STAR HEALTH

STAR
Personsl & Cat
ing |
Health
Insurance
Regd. & Corporate Office
LOporate Othce
AND ALLIED INS
1, New Tank
Street, OINSURANCE COMPANY LIMITED
The Health Insurance Claims Dept. VauvarValluvar Kottam
Kottam High
High Road,
Road, Nungambakkam, Chennai - 600 034.
SpeciNST No.15, Balaji Nuy ah. Chennai
Tee Complex, Whites Lane, 1st Floor, 50
U66010N20OSPLPhone U
-

N No: 1800 425 2255

Toll freo Fax No: 1800 425 Koy
COS6649 Emait 5
REQUEST FOR
CASHLESS HOSPITALISATION FOR asless.netwerk@alarhoakh.in Webste:
www.a . No1 29

POLICY PART -C
HEALTH INSURANCE
(TO BE FILLED IN BLOCK LETTERS)
DETAILS OF THE THIRD
PARTY
a. Name of TPAVNSurance company:
ADMINISTRATORINSURER/HOSPITAL
STAR HEALTH AND ALLIED INSURANCE
b. Toll free phone number COMPANY LIMITED
c. Tol free fax

d. Name ofHospital

LAddress
ONKARHULTTSPGCTAIr HospTTAL
iRchini ID
i.e-mail id
NAVLPETH PARNER
Cashiess ankar (@
gmall.coM.
TOBE FILLED BY
A Name of the Patient:
INSUREDPATIENT
MRS U]IdALA RAHuL
B. Gender: ADHAV Male
LFemale ThirdGender
C. Age:
26 (Years)/ (Month)
D. Date of Birth:
81o8 1394 (0DMMmY
E. Contact number.

F. Contact number of attending Relative:

gSs28 630 80
G. Insured Catd ID number.

A. Poicy numberName of

. Employee ID
Corporate:
Pl1s ol20 2/1a 2661 3
J.Curenty do you have any other mediclaim
/ health insurance. Yes

iCompany Name:
No
i.Give Details:

K. Do you have a
family Physician
Yes
L. Name of the family Physician:
DR.KETA HAN DE
M. Contact number,if
any
N. Current Address of Insured
422282S3S
Patient SAROLA SolANSHI
0.Occupation of Insured Patient
(PLEASE COMPLETE DECLARATION OF
THIS FORM)
 DETAILS OF PATIENT ADMITTED

A. Date of admission: (DD/MMYYY)

B. Time of admission: (HH:MM)

C. Is this emergency/planned hospitalization event Emergency Planned

O. Mandatory Past History of any chronic illness if yes (Since month/lyear)
Diabctes
ii. Hcart discase
ii. Osteoarthritis
.
iv. Asthma/COPD/Bronchitis
v. Cancer
vi. Alcohol/Drug abuse
vii. Any HIV or STD Relatcd ailment
vii. Rheumatoid Arthritis N
ix. Cercbrovascular Accident(Stroke)
N
I. Liver discase N
xi. Kidney discase
xii. Any other N
ailment,give details

E.
Expected number of Days/Stay in
hospital
F.
Days
Level Grade
of Surgery:
G. Days in ICU:

H. Room Type: Days

Per
PRTVATE pNoNA
day room rent +
nursing and service
charges +patients diet:
J.
Expected cost of investigation+
diagnostic:
K. ICU Charges: ADoo-
L. OT Charges

M.
Professional fees Surgeon +
Anesthetist fees+consultation
N.
Medicines+ Consumable Chargees:
O.
Other hospital expenses if any:
+Cost of lmplants (if
applicable please
specify):
hooo
P.
All-inclusive package
loooo
Q.
charges if any applicable
Sum Total expected cost of
hospitalization
226D 61
 TO BE FILLED BY TREATING DOCTOR/HOSPITAL

A. Name of the treating Doctor:

DR.KETAN IAN DE (cl:B S )
B. Contact number::
42 2.28 233
C. Nature of illness/Disease with presenting complaint:

D. Relevant Critical Findings:

S u r - r e l a l pa
E Duration of the present ailment
AtDays
iv. Date of First consultation
(DD/MMY"YYY)

