Royal Sundaram General Insurance Co.

Limited
(Formerly Known as Royal Sundaram Alliance Insurance Company Limited)
"Vishranthi Melaram Towers" No.2/319, Rajiv Gandhi Salai
(OMR), Karapakkam, Chennai - 600097.
Registered Office: 21, Patullos Road, Chennai 600 002.
Toll: 18602580000/18604250000 Mobile: 94444 48899.
Email:customer.services@royalsundaram.in, Website: www.royalsundaram.in
IRDA Registration No.102 | CIN-U67200TN2000PLC045611
December 22, 2022
SAMPATH KUMAR T .
No 7/6/A -2, VISHNUPURI COLONY
TEERZADIGUDA, NEAR DARGAH
MEDIPALLI
UPPAL
HYDERABAD - 500039
Telangana
C4-Hyderabad Branch

Policy Number / Certificate Number: HSAA009471000108 - MIG7

Dear Customer,
Thank you for renewing your Group Health Policy from Royal Sundaram. We are delighted to
have you as our customer.
We are enclosing the following documents pertaining to your plan:

1. Certificate of Insurance
2. Annexures
3. E-Health Card

As part of our environment friendly intiative we have stoped sending plastic health card(s) with
policy document & replacing it with e-health card(s)

Please submit your claim documents to the address of your TPA mentioned in your Policy Schedule.

Please preserve these documents carefully as they form part of our contract with you. We request
you to verify the above documents and ensure everything is in order.

In case you have any clarification or query, please write to us at

customer.services@royalsundaram.in or Contact our Customer Service Help desk at
18602580000/18604250000. You can also chat with our executives on www.royalsundaram.in

Assuring you of our best services always.

Yours sincerely,

Duly Authorised Signatory

________________________________________________________________________________________
Customer Services
Call: 18602580000/18604250000, Email: customer.services@royalsundaram.in
UIN - RSAHLGP22167V032122
 Royal Sundaram General Insurance Co. Limited
(Formerly Known as Royal Sundaram Alliance Insurance Company Limited)
"Vishranthi Melaram Towers" No.2/319, Rajiv Gandhi Salai
(OMR), Karapakkam, Chennai - 600097.
Registered Office: 21, Patullos Road, Chennai 600 002.
Toll: 18602580000/18604250000 Mobile: 94444 48899.
Email:customer.services@royalsundaram.in, Website: www.royalsundaram.in
IRDA Registration No.102 | CIN-U67200TN2000PLC045611
GROUP HEALTH POLICY
(For Customers of SBI Cards Limited)
Certificate of Insurance

Royal Sundaram General Insurance Co. Limited

C4 : C4-Hyderabad Branch
Address: Unit no 1112 and 1113, 10th floor,Vasavi MPM Grand,,Yella Reddy Guda
Ameerpet, HYDERABAD - 500082, TELANGANA
GSTIN: 36AABCR7106G1ZK

Certificate Number HSAA009471000108 AgencyCode OA500884

Master Policy SBMBMG0001 AgencyName SBI Cards and Payment
Number Services Limited
Name of the SAMPATH KUMAR T . Contact Number -39020202
Applicant
Address No 7/6/A -2, VISHNUPURI COLONY Period of Insurance
TEERZADIGUDA, NEAR DARGAH
MEDIPALLI From 00:00:00 hrs of 24/12/2022
UPPAL To Midnight of 23/12/2023
HYDERABAD
Telangana GST Invoice Number: HSAA00947108000
500039
Place of Supply: TELANGANA
Invoice Date: 24/12/2022
State Code: 36
Name of Group Manager SBI Cards and Payment Services
P Ltd

Nominee Name: Relationship with Applicant:

Policy Type - Floater
Insured Person(s) details
Name First Date of Age Relationship Floater Increase Pre Premium
Inception Birth with Sum in Sum Existing ( )
Date Applicant Insured ( Insured Disease(s)
) benefit
SAMPATH KUMAR T 23/12/2014 10/06/1984 38 SELF 300,000 150000 NONE 7,662
KALYANI T 23/12/2014 03/12/1991 31 SPOUSE NONE
PRAHARSHA T 23/12/2014 04/07/2014 8 DAUGHTER NONE
TIPPANI JAYESH VARMA 23/12/2017 29/04/2016 6 SON NONE

Waiting periods for the Ported Sum Insured

Name Sum Increase 30 day First Two Year PED Maternity
insured in Sum waiting Year Exclusions waiting Benefit
Insured period Exclusions period - 36 waiting
period
benefit Months
SAMPATH KUMAR T 300000.0 150000.0 Waived Off Waived Off Waived Off Waived Off 12 Months
KALYANI T 300000.0 150000.0 Waived Off Waived Off Waived Off Waived Off 12 Months
PRAHARSHA T 300000.0 150000.0 Waived Off Waived Off Waived Off Waived Off 12 Months
TIPPANI JAYESH VARMA 300000.0 150000.0 Waived Off Waived Off Waived Off Waived Off 12 Months
Cashless claims will be serviced by the below mentioned TPA.
Medi Assist Insurance TPA Pvt. Ltd
Tower D, 4th Floor,
IBC Knowledge Park,
4/1, Bannerghatta Road,
Bangalore 560029
Toll Free help line number - 1800 419 1172

