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: 1860-425-0000 Mobile: 94444 48899.
Email:[email protected], Website: www.royalsundaram.in
IRDA Registration No.102 | CIN-U67200TN2000PLC045611
October 24, 2019
BABU S
52 UMA SANKAR NAGAR
IIND CROSS
BEHIND AYYAPAN TEMPLE
HOSUR
HOSUR
TAMILNADU
635109
Mobile No: 9698632889
C0 - C0-Chennai Regional Office

HMA0023662000104

Dear BABU S

At the outset, we sincerely thank you for continuing your association with Royal Sundaram as your preferred Health
Insurance Partner and are happy to inform you that your policy stands renewed here with us.

While a comprehensive policy kit has been mailed to your registered E-mail ID, enclosed please find your policy
document.

Your Lifeline policy also offers a free health check-up for customers above 18 years of age. This health check-up is a
set of predefined number of tests arranged by Royal Sundaram through our empanelled network providers only.

Please note that customers insured under Classic plan will be eligible for health check-up every alternate year from
2nd renewal onwards and customer insured under Supreme and Elite plan will be eligible for health check-up on every
renewal. This benefit is not available on reimbursement basis.
To avail this benefit, please write to [email protected] by mentioning your policy details along with
your registered mobile number.

Please note that health card issued along with your policy in previous year does not have expiry date. In case you
misplace this card, don’t worry! At the time of logging claim at hospital your policy number mentioned herewith will
be sufficient.Your policy will be due for renewal on 25/10/2020.

Should you require any further assistance, we request you to call us on 1860 425 0000 or e-mail us at
[email protected]. You can also visit our website www.royalsundaram.in for more information on
Lifeline.

Alternatively, you can also write to us at:

Royal Sundaram General Insurance Co. Limited

Vishranthi Melaram Towers,No.2/319, Rajiv Gandhi Salai (OMR)
Karapakkam, Chennai – 600097
Being our valued customer, you are entitled to receive SMS/email updates from us on our service related
matters, at periodic intervals
We wish a very successful and healthy year ahead to you and your family.

For & on behalf of Royal Sundaram General Insurance Co. Limited

Authorized Signatory

________________________________________________________________________________________
Customer Services
Call: 1860 425 0000, Email: [email protected]
Lifeline | UIN-IRDAI/HLT/RSAI/P-H/V.II/32/15-16
 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: 1860-425-0000 Mobile: 94444 48899.
Email:[email protected], Website: www.royalsundaram.in
IRDA Registration No.102 | CIN-U67200TN2000PLC045611

Premium Certificate
For the purpose of deduction under section 80D of Income Tax amendment
act, 1961 and any amendments made thereafter.
Policy No MLF0000495000103
Policy Holder BABU S
Address 52 UMA SANKAR NAGAR
IIND CROSS
BEHIND AYYAPAN TEMPLE
HOSUR
HOSUR
635109
TAMILNADU
Policy Period 26/10/2019 - 25/10/2020

Premium Details

Particulars Gross Premium Goods & Services Tax Total Premium

Amount( in ) 7,505 1,350 8,855

This is to certify that Royal Sundaram General Insurance Co. Limited(Formerly Known as Royal Sundaram Alliance
Insurance Company Limited) has received an amount of 8,855 (Eight Thousand Eight Hundred Fifty Five) from
BABU S towards Payment of Health insurance premium as per the details mentioned above.

For and on behalf of Royal Sundaram General Insurance Co. Limited

Authorized Signatory
This document is digitally signed, hence counter signature / stamp is not required.
Location: Chennai
Date: October 24, 2019

Note:

1) Exemption under the certificate issued above is applicable to Medical Premium paid for Self, Spouse, Dependent
parents and Dependent children only as per the provisions of Section 80 D of Income Tax Act 1961.
2) In case of any discrepancy, the Policyholder is requested to contact the Company immediately.
3) This document must be surrendered to the Company in case of Cancellation of the Policy or for the issuance of a
fresh certificate in the case of any alteration in the Policy.

