DS Policy Schedule 11220011335300 V1.0

Star Health And Allied Insurance Company Limited
Date : 11-Jan-2022
To, IMPORTANT
Mr. SHANKAR PANDIYAN P,

21/3,MELAPALAYAM ROAD PANRUTI TK
PANRUTI
CUDDALORE DISTRICT
Panruti Town,Tamil Nadu-607106
Mobile : 9578689122
Dear Customer,
Re: Health Insurance Policy - 11220011335300
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 abinitio.
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,
Authorized 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 select the room as per your eligibility stipulated in your policy to avoid additional payment from your
pocket towards the proportionate increase which would invariably be charged by the hospital for the higher
room category occupied.
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,
SERIALNUMBER=00f82dcf76fdf6537e3331f8479ef45e7b4f3861b15475488cdf
R Margabandhu 3b2c3c26c3c9, ST=TAMIL NADU, OID.2.5.4.17=600034,

OID.2.5.4.20=513b7b33f2ce960f23148ea208744690e09638750806ca65f89e15
179f5fe50a, OU=UNDERWRITING - Chief Risk Officer, O=STAR HEALTH AND
ALLIED INSURANCE COMPANY, C=IN. Date :Tue Jan 11 15:27:56 IST 2022
Page 1 of 7
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@starhealth.in
Website :www.starhealth.in IRDAI Regn.no: 129
Family Health Optima Insurance Plan

Unique Identification No. SHAHLIP22030V062122
POLICY SCHEDULE
Policy No. : 11220011335300 Previous Policy No :
Customer Code : PI0000066824 GSTIN : 33AAJCS4517L1Z5
Customer Name : Mr. SHANKAR PANDIYAN P SAC Code : 997133 / Accident and Health
Insurance Services
Proposer Code : PI0000066824 Issuing Office Code : 111214
Proposer Name : Mr. SHANKAR PANDIYAN P Issuing Office Name : Branch Office - Cuddalore
Proposer Address : 21/3,MELAPALAYAM ROAD Issuing Office Address : No.41/1 G A B Complex , Opp
PANRUTI TK to Daily Thanthi,
PANRUTI Imperial Road , Cuddalore -
CUDDALORE DISTRICT 607 002
Panruti Town Tamil Nadu 607106
Cuddalore Town Tamil Nadu
607002
Phone No : 9578689122 Phone No : 04142-223456
E-mail Id : madhanshankar0@gmail.com E-mail Id : cuddalore@starhealth.in
Proposer GSTIN : NO Place of Supply : Tamil Nadu
Proposal date : 11-Jan-2022 Fulfiller Code : SH38846
Date of Inception : 11-Jan-2022
of first policy
Policy Category : New Intermediary : BA0000007921
Collection No : 171129004864
Code
Collection Date : 11-Jan-2022 Name : VASANTHI
:
Premium Rs. 20,465/- SURENDIRAN
CGST @ 9% : Rs. 1,842/-
Phone No :04142-
244635/9443443176
:
SGST @ 9% Rs. 1,842/-
E-mail Id : janakisuren@gmail.co
m
Total Premium : Rs. 24,149/-
Stamp Duty : Re. 1/-
Total Premium In Words : Rupees Twenty Four thousand one hundred forty
nine only
PERIOD OF INSURANCE : From : 11-Jan-2022 15:26 To : Midnight Of 10-Jan-2023
Installment Facility Option:No Premium Payment Frequency :Annual Installment Amount Rs. : 0/-
Basic Floater Sum Insured : Rs. 5,00,000/- Scheme Description : 2A+1C

In Words : Rupees Five lakhs only
Bonus : Rs. 0/- Limit of Coverage : Rs. 5,00,000/- Recharge Benefit : Rs. 1,50,000/-
Details of Insured Persons :
Sl. Age in Relationship Inception
Name of the Insured Gender Date of Birth ID Card No
no. Yrs with Proposer date
Mr. SHANKAR PANDIYAN P
1 Male 15-Jun-1970 51 Self PI0000066824 11-Jan-2022
Pre Existing Disease : No PED Declared

Mrs. TAMILSELVI S
2 Female 07-Apr-1973 48 Spouse ME0012320148 11-Jan-2022

Mr. MADHANKUMAR S
3 Male 06-Oct-1999 22 Son ME0012320149 11-Jan-2022
Entered by : CUSTPORTAL For Star Health and Allied Insurance Company Ltd.
Approved by : PORTAL
IRDA Regn.No.129
Corporate Identity Number U66010TN2005PLC056649

