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Aditya Birla Health Insurance Claim Form

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Aditya Birla Health Insurance Claim Form

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  1. Health Insurance Aditya Birla Health Insurance Co. Limited (A subsidiary of Aditya Birla Capital Ltd.) Activ Health - Product Benefit Table Product Name Activ Health Gold Platinum Platinum Platinum Product Features / Product Variants Enhanced Essential Enhanced Premiere Sum Insured (Rs.) 2 Lac, 3 Lac, 4 Lac, 5 Lac, 6 Lac, 7 Lac, 8 Lac, 9 Lac, 10 Lac, 15 Lac, 20 Lac, 25 Lac, 30 Lac, 40 Lac, 50 Lac, 100 Lac, 150 Lac, 200 Lacs 50,000, 75,000, 1 Lac, 2 Lac, 3 Lac, 4 Lac, 5 Lac, 6 Lac, 7 Lac, 8 Lac, 9 Lac, 10 Lacs, 15 Lac, 20 Lac, 25 Lac, 30 Lac, 40 Lac, 50 Lac, 100 Lac 2 Lac, 3 Lac, 4 Lac, 5 Lac, 6 Lac, 7 Lac, 8 Lac, 9 Lac, 10 Lac, 15 Lac, 20 Lac, 25 Lac, 30 Lac, 40 Lac, 50 Lac, 100 Lac, 150 Lac, 200 Lacs 10 Lac, 15 Lac, 20 Lac, 25 Lac, 30 Lac, 40 Lac, 50 Lac, 100 Lac, 150 Lac, 200 Lacs I. Basic Covers  1 In-patient Hospitalization Room Type Room Type Room Type Room Type Room Options upto S.I. - 3 L 1. Shared Room 2. Single Private A/C Room Room Options S.I. 4L and above Room Options upto S.I. - 3 L 1. Shared Room Room Options upto S.I. - 3 L 1. Shared Room Upto S.I. for all options 2. Single Private A/C Room 2. Single Private A/C Room Room Options S.I. 4L and above 1. Shared Room Room Options S.I. 4L and above 1. Shared Room Upto S.I. for all options Activ Health, Product UIN: ADIHLIP21574V032021. 1. Shared Room 2. Single Private A/C Room 3. Any Room 2. Single Private A/C 2. Single Private A/C Room Room 3. Any Room 3. Any Room ICU charges Upto S.I. ICU charges Upto S.I. 60 days ICU charges Upto S.I. 30 days ICU charges Upto S.I. 60 days Pre-hospitalization Medical Expenses 60 days 2 Post-hospitalization Medical Expenses 180 days 60 days 180 days 180 days 3 Day Care Treatment Covered up to Sum Insured Covered up to Sum Insured Covered up to Sum Insured Covered up to Sum Insured 4 Domiciliary Hospitalization Covered up to Sum Insured Covered up to Sum Insured Covered up to Sum Insured Covered up to Sum Insured 5 Road Ambulance Cover Covered up to Actual expenses per event in case of Network Providers Covered up to Actual expenses per event in case of Network Providers Covered up to Actual expenses per event in case of Network Providers Covered up to Actual expenses per event in case of Network Providers 6 Reimbursed up to Rs 5000 per Hospitalization for Non-Network Providers Reimbursed up to Rs 3000 per Hospitalization for Non-Network Providers Reimbursed up to Rs 5000 per Hospitalization for Non-Network Providers Reimbursed up to Rs 5000 per Hospitalization for Non-Network Providers Organ Donor Expenses Covered up to Sum Insured Not Available Covered up to Sum Insured Covered up to Sum Insured 7 Reload of Sum Insured Available (Upto 100% S.I.) Not Available Available (Upto 100% S.I.) Not Available 8 Super Reload Not Available Not Available Not Available 100% unlimited reload, available for same and unrelated illness 9 AYUSH Cover Covered up to Sum Insured Covered up to Sum Insured Covered up to Sum Insured Covered up to Sum Insured 10 Mental Illness Hospitalisation Sum Insured - Upto 4L: Rs. 50,000 Sum Insured - Upto 4L: Rs. 50,000 Covered up to Sum Insured Covered up to Sum Insured 11 Sum Insured 5L & above: Rs. 1,00,000 Sum Insured 5L & above: Rs. 1,00,000 Obesity Treatment Covered up to Sum Insured Covered up to Sum Insured Covered up to Sum Insured Covered up to Sum Insured 12 01

