Please help to choose Health insurance policy

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I am getting a health insurance policy(Aditya Birla Health Insurance’s Group Activ Health Plan) through Axis Bank with 10L cover for premium around 13k for age upto 55(for two adults) and then 10% premium increase. But it looks too good to be true. what i noticed is that below benefits are not available:
No Claim Bonus (NCB) / Multiplier Benefit
Restoration benefit / Refill benefit
Free health check-up

While i am getting similar plan from HDFc Ergo with 5 lakh cover for premium of 17k. Could you please help.

Below are TnC of Aditya Birla Health Insurance’s Group Activ Health Plan

The Benefits listed below shall be available to all Insured Persons as specified in the Policy Schedule or
Certificate of Insurance.
We will indemnify the Reasonable and Customary Charges incurred towards Necessary Medical
Treatment taken by the Insured Person during the Policy Period for an Illness, Injury or the conditions
described in the Benefits below if it is contracted or sustained by an Insured Person during the Policy
Period.
Benefits under this Section are subject to the terms, conditions and exclusions of this Policy and the
availability of the Sum Insured and subject always to any sub-limits for the Benefit as specified in the Policy
Schedule or Certificate of Insurance.
All claims must be made in accordance with the procedure set out in Section VI.
1. In-patient Hospitalization
1.1 In-patient Hospitalization
We will cover the Medical Expenses incurred towards one or more of the following arising out of an
Insured Person’s Hospitalization during the Policy Period following an Illness or Injury that occurs during
the Policy Period provided that:
(i) The Hospitalization is for Medically Necessary Treatment and follows written Medical Advice;
(ii) The Medical Expenses incurred are Reasonable and Customary Charges for one or more of the
following:
(1) Room Rent and other boarding charges;
(2) ICU Charges;
(3) Operation theatre expenses;
(4) Medical Practitioner’s fees including fees of specialists and anaesthetists treating the Insured Person;
(5) Qualified Nurses’ charges;
(6) Medicines, drugs and other allowable consumables prescribed by the treating Medical Practitioner;
(7) Investigative tests or diagnostic procedures directly related to the Injury/Illness for which the Insured
Person is Hospitalized and conducted within the same Hospital where the Insured Person is admitted;
(8) Anaesthesia, blood, oxygen and blood transfusion charges;
(9) Surgical appliances and prosthetic devices recommended by the attending Medical Practitioner that
are used intra operatively during a Surgical Procedure.
(iii) If the Insured Person is admitted in the Hospital in a room category/Room Rent higher than the
eligibility as specified in the Policy Schedule/Certificate of Insurance, then We shall be liable to pay only a
pro-rated proportion of the total Associated Medical Expenses (including surcharge or taxes thereon) in
the proportion of the difference between the Room Rent actually incurred and the entitled room
category/eligible Room Rent to the Room Rent actually incurred.
1.2 Day Care Treatment
We will cover the Medical Expenses incurred on the Insured Person’s Day Care Treatment during the Policy
Period following an Illness or Injury that occurs during the Policy Period provided that:
(i) The Medical Expenses are incurred, including for any procedure which requires a period of
specialized observation or care after completion of the procedure undertaken by an Insured Person
as Day Care Treatment and such list of Day Care Treatment is listed in Annexure I;

