To Date : 14-09-2021
ANANTHAGIRI INDUSTRIES PRIVATE LIMITED
B3, 464,16-3-V, VASANTH NAGAR,KUKATPALLY, MEDCHAL
HYDERABAD
Hyderabad TS, TELANGANA - 500088, INDIA
Subject : Policy Number : 4101210900000063-00
Dear Customer,
Welcome to SBI General.Thank you for choosing SBI General's Group Health Insurance Policy.We are
delighted to have you as our esteemed Customer.
We enclose the following documents pertaining to your Policy :
- Policy Schedule
- Policy Clauses & Wordings
- Grievance Redressal Letter
We have taken care that the documents reflect details of risk and cover as proposed by you. We
request you to verify and confirm that the documents are in order. Please ensure safety of these
documents as they form part of our contract with you. For all your future correspondence you may
have with us, kindly quote your Customer ID and Policy Number.
Customer ID : C09251
Policy Number : 4101210900000063-00
The Postal Address of your SBI General Branch that will service you in future is :
SBI GENERAL INSURANCE CO LTD - HYDERABAD,# 6-3-669/1, 3rd Floor, Ozone Commercial Complex,
Punjagutta Main Road, Hyderabad – 500082,,Hyderabad,ANDHRA PRADESH,INDIA-0,INDIA.
In case of any queries or suggestions, please do not hesitate to get in touch with us. You can
contact us at [email protected] or call our Customer Care Number 1800-102-1111 / 1800-
22-1111.
We look forward to a continuing and mutually beneficial relationship.
Yours sincerely,
Authorized Signatory
SBI General Insurance Company Ltd., Registered Office: & Corporate Office: SBI General Insurance
Company Ltd. 301, Natraj, Junction of Western Express Highway & Andheri Kurla Road, Andheri
(East), Mumbai – 400069.
CIN U66000MH2009PLC190546, IRDAI Registration No : 144
GROUP HEALTH INSURANCE POLICY - POLICY SCHEDULE
UIN - SBIHLGP21330V022021
SCHEDULE
Policy No : Servicing Branch Office : Issue Date :
4101210900000063-00 SBI GENERAL INSURANCE CO LTD - HYDERABAD,# 6-3- 14-09-2021
669/1, 3rd Floor, Ozone Commercial Complex,
Punjagutta Main Road, Hyderabad –
500082,,Hyderabad,ANDHRA PRADESH,INDIA-0,INDIA.
Intermediary Details :
Intermediary Name SBI BALANAGAR 6854
Intermediary Code 108779
Intermediary Contact Details Mobile No. Landline No. 9999999999
Insured Details :
Name of the Insured/Proposer : ANANTHAGIRI INDUSTRIES PRIVATE LIMITED
Address : B3, 464,16-3-V, VASANTH NAGAR,KUKATPALLY,
MEDCHAL
HYDERABAD
Hyderabad TS, TELANGANA - 500088, INDIA
Period of Insurance : From 06-09-2021 (00:00:00 Hrs) to 05-09-
2022 (23:59:59 Hrs)
Previous insurance policy no, if any : N/A
Name of the Administrator / TPA : MEDI ASSIST INSURANCE TPA PRIVATE LTD
No of Primary Insured Persons covered : 95 Employees
Total No of Insured Persons Covered : 251 [Commencement of Policy]
Total Sum Insured : 21,550,000.00
Details of Insured Persons : As per annexure attached
Compulsory Co-pay (If Applicable) : As per Category Sheet (Annexure A)
Add on Covers Opted : As per Category Sheet (Annexure A)
GST No : 36AASCA8444M1ZW
Coinsurance Details : 100.00%
CIN U66000MH2009PLC190546, IRDAI Registration No : 144
GROUP HEALTH INSURANCE POLICY - POLICY SCHEDULE
Attached to and forming part of Group Health Policy No 4101210900000063-00
Additional Conditions : Subject to the following additional Conditions and attached Clauses /
Endorsements / Warranties :
* Pre/Post Hospitalization covers for 30/60 days respectively.
* Cashless and Reimbursement Policy.
* Pre-Existing Diseases exclusion waiver waived for all members, First 30 Days Exclusion waiver
waived for all members. 1st Year exclusion waiver waived for all members.
* Employees shall be covered from DOJ subject to availability of sufficient CD balance being
maintained with insurer.
*Mid term increase in SI is not allowed.
*. Addition/deletion shall be done on prorata basis once in a month only subject to data being
provided to us by 15th of succeeding month.
*No individual can be covered more than once in the policy ? specifically if an employee and
spouse are working for the same organization both cannot cover each other . In case at the time
of claim it is found that the member is covered more than once, a deletion endorsement (without
any refund) of such member will be effected to ensure he/she is covered only once.
*For all admissible claims where treatment is taken at hospitals/nursing homes which are not in
the list of network hospitals empanelled by the Company/Administrator, insured person shall bear
10% of the eligible admissible claim.
