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:customer.services@royalsundaram.in, Website: www.royalsundaram.in
IRDA Registration No.102 | CIN-U67200TN2000PLC045611
May 12, 2021
JABEEN ANWAR GAIBEE
A/401 SADAF APT LIBERTY
HSG SOCIETY NR THAKUR BLDG
KISMAT COLONY RD
THANE
THANE
Maharashtra
400612
Suraksha Kawach - DCBSKH0003/SKC0004801000100
Dear JABEEN ANWAR GAIBEE
Thank you for choosing Royal Sundaram for your Suraksha Kawach policy.
We are delighted to have you as our customer.
We are enclosing the following documents pertaining to your plan:
1. Certificate of Insurance
2. Policy Terms & conditions
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 1860 425 0000. You can also chat with our executives
on www.royalsundaram.in
Assuring you of our best services at all times.
Yours sincerely,
Authorised Signatory
_______________________________________________________________________________
Customer Services
Call: 1860 425 0000 , Email: customer.services@royalsundaram.in
SURAKSHA KAWACH – UIN-RSAHLGP19010V011819
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:customer.services@royalsundaram.in, 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 SKC0004801000100
Policy Holder JABEEN ANWAR GAIBEE
Address A/401 SADAF APT LIBERTY
HSG SOCIETY NR THAKUR BLDG
KISMAT COLONY RD
THANE
THANE
400612
Maharashtra
Policy Period 06/05/2021 - 05/05/2022
Premium eligible for deduction under Section 80D
Particulars Gross Premium Goods & Services Tax Total Premium
Amount( in ) 2220 399.6 2619.6
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 2619.6 from JABEEN ANWAR GAIBEE 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: May 12, 2021
Note:
1) Exemption under the certificate issued above is applicable to the Hospital Cash portion of the Premium paid for Self
as per the provisions of Section 80 D of Income Tax Act 1961.
2) The above shown premium is part of the overall premium paid by the proposer for the Suraksha Kawach policy.
3) In case of any discrepancy, the Policyholder is requested to contact the Company immediately.
4) 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: customer.services@royalsundaram.in
SURAKSHA KAWACH - UIN-RSAHLGP19010V011819
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:customer.services@royalsundaram.in, Website: www.royalsundaram.in
IRDA Registration No.102 | CIN-U67200TN2000PLC045611
Suraksha Kawach
Certificate of Insurance
Name of Group Manager DCB Bank Ltd. Intermediary Code OA506664
Intermediary Name DCB Bank Ltd
Master Policy Number DCBSKH0003 Contact No. -
Certificate Number SKC0004801000100
Name of the Applicant /Insured JABEEN ANWAR GAIBEE Insured Address
Communication Address A/401 SADAF APT LIBERTY A/401 SADAF APT LIBERTY
HSG SOCIETY NR THAKUR BLDG HSG SOCIETY NR THAKUR BLDG
KISMAT COLONY RD KISMAT COLONY RD
THANE THANE
THANE THANE
400612 400612
Maharashtra Maharashtra
Policy Period: From 06/05/2021 To Midnight of 05/05/2022
Nominee Nominee Name Relationship with the Applicant Share of Address Contact
Details Benefit Number
Nominee Rashida juwaley MOTHER 100% A/401 SADAF APT
LIBERTY
A/401 SADAF APT
LIBERTY
HSG SOCIETY NR
THAKUR BLDG
KISMAT COLONY
RD
THANE
Details of Insured Person:
Insured Name Relationship with Gender Date of Birth Age PED / Disability
Applicant
JABEEN ANWAR SELF Female 24/02/1979 42
GAIBEE
Details of the Cover:
Section 4 (Hospital Cash)
Sum Insured per day: 5,000
Benefit period in days : 30 days per policy year
Base Covers Coverages
1 Coverage for Hospitalization Rs. 5,000 per day up to 30 days per policy year. The cover will
start after 48 hours of continuous hospitalisation. After 48hrs that
the payment will be made from day one only.
2 ICU Hospitalization Coverage In case of ICU - Sum insured Rs 10,000 per day up to 30 days
subject to the above condition.