_______________________________________________________________________________
Customer Services
Call: 18602580000/18604250000 , Email: customer.services@royalsundaram.in
UIN: RSAHLGP22167V032122
 Royal Sundaram General Insurance Co. Limited
(Formerly Known as Royal Sundaram Alliance Insurance Company Limited)
"Vishranthi Melaram Towers" No.2/319, Rajiv Gandhi Salai
(OMR), Karapakkam, Chennai - 600097.
Registered Office: 21, Patullos Road, Chennai 600 002.
Toll: 18602580000/18604250000 Mobile: 94444 48899.
Email:customer.services@royalsundaram.in, Website: www.royalsundaram.in
IRDA Registration No.102 | CIN-U67200TN2000PLC045611

Premium ( ) 7,662
TPA Fees ( ) 306
SGST 9%( ) 717.12
CGST 9%( ) 717.12
Total Premium ( ) 9,402.24

Please quote the certificate number in all your correspondences.

The coverage includes the below listed points.

Benefits:

• Cashless and Reimbursement benefit for admittance in hospitals across India.

• Cover for accidental hospitalisation without any waiting period
• 100% cover for Surgeon/Doctor Fees
• No disease specific sub limits
• 30 days Pre hospitalisation expenses
• 60 days Post hospitalisation expenses
• Ambulance Charges up to Rs.2,000/- per hospitalization.
• Day care treatments - No need for compulsory 24 hours inpatient hospitalization for certain
procedures (List of Day care treatments covered - Dialysis, Chemotherapy, Radiotherapy, Eye
surgery, Cataract, Lithotripsy (kidney stone removal) Tonsillectomy, D&C, Cardiac
Catheterization, Hydrocele Surgery, Hernia repair surgery, Treatments for Fracture and such
other Surgical Operations that necessitate hospitalisation less than 24 hours due to medical /
technological advancement / infrastructure facilities.)
• Increase in sum insured benefit: The Sum Insured shall be increased by 20% each for the first two
years and 10% during the third year for remaining claim free, subject to a maximum increase of
50%. In the event of a claim, the sum insured will get reduced in the same manner it was accrued,
and in any case, not below original sum insured proposed. This increase in sum insured will be
forfeited if the policy is not continued/renewed on or before policy expiry date or before expiry of
30-day grace period.
• Maternity benefit (available only under a floater policy) for an amount of Rs. 40,000/- covered
after four years of continuance coverage for insured member from the date of enrolment.
• Organ Donor expenses covered up to sum insured.
• Free Medical check-up once in 2 years irrespective of claim up to a limit of Rs1,500/- per insured
person, which will be facilitated by us through our network diagnostic centers.
• Health & Wellness Benefit: Various preventive healthcare and wellness services, namely health
related articles through email and Doctor on email chat.

Waiting Period:

• Waiting period of 30 days (in respect of any disease contracted by the Insured Person during the
first 30 days from the first inception date of the Policy)
• First year exclusions: Treatment of Congenital Internal Diseases or defects or anomalies, any type
of Migraine /Vascular head ache, Stones in the Urinary and Biliary systems, Surgery on Tonsils /
Adenoids, Gastric and Duodenal Ulcer, any type of Cyst/ Nodules / Polyps, any type of Breast
Lumps during the first year of the operation of the Policy with Us.
• Two Year Exclusions: Treatment of Spondylosis / Spondilitis – any type, Inter vertebral Disc

_______________________________________________________________________________
Customer Services
Call: 18602580000/18604250000 , Email: customer.services@royalsundaram.in
UIN: RSAHLGP22167V032122
 Royal Sundaram General Insurance Co. Limited
(Formerly Known as Royal Sundaram Alliance Insurance Company Limited)
"Vishranthi Melaram Towers" No.2/319, Rajiv Gandhi Salai
(OMR), Karapakkam, Chennai - 600097.
Registered Office: 21, Patullos Road, Chennai 600 002.
Toll: 18602580000/18604250000 Mobile: 94444 48899.
Email:customer.services@royalsundaram.in, Website: www.royalsundaram.in
IRDA Registration No.102 | CIN-U67200TN2000PLC045611
Prolapse and such other Degenerative Disorders. Cataract, Benign Prostatic Hypertrophy,
Hysterectomy, Fistula, Fissure in Anus, Piles, Hernia, Hydrocele, Sinusitis, Knee / Hip Joint
replacement, Chronic Renal Failure or end stage Renal Failure, Heart diseases, any type of
Carcinoma / Sarcoma / Blood Cancer, Osteoarthritis of any joint during the first two years of the
operation of the Policy with Us.
• Pre-existing disease covered after a period of 36 months.
• Maternity benefit available after a period of 48 months, only in a floater policy.
Limits:
• Room Rent (per day) covered up to actual cost for a Single Room (Non-ICU) and No capping on
ICU accommodation.
• Ambulance charges Rs.2,000/- per hospitalization.
Important Permanent Exclusions:
• Pregnancy and its complications not covered in an individual sum insured policy.
• Outpatient treatment charges
• Dental treatments unless requiring hospitalisation
• Cosmetic / weight management treatments/surgeries
• Treatments other than allopathic
• Arising out of hazardous occupation/ activities
• Alcoholism, Drug addiction
• Any conditions associated with AIDS
Note: The benefits, limits and exclusions specified above must be read in conjunction with the policy
document. In case of any conflict of the above details with policy terms and conditions, the details specified
herein above shall prevail over those specified in policy terms and conditions.