V. Past history of present ailment, if an

F. Provisional diagnosis:
ICD 10 code KDengut fever (rsi n
G. Proposed line of treatment:
. Medical Management
Surgical Management
TI. Intensive care
M. Investigation
. Non-allopathic treatment

H. f investigation and/or Medical Management, provide details:

i. Route orDrug Administration

. If surgical, name of surgery:

i. ICD I0 PCS code

. f other treatment, provide details:

. How did injury occur

NA
L. In case of accident:
NA
i. Is it RTA Yes No

ii. Date of injury Yes No

ii. Report to Police Yes No

iv. FIR NO Yes No

to substance
v. Injury/Disease caused due
vi. abuse/alcohol consumption Yes No
vii.Test conducted to establish this (if yes, attach report) No

M. In case of Maternity:
L. expected date of Delivery
NA (DD/MMYYYY)
 DECLARATION
(Please read very carefully)

A. Name of the treating doctor DR,KTAN ANDE

B. Qualification

C. Registration number with state code

otg 1o1634

FReg No

Patient/Insured Name and Sign

Hospital Seal
(Must include Hospital ld)
 DECLARATION BY THE PATIENT/
a. lagree alow the hospital to submit all original documents
to REPRESENTATIVE
pertaining to hospitalization to the Insurer/T.P.A after
agree to sign on the Final Bill & Discharge
the Summary,before my discharge. thg.discharge. I

b. Payment to hospital is govemed by the terms and conditions of the

bil,Iundertake to settle the bill as perthe terms and conditions of thepolicy.
In case the Insurer / TPA is not liable to setle the
hospital
policy.
C. All non-medical expenses and expenses not relevant to
curent hospitalization and the amounts over & above the limit authorized
by the Insurer/T.P.Anot govemed by the tems and conditions of the policy wil be paid by me.

d. Ihereby declare to abide by the terms and conditions of the policy andif at any time the facts disclosed by me are found to be false or
incorrect Iforfeit my claim and agree to indemnify
the Insurer /T.PA
e. Iagree and understand that T.P.A is in no way warranting the service of the hospital & that the Insurer / TPA is in no way
guaranteeing that the services provided by the hospital will be of a particular quality or standard.

f. Ihereby warant the truth ofthe forgoing pariculars in every respect and lagree that if l have made or shall make any false or untrue
statement, suppression or concealment with respect to the claim, my right to claim reimbursement of the said expenses shall be
absolutelyforfeited
9. lagree toindemnifythe hospital against all expenses incured on my behaf, which are not reimbursed bythe Insurer/TPA
h. "IWeauthorize Insurance Company/TPAto contact me/us through mobile/email for any update on this dlaim".

Authorization to Starhealth and allied Insurance Co.Ltd

Iam admitted in your Hospitankür huHaperioty HSPfo
Health Insurerto seek any
Co. Ltd. and its representatives, who is my
Thereby authorize Star health and allied Insurance me in connection
with the
the Medical Practitioners who have attended on
medical information/ records from you or from
case they seek any such information/records/
indoor case papers, kindly oblige.
above ailment and the treatment given. In

