STAR HEALTH AND ALLIED INSURANCE CO.Ltd.

,
No.15, SRI BALAJI COMPLEX,1st FLOOR, WHITES LANE,ROYAPETTAH,CHENNAI-
600014.
Toll Free No : 1800 102 4477 / 1800 425 2255 , www.starhealth.in

BILL ASSESSMENT SHEET - MEMBER PAYMENT

Intimation No CIR/2022/231115/3466038 Bill Approved Date

Insured Name Mr.SANJAY JAIN Policy No P/231115/01/2021/023785

Certificate of Insurance
No.
Claimant Name HARSHUL JAIN Product Name Family Health Optima Insurance - 2017
DOB/Age 24/12/2005 - 15 years
Policy Period 09-02-2021 to 08-02-2022
Address : 29/111, NAMAK KI MANDI
AGRA Hospital Name ANAND MANGAL HOSPITAL
*
AGRA (CB) Hospital Address SRI RAM TALKIES KAMLA
Pincode : 282003 NAGAR AGRA-00
AGRA AGRA - 282002
UTTAR PRADESH Uttar Pradesh
Telephone : 8859502999 DOA 13-11-2021

DOD 17-11-2021
Sum Insured 500000
Bonus 160887 Final Diagnosis DENGUE FEVER WITH TCP ,
Copay % 0.0%
SM Code / Name SH43545 / Mr.MANOJ KUMAR

Intermediary Code / BA0000201231 / Mr.MANISH ICD Codes Desc A97,

Name AGARWAL 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 &

1 18000 18000
Nursing Charges

Professional Fees
(Surgeon, Anastheist,
2 22500 22500
Consultation Charges
etc)

Investigation &
3 4290 40 4250 collection charge not payable
Diagnostics

a.i) Medicines -
4 10065 530 9535 Adult, becosules not payable
within Hospital

IRDA Regn.No.129
Corporate Identity Number U66010TN2005PLC056649
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)

5 Others 2750 2750 dmo, registration charge not payable

Total 57605

Deductibles (A + B) 3320

Hospital Discounts

Network Hospital Discounts

Deductions

NET AMOUNT (Total - Deductibles,

Hospital Discounts 54285
& Deductions)

IRDA Regn.No.129
Corporate Identity Number U66010TN2005PLC056649
Email ID : info@starhealth.in
 Amount claimed 57605

Total Deductions 3320

a. Non payable 3320

b. Proportionate Deductions 0

Approved Amount (after Total Deductions) 54285

Less: Hospital Discounts 0

Less: Other deductions 0

Net Amount (Approved amount - Hospital

54285
discounts and other deductions )

Amount considered 54285

Co-Pay Amount 0

Amount considered after co pay 54285

Exceeds sub limit 0

Less: Amount settled by other Insurer 0

Exceeds Sum Insured 0

Amount payable 54285

Claim Restrictions 0

Preauth approved amount 0

Amount payable to Hospital 0

Payable to Insured 54285

Less amount already paid to Insured 0

Balance payable to Insured 54285

Pre Hospitalisation Expenses

Amount Approved
Nature of Non Payable
S.No Bill No Bill Date Claimed Amount Disallowance Reasons / Remarks
Expenditure (B)
(A) (C)
Investigation and
1 2420 2420
Diagnostics
Total 2420 2420

Eligible Amt (As per Policy)

Amount payable 2420

Co pay Amount 0.0% 0

Net Payable / Eligible Amt * (After Co-pay) 2420

Exceeds the limit

Amount already paid to insured 0

Balance payable to Insured 2420

IRDA Regn.No.129
Corporate Identity Number U66010TN2005PLC056649
Email ID : info@starhealth.in
Post Hospitalisation Expenses

Amount
Nature of Non Payable Approved
S.No Bill No Bill Date Claimed Disallowance Reasons / Remarks
Expenditure (B) Amount
(A)
Total 0

Amount payable 0

Co pay Amount 0.0% 0

Net Payable / Eligible Amt * (After Co-pay) 0

Exceeds the limit 0

Amount already paid to insured 0

Balance payable to Insured 0

Consolidation Summary

Section Amount

Total amount claimed 60025

Hospitalisation payable amount 54285

Pre hospitalisation payable amount 2420

Post hospitalisation payable amount 0

Add on Benefit(Hospital Cash / Patient
0
care)
Total Claim Payable Amount 56705

IRDA Regn.No.129
Corporate Identity Number U66010TN2005PLC056649
Email ID : info@starhealth.in
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:

Mrs. Radha Vijayaraghavan,

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@ecoi.co.in

IRDA Regn.No.129
Corporate Identity Number U66010TN2005PLC056649
Email ID : info@starhealth.in