Waiting Periods
Pre-existing Disease Waiting Period Not Covered
Initial Waiting Period 30 days
First year exclusion for specific diseases 12 months
________________________________________________________________________________________
Customer Services
Call: 1860 425 0000, Email: customer.services@royalsundaram.in
SURAKSHA KAWACH - UIN-RSAHLGP19010V011819
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:customer.services@royalsundaram.in, Website: www.royalsundaram.in
IRDA Registration No.102 | CIN-U67200TN2000PLC045611
List of 17 Specific diseases excluded for first 12 months: Cataract, Stones in biliary and urinary systems, Hernia /
Hydrocele, Hysterectomy for any benign disorder, Lumps / cysts / nodules / polyps / internal tumours, Gastric and
Duodenal Ulcers, Surgery on tonsils / adenoids, Osteoarthrosis / Arthritis / Gout / Rheumatism / Spondylosis /
Spondylitis / Intervertebral Disc Prolapse, Fissure Fistula / Haemorrhoid, Sinusitis / Deviated Nasal Septum /
Tympanoplasty / Chronic Suppurative Otitis Media, Benign Prostatic Hypertrophy, Knee/Hip Joint replacement,
Dilatation and Curettage, Varicose veins, Dysfunctional Uterine Bleeding / Fibroids / Prolapse Uterus / Endometriosis,
Diabetes and related complications, Chronic Renal Failure or end stage Renal Failure.
Intermediary Details
Intermediary Name Intermediary Code Intermediary Contact No Intermediary Address
DCB Bank Ltd OA506664 -
Premium Details
Particulars Gross Premium Goods & Services Tax Total Premium
Amount( in ) 2220 399.6 2619.6
This Certificate forms part of the Terms and Conditions attached herewith. Please quote the Certificate Number in all
your correspondences.
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 May 12, 2021
GSTIN. 29AABCR7106G1ZF 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.
________________________________________________________________________________________
Customer Services
Call: 1860 425 0000, Email: customer.services@royalsundaram.in
SURAKSHA KAWACH - UIN-RSAHLGP19010V011819
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:customer.services@royalsundaram.in, Website: www.royalsundaram.in
IRDA Registration No.102 | CIN-U67200TN2000PLC045611
Important Terms and Conditions:
I. Cancellation
The below grid will be followed for an annual policy.
i. Annual Policies
Completed tenure of Policy Retention of Premium
less than 1 month 25% of annual rate
between 1 month and 3 months 50% of annual rate
between 3 months and 6 months 75% of annual rate
Above 6 months full annual premium
ii. Policy with tenure more than one year
Policy year in which policy is cancelled, we shall retain the premium as per below grid. However, for rest of years 5% of the
pro-rated annual Premium amount shall be retained. Pro-rated annual rate will be arrived on the basis of pro-rated rate from the
entire tenure premium.
In the year of cancellation, below grid shall apply for more than one year policies.
Completed tenure of Policy Retention of Premium
less than 1 month 25% of annual rate
between 1 month and 3 months 50% of annual rate
between 3 months and 6 months 75% of annual rate
Above 6 months full annual premium
iii. Cancellation/Termination by Us
The Company may at any time cancel this Policy on the grounds of mis-representation, fraud, non-disclosure of material facts as
sought to be declared on the Proposal Form or non-cooperation by the insured, by giving fifteen (15) days notice in writing by
courier/registered post with acknowledgement due to the Insured at his last known address in which case the Company shall not
refund to the insured any portion of the premium.
The Insured may also cancel this Policy by giving fifteen (15) days notice in writing to the Company, for the cancellation of this Policy, in which
case the Company shall from the date of receipt of the notice cancel the Policy and refund the premium for the period his Policy will not be in force,
by retaining premium as per aforesaid cancellation clause, provided that no refund of premium shall be made if any claim has been made under the
Policy by or on behalf of the insured.
iv. Automatic Termination
The cover shall terminate immediately on the earlier of the following events:
Upon the death of the Insured Person in which case the Company will refund premium calculated on pro-rata basis for the
unexpired period subject there being no claim under the policy.
Claims Procedure:
Hospital Cash
The claim form duly completed in all respects along with all documents (if applicable) listed below should be submitted within 30
days from the date of hospitalisation:
1. Duly completed and signed claim form alongwith medical certificate from the attending physician forming part of the claim
form.
2. Discharge summary/Death Summary issued by the Hospital, in the event of a hospitalization, describing the nature of the
complaints and its duration, treatment given, advice on discharge etc.
3. Copy of hospitalization bill to confirm number of days stay in ICU
4. All medical reports and prescriptions from first consultation leading to diagnosis of the illness
5. Any other claim document as may be required by the Company
Acceptance of photocopies :Since this is a benefit policy, all medical records may be accepted in photocopies except in cases where
genuineness is suspected.
