IMPORTANT

To,

Mr.VINOD. A.V,
TC 6/1773, KALLUMALAYIL MELE PUTHEN VEEDU,
PTP NAGAR,
TVM
Thiruvananthapuram,Thiruvananthapuram,Kerala -695038
Mobile : 9809494318.

Dear Customer,

Re: Health Insurance Policy - P/181116/01/2019/003035

We are extremely thankful for availing health insurance from us and we enclose the policy along with the
terms and conditions.

The said policy has been prepared based on the details furnished by you in the proposal form (copy
enclosed) and the medical reports, wherever applicable. We shall thank you if you can verify the policy to
ensure that all the details are incorporated correctly as per the proposal. In case of any discrepancy
noticed, please communicate the same to us immediately. You will appreciate that it is the primary duty
of the proposer to fill the proposal form and also to make sure that the proposal contains all the details
correctly so also the policy has incorporated the details correctly.

This insurance policy is subject to various exclusions including exclusion for pre-existing diseases and
conditions in this policy. If there is suppression of any material fact in the proposal, the contract shall
become null and void ab initio.

We would like to mention that we have incorporated the name of the intermediary as indicated by you in
the proposal who will be of assistance to you.

The policy is subject to the condition of "free look period". As per this condition, a free look period of 15
days from the date of receipt of the policy is available to you to review the terms and conditions of the
policy. In case you are not satisfied with the terms and conditions, you may seek cancellation of the
policy and in such an event, we shall allow refund of premium paid after adjusting the cost of pre-
acceptance medical screening, if any, stamp duty charges, and proportionate risk premium for the period
on cover, provided no claim has been made until such cancellation.

We wish you good health and we look forward to serve you in the days to come.

With kind regards,

Authorised Signatory
In case of a need for hospitalization, kindly prefer our network hospital (list is available in our website) for
a quick response to your claim request. Please stay in eligible room as stated in the policy, to avoid
payment of proportionate increased charges claimed by the hospitals, from your hand.
Sum insured of this Policy is meant for utilization till its expiry. Bearing this aspect in mind, we have no
doubt, you will choose appropriate hospital, room rent and treatment charges, etc.

Should you need any assistance, our customer care will be delighted to assist you, whose toll free no. is
1800-425-2255/1800-102-4477.

However, the ultimate decision will be that of yours only.

CN=R Margabandhu,

R Margabandhu
SERIALNUMBER=00f82dcf76fdf6537e3331f8479ef45e7b4f3861b154
75488cdf3b2c3c26c3c9, ST=TAMIL NADU, OID.2.5.4.17=600034,
OID.2.5.4.20=513b7b33f2ce960f23148ea208744690e09638750806c
a65f89e15179f5fe50a, OU=UNDERWRITING - Chief Risk Officer,
O=STAR HEALTH AND ALLIED INSURANCE COMPANY, C=IN.
Date :Sun Nov 17 18:12:47 IST 2019

1 of 6

Regd.&Corporate Office:1,New Tank Street,Valluvar Kottam High Road,Nungambakkam,Chennai - 600034,Phone : 044 -28302700 / 28288800 Toll Free Fax No: 1800-425-5522 Toll Free
No:1800-425-2255 / 1800-102-4477,CIN :U66010TN2005PLC056649 Email :support@starthealth.in Website :www.starhealth.in IRDAI Regn.no: 129
 MEDICLASSIC INSURANCE POLICY (INDIVIDUAL)
SCHEDULE
Unique Identification No.IRDA/NL-HLT/SHAI/P-H/V.II/400/13-14

Policy No. : P/181116/01/2019/003035 Previous Policy No. :