Authorised Signatory Page 2 of 7
Email ID: info@starhealth.in
Attached to and forming part of Policy No: 11220011335300
Nominee Details:
Nominee Details for the Proposer Appointee Details
S.No Name Relationship Age % of the Appointee Name Appointee Relationship
with proposer claim Age with nominee
1 TAMILSELVI Spouse 48 100
Sector Classification:
Urban No
''CONSOLIDATED STAMP DUTY PAID VIDE G.O.(RT) NO.231 DATED.12TH JULY 2021''
Please check whether the details given by you about the insured persons in the proposal form are incorporated
correctly in the policy schedule. If you find any discrepancy, please inform us within 15 days from the date of
receipt of the policy, failing which the details relating to the insured person given in the policy schedule are deemed
to have been accepted by you.
Warranted that in case of dishonor of premium cheque(s), the Company shall not be liable under the policy and the
policy shall be void abinitio (from inception).
THE INSURANCE UNDER THIS POLICY IS SUBJECT TO CONDITIONS, CLAUSES, WARRANTIES,
EXCLUSIONS ETC., ATTACHED.
Important
“This policy covers 68 other excluded expenses. Accordingly, exclusion (Code Excl 37) appearing in
the policy wordings stands deleted”
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.
Toll Free No : 1800 425 2255 / 1800 102 4477 Email: support@starhealth.in, Fax No: 1800 425 5522.
In witness whereof the undersigned being authorized by and on behalf of the company has set his hand at Branch
Office - Cuddalore on 11th Day of January 2022.
Hospitalisation Benefit Policy

Premium Certificate for the purpose of deduction under Section 80 D of Income Tax (Amendment) Act,1986
Policy No : 11220011335300 Type of Policy : Family Health Optima Insurance

Plan - 2021
Issue Office : 111214-Branch Office - Cuddalore
Address : No.41/1 G A B Complex , Opp to Daily Thanthi,

Imperial Road , Cuddalore - 607 002
Cuddalore Town Tamil Nadu 607002
Tel / Fax : 04142-223456
Email : cuddalore@starhealth.in
This is to certify that Mr. SHANKAR PANDIYAN P has paid Rs 24,149/- (Total Premium : Indian Rupees
Twenty Four thousand one hundred forty nine only ) towards Premium for Hospitalization Insurance vide
Policy No: 11220011335300 for the Period 11-Jan-2022 To 10-Jan-2023 issued on 11-Jan-2022.
Payment received by Payment Gateway vide Receipt No: 171129004864/1 Receipt Date: 11-Jan-2022
Note :- This Certificate must be surrendered 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.
Date : 11-Jan-2022 For and on behalf of
Place : Branch Office - Cuddalore Star Health and Allied Insurance Company Ltd.
IRDA Regn.No.129
Corporate Identity Number U66010TN2005PLC056649 Authorised Signatory
Email ID: info@starhealth.in
Star Health and Allied Insurance

Emergency Help Line No.1800 425 2255/1800 102 4477 Company Limited
e-mail : support@starhealth.in Website :www.starhealth.in
Customer Identity Card
Please quote the Customer Id No. for assistance
Customer ID No. : PI0000066824
This Card is valid until otherwise Cancelled. Name : Mr. SHANKAR PANDIYAN P
This ID Card is invalid,if the insurance cover is not in force. Date Of Birth : 15-Jun-1970 Age : 51 Years
Immediate Intimation to 'Star' through above Tel Nos. is a must in Gender : Male Office Code : 111214
case of Hospitalisation. Valid From : 11-Jan-2022 TA/SSM/SM Code :SH38846
At the time of hospitalisation,kindly submit any Government Agent/Broker/TE Code : BA0000007921
approved photo ID Card.
Corporate Identity Number : U66010TN2005PLC056649 IRDAI Regn.No:129
Star Health and Allied Insurance Star Health and Allied Insurance
Company Limited Company Limited
Customer Identity Card Customer Identity Card
Customer ID No. : ME0012320148 Customer ID No. : ME0012320149
Name : Mrs. TAMILSELVI S Name : Mr. MADHANKUMAR S
Date Of Birth : 07-Apr-1973 Age : 48 Years Date Of Birth : 06-Oct-1999 Age : 22 Years
Gender : Female Office Code : 111214 Gender : Male Office Code : 111214
Valid From : 11-Jan-2022 TA/SSM/SM Code :SH38846 Valid From : 11-Jan-2022 TA/SSM/SM Code :SH38846
Agent/Broker/TE Code : BA0000007921 Agent/Broker/TE Code : BA0000007921
IRDAI Regn.No:129 IRDAI Regn.No:129
*This is a temporary ID card issued along with the policy. Original ID card will be dispatched shortly.
Tax Invoice
Invoice No. : 332201I000771177 Customer ID : PI0000066824
Invoice Date : 11-Jan-2022 Policy No. : 11220011335300
Recipient Supplier
GSTIN : NO GSTIN : 33AAJCS4517L1Z5
Name : Mr. SHANKAR PANDIYAN P Name : Star Health and Allied Insurance Co Ltd -
Branch Office - Cuddalore
Address : 21/3,MELAPALAYAM ROAD PANRUTI TK Address : No.41/1 G A B Complex , Opp to Daily Thanthi,
PANRUTI Imperial Road , Cuddalore - 607 002
CUDDALORE DISTRICT
City : Panruti Town Pin Code : 607106 City : Cuddalore Town Pin Code : 607002
State : Tamil Nadu Client : IND State : Tamil Nadu Place of : Tamil Nadu
Category supply
Taxable IGST @ UT/SGST @ CESS @ Total Invoice