________________________________________________________________________________________
Customer Services
Call: 1860 425 0000, Email: [email protected]
Lifeline | UIN-IRDAI/HLT/RSAI/P-H/V.II/32/15-16
 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: 1860-425-0000 Mobile: 94444 48899.
Email:[email protected], Website: www.royalsundaram.in
IRDA Registration No.102 | CIN-U67200TN2000PLC045611

Part I
Policy Document - Insurance Certificate
Royal Sundaram General Insurance Co. Limited
C0 : C0-Chennai Regional Office
Address:Sundaram Towers Invoice Date : 26/10/2019
No.45 and 46
Whites Road GST Invoice Number : MLF000049503000
CHENNAI - 600014, TAMILNADU
GSTIN: 33AABCR7106G1ZQ

Policy Number MLF0000495000103

BABU S
Master Reference Number HMA0023662000104
52 UMA SANKAR
NAGAR Policy Commencement Date and Time 26/10/2019 00:00:00
IIND CROSS Policy Expiry Date and Time 25/10/2020 23:59:59
BEHIND AYYAPAN
TEMPLE Total Sum Insured 200,000
HOSUR Lifeline
HOSUR
Product Name
635109 Plan Name Classic
TAMILNADU 2A+1C
Place of Supply:
Cover Type
TAMILNADU Policy Period 1 Year
State Code : 33
Renewal Due Date 26/10/2020
Mobile: 9698632889 997133
Account code of service

Insured Person
Name of the Insured Date of Age Gender Relationship with the Insured in Pre Existing Personal
Person (s) Birth Policyholder Lifeline (since) Disease(s) Waiting
Period *
BABU S 01/02/1974 45 Male SELF 26/10/2016
PARIMALA K A 05/06/1981 38 Female SPOUSE 26/10/2016
RAKSHITH RAHUL B 12/06/2000 19 Male SON 26/10/2016

(* - Please refer clause 4.d of Part II of the schedule)

Cover Details
Name of the Insured Person (s) Base Sum Insured ( ) No Claim Bonus ( ) Total Available Sum Insured ( ) *
BABU S 200,000 100,000 300,000
PARIMALA K A 100,000 300,000
RAKSHITH RAHUL B 100,000 300,000

(* - Our maximum liability per person will be upto the Total Available Sum Insured available against that Insured Person and Cumulative liability
will be upto the max of Total Available Sum Insured)

Optional Benefit/Feature Details

Optional Benefit/Feature Effective (Yes/No) Details
Top-up Plan No NA
Hospital Cash Benefit No 0 per day
Option to inlcude US and Canada for Worldwide No NA
Emergency Hospitalization and International
Treatment for 11 specified Critical Illness

________________________________________________________________________________________
Customer Services
Call: 1860 425 0000, Email: [email protected]
Lifeline | UIN-UIN-IRDAI/HLT/RSAI/P-H/V.II/32/15-16
Nominee Details
Nominee Name Relationship

Premium Details
Net Premium ( Loading ( ) CGST ( ) SGST( ) Gross Premium ( Gross
) (9% ) (9% ) ) Premium ( )
(in words)
7,505 0 675 675 8,855 Eight Thousand
Eight Hundred
Fifty Five Rupees
and Zero Paise

Indication if tax payable under reverse charge - No

Special Conditions/Permanent Exclusions (if any):
Insured Name CoPay % Permanent Exclusion
BABU S 0.0
PARIMALA K A 0.0
RAKSHITH RAHUL B 0.0

Disease Code Reference

ICD Code Disease Description

Pre-existing Diseases with Portability Benefit carried from prior health insurance policy (From other insurer /
Royal Sundaram)
(A) (B) (C) (D) (E) (F)
Name of the Insured Person(s) Pre-existing Sum Insured limit Pre-existing Balance Sum Pre-existing
Diseases carried over from Diseases Insured ( ) Diseases
previous insurance waiting Waiting
policy ( ) period for period for
(C) (E)
BABU S NIL 240000 Waived-off NIL Waived-off
PARIMALA K A NIL 240000 Waived-off NIL Waived-off
RAKSHITH RAHUL B NIL 240000 Waived-off NIL Waived-off

