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
April 07, 2023
ASHISH SHETTY
Gebbs health care
D/203 Casa Elite, Lakeshore Greens,
Palava Phase 2, Dombivali East
-
THANE - 421204
MAHARASHTRA
M6-Khar Branch

Policy Number / Certificate Number: HSAA131655000105 - 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

M6 : M6-Khar Branch
Address: Lakshmi Commercial Complex, 605-606,6th Floor,Senapato Bapat
Marg,Dadar(West)
MUMBAI - 400028, MAHARASHTRA
GSTIN: 27AABCR7106G1ZJ

Certificate Number HSAA131655000105 AgencyCode OA500884

Master Policy SBMBMG0001 AgencyName SBI Cards and Payment
Number Services Limited
Name of the ASHISH SHETTY Contact Number -39020202
Applicant
Address Gebbs health care Period of Insurance
D/203 Casa Elite, Lakeshore Greens,
Palava Phase 2, Dombivali East From 00:00:00 hrs of 18/04/2023
- To Midnight of 17/04/2024
THANE
MAHARASHTRA GST Invoice Number: HSAA13165505000
421204
Place of Supply: MAHARASHTRA
Invoice Date: 18/04/2023
State Code: 27
Name of Group Manager SBI Cards and Payment Services
P Ltd

Nominee Name: BIMALA SHETTY Relationship with Applicant: MOTHER

Policy Type - Individual
Insured Person(s) details
Name First Date of Age Relationship Individual Increase Pre Premium
Inception Birth with Sum in Sum Existing ( )
Date Applicant Insured ( Insured Disease(s)
) benefit
ASHISH SHETTY 18/04/2018 02/06/1991 31 SELF 300,000 150000 NIL 3,104

Waiting periods for the Ported Sum Insured

Name Sum Increase 30 day First Two Year PED waiting period -
insured in Sum waiting Year Exclusions 36 Months
Insured period Exclusions
benefit
ASHISH SHETTY 300000.0 150000.0 Waived Off Waived Off Waived Off
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

Premium ( ) 3,104
TPA Fees ( ) 124
SGST 9%( ) 290.52

_______________________________________________________________________________
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
CGST 9%( ) 290.52
Total Premium ( ) 3,809.04

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.
• 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
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.
Limits:

_______________________________________________________________________________
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

• 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.ASHISH SHETTY has paid 3809 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 April 07, 2023
GSTIN. 27AABCR7106G1ZJ PAN Number : AABCR 7106G
669c26cc43e4a77f9b19ceb543174eb9
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: 2023.04.07

18:31:05 IST
Reason: For
RoyalSundaram
Call: 18602580000/18604250000 , Email: customer.services@royalsundaram.in 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:ASHISH SHETTY

Policy Number: HSAA131655

Membership No:HSAA131655A

Date Of Birth:02/06/1991
Valid From:18/04/2018
 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
M6 : M6-Khar Branch
Address:
Lakshmi Commercial Complex, 605-606,6th Floor,Senapato Bapat Marg,Dadar(West)
MUMBAI - 400028, MAHARASHTRA
GSTIN: 27AABCR7106G1ZJ

Policy Number : HSAA131655000105

GST Invoice Number : HSAA13165505000
Invoice Date : 18/04/2023

Insured/Recipient Name and Address:

ASHISH SHETTY
Gebbs health care, D/203 Casa Elite, Lakeshore Greens,, Palava Phase 2, Dombivali East
-, THANE
State: MAHARASHTRA
Pincode: 421204
Place of Supply: MAHARASHTRA
State Code : 27

Accounting code of service :997133

Accident and health insurance services

Taxable Premium 3,228.00

CGST 9% 290.52

SGST 290.52
9%

Gross Premium 3,809.04

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