Total Discount CGST @ 9%
Value 18% 9% 1% Value
HSN / SAC Description of
Code Service(s) F=C*
D=C* E=C* G= C * H=C+D+
A B C=A-B UTGST or
IGST CGST Cess E+ F + G
SGST
Insurance
997133 20,465.00 0 20,465.00 0 1,842.00 1,842.00 0 24,149.00
Services
Total Invoice Value (in Figures) : Rs. 24,149/-

Total Invoice Value (in Words) : Rupees Twenty Four thousand one hundred forty nine 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
IRDA Regn.No.129 Corporate Identity Number U66010TN2005PLC056649 Email ID: stargst@starhealth.in
Name Of the Product Family Health Optima Insurance Plan
Product UIN No. SHAHLIP22030V062122
Summary of Important Benefits

Refer to
Particulars of Coverage / Benefits Policy
S.No Benefit Limits (in Rs.) clause No.
Sum Insured (in Rs.) 1,00,000 2,00,000 3,00,000 4,00,000 5,00,000 10,00,000 15,00,000 20,00,000 25,00,000
Room Rent (Per Day) - Up to

1 *Hospitalization expenses will be considered in 2,000 2,000 5,000 5,000 Single Standard A/C Room 2(A)
proportion to the eligible Room Rent
Surgeon, Anesthetist, Medical Practitioner,

2 Actual 2(B)
Consultants, Specialist Fees
Anesthesia, Blood, Oxygen, Operation theatre
3 Actual 2(C)
charges, ICU Charges, Medicines and Drugs
Limit Per Eye (Up to) 12,000 12,000 25,000 30,000 40,000 50,000 50,000 50,000 50,000
4 Cataract treatment 2(E)
Limit Per Policy Period (Up to) 12,000 12,000 35,000 45,000 60,000 75,000 75,000 75,000 75,000
Limit Per Hospitalization 750 750 750 750 750 750 750 750 750
Emergency
5 2(F)
Ambulance
Limit Per Policy Period 1,500 1,500 1,500 1,500 1,500 1,500 1,500 1,500 1,500
6 Air Ambulance N/A N/A N/A N/A Covered up to 10% of the Sum Insured per policy period 2(G)
7 Pre-Hospitalization 60 days 60 days 60 days 60 days 60 days 60 days 60 days 60 days 60 days 2(H)
8 Post-Hospitalization 90 days 90 days 90 days 90 days 90 days 90 days 90 days 90 days 90 days 2(I)
9 Day Care Treatments / Procedures All Day Care Procedures 2(D)
10 Domiciliary Hospitalization Coverage for a period exceeding three days. 2(J)
11 Organ Donor Expenses (Per Policy Period) 10% of the Sum insured or Rs.1,00,000/- whichever is less 2(K)
Cost of Health Check-up (Available after every
12 N/A N/A 750 1,000 1,500 2,000 2,500 3,000 3,500 2(L)
claim free year) Up to
10% of the Sum Insured or maximum of Rs.50,000/- whichever is less in a policy year (Available if
13 Coverage for New Born Baby 2(M)
the mother is covered under the policy for a continuous period of 12 months)
Emergency Domestic Medical Evacuation
14 5,000 5,000 5,000 5,000 7,500 7,500 7,500 10,000 10,000 2(N)
(Per Hospitalization) Up to
15 Compassionate Travel Up to N/A N/A N/A N/A N/A 5,000 5,000 5,000 5,000 2(O)
16 Repatriation of Mortal Remains (Per Policy Period) 5,000 5,000 5,000 5,000 5,000 5,000 5,000 5,000 5,000 2(P)
Treatment in Valuable Service Provider (Lump-Sum
17 1% of the Sum Insured subject to a maximum of Rs.5,000/- is payable as lumpsum per policy period 2(Q)
benefit)
18 Shared Accommodation(Benefit Amount Per Day) N/A N/A 800 800 800 800 800 1,000 1,000 2(R)
AYUSH Treatment (Ayurveda, Unani, siddha and