  2. Home Treatment S.I. Upto 4L - Rs. 25,000 S.I. Upto 4L - Rs. 25,000 Covered up to Sum Insured Covered up to Sum Insured 13 S.I. 5L and above - Rs. 50,000 S.I. 5L and above - Rs. 50,000 Modern Treatment Methods and Advancement in Technologies Upto S.I. for Listed Procedures Upto S.I. for Listed Procedures Upto Sum Insured for Listed Procedures Upto Sum Insured for Listed Procedures 14 Co-Payment of 50% for Robotic Surgeries Co-Payment of 50% for Robotic Surgeries Domestic Emergency Assistance Services (including Air Ambulance) Available Not Available Available Available 15 International Emergency Assistance Services (including Air Ambulance) Available Not Available Available Available 16 OPD Cover Not Available Not Available 15L and above Rs.1000 15L and above Rs.1000 17 Post-hospitalisation Physiotherapy cover Not Available Not Available Not Available Available 18 Premium Waiver Not Available Not Available 1 Policy Year premium waiver, for detection of Listed Illnesses for adults 18 & above 1 Policy Year premium waiver, for detection of Listed Illnesses for adults 18 & above 19 Co-payment for treatment in a Higher Zone For All S.I. Options For S.I. 3 Lac and below Zone II to Zone I: 10% Zone III to Zone II: 15% Zone III to Zone I: 25% For S.I. 3 Lac and below Zone II to Zone I: 10% Not Applicable 20 Zone II to Zone I: 10% Zone III to Zone II: 15% Zone III to Zone I: 25% Zone III to Zone II: 15% Zone III to Zone I: 25% For SI 4L and above - For S.I. 4L and above - Not Applicable Activ Health, Product UIN: ADIHLIP21574V032021. Not Applicable Mandatory Co- payment Not Applicable 20% for all S.I. options Not Applicable Not Applicable 21 II. Additional Benefits Cumulative Bonus Applicable on Sum Insured: Applicable on Sum Insured: Applicable on Sum Insured: Applicable on Sum Insured: 22 20% increase, Max up to 100% (up to maximum of 50 Lacs) 10% increase, Max up to 100% (up to maximum of 50 Lacs) 50% increase, Max up to 100% (Upto maximum of 1 Cr) 50% increase, Max up to 100% (Upto maximum of 1 Cr) Dental Consultation & Investigations Not Available Not Available Available for S.I. 15 Lac and above Available 23 Health Check- up Program Available, Once in a Policy Year Available, Once in a Policy Year Available, Once in a Policy Year Available, Once in a Policy Year 24 Second E-Opinion for Major Illnesses Available Available Available Available 25 Recovery Benefit 1% of Sum Insured, max of INR 10,000 (Consecutive 10 days of hospitalization due to accident) Not Available 1% of Sum Insured, max of INR 10,000 (Consecutive 10 days of hospitalization due to accident) Not Available 26 III. Value Added Benefits Chronic Management Program (OPD) Not Available Available, As per Annexure 1 Available, As per Annexure 1 Available, As per Annexure 1 27 TM Health Assessment Not Available Available Available Available 28 TM HealthReturns Not Available Available, upto 50% of Premium Available, upto 100% of Premium Available, upto 100% of Premium 29 Expert Health Coach Available - Medical, Nutritional, Mental & Fitness Available - Medical, Nutritional, Mental & Fitness For S.I. 4 Lakhs and above: Available - Medical, Nutritional, Mental & Fitness, Mental Counselling session, Homeopathy tele consultation Available - Medical, Nutritional, Mental & Fitness, Mental Counselling session, Homeopathy tele consultation 30 For S.I. 3 Lakhs and below: Available - Medical, Nutritional, Mental & Fitness 02