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(ii) The Day Care Treatment is for Medically Necessary Treatment and follows the written Medical
Advice;
(iii) We will not cover any OPD Treatment under this Benefit.
1.3 Domiciliary Hospitalization
We will cover Medical Expenses incurred for the Insured Person’s Domiciliary Hospitalization during the
Policy Period following an Illness or Injury that occurs during the Policy Period provided that:
(i) The Domiciliary Hospitalisation continues for at least 3 consecutive days in which case We will make
payment under this Benefit in respect of Medical Expenses incurred from the first day of Domiciliary
Hospitalisation;
(ii) The treating Medical Practitioner confirms in writing that Domiciliary Hospitalization was medically
required and the Insured Person’s condition was such that the Insured Person could not be
transferred to a Hospital or the Insured Person satisfies Us that a Hospital bed was unavailable;
(iii) If a claim is accepted under this Benefit then We shall not pay any Post-hospitalization Medical
Expenses, but We will accept a claim for Pre-hospitalization Medical Expenses subject to the terms
and conditions of Section <<1.4.>> below;
(iv) We shall not be liable to pay for any claim in connection with:
(1) Asthma, bronchitis, tonsillitis and upper respiratory tract infection including laryngitis and
pharyngitis, cough and cold, influenza;
(2) Arthritis, gout and rheumatism;
(3) Chronic nephritis and nephritic syndrome;
(4) Diarrhea and all type of dysenteries, including gastroenteritis;
(5) Diabetes mellitus and insipidus;
(6) Epilepsy;
(7) Hypertension;
(8) Psychiatric or psychosomatic disorders of all kinds;
(9) Pyrexia of unknown origin.
1.4 Pre – hospitalization Medical Expenses
We will cover, on a reimbursement basis, the Insured Person’s Pre-hospitalization Medical Expenses
incurred in respect of an Illness or Injury that occurs during the Policy Period upto the number of days as
specified in the Policy Schedule or Certificate of Insurance, provided that:
(i) We have accepted a claim for In-patient Hospitalization under Section 1.1 above;
(ii) The date of admission to the Hospital for the purpose of this Benefit shall be the date of the Insured
Person’s first admission to the Hospital in relation to the same Illness for which We have accepted
an In-patient Hospitalization claim under Section 1.1 above.
1.5 Post – hospitalization Medical Expenses
We will cover, on a reimbursement basis, the Insured Person’s Post-hospitalization Medical Expenses
incurred following an Illness or Injury that occurs during the Policy Period upto the number of days as
specified in the Policy Schedule or Certificate of Insurance, provided that:
(i) We have accepted a claim for In-patient Hospitalization under Section 1.1 above;
(ii) The date of discharge from the Hospital for the purpose of this Benefit shall be the date of the
Insured Person’s last discharge from the Hospital in relation to the same Illness for which We have
accepted an In-patient Hospitalization claim under Section 1.1 above.

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1.6 Organ Donor Expenses
We will cover the Medical Expenses incurred for an organ donor’s treatment for the harvesting of the
organ donated up to the limit as specified in the Policy Schedule or Certificate of Insurance provided that:
(i) The donation conforms to The Transplantation of Human Organs Act 1994 and the organ is for the
use of the Insured Person;
(ii) The organ transplant is medically required for the Insured Person as certified in writing by a Medical
Practitioner;
(iii) We will not cover:
(1) Pre-hospitalization Medical Expenses or Post-hospitalization Medical Expenses of the organ
donor;
(2) Screening expenses of the organ donor;
(3) Any other Medical Expenses as a result of the harvesting from the organ donor;
(4) Costs directly or indirectly associated with the acquisition of the donor’s organ;
(5) Transplant of any organ/tissue where the transplant is experimental or investigational;
(6) Expenses related to organ transportation or preservation;
(7) Any other medical treatment or complication in respect of the donor, consequent to
harvesting.

1.7 Road Ambulance Expenses
We will cover the costs incurred up to the limit as specified in the Policy Schedule or Certificate of
Insurance on transportation of the Insured Person by road Ambulance to a Hospital for treatment in an
Emergency following an Illness or Injury which occurs during the Policy Period. We will also cover the costs
incurred on transportation of the Insured Person by road Ambulance in the following circumstances up to
the limits specified in the Policy Schedule or Certificate of Insurance:
(i) it is medically required to transfer the Insured Person to another Hospital or diagnostic centre during
the course of Hospitalization for advanced diagnostic treatment in circumstances where such facility
is not available in the existing Hospital;
(ii) it is medically required to transfer the Insured Person to another Hospital during the course of
Hospitalization due to lack of super speciality treatment in the existing Hospital.
2. Pre-Existing Disease Waiting Period
We will not make any payment for any claim in respect of any Insured Person directly or indirectly
caused by, based on, arising out of, relating to or howsoever attributable to any Pre-Existing Diseases or
any complication arising from the same, until the time period specified in the Policy Schedule or
Certificate of Insurance in this regard has elapsed since the Start Date of the first Policy with Us.
3. Two Year Waiting Period
A waiting period of 24 months from the Start Date shall apply to the treatment, whether medical or
surgical and of the Illness/conditions and their complications mentioned below.
Body System Illness Treatment/ Surgery
1 Eye Cataract Cataract Surgery
Glaucoma Glaucoma Surgery