*The policy excludes treatment with or coverage of Cochlear Implant Procedure, Femtolaser,
Retrograde intra renal surgery, Quantum magnetic resonance therapy, Holter monitoring unless
otherwise specifically covered as per Policy Schedule
*Mid term inclusion of Spouse & children shall only be allowed only in case of marriage, child
birth and legal adoption. The same is to be intimated to us within 30 days from date of
marriage/child birth/adoption.
*Advance Procedures
Covered wherever Medically Indicated either as in patient or as part of day care treatment in a
hospital up to 50% of Sum Insured? for below mentioned procedure
A. Uterine Artery Embolization and HIFU (High Intensity Focused Ultrasound)
B. Balloon Sinuplasty
C. Deep Brain Stimulation
D. Oral Chemotherapy
E. Immunotherapy - Monoclonal Antibody to be given as injectionF. Intra Vitreal Injections
G. Robotic SurgeriesH. Stereotactic Radio SurgeriesI. Bronchial Thermoplasty
J. Vaporisation of the Prostrate ( Green Laser Treatment or Holmium Laser Treatment)
K. IONM - (lntra Operative Neuro Monitoring)
L. Stem Cell Therapy: Hematopoietic stem cells for bone marrow transplant for haematological
conditions to be covered
*Administration/ Registration/ Service Charges & Misc. Charges are not payable
*Minimum and Maximum age at entry for Employee are 18 years and 65 years respectively. Dependent
children covered upto 23 years of age (unmarried and financially dependent only) for all
employees.Census Exception : Mr CHINTHIREDDY ANANTHAREDDY (Emp ID-K001) and spouse aging >65 are
covered as an one time exception under the policy.
*Domicilary Hospitalization 20% of SI to a maximum of Rs. 20000
*Maternity Benefit Cover for employee and spouse only. Upto 2 living births only. Normal
CIN U66000MH2009PLC190546, IRDAI Registration No : 144
GROUP HEALTH INSURANCE POLICY - POLICY SCHEDULE
Attached to and forming part of Group Health Policy No 4101210900000063-00
delivery limit: Rs. 25000 and caesarean section limit: Rs. 40000
*Pre-natal/ Post natal hospialization expenses covered up to Rs. 5000 within Maternity benfit
limit.
*9 months Waiting Period not Applicable
*Baby cover from Day 1 Within floater SI
*Congenital internal disease cover Covered for all within floater SI . External Congential
covered for Life threatening condition only. Purely Non-Cosmetic in nature.
*Ambulance charges Covered upto 1% of SI or Rs. 1,500 per family whichever is less
*Room Rent Capping In case insured opts for a higher room category than eligibility:1) For
normal Room & ICU / ICCU / NICU : Proportionate deductions will be applicable on defined
nullassociate medical expenses.Associated Medical Expenses shall include Room Rent, nursing
charges, operation theatre charges, fees of Medical Practitioner/surgeon/ anaesthetist/
Specialist conducted within the same Hospital where the Insured Person has been admitted. The
below expenses are not part of associate medical expenses a. Cost of Pharmacy and consumables b.
Cost of implants and medical devices c. Cost of diagnostics
2) For admission in ICU / ICCU - proportionate deduction will only be done on the ICU / ICCU
room rent, and not on any other associated medical expenses etc. Room Rent is inclusive of
nursing charges
*Genetic Disorder 25% of Individual or Family SI Limit or Rs. 2 Lakhs per insured which ever is
lower subject to available Balance SI
*HIV/AIDS/Mental Illness 10% of Individual or Family SI limit or Rs 1 lac per insured whichever
is lower subject to available Balance SI.
*Toric Lens covered upto 30,000/- per eye
*Treatment for Refractive Error Covered with refractive error +/- 7.5
* All other terms and conditions as per Group Health Insurance Policy wordings as attached
CIN U66000MH2009PLC190546, IRDAI Registration No : 144
GROUP HEALTH INSURANCE POLICY - POLICY SCHEDULE
Attached to and forming part of Group Health Policy No 4101210900000063-00
Premium Computation
Particulars Amount ( INR )
Gross Premium 614,406.99
CGST : @9.00% 55,296.63
SGST : @9.00% 55,296.63
Final Premium 724,999.25
Collection Details: Receipt No. 4401210900000160 Receipt Date. 14-09-2021
Consolidated Stamp Duty paid INR 25.0/- towards Insurance Policy Stamps vide Order No.
CSD/360/2019/917/19 Dated 13-03-2019 of General Stamps Office Mumbai.
P.S. If premium paid through cheque, the policy is void abinitio in case of dishonour of cheque.
Signed at : Mumbai HO For SBI General Insurance Company Limited
Date : 14-09-2021 Signatory :
CIN U66000MH2009PLC190546, IRDAI Registration No : 144
GROUP HEALTH INSURANCE POLICY - POLICY SCHEDULE
Attached to and forming part of Group Health Policy No 4101210900000063-00
Important Note :
Please examine this Policy including its attachment Schedule/ Annexture if any. In the event of any
discrepancy, contact the office of the Company immediatelt, it being noted that this Policy shall
be otherwise considered as being entirely in order.
In case of payment by cheque, in the event dishonor of cheque for any reason whatsover, insurance
provided under this document automatically stands cancelled from the inception irrespective of
whether a seperate communication is sent or not.Any claim arrising or related to consequences of
the pre-existing disease is excluded from the scope of policy cover unless the same is covered on
payment of premium and coverage terms mentioned in the schedule.