  3. IV. Inbuilt Premiere Benefit (Applicable only to Platinum – Premiere Plan) International Coverage for Major Illnesses Not Available Not Available Not Available S.I. - 3 Cr / 6 Cr 31 Personal Accident Cover (AD, PTD) Not Available Not Available Not Available S.I. - 50L / 100L 32 Critical Illness Cover Not Available Not Available Not Available S.I. - 5L / 10L / 15L / 20L / 25L 33 Survival Period - 15 days V. Optional Covers Personal Accident Cover (AD, PTD) S.I. - 5L, 10L, 15L, 20L, 30L S.I. - 5L, 10L, 15L, 20L, 30L S.I. - 5L, 10L, 15L, 20L, 30L Not Applicable 34 Critical Illness Cover S.I. - 3L, 5L, 10L, 15L, 20L S.I. - 3L, 5L, 10L, 15L, 20L S.I. - 3L, 5L, 10L, 15L, 20L Not Applicable 35 Survival Period - 15 days Survival Period - 15 days Survival Period - 15 days Not Applicable International Coverage for Major Illnesses S.I. - 3Cr/6 Cr, available with base S.I. of 10L & above only S.I. - 3Cr/6 Cr, available with base S.I. of 10L & above only S.I. - 3Cr/6 Cr, available with base S.I. of 10L & above only Not Applicable 36 Preferred Provider Network (PPN) Discount 10% discount available 10% discount available 10% discount available 10% discount available 37 Waiver of mandatory co-payment Not Available Available for all S.I. options Not Available Not Available 38 Maternity Expenses Available Available Available Not Available 39 . Maternity Expenses I Normal Delivery - Normal Delivery - Normal Delivery - Rs. 75,000 Not Available Rs. 75,000 Rs. 75,000 C-Section Delivery - Rs. 1,00,000 C-Section Delivery - Rs. 1,00,000 C-Section Delivery - Rs. 1,00,000 Activ Health, Product UIN: ADIHLIP21574V032021. ii. New Born Baby Expenses Covered upto Maternity Sum Insured Covered upto Maternity Sum Insured Covered upto Maternity Sum Insured Not Available iii. Vaccination Expenses Covered upto Maternity Sum Insured Covered upto Maternity Sum Insured Covered upto Maternity Sum Insured Not Available iv. Stem Cell Preservation Rs. 35,000, over and above Maternity Sum Insured OPD Limit : Rs. 5000 to Rs. 20,000, in multiples of Rs. 1,000 Rs. 35,000, over and above Maternity Sum Insured OPD Limit : Rs. 5000 to Rs. 20,000, in multiples of Rs. 1,000 Rs. 35,000, over and above Maternity Sum Insured OPD Limit : Rs. 5000 to Rs. 20,000, in multiples of Rs. 1,000 Not Available OPD Expenses Not Available 40 General Medical Practitioner/ Specialist Medical Practitioner: 10% of OPD Limit per visit, Medicine and Diagnostic: 50% of OPD Limit General Medical Practitioner/ Specialist Medical Practitioner: 10% of OPD Limit per visit, Medicine and Diagnostic: 50% of OPD Limit General Medical Practitioner/ Specialist Medical Practitioner: 10% of OPD Limit per visit, Medicine and Diagnostic: 50% of OPD Limit Road Traffic Accident Diagnostic (over and above OPD Limit): Rs. 10,000 Road Traffic Accident Diagnostic (over and above OPD Limit): Rs. 10,000 Road Traffic Accident Diagnostic (over and above OPD Limit): Rs. 10,000 Cumulative Bonus applicable on Unutilized OPD Expenses*: 5% increase carry forward available for 12 months from the completion of policy year, up to No limit, No reduction on claim. Cumulative Bonus applicable on Unutilized OPD Expenses*: 5% increase carry forward available for 12 months from the completion of policy year, up to No limit, No reduction on claim. Available on individual basis for individual and family floater type policies *Not applicable for OPD limit for