2 Ear Nose Throat Serous Otitis Media

Sinusitis Sinus Surgery

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Rhinitis Surgery for the nose
Tonsillitis Tonsillectomy
Tympanitis Tympanoplasty
Deviated Nasal Septum Surgery for Deviated Nasal

Septum

Otitis Media Surgery or Treatment for Otitis

Media
Adenoiditis Adenoidectomy
Mastoiditis Mastoidectomy
Cholesteatoma Resection of the Nasal Concha

3 Gynecology All Cysts & Polyps of the female
genito urinary system

Dilatation & Curettage
Polycystic Ovarian Disease Myomectomy
Uterine Prolapse Uterine prolapsed Surgery
Fibroids (Fibromyoma) Hysterectomy unless
necessitated by malignancy
Breast lumps Any treatment for Menorrhagia
Prolapse of the uterus
Dysfunctional Uterine Bleeding
(DUB)
Endometriosis
Menorrhagia
Pelvic Inflammatory Disease

4 Orthopedic /
Rheumatological

Gout Joint replacement Surgery
Surgery for Prolapse of the
intervertebral disc

Rheumatism, Rheumatoid
Arthritis
Non infective arthritis
Osteoarthritis
Osteoporosis
Prolapse of the intervertebral
disc
Spondylopathies

5 Gastroenterology
(Alimentary
Canal and related
Organs)

Stone in Gall Bladder and Bile
duct

Cholestectomy / Surgery for
Gall Bladder

Cholecystitis Surgery for Ulcers (Gastric /
Pancreatitis Duodenal)
Fissure, Fistula in ano,
hemorrhoids (piles), Pilonidal
Sinus, Ano-rectal & Perianal
Abscess
Rectal Prolapse
Gastric or Duodenal Erosions or
Ulcers + Gastritis & Duodenitis
Gastro Esophageal Reflux Disease
(GERD)

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Cirrhosis

6 Urogenital
(Urinary and
Reproductive
system

Stones in Urinary system (Stone
in the Kidney, Ureter, Urinary
Bladder)

Prostate Surgery

Benign Hypertrophy /
Enlargement of Prostate (BHP /
BEP)
Hernia, Hydrocele, Surgery for Hydrocele,
Rectocele and Hernia
Varicocoele / Spermatocoele Surgery for Varicocoele /
Spermatocoele

7 Skin skin tumour (unless malignant) Removal of such tumour unless

All skin diseases malignant

8 General Surgery Any swelling, tumour, cyst,
nodule, ulcer, polyp anywhere in
the body (unless malignant)

Surgery for cyst, tumour,
nodule, polyp unless malignant
Varicose veins, Varicose ulcers Surgery for Varicose veins and
Congenital Internal Diseases or Varicose ulcers
Anomalies

If any of the Illness/conditions listed above are Pre-Existing Diseases, then they will be covered only after
the completion of the Pre-Existing Disease Waiting Period described under Section <<42>>.
4. First 30 Days waiting Period
Any treatment taken during the first 30 days of the Start Date shall not be covered under the Policy, unless
the treatment is required as a result of an Accident that occurs during the Policy Period.
V. Permanent 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:
1. Treatment directly or indirectly 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 defense, rebellion, uprising,
revolution, insurrection, military or usurped acts, nuclear weapons / materials, chemical and
biological weapons, ionizing radiation, contamination by radioactive material or radiation of any
kind, nuclear fuel, nuclear waste.
2. Committing or attempting to commit a breach of law with criminal intent, intentional self- Injury
or attempted suicide while Insured Person is sane or insane.
3. Willful or deliberate exposure to danger, intentional self- Injury, non- adherence to Medical
Advice, participation or involvement in naval, military or air force operation, circus personnel,
racing in wheels or horseback, diving, aviation, scuba diving, parachuting, hang-gliding, rock or
mountain climbing, bungee jumping, parasailing, ballooning, skydiving, river rafting, polo, snow
and ice sports in a professional or semi- professional nature.