________________________________________________________________________________________
Customer Services
Call: 1860 425 0000, Email: customer.services@royalsundaram.in
SURAKSHA KAWACH - UIN-RSAHLGP19010V011819
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:customer.services@royalsundaram.in, Website: www.royalsundaram.in
IRDA Registration No.102 | CIN-U67200TN2000PLC045611
III. Important Exclusions:
Hospital Cash
The Company shall not be liable to make any payment under this Policy for or in respect of any claim directly or indirectly caused
by, based on, arising out of or howsoever attributable to any of the following;
i. Outpatient (OPD) treatment charges
ii. Alternative Treatment, Naturopathy, hydrotherapy, Ayurvedic, Homeopathy, Acupuncture, Reflexology, Chiropractic
treatment or any other form of indigenous system of medicine
iii. Dental treatment, dentures or surgery of any kind unless necessitated due to an accident and requiring minimum 24 hours
Hospitalization or treatment of irreversible bone disease involving the jaw which cannot be treated in any other way, but not
if it is related to gum disease or tooth disease or damage.
iv. Circumcision unless necessary for treatment of a disease, illness or injury.
v. Birth control procedures, contraceptive supplies or services including complications arising due to supplying services,
hormone replacement therapy and voluntary termination of pregnancy during the first 12 weeks from the date of
conception, surrogate or vicarious pregnancy.
vi. Any treatment arising from or traceable to pregnancy (including voluntary termination), miscarriage (unless due to an
accident), childbirth, maternity (including Caesarean section), abortion or complications of any of these. This exclusion
will not apply to ectopic pregnancy.
vii. Alopecia, baldness, wigs, or toupees and hair fall treatment,
viii. Laser surgery for treatment of focal error correction other than for focal error of +/- 7 or more and is Medically Necessary.
ix. All conditions directly or indirectly caused due to or associated with human T-cell Lymph tropic virus type III (HTLV-III or
IITLB-III) or Lymphadinopathy Associated Virus (LAV) and its variants or mutants, Acquired Immune Deficiency
Syndrome (AIDS) whether or not arising out of HIV, AIDS related complex syndrome (ARCS) and all diseases/Illness/Injury
caused by and/or related to HIV.
x. All sexually transmitted diseases including but not limited to Genital Warts, Syphilis, Gonorrhoea, Genital Herpes,
Chlamydia, Pubic Lice and Trichomoniasis.
xi. Artificial life maintenance, including life support machine use, where such treatment will not result in recovery or
restoration of the previous state of health.
xii. Developmental problems including learning difficulties eg. Dyslexia, behavioural problems including attention deficit
hyperactivity disorder (ADHD)
xiii. Sleep Apnea Syndrome, general debility, ageing, convalescence, sanatorium treatment, rehabilitation measures, private
duty nursing, respite care, run down condition or rest cure, congenital external anomalies or defects, sterility, fertility,
infertility including IVF and other
assisted conception procedures and its complications, subfertility, impotency, venereal disease, puberty, menopause or
intentional self-injury, suicide or attempted suicide (whether sane or insane), ailment requiring treatment due to use,
abuse or a consequence or influence of any substance, intoxicant, drug, alcohol or hallucinogen and treatment for de-addiction,
or rehabilitation.
xiv. Any treatment received in convalescent homes, convalescent hospitals, health hydros, nature cure clinics or similar
establishments.
xv. A stay without undertaking any treatment or any other purpose other than for receiving eligible treatment of a type that
normally requires a stay in the hospital.
xvi. Treatment of any mental illness or sickness or disease including a psychiatric condition, disorganization of personality or
mind, or emotions or behaviour, including stress, Parkinsons or Alzheimer's disease even if caused or aggravated by or related
to an Accident or Illness or general debility or exhaustion ("run-down condition").
xvii. Any Cosmetic Surgery, aesthetic treatment (including but not limited to xanthelesema, syringoma, acne and alopecia)
unless forming part of treatment for cancer or burns, surgery for sex change or treatment of obesity/morbid obesity (unless
certified to be life threatening) or treatment/surgery /complications/illness arising as a consequence thereof.
xviii. X-ray or laboratory examinations or other diagnostic studies not consistent with or incidental to the diagnosis and
treatment even if the same requires confinement at a Hospital.
xix. Organ transplant surgery involving organs not harvested from a human body.
xx. Any condition caused by ionizing radiation or contamination by radioactivity from any nuclear fuel or from any nuclear
waste from the combustion of nuclear fuel.