Road Traffic Accident diagnostics Cumulative Bonus applicable on Unutilized OPD Expenses*: 5% increase carry forward available for 12 months from the completion of policy year, up to No limit, No reduction on claim. Available on individual basis for individual and family floater type policies *Not applicable for OPD limit for Road Traffic Accident diagnostics Available on individual basis for individual and family floater type policies *Not applicable for OPD limit for Road Traffic Accident diagnostics Hospital Cash Benefit Rs. 500 to Rs. 5000 in multiples of Rs. 500 Rs. 500 to Rs. 5000 in multiples of Rs. 500 A deductible of 24 hours shall apply under this Benefit. Rs. 500 to Rs. 5000 in multiples of Rs. 500 A deductible of 24 hours shall apply under this Benefit. Not Available 41 A deductible of 24 hours shall apply under this Benefit. 03

  4. Note: 1 Eligibility and Coverage: a) Minimum Age at entry: i. Family Floater Policy: • 91 days (for dependent child) and 18 years (for adults). • Dependent Children from age - 91 days to 5 years will be covered only if one adult is covered under Family Floater Policy. b) ii. Individual Policy: • In case of an Individual Policy, minimum age at entry is 5 years. Maximum Age at entry: • • Gold - Enhanced, Platinum - Essential and Enhanced - No Maximum age at entry. Platinum - Premiere Plan - 65 years for both Individual and Family Floater Policy. Note: 1. 2. Children up to 25 years can be covered under the Floater as dependents. Age is calculated as no. of years completed as on last birthday. 3. 4. Individual Policy: Children beyond 25 years, if dependent on the parents can be covered under an Individual Policy . Family Floater Policy: Dependent child in a Family Floater Policy is not eligible for the Benefits under Chronic Management Program, even when his condition progresses to any of the Specified Chronic Conditions but is eligible to avail Inpatient Hospitalization for the said Condition. 2. Policy Type: The Policy can be purchased on an Individual basis or a Family Floater basis. a b) In case of an Individual Policy, each Insured Person under the Policy will have a separate Sum Insured. In case of a Floater Policy, one family will share a single Opted Sum Insured. Relationships Covered: a) Family Floater Policy: • New Business: Self & legally wedded spouse, dependent children upto 3 (i.e. natural or legally adopted) between the age 3 months to 25 years. • Renewal only: All relationships issued a Policy under UIN: IRDAI/HLT/ABHI/P-H/V.1/32/16-17 to be continued as renewal only. Activ Health, Product UIN: ADIHLIP21574V032021. b) Individual Policy: • Self, legally married spouse as long as they continue to be married, son, daughter, mother, father, brother, sister, mother in-law, father in-law, grandfather, grandmother, grandson, granddaughter, son in-law, daughter in-law, brother in-law, sister in-law, nephew, niece. Note: Son/Daughter/Child will include Legally Adopted Child and Step Child. Optional covers under Family Floater Policies, if chosen, will be applicable to all members in the Policy except in case of Personal Accident 3. cover (AD, PTD), Critical Illness Cover, International coverage for Major Illnesses . 4. 5. Critical Illness Cover - Minimum entry age 18 years and maximum entry age is 65 years. Personal Accident Cover (AD, PTD) - Minimum entry age 5 years and maximum entry age is 65 years. Adult member - To select among the available options (S.I. - 5L, 10L, 15L, 20L, 30L) on Individual Basis . Child - For child, applicable Sum Insured 5 Lacs Only . 