This is a Contract between the Company and the Insured Person(s). The Insured Person(s) shall not
transfer, assign, alienate or in any way pass the benefits and /or liabilities to any other person,
institution, hospital, company or body corporate without specific approval in writing by a duly
authorised officerof the company. However, if the Insured Person(s) is permanently incapacitated or
deceased, the legal heirs of the insured may represent him in respect of claim under the policy.
All terms, conditions and exclutions as per standard policy wordings attached with this schedule.
CIN U66000MH2009PLC190546, IRDAI Registration No : 144
GROUP HEALTH INSURANCE POLICY - POLICY SCHEDULE
Attached to and forming part of Group Health Policy No 4101210900000063-00
ANNEXURE 'A' (Category Chart)
Group SI 1.5 LAC
Covers LIMITS
Family Definition Floater option SELF + SPOUSE + 2 CHILD.
Type of Cover Family Floater
Sum Insured 150,000.00
IN-PATIENT Maximum limit : 150,000.00
CONGENITAL DISEASE Maximum limit : 150,000.00
PRE-EXISTING DISEASE Maximum limit : 150,000.00
DOMICILIARY Maximum limit : 20,000.00
MATERNITY Maximum limit : 25,000.00
PRE-NATAL AND POST-NATAL COMBINED Maximum limit : 5,000.00
MATERNITY (CAESAREAN) Maximum limit : 40,000.00
PRE-NATAL AND POST-NATAL COMBINED Maximum limit : 5,000.00
NEW BORN BABY Maximum limit : 150,000.00
BED LIMIT Maximum limit : 1,500.00
INTENSIVE CARE UNIT Maximum limit : 3,750.00
AMBULANCE ONLY Maximum limit : 1,500.00
First year exclusion waiver Yes
30 Days exclusion waiver Yes
Pre Hospitalization Yes 30.0 day(s)
Post Hospitalization Yes 60.0 day(s)
COPAY Yes, Network copay : 0.0% & Non-Network copay :
10.0%
CIN U66000MH2009PLC190546, IRDAI Registration No : 144
GROUP HEALTH INSURANCE POLICY - POLICY SCHEDULE
Attached to and forming part of Group Health Policy No 4101210900000063-00
ANNEXURE 'A' (Category Chart)
Group SI 2.5 LAC
Covers LIMITS
Family Definition Floater option SELF + SPOUSE + 2 CHILD.
Type of Cover Family Floater
Sum Insured 250,000.00
IN-PATIENT Maximum limit : 250,000.00
CONGENITAL DISEASE Maximum limit : 250,000.00
PRE-EXISTING DISEASE Maximum limit : 250,000.00
DOMICILIARY Maximum limit : 20,000.00
MATERNITY Maximum limit : 25,000.00
PRE-NATAL AND POST-NATAL COMBINED Maximum limit : 5,000.00
MATERNITY (CAESAREAN) Maximum limit : 40,000.00
PRE-NATAL AND POST-NATAL COMBINED Maximum limit : 5,000.00
NEW BORN BABY Maximum limit : 250,000.00
BED LIMIT Maximum limit : 3,750.00
INTENSIVE CARE UNIT Maximum limit : 6,250.00
AMBULANCE ONLY Maximum limit : 1,500.00
First year exclusion waiver Yes
30 Days exclusion waiver Yes
Pre Hospitalization Yes 30.0 day(s)
Post Hospitalization Yes 60.0 day(s)
COPAY Yes, Network copay : 0.0% & Non-Network copay :
10.0%
CIN U66000MH2009PLC190546, IRDAI Registration No : 144
GROUP HEALTH INSURANCE POLICY - POLICY SCHEDULE
Attached to and forming part of Group Health Policy No 4101210900000063-00
ANNEXURE 'B'
Sr No Name of the Co-Insurance Base Premium Tax (In INR) Final Premium
Insurance Share (%) (In INR) (In INR)
Company
1 SBI General 100.00
Insurance Co.
Ltd.-SBI
Total 100.00
CIN U66000MH2009PLC190546, IRDAI Registration No : 144
GROUP HEALTH INSURANCE POLICY - POLICY SCHEDULE
Attached to and forming part of Group Health Policy No 4101210900000063-00
INTIMATING A CLAIM
For Intimating a Claim with us please contact us through the following channels :
Phone : 1800-102-1111/1800-22-1111(Toll Free 8:00 am to 8:00 pm from Monday to Saturday)
Email - [email protected]
Facsimile - 1800-102-7244/1800-22-7244(Toll Free)
CLAIM SETTLEMENT
The Company will settle the claim under this policy within 30 days from the date of receipt of
necessary documents required for assessing the claim. In the event that the Company decides to
reject a claim made under this policy, the Company shall do so within a period of thirty days of
the Survey Report or the additional Survey Report, as the case may be, in accordance with the
provisions of Protection of Policyholder's Interest Regulations 2017.
CIN U66000MH2009PLC190546, IRDAI Registration No : 144