Customer Code : AA0007312713 GSTIN : 32AAJCS4517L1Z7
Customer Name : Mr.VINOD. A.V SAC Code : 997133/Accident and Health Insurance Services
Proposer's Code : 9646276 Issuing Office Code : 181116
Proposer's Name : Mr.VINOD. A.V Issuing Office Name : Branch Office - Neyyattinkara
Address : TC 6/1773, KALLUMALAYIL MELE Address : 1st Floor, Vamaputhra Building,
PUTHEN VEEDU, Cape Road,
PTP NAGAR, Neyyattinkara
TVM Thiruvananthapuram - 695121
Thiruvananthapuram,Thiruvananth Phone No : 0471-2224511
apuram,Kerala-695038 E-mail Id : Neyyattinkara.bo@starhealth.in
Phone No : 0/9809494318/ Place of Supply : -
E-mail Id : 0
Fulfiller Code : SH42506
Proposer GSTIN : - Specified Person Code / Name : SP0439152720 / Suresh Babu P
Proposal date : 07/08/2018
Date of Inception of first policy : 10/08/2018
Intermediary Code : CO0000000115
Renewal Year : NEW
Receipt No : 1226003310 Name : M/S.KERALA GRAMIN
Receipt Date : 10/08/2018 BANK
Premium :Rs 3,230 /-
CGST @9% :Rs 291 /- SGST / UTGST @9% :Rs 291 /- Phone No : 0483-2733509/0483-2733509
Stamp Duty :Rs 1 /- Total Premium :Rs 3812 /-
E-mail Id : kgbho@keralagbank.com
Total Premium In Words : Rupees Three Thousand Eight Hundred Twelve Only
PERIOD OF INSURANCE : 10/08/2018 15:17:00 TO : Midnight Of 09/08/2019 Add On Cover Opted
2.Hospital Cash Cover

Details of Insured Persons : No. of Persons Insured: 1

Sl. Name Sex Date of Birth Age in Relationship Sum Insured Cumu.Bon Add On ID Card No Pre-existing Inception
no. Yrs with Proposer (Rs.) us (Rs.) Covers Disease/s Date

1 Mr.VINOD. A.V M 03/05/1988 30 SELF 200000 0 2 9646276-1 NIL 10/08/2018

Expenses relating to the hospitalisation will be in proportion to the room rent stated in the policy.
Condition No. 4 regarding delay in payment of claim shall read as follows and not as stated in policy wordings:
"The Company shall pay interest as per Insurance Regulatory and Development Authority of India (Protection of Policyholders' Interests)
Regulations, 2017, in case of delay in payment of an admitted claim under the Policy"

IMPORTANT
IN THE EVENT OF HOSPITALIZATION OF INSURED PERSON, INTIMATION SHOULD BE GIVEN TO THE COMPANY IMMEDIATELY,
HOWEVER, WITHIN 24 HRS FROM THE TIME OF ADMISSION.
Sector Classification :

Urban

Entered by : SH3901 This is an electronically generated For Star Health and Allied Insurance Company Ltd.
document(Policy Schedule).
Consolidated Stamp Duty paid vide
certificate NO: Adj/CS/277/102437/10

Authorised Signatory
IRDAI Regn. No 129
Corporate Identity Number U66010TN2005PLC056649
Email ID : info@starhealth.in Please see overleaf 2 of 6

Regd.&Corporate Office:1,New Tank Street,Valluvar Kottam High Road,Nungambakkam,Chennai - 600034,Phone : 044 -28302700 / 28288800 Toll Free Fax No: 1800-425-5522 Toll Free
No:1800-425-2255 / 1800-102-4477,CIN :U66010TN2005PLC056649 Email :support@starthealth.in Website :www.starhealth.in IRDAI Regn.no: 129
 Attached to and forming part of Policy No : P/181116/01/2019/003035

Toll Free No : 1800 425 2255 / 1800 102 4477 Email: support@starhealth.in Fax No: 1800 425 5522.

