This document serves as a comprehensive knowledge base for an Agentic AI to provide detailed information regarding SBI General Health Insurance products, coverage options, and premium calculation logic.

—

### I. Portfolio Overview and Strategic Positioning
SBI General Insurance operates as a joint venture between the State Bank of India and global entities, offering a tiered ecosystem of health insurance products designed for various socioeconomic profiles, from middle-income families to High Net Worth Individuals (HNI). The portfolio addresses high medical inflation (estimated at 14-15% annually) through modular product architectures like the **Health Alpha** and **Super Health** series.

**Key Systemic Benefits:**
* **0% GST:** Effective September 22, 2025, individual and family floater health insurance is available at 0% GST to enhance affordability.
* **Network:** Access to over 18,324 network hospitals across India.
* **Solvency and Performance:** The company reports a solvency ratio of 2.03 and a claim settlement ratio of 95.11%.

—

### II. Core Health Insurance Products

#### 1. SBI General Health Alpha
Health Alpha is a next-generation customizable product featuring two mandatory base covers (Hospitalization and/or Personal Accident) and over 35 optional covers.

* **Variants:**
* **Alpha Select:** Targets Tier 2 cities and individuals under 45 years with mid-range SI options.
* **Alpha Ultimate:** High-value segment for urban middle-income and HNI, offering Sum Insured (SI) up to “Unlimited”.
* **Alpha Senior:** Specialized for customers aged 56+ with sub-variants like Prime and Ultima.
* **Sum Insured Options:** Ranges from ₹5 Lakhs to Unlimited SI. Options include 5, 7.5, 10, 12.5, 15, 20, 25, 30, 35, 50, 75, 100, 150, 200, 250, 300 Lakhs and Unlimited.
* **Actuarial Innovation:**
* **Endless Sum Insured:** For SI ≥ ₹10 Lakhs, it provides one lifetime claim without any limit on the Base SI.
* **Plan Ahead:** Continuity benefit for waiting periods transferred to newly married spouses (up to 35 years) or newborn children added within 120 days.
* **Gym & Sports Injury Cover:** Includes specialist consultations, diagnostics, and physical therapy for fitness-related injuries.

#### 2. SBI General Super Health Insurance
Super Health focuses on built-in multipliers and multi-dimensional safeguards.

* **Variants:**
* **Elite/Prime:** Basic multipliers with standard room rent caps; SI ₹3 Lakh to ₹10 Lakh.
* **Premier:** Expanded daycare procedures; SI ₹15 Lakh to ₹25 Lakh.
* **Platinum:** No room rent sub-limits, includes global cover; SI ₹30 Lakh to ₹75 Lakh.
* **Platinum Infinite:** Highest tier; includes Loyalty Credit (50% SI increase irrespective of claims); SI ₹1 Crore to ₹2 Crore.
* **Key Feature Covers:**
* **Health Multiplier:** Increases SI by 2x or 3x if diagnosed with one of 37 listed serious illnesses.
* **ReInsure Benefit:** Unlimited reinstatement of SI for both related and unrelated illnesses after partial or complete exhaustion.
* **Claims Shield:** Covers non-medical consumables (gloves, masks, etc.) to minimize out-of-pocket costs.

#### 3. SBI General Health Edge
Positioned as a modular, budget-friendly plan with a starting daily premium as low as ₹15-₹17.
* **Sum Insured:** ₹3 Lakhs to ₹25 Lakhs.
* **Core Benefit:** Unlimited SI Refill for both related and unrelated illnesses.
* **Structure:** 9 basic indemnity covers and 18 optional add-ons.

#### 4. Top-Up and Super Top-Up Plans
* **Arogya Top Up:** Activates after a *single* claim exceeds the chosen deductible.
* **SBIG Health Super Top-Up:** Activates based on the *cumulative total* of all claims in a policy period exceeding the deductible. Offers SI up to ₹4 Crore and deductibles from ₹2 Lakh to ₹2 Crore.

—

### III. Optional Covers and Add-Ons (Detailed)
The portfolio allows deep customization through specific riders:
* **Transportation:** Road Ambulance, Air Ambulance (Domestic), and Radio Cab (for transport to/from hospital).
* **Wellness:** Health Assistance (AI Coaching), Dietician e-consultations, and Unlimited Gym Membership.
* **Lifestyle & Specialized Surgery:** Bariatric Surgery (for obesity with BMI ≥ 40 or ≥ 35 with co-morbidities), Reconstructive Surgery (following accidents), Prosthetics, and Gender Reassignment (compliant with 2019 Act).
* **Financial Modifiers:** Voluntary Deductible (Annual Aggregate or Per Claim) and Voluntary Co-Payment (10% or 20%) to reduce premiums.
* **Care-based:** Companion Cover (daily cash for an adult accompanying the insured) and Home Modification Benefit (for adjustments due to disablement).

—

### IV. Eligibility, Waiting Periods, and Exclusions

#### 1. Eligibility Criteria
* **Entry Age (Adults):** Minimum 18 years; most plans have no maximum entry age for lifelong renewability.
* **Entry Age (Children):** From 91 days up to 25 or 30 years depending on the plan.
* **Family Floater:** Typically covers up to 4 adults and any number of children (including parents and parents-in-law).

