STAR HEALTH AND ALLIED INSURANCE CO.LTD.

,
4th Floor, Carmel Towers, Cotton Hill P.O, Vazhuthacaud, Trivandrum- 695 014.

Customer Care Number - 044 6900 6900 / Corporate Customers - 044 43664666

Chat - +91 9597652225, www.Starhealth.in

DENIAL OF PREAUTHORISATION REQUEST FOR CASHLESS TREATMENT

TO, DATE : 18-MAY-2022
HOSPITAL : Valluvanad Hospital
ADDRESS : Ushus Koottanad Post,Palakkad
OTTAPPALAM - 679533
Kerala

Name of Insured Patient : SANI M SABU Age / Sex : 24 / Female

Date of admission : 10-MAY-2022 Diagnosis : AFI

Room category : Not Mentioned Product Name : Family Health Optima Insurance - 2017

Policy Number : P/181216/01/2022/001256 Policy Start Date : 19-MAY-2021

Claim intimation No. : CIR/2023/181216/0165797 Policy End Date : 18-MAY-2022

Dear Sirs,

We have scrutinized your request for approval for cashless treatment of the above insured patient for the diagnosed disease of
AFI.
Based upon the information / clarification provided we are not in a position to decide upon the admissibility of the claim. The insured,
may however approach us seeking reimbursement of expenses relating to the captioned admission
Hence we deny the approval for cashless treatment of the above diagnosed disease.

The insured may however submit the documents to us seeking reimbursement of the expenses incurred relating to the treatment
of the above disease.
A letter addressed to the insured is attached. Please hand over a copy of this letter to the insured.

Thanking you,

Yours faithfully,

SH034981

18-MAY-2022 05:59 PM

Authorized Signatory.

IRDA Regn.No.129
Corporate Identity Number L66010TN2005PLC056649
Email ID : info@starhealth.in
 STAR HEALTH AND ALLIED INSURANCE CO.LTD.,
4th Floor, Carmel Towers, Cotton Hill P.O, Vazhuthacaud, Trivandrum- 695 014.

Customer Care Number - 044 6900 6900 / Corporate Customers - 044 43664666

Chat - +91 9597652225, www.Starhealth.in

DENIAL OF PREAUTHORISATION REQUEST FOR CASHLESS TREATMENT

TO, DATE : 18-MAY-2022
Mr./ Ms.Sabu M Mathew
MANAKKAKUDIYIL (HOUSE),
PARUTHIPRA, VENNUR (POST), 680587,
THRISSUR (DT. )
MANAKKAKUDIYIL (HOUSE),
PARUTHIPRA, VENNUR (POST), 680587,
THRISSUR (DT. )
Pazhayannur
Pincode : 680587
Thrissur
Kerala
Telephone : 8547087690

Name of Insured Patient :SANI M SABU Age / Sex : 24 / Female

Date of admission : 10-MAY-2022 Diagnosis :AFI

Room category : Not Mentioned Product Name :Family Health Optima Insurance - 2017

Policy Number : P/181216/01/2022/001256 Policy Start Date : 19-MAY-2021

Claim intimation No. : CIR/2023/181216/0165797 Policy End Date : 18-MAY-2022

Hospital & Location : Valluvanad Hospital, OTTAPPALAM, Kerala

Dear Customer,

We refer to your request for approval for cashless treatment at the above referred hospital for the above diagnosed disease of the
insured patient.

Based upon the information / clarification provided we are not in a position to decide upon the admissibility of the claim. The insured,
may however approach us seeking reimbursement of expenses relating to the captioned admission

Hence we deny the approval for cashless treatment of the above diagnosed disease.

You may however submit the documents to us seeking reimbursement of the expenses incurred relating to the treatment of the
insured patient.

You are therefore requested to submit the following original documents in this regard:

1. Enclosed claim form duly completed and signed by the insured.

2. Discharge summary.
3. Hospital final bill with break up details.
4. All other bills and receipts.
5. Investigation reports,X ray, scans etc.,
6. Prescription of the treating doctor.
7. Earlier treatment records, if any.
8. A copy of a cancelled cheque to enable us to remit the amount in settlement of the admissible claim amount to your
Bank account.
9. In case the claimed amount exceeds Rs.1,00,000 a copy of your PAN card as required by the provisions of the Prevention of

IRDA Regn.No.129
Corporate Identity Number L66010TN2005PLC056649
Email ID : info@starhealth.in
 STAR HEALTH AND ALLIED INSURANCE CO.LTD.,
4th Floor, Carmel Towers, Cotton Hill P.O, Vazhuthacaud, Trivandrum- 695 014.

Customer Care Number - 044 6900 6900 / Corporate Customers - 044 43664666

Chat - +91 9597652225, www.Starhealth.in

Money Laundering Act.

On receipt of the above documents, your claim for reimbursement of expenses will be processed and the admissibility of the claim
will be decided as per the policy terms and conditions of the policy issued to you. A copy of this letter together with a claim form is
being mailed to your residential address as appearing on the policy.

In case you are not satisfied with the above 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,

2nd Floor, Pulinat Bldg.,
Opp. Cochin Shipyard, M. G. Road,
Ernakulam - 682 015
Tel : 0484 - 2358759 / 2359338
Fax : 0484 - 2359336
bimalokpal.ernakulam@cioins.co.in

Thanking you,

Yours faithfully,

SH034981

18-MAY-2022 05:59 PM

Authorized Signatory.

CC : Branch Office - Patturaickal

STAR HEALTH AND ALLIED INSURANCE CO.LTD.
3rd Floor,Panicker's Tower,V/508/20,,Tuda Road,Thiruvampady Po,Thrissur 680022

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