a) Patient's / Insured's Name tRs-VllALA RAHUL ADHAv

b) Contact number

c)e-mailld
d) Patient's / Insured's Signature
Time: n_
Date
Ol08120
HOSPITAL DECLARATION
documents pertaining to hospitalization.
authorized TPA/
Insurance Company official verifying
a. We have no objection to any checklist below will be
sent to TPA/
insured / patient as per the
duly
documents countersigned by the
b. All valid original discharge.
within 7 days of the patient's between
insurance Company the event any discrepancy
will not be Liable to
make the payment in of
we agree that
TPA/ Insurance Company
C. or other documents
and discharge summary
the facts in this form presence
his representative in our
declaration has been signed
by the patient or by for
The patient take the sole responsibility
d.
raised regarding this hospitalization and we
clarifications for the queries
e. We agree to provide
clarifications.
any delay in offering
conditions agreed in the MOU
f. We will abide by the tens and insured in excess of Agreed
Package Rates except
costs
would be collected liom the
additional amount rent than eligibility choosing
We confim that no
additional charges due
to opting higher room
g. amounts (including
towards non-admissible
envisaged/considered in package).
treatment which is not for costs towards
separate line of the insured except
the deposit amount collected from
recoveries would be
made from
room rent than eligibility/
choosing separate ine
h. We confim that no due to opting higher
additional charges
(including
non-admissible amounts in package).
envisaged/considered
of treatment which is not Package Rate_/ the
amount from the Insured in excess of Agreed
of any additional take
In the event of unauthonzed recoysry us (the Network Provider) and.lgh
the to recover the same from
right
authorized TPA MnisuraiceCormpanyreserves
MOU or applicable laws.
necessary action as providad undetAne
Dostor's Signature
Hospital Seal
 DECLARATION BY THE PATIENT
a. 1agree lo allow the hospital to submit
agree to sign on the Final Bill &the
all orlginal
documents pertaining to
/REPRESENTATIVE
hospitalization to the Insurer/T.PA after thg,.discnarge.
Dlscharge Summary,before my discharge.
b. Payment to hospital is govemed by the terms
bill, Iundertako to seltle the bill as per the tormsand conditions of the policy, In case the Insurer /TPAis not liable to settle the
and conditions of the
policy. hospila
C. All non-medical
expenses and exponses not relevant to
current hospitalization and the amounts over&
by the Insurer/TP.Anot govemed by the terms
and conditions of the policy will be
above the limit authonzeo
paid by me.
d. hereby declare to abide by the terms and conditions of the
policy andjf at any time the facts disclosed by me are found to be false or
incorrect Iforfeit my claim and agree to
indemnity the Insurer/T.PA
e. agree and understand that T.P.A is in no way warranting the service of the hospital & that the Insurer / TPA is in no way
guaranteelng that the services provided by the hospital will be of a particular quality or standard.
f. Thereby warrant the truth of the forgoing pearticulars in every respect and l agree that if I have made or shall make any false or untrue
statement, suppression or concealment with respect to the claim, my right to claim reimbursement of the said expenses shall be

absolutely forfeited.
which are not reimbursed bythe Insurer/TPA
g. agree to indemnify the hosplital against all expenses incured on my behalf,
mobile/email for any update on this claim.
h. "I/We authorize Insurance Company/TPAto contact me/us through
Authorization to Star health and allied Insurance Co. Ltd
I am admitted in your Hospita(nkar
dHspeticty OSPFom
to seek any
who is my Health Insurer
Insurance Co. Ltd. and its representatives, the
have attended on me in connection with
health and allied
I hereby authorize Star Medical Practitioners who
from the oblige.
records / indoor case papers, kindly
records from you or
medical information/ such information /
In case they seek any
treatment given.
above ailment and the HRs-lalALA RAHUL ADAAV
Name
Patient's /Insured's
a)
b) Contact number

c)e-mailld
Insured's Signature
Patient's/
d) Time
09/08202 HOSPITAL DECLARATION
Date documents pertaining to
hospitalization.

official verifying
Insurance Company sent to TPA
authorized TPA/ below will be
checklist
no objection to any / patient as per the
a.
We have by the
insured
countersigned
documents duly between
discharge.
All valld original
discrepancy
b. within 7 days
of the patient's in the event of any
Company make the payment
insurance Liable to
Company
will not be
Insurance
documents.
that TPA/ or other
C. we agree summary
in our presence
this form and discharge representative for
the facts in or by his the sole
responsibilty

has been signed

by the patient hospitalization
and we take
declaration this
The patient raised regarding
d. clarifications
for the queries
provide
e.
We agree to claifications.
costs
any delay in offering conditions agreed
in the MOU Package
Rates except

and of Agreed
insured in eligibility choosing
excess
terms
by the liom the rent than
f.We will abide would be
collected
higher
room
amount due to opting
no
additional
additional charges
that
We confirm (including in package). costs toward=
except for
amounts
9 non-admissible
envisaged/considered

from the
insured
li-
towards
treatment
which is not amount
collected
choosing
separate
line of the deposit eligibility/
separate made from room
rent than
would be higher
recoveries
charges
due to opting
that no
We confirm
additional

h. (including
in package).
Rates/ thes
Package
amounts
of Agreed
non-admissible in and./gf take=
e n v i s a g e d / c o n s i d e r e d
excess
Insured
from the Network Povider)
treatment which is not additional
amount
(the
of af n n y ama from ys