6. 7. International Coverage for Major Illnesses - Minimum entry age 91 days and maximum entry age is 65 years. Chronic Management Program where it is applicable, shall be covered for adult members of the age 18 years and above . 8. 9. International Coverage for Major Illnesses benefit is applicable only for Insured Person(s) who are Indian Citizens residing in India. International Coverage for Major Illnesses benefit (Inbuilt Premiere Benefit / Optional Benefit) - Cap on the Sum Insured claimable under this Policy in the Insured Person’s lifetime, shall be limited to twice the Sum Insured specified for that Insured Person in the Policy Year during 10. Waiting Period(s): a. Pre Existing Disease: Gold Enhanced, Platinum Enhanced / Premiere - 36 months, Platinum Essential - 48 months . which the Major Illness was first diagnosed for the Insured Person. b. c. d. Specified Disease / Procedure Waiting Period: 24 Months . Specified Disease / Procedure Waiting Period: 48 Months . Initial Waiting Period: • 30 Days (not applicable in case of accident and subsequent renewal) . • For Section - Personal Accident: No initial Waiting Period applicable. • For Section - Critical Illness: We shall not be liable to make any payment in respect of any Critical Illness whose signs or symptoms first occur within 90 days from the Inception Date of cover. 04

  5. 11. Inbuilt Premiere Benefit (Applicable only to Platinum - Premiere Plan) 1. For Platinum - Premier Plan, International Coverage for Major Illness, Personal Accident Cover (AD, PTD), Critical Illness Cover are Inbuilt Benefits and shall be available at Individual / Multi Individual basis only for both Individual and Family Floater Policy. 2. Minimum and maximum age at entry a. International Coverage for Major Illness - Minimum age is 91 days and maximum age is 65 years . b. Personal Accident - Minimum age is 5 years and maximum age is 65 years . c. Critical Illness - Minimum age is 18 years and maximum age is 65 years. 3. Availability of cover: a. International Coverage for Major Illnesses - All member on individual basis. 4. b. Personal Accident - All member on individual basis. c. Critical Illness - All member on individual basis. Sum Insured Eligibility for: 1. International Coverage for Major Illness i. To select from S.I. - 3Cr / 6Cr by all members on Individual basis . 2. Personal Accident Cover ii. For Earning Member(s) - To select among options Sum Insured - 50L / 100L. iii. Non-earning Spouse - 30 Lacs. iv. Children - 10 Lacs. 3. Critical Illness Cover v. To select from S.I. - 5L / 10L / 15L / 20L / 25L. 12. HealthReturns TM TM • • Plan Platinum - Essential/Enhanced - HealthReturns is calculated as percentage of premium available for base cover and not optional cover. TM Plan Platinum - Premier - HealthReturns is calculated as percentage of premium available for base cover (except International Activ Health, Product UIN: ADIHLIP21574V032021. Coverage for Major Illness, Critical Illness and Personal Accident Cover (AD, PTD) and not optional cover. 13. Mandatory co-payment is not applicable for optional Benefits - Personal Accident (AD, PTD) and Critical Illness cover. 14. Waiver of co-payment is applicable for base benefit and not optional covers except PPN discount, if opted. 05