#### 2. Waiting Periods (Standard)
* **Initial Waiting Period:** 30 days for all illnesses except accidental hospitalization.
* **Specific Diseases:** 12 to 24 months for procedures like cataract, hernia, joint replacement, etc.
* **Pre-Existing Diseases (PED):** Standard 24 to 48 months. *Note: Health Alpha and Super Top-Up allow reduction of PED waiting to 12 months for an extra premium.*
* **Maternity:** 24 months (Family Floater) to 48 months (Single Adult).

#### 3. Standard Exclusions
* Investigation/Evaluation only.
* Cosmetic or plastic surgery (unless reconstructive).
* Breach of law with criminal intent.
* Alcoholism, drug, or substance abuse.
* Sterility and infertility (unless specific ART cover is opted).

—

### V. Premium Determination and Calculation Logic

#### 1. Fundamental Determinants
* **Age:** Premiums are grouped into “age bands” and increase as risk susceptibility rises with age.
* **Sum Insured:** Higher coverage increases premiums, though not proportionately.
* **Geography (Zone-Based Pricing):**
* **Zone A:** Metro cities (Delhi/NCR, Mumbai, etc.) with higher treatment costs and premiums.
* **Zone B:** Rest of India; typically eligible for a ~20% discount compared to Zone A.
* *Warning:* Relocating from Zone B to Zone A without informing the insurer may trigger a 10-20% co-payment on claims.

#### 2. Discounts
* **Family Discount:** 2 members (25%), 3 members (30%), >3 members (35%).
* **Term Discount:** For multi-year payments (e.g., 4% for 2 years, 7.5% to 9% for 3 years).
* **Online/Direct:** 10% to 15% discount for digital purchases.
* **Wellness (Walk Healthy):** Up to 30% discount on renewal premium based on step count achievements.
* **Welcome Discount:** 5% if purchased within 5 days of receiving a quote.

#### 3. Calculation Algorithm (Reference: Health Alpha Select)
To calculate final premium:
1. **Determine Individual Base Office Premium** based on Age Band and SI.
2. **Apply Base Modifiers** (e.g., Room Rent Category discount: 7.5% for Single Private AC, 10% for Twin Sharing).
3. **Apply Aggregate & Floater Discount** based on total members.
4. **Add Optional Cover Premiums** (Maternity, OPD, Critical Illness, etc.).
5. **Apply Zonal Modifier** (20% discount for Zone B).
6. **Add GST (0% as of Sept 2025).**

—

### VI. Premium Reference Tables

#### Table A: Health Alpha Select Individual Base Premiums (Zone A, Excl. GST)
| Age Band | SI: 5 Lakh | SI: 10 Lakh | SI: 25 Lakh | SI: 50 Lakh | SI: 1 Crore |
| :— | :— | :— | :— | :— | :— |
| **0-17** | 5,423.00 | 6,500.00 | 9,750.00 | 11,777.00 | 13,558.00 |
| **18-35** | 6,943.00 | 8,321.00 | 12,482.00 | 15,078.00 | 17,358.00 |
| **36-40** | 8,131.00 | 9,746.00 | 14,620.00 | 17,661.00 | 20,332.00 |
| **46-50** | 11,911.00 | 14,277.00 | 21,416.00 | 25,870.00 | 29,784.00 |
| **61-65** | 32,921.00 | 39,468.00 | 59,299.00 | 71,574.00 | 82,302.00 |

#### Table B: Super Health Prime – Single Adult Base Premiums (Office Premium)
| Age Band | SI: 5 Lakh | SI: 10 Lakh | SI: 15 Lakh | SI: 25 Lakh |
| :— | :— | :— | :— | :— |
| **18-35** | 7,904 | 9,313 | 10,378 | 12,398 |
| **36-45** | 9,242 | 10,904 | 12,122 | 14,462 |
| **56-60** | 22,799 | 26,572 | 29,127 | 34,477 |
| **76-80** | 65,578 | 77,403 | 84,992 | 1,00,592 |

#### Table C: Add-on Cost Relativity Examples
* **OPD Cover:** Base Rate ₹9,175 × Limit Relativity (0.30 for ₹5k limit) × Member Relativity (1.20 for 2 members).
* **Critical Illness (CI):** Premium = (CI SI / 1,000) × Per Mille Rate (e.g., 2.01 for ages 31-35; 42.06 for 61-65).
* **Hospital Daily Cash (HDC):** Age 36-40 (₹413 for ₹1k limit); Age 61-65 (₹1,347 for ₹1k limit).

—

### VII. Claims and Operational Procedures
* **Claim Types:**
* **Cashless:** Only at Network Hospitals. Requires pre-authorization (planned: 72 hours prior; emergency: within 24 hours of admission).
* **Reimbursement:** For non-network hospitals. Must intimate within 24-48 hours and submit documents within 30 days of discharge.
* **Required Documents:** Duly filled claim form, discharge summary, final hospital bills, investigation reports, and KYC documents (Aadhar/PAN).
* **Timelines:** Claims are typically settled or rejected within 15 days of receipt of all documents. Failure to meet timelines entitles the claimant to interest at bank rate plus 2%.