attack, or any other Heart Disease, abnormal lipid levels
- Stroke, Paralysis in any form, or any other Cerebrovascular Disease
- Diabetes, thyroid/parathyroid, or any other Endocrinal Disease, any Kidney Disease
- Acute / Chronic Liver Failure or Disease, Cirrhosis of Liver, Alcoholic liver disease, any pancreatic disease
- Any Lung Disease (e.g. COPD, Parenchymal lung disease, Pulmonary Embolism)
- Blood Disorders, Gastro-Intestinal Diseases, Ulcer, or any disorder of the bones, spine, or muscle
- Any Cancer or Cancerous growth
- Any Mental or Psychiatric condition, Genetic Disease, autoimmune disease, or disease related to the central nervous system; Congenital conditions
- HIV / AIDS or AIDS-related complications
- COVID positive in the last 3 months
- Any history of sudden loss of weight in the last 1 year
2. Terms & Conditions
- Valid only for Indian citizens.
- All insured persons must be 18–60 years of age at policy inception. The policy is issued for the tenure specified in the Policy Certificate.
- Issued on the basis of the Disclosure to Information norm — including all information provided in the Proposal Form and any related application or submission.
- This is a contract of insurance between the policyholder and Aditya Birla Health Insurance Ltd., subject to receipt of full premium and the policy's terms, conditions, and exclusions.
3. Coverage Description — Group Personal Accident
| Sum Insured | INR 1 Lac |
|---|---|
| Insured | Primary member |
| Age Band | 18 – 60 years |
| Coverages | GPA: Accidental Death (AD) + Permanent Total Disablement (PTD) + Permanent Partial Disablement (PPD) + Loss of Job (LOJ) — 5% of PTD or PPD Sum Insured (whichever is higher), up to a maximum of ₹75,000 |
| PED (Pre-Existing Disease) | Not covered Excluded |
| TPA | Claim service is in-house (no third-party administrator) |
| Age Band | Premium |
|---|---|
| 18 – 60 | INR 169 |
4. Loss of Job Benefit — Group Activ Secure
If a claim for Permanent Total Disablement (PTD) or Permanent Partial Disablement (PPD) has been accepted under Section III.1.A.2 or III.1.A.3, an additional amount is payable — provided the insured person is disabled from engaging in their primary occupation and loses their source of income.
a. Salaried persons
A lump sum equal to 3 months' salary, based on the last 3 months' salary slips. Salary includes Basic Salary, Daily Allowance, and other regular employer-paid allowances.
Excluded from salary: overtime, seasonal allowance, bonus, variable pay, performance bonus, tips, commissions, or any other special or in-kind compensation, and income from other sources. If the insured earns from more than one source, only the higher is considered.
b. Self-employed persons (or where salary information is unavailable)
5% of the Sum Insured under PTD (Section III.1.A.2) or PPD (Section III.3), whichever is higher, up to a maximum of ₹75,000 — payable as a lump sum or in three equal monthly instalments, as specified in the Policy Schedule or Certificate of Insurance.
5. Documents Required for Specific Benefits
If submitted details are incomplete or insufficient, the insurer will request additional information or documentation.
- Document pertaining to the section under which the benefit is payable — i.e., Permanent Total Disablement / Permanent Partial Disablement
- Loss of employment / termination letter, indicating the reason for termination
- Proof of employment (appointment letter / salary slips)
6. Exclusions
No payment is made for any claim directly or indirectly caused by, based on, arising out of, relating to, or attributable to the following:
A. Standard Exclusions
1. Investigation & Evaluation Excl04
Expenses for admission primarily for diagnostics/evaluation, or diagnostic expenses unrelated to the current diagnosis and treatment.
2. Rest Cure, Rehabilitation & Respite Care Excl05
Admission primarily for enforced bed rest rather than treatment. Includes custodial care (help with daily living activities) and end-of-life support services.
3. Obesity / Weight Control Excl06
Surgical treatment for obesity is excluded unless all of the following are met: doctor-advised, supported by clinical protocols, patient is 18+, and BMI ≥ 40 (or ≥ 35 with a qualifying comorbidity such as obesity-related cardiomyopathy, coronary heart disease, severe sleep apnea, or uncontrolled Type 2 Diabetes, following failed non-surgical weight loss attempts).
4. Change-of-Gender Treatments Excl07
Treatment, including surgical management, to change bodily characteristics to those of the opposite sex.
5. Cosmetic or Plastic Surgery Excl08
Excluded unless for reconstruction following an accident, burns, or cancer, or as certified medically necessary to remove a direct health risk.
6. Hazardous or Adventure Sports Excl09
Treatment necessitated by participation as a professional in sports such as para-jumping, rock climbing, mountaineering, rafting, motor/horse racing, scuba diving, hang gliding, skydiving, deep-sea diving.
7. Breach of Law Excl10
Treatment arising from committing or attempting a breach of law with criminal intent.