  6. Annexure 1 to Product Benefit Table 1. a) Single Chronic Condition Asthma Category Sub Category Number of Reimbursement Cost (Per Unit in INR) Reimbursement Cost (Annual in INR) Visits Consultation GP Consultation with MER or Specialist Consultation with MER 2 500 1000 Pathology Chest X-ray 1 150 150 Pathology Spirometry test 1 1500 1500 Total 2650 Hypertension Category Sub Category Number of Reimbursement Cost (Per Unit in INR) Reimbursement Cost (Annual in INR) Visits Consultation GP Consultation with MER or Specialist Consultation with MER 2 500 1000 Pathology Cholesterol Profile 1 300 300 Pathology ECG 1 150 150 Total 1450 Hyperlipidemia Category Sub Category Number of Visits Reimbursement Cost (Per Unit in INR) Reimbursement Cost (Annual in INR) Consultation GP Consultation with MER or Specialist Consultation with MER 2 500 1000 Activ Health, Product UIN: ADIHLIP21574V032021. Pathology Cholesterol Profile 1 300 300 Pathology ECG 1 150 150 Total 1450 Diabetes-Mellitus-1 Category Sub Category Number of Visits Reimbursement Cost (Per Unit in INR) Reimbursement Cost (Annual in INR) Consultation GP Consultation with MER or Specialist Consultation with MER 2 500 1000 Consultation Consultation (Ophthalmologist) 1 500 500 Pathology HBA1c 2 300 600 Pathology Creatinine 1 150 150 Total 2250 Diabetes-Mellitus-2 Category Sub Category Number of Reimbursement Cost (Per Unit in INR) Reimbursement Cost (Annual in INR) Visits Consultation GP Consultation with MER or Specialist Consultation with MER 2 500 1000 Consultation Consultation (Ophthalmologist) 1 500 500 Pathology HBA1c 2 300 600 Pathology Creatinine 1 150 150 Total 2250 Annexure 1(b)-Co-morbid Conditions: 1. b) Co-morbid Conditions Hypertension Hyperlipidemia Category Sub Category Number of Visits Reimbursement Cost (Per Unit in INR) Reimbursement Cost (Annual in INR) Consultation GP Consultation with MER or Specialist Consultation with MER 2 500 1000 Pathology Cholesterol Profile 1 300 300 Pathology ECG 1 150 150 Total 1450 06

  7. Asthma Hypertension Category Sub Category Number of Visits Reimbursement Cost (Per Unit in INR) Reimbursement Cost (Annual in INR) Consultation GP Consultation with MER or Specialist Consultation with MER 2 500 1000 Pathology Chest X-ray 1 150 150 Pathology Spirometry test 1 1500 1500 Pathology Cholesterol Profile 1 300 300 Pathology ECG 1 150 150 Total 3100 Asthma Hyperlipidemia Category Sub Category Number of Reimbursement Cost (Per Unit in INR) Reimbursement Cost (Annual in INR) Visits Consultation GP Consultation with MER or Specialist Consultation with MER 2 500 1000 Pathology Chest X-ray 1 150 150 Pathology Spirometry test 1 1500 1500 Pathology Cholesterol Profile 1 300 300 Pathology ECG 1 150 150 Total 3100 Asthma Hypertension Hyperlipidemia Category Sub Category Number of Visits Reimbursement Cost (Per Unit in INR) Reimbursement Cost (Annual in INR) Activ Health, Product UIN: ADIHLIP21574V032021. GP Consultation with MER or Specialist Consultation with MER 2 500 1000 Consultation Pathology 1 150 150 Chest X-ray Pathology Spirometry test 1 1500 1500 Pathology Cholesterol Profile 1 300 300 Pathology ECG 1 150 150 Total 3100 Asthma Diabetes-Mellitus-1 Category Sub Category Number of Reimbursement Cost (Per Unit in INR) Reimbursement Cost (Annual in INR) Visits Consultation GP Consultation with MER or Specialist Consultation with MER 2 500 1000 Consultation Consultation (Ophthalmologist) 1 500 500 Pathology Chest X-ray 1 150 150 Pathology Spirometry test 1 1500 1500 Pathology HBA1c 2 300 600 Pathology Creatinine 1 150 150 Total 3900 Asthma Diabetes-Mellitus-2 Category Sub Category Number of Reimbursement Cost (Per Unit in INR) Reimbursement Cost (Annual in INR) Visits Consultation GP Consultation with MER or Specialist Consultation with MER 2 500 1000 Consultation Consultation (Ophthalmologist) 1 500 500 Pathology Chest X-ray 1 150 150 Pathology Spirometry test 1 1500 1500 Pathology HBA1c 2 300 600 Pathology Creatinine 1 150 150 Total 3900 07