Accounting code of service:997133

Indication if tax payable under reverse charge - No
Income Tax Certificate
This is to certify that Mr./Ms.SAMPATH KUMAR T . has paid 9402 towards Health Insurance for the
above-mentioned persons under scheme approved by IRDAI.This Certificate is issued for the purpose of
claiming deduction under Section 80D of Income Tax Act, 1961. Kindly select the appropriate premium
from the above table in respect of self, spouse and dependent children to claim Income Tax exemption
as per the provisions of Section 80D of Income Tax Act 1961.
Master Policy is duly stamped.
Provided that in the case of a policy of general insurance where the remittance made by the proposer or the
policyholder is not realised by the insurer, the policy shall be treated as void ab initio.
IN WITNESS WHEREOF, this Certificate of Insurance has been signed at Chennai on December 22, 2022
GSTIN. 36AABCR7106G1ZK PAN Number : AABCR 7106G
6c6cc002a057112ab5e7aa7954083cc6
For Royal Sundaram General Insurance Co. Limited,
Duly Authorized Signatory
This document is digitally signed, hence counter signature / stamp is not required.

Signature Not
_______________________________________________________________________________
Verified
Digitally signed by NIKHIL
PRABHAKAR APTE
Customer Services Date: 2022.12.22
11:37:57 IST
Reason: For
Call: 18602580000/18604250000 , Email: customer.services@royalsundaram.in RoyalSundaram
Location: Chennai

UIN: RSAHLGP22167V032122
 Royal Sundaram General Insurance Co. Limited
(Formerly Known as Royal Sundaram Alliance Insurance Company Limited)
"Vishranthi Melaram Towers" No.2/319, Rajiv Gandhi Salai
(OMR), Karapakkam, Chennai - 600097.
Registered Office: 21, Patullos Road, Chennai 600 002.
Toll: 18602580000/18604250000 Mobile: 94444 48899.
email:customer.services@royalsundaram.in, Website: www.royalsundaram.in
IRDA Registration No.102 | CIN-U67200TN2000PLC045611

Name: SAMPATH KUMAR T Name: KALYANI T

Policy Number: HSAA009471 Policy Number: HSAA009471

Membership No: HSAA009471A Membership No: HSAA009471B

Date Of Birth:10/06/1984 Date Of Birth:03/12/1991

Valid From: 23/12/2014 Valid From:23/12/2014

Name: TIPPANI JAYESH VARMA

Name: PRAHARSHA T
Policy Number: HSAA009471
Policy Number: HSAA009471
Membership No: HSAA009471D
Membership No: HSAA009471C
Date Of Birth:29/04/2016
Date Of Birth:04/07/2014
Valid From:23/12/2017
Valid From: 23/12/2014
 Royal Sundaram General Insurance Co. Limited
(Formerly Known as Royal Sundaram Alliance Insurance Company Limited)
"Vishranthi Melaram Towers" No.2/319, Rajiv Gandhi Salai
(OMR), Karapakkam, Chennai - 600097.
Registered Office: 21, Patullos Road, Chennai 600 002.
Toll: 18602580000/18604250000 Mobile: 94444 48899.
email:customer.services@royalsundaram.in, Website: www.royalsundaram.in
IRDA Registration No.102 | CIN-U67200TN2000PLC045611

GST Invoice
Royal Sundaram General Insurance Co. Limited
C4 : C4-Hyderabad Branch
Address:
Unit no 1112 and 1113, 10th floor,Vasavi MPM Grand,,Yella Reddy Guda
Ameerpet, HYDERABAD - 500082, TELANGANA
GSTIN: 36AABCR7106G1ZK

Policy Number : HSAA009471000108

GST Invoice Number : HSAA00947108000
Invoice Date : 24/12/2022

Insured/Recipient Name and Address:

SAMPATH KUMAR T .
No 7/6/A -2, VISHNUPURI COLONY, TEERZADIGUDA, NEAR DARGAH, MEDIPALLI
UPPAL, HYDERABAD
State: TELANGANA
Pincode: 500039
Place of Supply: TELANGANA
State Code : 36

Accounting code of service :997133

Accident and health insurance services

Taxable Premium 7,968

CGST 9% 717.12

SGST 717.12
9%

Gross Premium 9,402.24

I/We hereby declare that though our aggregate turnover in any preceding financial year from 2017-18 onwards is more than the aggregate
turnover notified under sub-rule (4) of rule 48, we are not required to prepare an invoice in terms of the provisions of the said sub-rule.

Signature

Note:This document is digitally signed

This document is electronically generated. This document should be issued along with the Policy document. This document stands invalid, if
issued separately