8. Excluded Providers Excl11
Treatment at hospitals/practitioners specifically excluded by the insurer (per Annexure VI / insurer website). Exception: in life-threatening situations or post-accident, expenses up to stabilization are payable.
9–15. Additional Standard Exclusions
- Alcoholism / substance abuse and consequences thereof Excl12
- Health hydros, spas, nature cure clinics, or nursing homes attached to such facilities, or admissions arranged for domestic reasons Excl13
- Non-prescription dietary supplements (vitamins, minerals, organic substances) unless prescribed as part of hospitalization/day-care Excl14
- Refractive error correction below 7.5 dioptres Excl15
- Unproven treatments lacking significant medical documentation of effectiveness Excl16
- Sterility & infertility — contraception, sterilization, IVF/ZIFT/GIFT/ICSI, surrogacy, reversal of sterilization Excl17
- Maternity expenses — childbirth-related costs (except ectopic pregnancy), miscarriage (unless accident-caused), lawful termination Excl18
B. Specific Exclusions
16. Circumstantial Exclusions
- War, invasion, war-like operations, civil war, rebellion, insurrection, or military/naval/air-force operations
- Usurped acts, nuclear/chemical/biological weapons, ionizing radiation, radioactive contamination, nuclear fuel or waste
- Direct participation in terrorist acts
17. Behavioural Exclusions
- Suicide or attempted suicide, wilful self-inflicted injury
- Illegal acts by the insured person
- Injury from consumption/abuse of alcohol, intoxicants, or drugs (except as prescribed by a doctor for non-addiction treatment)
18. Medical Exclusions
- Routine examinations and preventive health check-ups
- Circumcision (unless illness/injury-necessitated)
- Outpatient-only treatment (unless OPD benefit is opted)
- Preventive care, vaccination, immunization (except post-bite treatment); psychiatric/psychological testing
- Nutritional/electrolyte supplements unless certified necessary as part of a covered claim
- External congenital anomalies, diseases, or defects
- Stem cell therapy (except hematopoietic stem cells for bone marrow transplant), growth hormone therapy, hormone replacement therapy
- Dentures, implants, artificial teeth
- Health check-ups or medical certificates for employment/travel purposes
19. Prosthesis & Devices
- Hearing aids, spectacles, contact lenses, optometric therapy, multifocal lenses
- Wigs, toupees, and related expenses
- Prosthesis, corrective/external durable medical equipment, wheelchairs, crutches, sleep-apnea devices, CAPD equipment, BP/sugar monitors, glucometers, nebulizers, oxygen concentrators, cochlear implants (unless accident-necessitated), artificial limbs
20–23. Further Exclusions
- Non-medical expenses per Annexure V (Lists II, III & IV), unless part of in-patient hospitalization
- Specific treatments: RFQMR, ECP/EECP, Hyperbaric Oxygen Therapy, KTP/Femto laser surgeries, cyber knife treatment, bioabsorbable stents/valves/implants, RF ablation probes
- Activities & profession: treatment by unregistered practitioners, practitioners acting outside licensed scope, or by a family member/co-resident practitioner (unless pre-approved)
- Geographical: treatment taken outside India
C. Permanent Exclusions — Specific to Personal Accident
No payment is made for claims directly or indirectly caused by or arising from:
- Any Pre-Existing Disease/Injury, or disability arising from a PED not directly caused by the accident
- More than one claim in a Policy Period where total liability would exceed the Sum Insured (Additional Covers excepted)
- Suicide, attempted suicide, or intentional self-inflicted injury (regardless of mental state)
- Strokes, fits, or convulsions affecting the entire body
- Certification by a practitioner who is a family member or shares the insured's residence
- War, foreign invasion, hostilities, warlike operations, military/naval/air-force duty, civil war, rebellion, insurrection
- Congenital external diseases, defects, or anomalies
- Bacterial infections (except pyogenic infection from an accidental cut/wound)
- Medical/surgical treatment not solely and directly necessitated by an accident
- Change of profession post-inception that increases risk, unless accepted and endorsed
- Breach of law, felony, riot, crime, misdemeanour, or civil commotion with criminal intent
- Use/abuse of any substance, intoxicant, drug, alcohol, or hallucinogen
- Childbirth or pregnancy-related death/disablement, including ectopic pregnancy, unless accident-caused
- Flying activity, except as a fare-paying passenger on a recognized, scheduled airline
- Speed contests/racing, bungee jumping, parasailing, ballooning, parachuting, skydiving, paragliding, hang gliding, technical mountain/rock climbing, potholing, abseiling, deep-sea diving with hard helmet, polo, and competitive snow/ice sports
- Naval, military, or air force operations
- Underground mining, tunnelling, explosives work, high-tension electrical installation, jockeying, circus work, or other hazardous activities
- Accidental death/injury occurring more than 12 calendar months after the accident date
- Death or disablement not directly caused by an accident
- Ionizing radiation, radioactive contamination, nuclear fuel/waste, or chemical/biological attack (as defined)
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