STAR HEALTH AND ALLIED INSURANCE CO.Ltd.

,
No.15, SRI BALAJI COMPLEX,1st FLOOR, WHITES LANE,ROYAPETTAH,CHENNAI-
Customer Care Number - 044 6900 6900 | Corporate Customers - 044
43664666 |
Chat - +91 9597652225, www.Starhealth.in

BILL ASSESSMENT SHEET - HOSPITAL PAYMENT

Intimation No CIR/2025/231123/0108415 Bill Approved Date

Insured Name SHIVAM GARG Policy No 11240311344600

Certificate of Insurance
No.
Claimant Name SAKSHI GARG Product Name Family Health Optima Insurance Plan
DOB/Age 20/12/2022 - 0 years
Policy Period 26-06-2023 to 25-06-2024
Address : 04 SIRIYA SARAYA GALI,
SONKH DEHAT, Hospital Name AMAR HEALTHCARE
SONKH
NA Hospital Address Radhapuram Crossing, Highway Nh-2
Pincode : 281123 MATHURA - 281004
NA Uttar Pradesh
NA
Telephone : 7017914438 DOA 23-04-2024

DOD 26-04-2024
Sum Insured 500000
Bonus 0 Final Diagnosis ACUTE GASTROENTERITIS WITH
Copay % 0.0% SEVERE DEHYDRATION,
SM Code / Name SH43554 / SANDEEP KUMAR MITTAL

Intermediary Code / BA0000190975 / SEEMA AGARWAL ICD Codes Desc A09.9,

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)

Room Rent(Inclusive
1 of GST) & Nursing 12000 12000
charges

Professional Fees
(Surgeon, Anastheist,
2 4000 4000 ,
Consultation Charges
etc)

Investigation &
3 1950 1950
Diagnostics

a.ii) Medicines -
4 12921 558 12363 thermometer,uro bag,cotton not payable
outside Hospital

5 Others 700 700 file,op not payable ,

IRDAI Registration No: 129 | CIN: L66010TN2005PLC056649 | Ph: 044-28288800 | Email: 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 31571

Deductibles (A + B) 1258

Hospital Discounts

Network Hospital Discounts -3637 Refer Note #1

Deductions

NET AMOUNT (Total - Deductibles,

Hospital Discounts 26676
& Deductions)

IRDAI Registration No: 129 | CIN: L66010TN2005PLC056649 | Ph: 044-28288800 | Email: info@starhealth.in
 Amount claimed 31571

Total Deductions 1258

a. Non payable 1258

b. Proportionate Deductions 0

Approved Amount (after Total Deductions) 30313

Less: Hospital Discounts 0

Less: Other deductions 0

Net Amount (Approved amount - Hospital

26676
discounts and other deductions )

Amount considered 26676

Co-Pay Amount 0

Amount considered after co pay 26676

Exceeds sub limit 0

Less: Amount settled by other Insurer 0

Exceeds Sum Insured 0

Amount payable 26676

Claim Restrictions 0

Preauth approved amount 26676

Amount payable to Hospital 26676

Less: Network Hospital Discount 3637

Net Amount payable to Hospital 26676

Consolidation Summary

Section Amount

Total amount claimed 31571

Hospitalisation payable amount 26676

Pre hospitalisation payable amount 0

Post hospitalisation payable amount 0

Add on Benefit(Hospital Cash / Patient
0
care)
Total Claim Payable Amount 26676

IRDAI Registration No: 129 | CIN: L66010TN2005PLC056649 | Ph: 044-28288800 | Email: info@starhealth.in
 # Remarks

Note Disallowance Reasons / Remarks

*12% Discount on final approved amount.w.e.f-31-Mar-2021. Discount will apply on accepted MINI SOC Discount will not
apply on ANH Package rates.

#1

IRDAI Registration No: 129 | CIN: L66010TN2005PLC056649 | Ph: 044-28288800 | Email: info@starhealth.in