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4. Abuse or the consequences of the abuse of intoxicants or hallucinogenic substances such as
intoxicating drugs and alcohol, including smoking cessation programs and the treatment of
nicotine addiction or any other substance abuse treatment or services, or supplies.
5. Weight management programs or treatment in relation to the same including vitamins and tonics,
treatment of obesity (including morbid obesity).
6. Treatment for correction of eye sight due to refractive error including routine examination.
7. All routine examinations and preventive health check-ups.
8. Cosmetic, aesthetic and re-shaping treatments and Surgeries:
Plastic Surgery or cosmetic Surgery or treatments to change appearance unless medically required
and certified by the attending Medical Practitioner for reconstruction following an Accident,
cancer or burns.
9. Circumcisions (unless necessitated by Illness or Injury and forming part of treatment); aesthetic
or change-of-life treatments of any description such as sex transformation operations.
10. Non- allopathic treatment, except as per coverage of AYUSH Treatment.
11. Conditions for which treatment could have been done on an out-patient basis without any
Hospitalization.
12. Unproven/Experimental treatment, investigational treatment, devices and pharmacological
regimens.
13. Admission primarily for diagnostic purposes not related to Illness for which Hospitalization has
been done.
14. Convalescence (except as per the coverage as coverage defined in Section 11 – Recovery Benefit),
cure, rest cure, sanatorium treatment, rehabilitation measures, private duty nursing, respite care,
long-term nursing care or custodial care.
15. Preventive care, vaccination including inoculation and immunizations (except in case of post-bite
treatment); any physical, psychiatric or psychological examinations or testing
16. Admission for enteral feedings (infusion formulas via a tube into the upper gastrointestinal tract)
and other nutritional and electrolyte supplements unless certified to be required by the attending
Medical Practitioner as a direct consequence of an otherwise covered claim.
17. Hearing aids, spectacles or contact lenses including optometric therapy, multifocal lens.
18. Treatment for alopecia, baldness, wigs, or toupees, and all treatment related to the same.
19. Medical supplies including elastic stockings, diabetic test strips, and similar products.
20. Any expenses incurred on prosthesis, corrective devices external durable medical equipment of
any kind, like wheelchairs crutches, instruments used in treatment of sleep apnea syndrome or
continuous ambulatory peritoneal dialysis (C.A.P.D.) and oxygen concentrator for bronchial
asthmatic condition, cost of cochlear implant(s) unless necessitated by an Accident or required
intra-operatively. Cost of artificial limbs, crutches or any other external appliance and/or device
used for diagnosis or treatment (except when used intra-operatively).
21. Psychiatric or psychological disorders, mental disorders (including mental health treatments),

Parkinson and Alzheimer’s disease, general debility or exhaustion (“rundown condition”), sleep-
apnea, stress.

22. External Congenital Anomalies, diseases or defects, genetic disorders.
23. Stem cell therapy or surgery, or growth hormone therapy
24. Venereal disease, all sexually transmitted disease or Illness including but not limited to genital
warts, Syphilis, Gonorrhea, Genital Herpes, Chlamydia, Pubic Lice and Trichomoniasis.
25. “AIDS” (Acquired Immune Deficiency Syndrome) and/or infection with HIV (Human
Immunodeficiency Virus) including but not limited to conditions related to or arising out of