In the event of the policy being withdrawn in future, intimation about the withdrawal will be sent 3 months prior to the date when renewal falls
due.The insured will have the option of migrating to any other similar health insurance policy offered by the Company at the relevant time.
Continuity of benefits for waiting period and bonus, if any and if applicable, will be given provided the insured had been renewing the policy without
any break (or renewing within the grace period offered)

Nominee Details

Nominee Details for the proposer Appointee Details

S.No. Name Relationship Age % Appointee Relationship

Age
with proposer Name with Nominee

Additional terms under Renewability

In the event of this policy being withdrawn / modified with revised terms and / or premium with the prior approval of the Competent Authority, the
insured will be intimated three months in advance and accommodated in any other equivalent health insurance policy offered by the Company, if
requested for by the Insured Person, at the relevant point of time.
In witness whereof the undersigned being authorized by and on behalf of the company has set his hand at Branch Office - Neyyattinkara on 10th
Day of August 2018.

Entered by : SH3901 This is an electronically generated For Star Health and Allied Insurance Company Ltd.
document(Policy Schedule).
Consolidated Stamp Duty paid vide
certificate NO: Adj/CS/277/102437/10

Authorised Signatory

Please see overleaf 3 of 6

Regd.&Corporate Office:1,New Tank Street,Valluvar Kottam High Road,Nungambakkam,Chennai - 600034,Phone : 044 -28302700 / 28288800 Toll Free Fax No: 1800-425-5522 Toll Free
No:1800-425-2255 / 1800-102-4477,CIN :U66010TN2005PLC056649 Email :support@starthealth.in Website :www.starhealth.in IRDAI Regn.no: 129
 Hospitalisation Benefit Policy
Premium Certificate for the purpose of deduction under Section 80 D of Income Tax (Amendment) Act,1986

Policy No : P/181116/01/2019/003035 Type Of Policy : Mediclassic Individual Revised

Issue Office : 181116 - Branch Office - Neyyattinkara

Address : 1st Floor, Vamaputhra Building, Cape Road,

Neyyattinkara
Thiruvananthapuram - 695121
Toll Free No : 0471-2224511
Email : Neyyattinkara.bo@starhealth.in

This is to certify that Mr.VINOD. A.V has paid Rs 3812 (Total Premium In Words : Indian Rupees Three Thousand Eight
Hundred Twelve Only ) towards Premium for Hospitalization Insurance vide Policy No: P/181116/01/2019/003035 for the
Period 10-AUG-18 To 09-AUG-19 issued on 10-AUG-18 .
Payment received by Cheque/Credit/Debit Card vide collection No:1226003310

Note :- This Certificate must be surrendred to the Insurance Company for issuance of fresh Certificate in case of Cancellation
of the Policy or any alteration in the Insurance affecting the Premium.

For and on behalf of

Star Health and Allied Insurance Company Ltd.

Authorised Signatory

Entered by : SH3901 This is an electronically generated For Star Health and Allied Insurance Company Ltd.
document(Policy Schedule).
Consolidated Stamp Duty paid vide
certificate NO: Adj/CS/277/102437/10

Authorised Signatory

Please see overleaf 4 of 6

Regd.&Corporate Office:1,New Tank Street,Valluvar Kottam High Road,Nungambakkam,Chennai - 600034,Phone : 044 -28302700 / 28288800 Toll Free Fax No: 1800-425-5522 Toll Free
No:1800-425-2255 / 1800-102-4477,CIN :U66010TN2005PLC056649 Email :support@starthealth.in Website :www.starhealth.in IRDAI Regn.no: 129
 Star Health and Allied Insurance
Company Limited
Emergency Help Line No. 1800 425 2255 / 1800 102 4477
e-mail : support@starhealth.in Website : www.starhealth.in Customer Identity Card

Please quote the Customer Id No. for assistance Customer ID No. : 9646276-1
This Card is valid until otherwise Cancelled. Name : Mr.VINOD. A.V
This ID Card is invalid, if the insurance cover is not in force. Date Of Birth : 03-MAY-88 Age : 30 Years
Immediate intimation to 'Star' through above Tel Nos. is a must
Gender : Male Office Code : 181116
in case of Hospitalisation.
For Free Medical Advice Call TOLL FREE 1800 425 2255 Valid From : 10-AUG-18 SSM/SM Code : SH42506
Agent/Broker/MT Code : CO0000000115

Personal and Caring

*This is a temporary ID card issued along with the policy. Original ID cards will be dispatched shortly.