  8. Hypertension Diabetes-Mellitus-1 Category Sub Category Number of Visits Reimbursement Cost (Per Unit in INR) Reimbursement Cost (Annual in INR) Consultation GP Consultation with MER or Specialist Consultation with MER 2 500 1000 Consultation Consultation (Ophthalmologist) 1 500 500 Pathology HBA1c 2 300 600 Pathology Creatinine 1 150 150 Pathology Cholesterol Profile 1 300 300 Pathology ECG 1 150 150 Total 2700 Hypertension Diabetes-Mellitus-2 Category Sub Category Number of Reimbursement Cost (Per Unit in INR) Reimbursement Cost (Annual in INR) Visits Consultation GP Consultation with MER or Specialist Consultation with MER 2 500 1000 Consultation Consultation (Ophthalmologist) 1 500 500 Pathology HBA1c 2 300 600 Pathology Creatinine 1 150 150 Pathology Cholesterol Profile 1 300 300 Pathology ECG 1 150 150 Total 2700 Activ Health, Product UIN: ADIHLIP21574V032021. Hyperlipidemia Diabetes-Mellitus-1 Category Sub Category Number of Reimbursement Cost (Per Unit in INR) Reimbursement Cost (Annual in INR) Visits Consultation GP Consultation with MER or Specialist Consultation with MER 2 500 1000 Consultation Consultation (Ophthalmologist) 1 500 500 Pathology HBA1c 2 300 600 Pathology Creatinine 1 150 150 Pathology Cholesterol Profile 1 300 300 Pathology ECG 1 150 150 Total 2700 Hyperlipidemia Diabetes-Mellitus-2 Category Sub Category Number of Reimbursement Cost (Per Unit in INR) Reimbursement Cost (Annual in INR) Visits Consultation GP Consultation with MER or Specialist Consultation with MER 2 500 1000 Consultation Consultation (Ophthalmologist) 1 500 500 Pathology HBA1c 2 300 600 Pathology Creatinine 1 150 150 Pathology Cholesterol Profile 1 300 300 Pathology ECG 1 150 150 Total 2700 Hypertension Hyperlipidemia Diabetes-Mellitus-1 Category Sub Category Number of Reimbursement Cost (Per Unit in INR) Reimbursement Cost (Annual in INR) Visits Consultation GP Consultation with MER or Specialist Consultation with MER 2 500 1000 Consultation 500 Consultation (Ophthalmologist) 1 500 Pathology 300 HBA1c 2 600 Pathology 150 Creatinine 1 150 Pathology Cholesterol Profile 1 300 300 Pathology ECG 150 150 1 Total 2700 08

  9. Hypertension Hyperlipidemia Diabetes-Mellitus-2 Category Sub Category Number of Visits Reimbursement Cost (Per Unit in INR) Reimbursement Cost (Annual in INR) Consultation GP Consultation with MER or Specialist Consultation with MER 2 500 1000 Consultation Consultation (Ophthalmologist) 1 500 500 Pathology 2 600 HBA1c 300 Pathology Creatinine 150 150 1 Pathology Cholesterol Profile 1 300 300 Pathology ECG 1 150 150 Total 2700 Asthma Hypertension Diabetes-Mellitus-1 Category Sub Category Number of Visits Reimbursement Cost (Per Unit in INR) Reimbursement Cost (Annual in INR) Consultation GP Consultation with MER or Specialist Consultation with MER 2 500 1000 Consultation Consultation (Ophthalmologist) 1 500 500 Pathology Chest X-ray 1 150 150 Pathology Spirometry test 1 1500 1500 Pathology HBA1c 2 300 600 Pathology Creatinine 1 150 150 Pathology Cholesterol Profile 1 300 300 Pathology