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HIV/AIDS such as ARC (AIDS Related Complex), Lymphomas in brain, Kaposi’s sarcoma,
tuberculosis.
26. Complications arising out of pregnancy (including voluntary termination), miscarriage (except as
a result of an Accident or Illness), maternity or birth (including caesarean section) except in the
case of ectopic pregnancy for In-patient only.
27. Treatment for sterility, infertility, sub-fertility or other related conditions and complications
arising out of the same, assisted conception, surrogate or vicarious pregnancy, birth control, and
similar procedures contraceptive supplies or services including complications arising due to
supplying services.
28. Expenses for organ donor screening, or save as and to the extent provided for in the treatment of
the donor (including Surgery to remove organs from a donor in the case of transplant Surgery).
29. Admission for Organ Transplant but not compliant under the Transplantation of Human Organs
Act, 1994 (amended).
30. Treatment and supplies for analysis and adjustments of spinal subluxation, diagnosis and
treatment by manipulation of the skeletal structure; muscle stimulation by any means except
treatment of fractures (excluding hairline fractures) and dislocations of the mandible and
extremities.
31. Dentures and artificial teeth, Dental Treatment and Surgery of any kind, unless requiring
Hospitalization due to an Accident.
32. 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.
33. Artificial life maintenance, including life support machine used to sustain a person, who has been
declared brain dead, as demonstrated by:

1. Deep coma and unresponsiveness to all forms of stimulation; or
2. Absent pupillary light reaction; or
3. Absent oculovestibular and corneal reflexes; or
4. Complete apnea.

34. Treatment for developmental problems, learning difficulties eg. Dyslexia, behavioral problems
including attention deficit hyperactivity disorder (ADHD).
35. Treatment for Age Related Macular Degeneration (ARMD) , treatments such as Rotational Field
Quantum Magnetic Resonance (RFQMR), External Counter Pulsation (ECP), Enhanced External
Counter Pulsation (EECP), Hyperbaric Oxygen Therapy.
36. Expenses which are medically not required such as items of personal comfort and convenience
including but not limited to television (if specifically charged), charges for access to telephone and
telephone calls (if specifically charged), food stuffs (save for patient’s diet), cosmetics, hygiene
articles, body care products and bath additives, barber expenses, beauty service, guest service as
well as similar incidental services and supplies, vitamins and tonics unless certified to be required
by the attending Medical Practitioner as a direct consequence of an otherwise covered claim.
37. Treatment taken from a person not falling within the scope of definition of Medical Practitioner.
38. Treatment charges or fees charged by any Medical Practitioner acting outside the scope of license
or registration granted to him by any medical council.
39. Treatments rendered by a Medical Practitioner who is a member of the Insured Person’s family
or stays with him, save for the proven material costs are eligible for reimbursement as per the
applicable cover.
40. Any treatment or part of a treatment that is not of a reasonable charge, is not a Medically
Necessary Treatment; drugs or treatments which are not supported by a prescription.

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41. Charges related to a Hospital stay not expressly mentioned as being covered, including but not
limited to charges for admission, discharge, administration, registration, documentation and
filing, including MRD charges (medical records department charges).
42. Non-medical expenses including but not limited to RMO charges, surcharges, night charges,

service charges levied by the Hospital under any head and as specified in the Annexure V for non-
medical expenses.

43. Treatment taken outside India.
44. Insured Person whilst flying or taking part in aerial activities except as a fare-paying passenger in
a regular scheduled airline or air charter company.

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I came a across an excellent handbook on health insurance by Mr. Mevin Joseph (please google: health insurance simplified by melvin joseph), while it may not recommend a particular product or policy, it will educate you a lot about feature that are essential and features/add-ons which are just marketing jargons. My two cents: the policy should have no room rent limit

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prasun.com138 wrote:

I came a across an excellent handbook on health insurance by Mr. Mevin Joseph (please google: health insurance simplified by melvin joseph), while it may not recommend a particular product or policy, it will educate you a lot about feature that are essential and features/add-ons which are just marketing jargons. My two cents: the policy should have no room rent limit

Sure. Thank for the info

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