Personal Exclusions with Portability Benefit carried from prior health insurance policy (From other insurer /
Royal Sundaram)
(A) (B) (C) (D) (E) (F)
Name of the Insured Person(s) Personal Sum Insured limit Personal Balance Sum Personal
Diseases carried over from waiting Insured ( ) waiting
previous insurance period for period for
policy ( ) (C) (E)
BABU S NA NA NA NA NA
PARIMALA K A NA NA NA NA NA
RAKSHITH RAHUL B NA NA NA NA NA

Specified Exclusions with Portability Benefit carried from prior health insurance policy (From other insurer /
Royal Sundaram)
(A) (B) (C) (D) (E)
Name of the Insured Person(s) Sum Insured limit Specific Waiting Balance Sum Specific
carried over from Periods for (B) Insured ( ) Waiting
previous insurance Periods for
policy ( ) (D)
BABU S 240000 Waived-off NA Waived-off
PARIMALA K A 240000 Waived-off NA Waived-off
RAKSHITH RAHUL B 240000 Waived-off NA Waived-off

________________________________________________________________________________________
Customer Services
Call: 1860 425 0000, Email: [email protected]
Lifeline | UIN-UIN-IRDAI/HLT/RSAI/P-H/V.II/32/15-16
Other Waiting Periods
Name of the Insured Initial Waiting period Initial Waiting period Waiting period for
Person (s) of 30 days of 90 days for Critical Maternity Benefit
Illness
BABU S Not Applicable Not Applicable Not Applicable
PARIMALA K A Not Applicable Not Applicable Not Applicable
RAKSHITH RAHUL B Not Applicable Not Applicable Not Applicable

We reserve the right to modify or amend the terms and the applicability of the Portability Benefit in accordance with the provisions of the
regulations and guidance issued by the Insurance Regulatory and Development Authority as amended from time to time.
This Schedule forms part of the Terms and conditions attached herewith. Please quote the Policy Number in all your correspondences.
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 October 24, 2019 Consolidated Stamp Duty Paid to the
Government of Tamil Nadu.

GSTIN. 33AABCR7106G1ZQ PAN Number : AABCR 7106G IRDA Regn No. 102

For Royal Sundaram General Insurance Co. Limited,

Authorised Signatory
This document is digitally signed, hence counter signature / stamp is not required.

Service Provider Details:

The Following benefits (Second Opinion for Critical Illness, Emergency Domestic Evacuation, Worldwide Emergency Hospitalization and
International Treatment for 11 specified Critical Illness) are serviced through below mentioned Service Provider

Name of Service Provider: Europ Assistance India Ptvt. Ltd

Contact details of Service Provider: 91-22-67347878

Address of Service Provider: 301, C Wing, Business Square, Andheri Kurla Road,
Chakala, Andheri (E), Mumbai - 400093

Cashless claims will be serviced by the below mentioned TPA.

Name & Address of 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

39e42dadfaab60ac37e069d6e857396d

Signature Not
Verified
________________________________________________________________________________________ Digitally signed by NIKHIL
PRABHAKAR APTE
Customer Services Date: 2019.10.24
21:36:15 IST
Reason: For
Call: 1860 425 0000, Email: [email protected] RoyalSundaram
Location: Chennai

Lifeline | UIN-UIN-IRDAI/HLT/RSAI/P-H/V.II/32/15-16
 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: 1860-425-0000 Mobile: 94444 48899.
email:[email protected], Website: www.royalsundaram.in
IRDA Registration No.102 | CIN-U67200TN2000PLC045611

Name: BABU S Name: PARIMALA K A

Policy Number: MLF0000495 Policy Number: MLF0000495

Membership No:MLF0000495A Membership No:MLF0000495B

Date Of Birth: 01/02/1974 Date Of Birth: 05/06/1981

Valid From: 26/10/2019 Valid From: 26/10/2019

Name: RAKSHITH RAHUL B

Policy Number: MLF0000495

Membership No:MLF0000495C

Date Of Birth: 12/06/2000

Valid From: 26/10/2019