xxi. A condition directly or indirectly, caused by or arising from or attributable to foreign invasion, act of foreign enemies,
hostilities, warlike operations (whether war be declared or not or while performing duties in the armed forces of any country),
civil war, public defence, rebellion, revolution, insurrection, military or usurped power, active participation in strikes, riot or
civil commotion.
xxii. Any physical, medical or mental condition or treatment or service that is specifically excluded in the Policy Schedule/
Certificate of Insurance under Special Conditions.
xxiii. Any Hospitalization of the Insured Person due to him committing any breach of law with criminal intent.
xxiv. Any Certification / Diagnosis / Treatment by a family member, or a person who stays with the Insured Person, or from
persons not registered as Medical Practitioners under the respective Medical Councils, or from a Medical Practitioner
________________________________________________________________________________________
Customer Services
Call: 1860 425 0000, Email: customer.services@royalsundaram.in
SURAKSHA KAWACH - UIN-RSAHLGP19010V011819
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:customer.services@royalsundaram.in, Website: www.royalsundaram.in
IRDA Registration No.102 | CIN-U67200TN2000PLC045611
who is practicing outside the discipline that he is licensed for, or any diagnosis or treatment that is not scientifically
recognized or Unproven Experimental Treatments or pharmacological regimens, or any form of clinical trials or any
kind of self-medication and its complications.
xxv. Any treatment arising out of Adventure or Hazardous Sports
IV. Free Look Provision:
At the inception of the policy the Insured Person will be allowed a period of 15 days (30 days for Telesales, Online and Web
aggregators) from the date of receipt of the policy to review the terms and conditions of the policy and to return the same if
not acceptable. If Insured Person has not made any claim during the free look period, he will be entitled to the following,
provided no claim has been settled or lodged for the period the policy has been in force:
a) A refund of the premium paid less any expenses incurred by the Insurer on medical examination of the insured person and
the stamp duty charges or;
b) where the risk has already commenced and the option of return of the policy is exercised, a deduction towards the
proportionate risk premium for period on cover or;
c) Where only a part of the risk has commenced, such proportionate risk premium commensurate with the risk covered during
such period.
All rights under this Policy shall immediately stand extinguished on the free look cancellation of the Policy.
V. Notices:
1. Notices Any notice, direction or instruction given under this Policy shall be in writing and delivered by hand, post, or
facsimile to: a. Policyholder/Insured Person at the address specified in the Policy Schedule/Certificate of Insurance
or at the changed address of which the Company must receive written notice.
2. The Company at the following address:
M/s. Royal Sundaram General Insurance Co. Limited.,
Corporate office: Vishranthi Melaram Towers, No. 2 / 319 Rajiv
Gandhi Salai (OMR), Karapakkam, Chennai 600097
3. the Company may send the Insured Person other information through electronic and telecommunications means with respect
to the Policy from time to time
________________________________________________________________________________________
Customer Services
Call: 1860 425 0000, Email: customer.services@royalsundaram.in
SURAKSHA KAWACH - UIN-RSAHLGP19010V011819
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:customer.services@royalsundaram.in, Website: www.royalsundaram.in
IRDA Registration No.102 | CIN-U67200TN2000PLC045611
GST Invoice
Royal Sundaram General Insurance Co. Limited
XO : XO-BANGALORE MARTHAHALLI
Address:
Survey No.26/2, Kadubisinahalli Village , Varthur Hobli, ,Bellandur Post
BENGALURU - 560103, KARNATAKA
GSTIN: 29AABCR7106G1ZF
Policy Number : SKC0004801000100
GST Invoice Number : SKC000480100000
Invoice Date : 06/05/2021
Insured/Recipient Name and Address:
JABEEN ANWAR GAIBEE
A/401 SADAF APT LIBERTY, HSG SOCIETY NR THAKUR BLDG, KISMAT COLONY RD
THANE, THANE
State: MAHARASHTRA
Pincode: 400612
Place of Supply: MAHARASHTRA
State Code : 27
Accounting code of service :997133
Accident and health insurance services
Taxable Premium 2,220
IGST 18% 399.6
Gross Premium 2,619.6
Branch code : XO-BANGALORE MARTHAHALLI
Address:
Survey No.26/2, Kadubisinahalli Village , Varthur Hobli, ,Bellandur Post
BENGALURU - 560103, KARNATAKA
Indication if tax payable under reverse charge - No
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