ECG 1 150 150 Activ Health, Product UIN: ADIHLIP21574V032021. Total 4350 Asthma Hypertension Diabetes-Mellitus-2 Category Sub Category Number of Reimbursement Cost (Per Unit in INR) Reimbursement Cost (Annual in INR) Visits Consultation GP Consultation with MER or Specialist Consultation with MER 2 500 1000 Consultation Consultation (Ophthalmologist) 1 500 500 Pathology Chest X-ray 1 150 150 Pathology Spirometry test 1 1500 1500 Pathology HBA1c 2 300 600 Pathology Creatinine 1 150 150 Pathology Cholesterol Profile 1 300 300 Pathology ECG 1 150 150 Total 4350 Asthma Hyperlipidemia Diabetes-Mellitus-1 Category Sub Category Number of Reimbursement Cost (Per Unit in INR) Reimbursement Cost (Annual in INR) Visits Consultation GP Consultation with MER or Specialist Consultation with MER 2 500 1000 Consultation Consultation (Ophthalmologist) 1 500 500 Pathology Chest X-ray 1 150 150 Pathology Spirometry test 1 1500 1500 Pathology HBA1c 2 300 600 Pathology Creatinine 1 150 150 Pathology Cholesterol Profile 1 300 300 Pathology ECG 1 150 150 Total 4350 09

  10. Asthma Hyperlipidemia Diabetes-Mellitus-2 Category Sub Category Number of Reimbursement Cost (Per Unit in INR) Reimbursement Cost (Annual in INR) Visits Consultation GP Consultation with MER or Specialist Consultation with MER 2 500 1000 Consultation Consultation (Ophthalmologist) 1 500 500 Pathology Chest X-ray 1 150 150 Pathology Spirometry test 1 1500 1500 Pathology HBA1c 2 300 600 Pathology Creatinine 1 150 150 Pathology Cholesterol Profile 1 300 300 Pathology ECG 1 150 150 Total 4350 Asthma_Diabetes Mellitus-1_Hypertension_Hyperlipidaemia Category Sub Category Number of Visits Reimbursement Cost (Per Unit in INR) Reimbursement Cost (Annual in INR) Consultation GP Consultation with MER or Specialist Consultation with MER 2 500 1000 Consultation Consultation (Ophthalmologist) 1 500 500 Pathology Chest X-ray 1 150 150 Pathology Spirometry test 1 1500 1500 Pathology HBA1c 2 300 600 Pathology Creatinine 1 150 150 Activ Health, Product UIN: ADIHLIP21574V032021. Pathology Cholesterol Profile 1 300 300 Pathology ECG 1 150 150 Total 4350 Asthma_Diabetes Mellitus-2_Hypertension_Hyperlipidaemia Category Sub Category Number of Reimbursement Cost (Per Unit in INR) Reimbursement Cost (Annual in INR) Visits Consultation GP Consultation with MER or Specialist Consultation with MER 2 500 1000 Consultation Consultation (Ophthalmologist) 1 500 500 Pathology Chest X-ray 1 150 150 Pathology Spirometry test 1 1500 1500 Pathology HBA1c 2 300 600 Pathology Creatinine 1 150 150 Pathology Cholesterol Profile 1 300 300 Pathology ECG 1 150 150 Total 4350 Aditya Birla Health Insurance Co. Limited. IRDAI Reg.153. CIN No. U66000MH2015PLC263677. Product Name: Activ Health, Product UIN: ADIHLIP21574V032021. Address: 9th Floor, Tower 1, One World Centre, Jupiter Mills Compound, 841, Senapati Bapat Marg, Elphinstone Road, Mumbai 400013. Email: care.healthinsurance@adityabirlacapital.com, Website: adityabirlahealthinsurance.com, Telephone: 1800 270 7000. Trademark/Logo Aditya Birla Capital is owned by Aditya Birla Management Corporation Private Limited and Trademark/logo HealthReturns, Healthy Heart Score and Active Dayz are owned by Momentum Metropolitan Life Limited (Formerly known as MMI Group Limited). These trademark/Logos are being used by Aditya Birla Health Insurance Co. Limited under licensed user agreement(s). Contact us: 1800 270 7000

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