STAR HEALTH AND ALLIED INSURANCE CO.Ltd.

,
No.15, SRI BALAJI COMPLEX,1st FLOOR, WHITES LANE,ROYAPETTAH,CHENNAI-
600014.
Customer Care Number - 044 6900 6900 / Corporate Customers - 044 43664666

Chat - +91 9597652225, www.Starhealth.in

BILL ASSESSMENT SHEET - MEMBER PAYMENT

Intimation No CIR/2024/161115/0435635 Bill Approved Date 25-07-2023

Insured Name Mr.SANJEEV ARORA Policy No P/161115/01/2023/026009

Certificate of Insurance
No.
Claimant Name MANYA ARORA Product Name Family Health Optima Insurance Plan
DOB/Age 22/07/2002 - 20 years
Policy Period 31-03-2023 to 30-03-2024
Address : 5/30, NEW COLONY,
NEAR SUNHERI MASZID, Hospital Name Kanpur Medical centre Pvt. Ltd.
FARRUKHABAD
FARRUKHABAD (FATEHGARH) Hospital Address #120/500 (24),,Lajpat Nagar
Pincode : 209625 KANPUR - 208005
FARRUKHABAD Uttar Pradesh
UTTAR PRADESH
Telephone : 9598431001 DOA 05-07-2023
DOD 07-07-2023
Sum Insured 500000
Bonus 275000 Final Diagnosis CHOLELITHIASIS,
Copay % 0.0%
SM Code / Name SH12369 / Mr.SATISH PAINULY

Intermediary Code / BA0000470969 / Mrs.SANGITA RANI ICD Codes Desc K80,

Name SECTION

Hospitalisation Expenses
Amount Disallowed
Approve
Nature of Amount Non Proportionate
SNo Bill No Bill Date d Disallowance Reasons / Remarks
Expenditure Claimed Payable Deduction
Amount
(A) (B)

IRDA Regn.No.129
Corporate Identity Number L66010TN2005PLC056649
Email ID : info@starhealth.in
 Amount Disallowed
Approve
Nature of Amount Non Proportionate
SNo Bill No Bill Date d Disallowance Reasons / Remarks
Expenditure Claimed Payable Deduction
Amount
(A) (B)
Total

Deductibles (A + B)

Hospital Discounts

Network Hospital Discounts

Deductions

NET AMOUNT (Total - Deductibles,

Hospital Discounts
& Deductions)

IRDA Regn.No.129
Corporate Identity Number L66010TN2005PLC056649
Email ID : info@starhealth.in
Amount claimed 0

Total Deductions 0

a. Non payable 0

b. Proportionate Deductions 0

Approved Amount (after Total Deductions) 0

Less: Hospital Discounts 0

Less: Other deductions 0

Net Amount (Approved amount - Hospital

0
discounts and other deductions )

Amount considered 0

Co-Pay Amount 0

Amount considered after co pay

Exceeds sub limit 0

Less: Amount settled by other Insurer 0

Exceeds Sum Insured 0

Amount payable 0

Claim Restrictions 0

Installment Premium Adjusted 13652

Preauth approved amount 54000

Amount payable to Hospital 40348

Payable to Insured 0

Less amount already paid to Insured 0

Balance payable to Insured 0

IRDA Regn.No.129
Corporate Identity Number L66010TN2005PLC056649
Email ID : info@starhealth.in
Pre Hospitalisation Expenses

Amount Approved
Nature of Non Payable
S.No Bill No Bill Date Claimed Amount Disallowance Reasons / Remarks
Expenditure (B)
(A) (C)
BILL DATED 3.7 NO
1 Professional Fees 950 950 PRESCRIPTION HENCE
DISALLOWED,
BILL DATED 3.7 RS 400 , RS 375 ,
Investigation and
2 4005 3255 750 4.7 RS 2480, NO REPORT HENCE
Diagnostics
DISALLOWED
BILL DATED 3.7 NO
3 a)Medicines 325 205 120 PRESCRIPTION HENCE
DISALLOWED
Total 5280 870

Eligible Amt (As per Policy)

Amount payable 870

Co pay Amount 0.0% 0

Net Payable / Eligible Amt * (After Co-pay) 870

Exceeds the limit

Amount already paid to insured 0

Balance payable to Insured 870

Post Hospitalisation Expenses

Amount
Nature of Non Payable Approved
S.No Bill No Bill Date Claimed Disallowance Reasons / Remarks
Expenditure (B) Amount
(A)
BILL DATED 15.7, NO
1 Professional Fees 1300 600 700 PRESCRIPTION HENCE
DISALLOWED,
Investigation and BILL DATED 7.7, NO REPORT
2 900 900
Diagnostics HENCE DISALLOWED

3 a)Medicines 941 354 587 OPSITE OP NOT PAYABLE

Total 3141 1287

Amount payable 1287

Co pay Amount 0.0% 0

Net Payable / Eligible Amt * (After Co-pay) 1287

Exceeds the limit 0

Amount already paid to insured 0

Balance payable to Insured 1287

Consolidation Summary

Section Amount

IRDA Regn.No.129
Corporate Identity Number L66010TN2005PLC056649
Email ID : info@starhealth.in
 Total amount claimed 8421

Hospitalisation payable amount 0

Pre hospitalisation payable amount 870

Post hospitalisation payable amount 1287

Add on Benefit(Hospital Cash / Patient
0
care)
Total Claim Payable Amount 2157

Balance Premium Payable 0

Amount payable to Insured (After

2157
Premium Deduction)
The balance premium payable towards the remaining instalment Premium is adjusted from the admissible claim of Rs.2157/- Hence the
balance amount payable is Rs.2157/-

In case of any questions on the settlement amount, kindly contact our Senior Doctor at (7305619888)

In case you are not satisfied with the decision, you may represent to our Grievance Department at the
following address:

Dr. Guru Mageswaran,

Grievance Redressal Officer,
Corporate Grievance Department,
4th Floor, Balaji Complex, No. 15, Whites Lane,
Whites Road, Royapettah, Chennai- 600014.
(Land mark: In the lane next to Satyam Theatre Parking Area)
Telephone : 044-4366 4600,Exclusive Number for Senior Citizen : 044-6900 7500
E-mail id:- gro@starhealth.in

Thereafter if you wish to pursue the matter further, you may represent to the Office of the Insurance
Ombudsman whose address is given below:

Office of the Insurance Ombudsman,

Bhagwan Sahai Palace,
4th Floor, Main Road,
Naya Bans, Sector 15,
Distt: Gautam Buddh Nagar, U.P-201301
Tel : 0120-2514250 / 2514252 / 2514253
bimalokpal.noida@cioins.co.in

IRDA Regn.No.129
Corporate Identity Number L66010TN2005PLC056649
Email ID : info@starhealth.in