Entered by : SH3901 This is an electronically generated For Star Health and Allied Insurance Company Ltd.
document(Policy Schedule).
Consolidated Stamp Duty paid vide
certificate NO: Adj/CS/277/102437/10

Authorised Signatory

Please see overleaf 5 of 6

Regd.&Corporate Office:1,New Tank Street,Valluvar Kottam High Road,Nungambakkam,Chennai - 600034,Phone : 044 -28302700 / 28288800 Toll Free Fax No: 1800-425-5522 Toll Free
No:1800-425-2255 / 1800-102-4477,CIN :U66010TN2005PLC056649 Email :support@starthealth.in Website :www.starhealth.in IRDAI Regn.no: 129
 TAX Invoice

Invoice No. : 32E226Y19P000263 Customer ID : AA0007312713

Invoice Date : 10/08/18 Policy No : P/181116/01/2019/003035
Recipient Supplier

GSTIN : - GSTIN : 32AAJCS4517L1Z7

Proposer's : Mr.VINOD. A.V NAME : Star Health and Allied Insurance Co Ltd
Name - Branch Office - Neyyattinkara
Address : TC 6/1773, KALLUMALAYIL MELE Address : 1st Floor, Vamaputhra Building, Cape
PUTHEN VEEDU, Road,
PTP NAGAR, Neyyattinkara
TVM Thiruvananthapuram - 695121
City : Thiruvananthapuram,Thiruvanantha City : NEYYATTINKARA
puram,Kerala-695038
State : Kerala State : Kerala
Pincode : 695038 Pincode : 695121
Client Category : IND Place of Supply : 32 - Kerala

HSN / Description of Total Discount TaxableValue IGST @ 18% CGST @9% UT/SGST@9% CESS@1% Total Invoice Value
SAC Service(s)
A B C=A-B D = C * IGST E=C F=C G=C*Cess H=C+D+E+F+G
Code
*CGST *UTGST or
SGST
997133 Insurance 3230 0 3230 291 291 Rs. 3812 /-
Services

Total Invoice Value (in Figures) : Rs. 3812 /-

Total Invoice Value (in Words) : Rupees: Three thousand eight
hundred twelve only
Amount of Tax Subject to reverse Charge : No

Important Note:

The invoice is issued as per Section 31 of the CGST Act

In case no GSTIN or incorrect GSTIN is provided by the Proposer at Proposal stage, Star Health and Allied Insurance Co Ltd shall not be
responsible for any Input Tax Credit losses and no subsequent revision of invoice will be undertaken.

E. & O.E

This is a digitally signed document and hence no physical signature is required

IRDAI Regn. No 129 Corporate Identity Number U66010TN2005PLC056649 Email ID : stargst@starhealth.in

Entered by : SH3901 This is an electronically generated For Star Health and Allied Insurance Company Ltd.
document(Policy Schedule).
Consolidated Stamp Duty paid vide
certificate NO: Adj/CS/277/102437/10

Authorised Signatory

Please see overleaf 6 of 6

Regd.&Corporate Office:1,New Tank Street,Valluvar Kottam High Road,Nungambakkam,Chennai - 600034,Phone : 044 -28302700 / 28288800 Toll Free Fax No: 1800-425-5522 Toll Free
No:1800-425-2255 / 1800-102-4477,CIN :U66010TN2005PLC056649 Email :support@starthealth.in Website :www.starhealth.in IRDAI Regn.no: 129