19 10,000 10,000 10,000 10,000 15,000 15,000 15,000 20,000 20,000 2(S)
Homeopathy Systems of medicines) Up to
Available from a Doctor in the Company’s network of Medical Practitioners.

20 Second Medical Opinion 2(T)
Mail: “e_medicalopinion@starhealth.in”
Assisted Reproduction Treatment (Limit for every

21 N/A N/A N/A N/A 1,00,000 2,00,000 2,00,000 2,00,000 2,00,000 2(U)
block of 36 months and payable on renewal)
Available for three times per policy period and 100% of the Sum Insured at each
22 Automatic Restoration of Sum Insured N/A N/A 2(V)
time
23 Recharge Benefit N/A N/A 75,000/- 1,00,000/- 1,50,000/- 1,50,000/- 1,50,000/- 1,50,000/- 1,50,000/- 2(W)
Additional Sum Insured for Road Traffic Accident

24 25% of the Sum Insured subject to a maximum of 5,00,000 2(X)
(Once in a Policy Period)
The insured is entitled to Bonus of 25% of expiring Basic Sum Insured and
25 BONUS N/A N/A 2(Z)
additional 10% of the expiring Sum Insured in the subsequent years
The Policy is subject to 20% Co-Pay for each and every claim for person whose age at the time entry is
26 Co-Payment 2(AA)
61 years and above.
27 Coverage for Modern Treatement Covered up to the limits mentioned in the policy clause 2(Y)
28 Installment facility (if Opted) Available 4(13)
N/A = Benefits not available to the respective Sum Insured.

Note: The above information is only indicative. For complete details of the Terms & Conditions kindly read the policy wordings attached.

DS Policy Schedule 11220011335300 V1.0

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Star Health And Allied Insurance Company Limited

Mr. SHANKAR PANDIYAN P,

Re: Health Insurance Policy - 11220011335300

With kind regards,

R Margabandhu 3b2c3c26c3c9, ST=TAMIL NADU, OID.2.5.4.17=600034,

Family Health Optima Insurance Plan

Basic Floater Sum Insured : Rs. 5,00,000/- Scheme Description : 2A+1C

Pre Existing Disease : No PED Declared

Pre Existing Disease : No PED Declared

Pre Existing Disease : No PED Declared

Corporate Identity Number U66010TN2005PLC056649

Attached to and forming part of Policy No: 11220011335300

1 TAMILSELVI Spouse 48 100

Authorised Signatory Page 3 of 7

Hospitalisation Benefit Policy

Policy No : 11220011335300 Type of Policy : Family Health Optima Insurance

Address : No.41/1 G A B Complex , Opp to Daily Thanthi,

Cuddalore Town Tamil Nadu 607002

Tel / Fax : 04142-223456

Date : 11-Jan-2022 For and on behalf of

Corporate Identity Number U66010TN2005PLC056649 Authorised Signatory

Email ID: info@starhealth.in

Authorised Signatory Page 4 of 7

Star Health and Allied Insurance

Corporate Identity Number : U66010TN2005PLC056649 IRDAI Regn.No:129

IRDAI Regn.No:129 IRDAI Regn.No:129

Authorised Signatory Page 5 of 7

Taxable IGST @ UT/SGST @ CESS @ Total Invoice

Total Invoice Value (in Figures) : Rs. 24,149/-

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

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

Authorised Signatory Page 6 of 7

Name Of the Product Family Health Optima Insurance Plan

Product UIN No. SHAHLIP22030V062122

Summary of Important Benefits

Room Rent (Per Day) - Up to

Surgeon, Anesthetist, Medical Practitioner,

9 Day Care Treatments / Procedures All Day Care Procedures 2(D)

10 Domiciliary Hospitalization Coverage for a period exceeding three days. 2(J)

AYUSH Treatment (Ayurveda, Unani, siddha and

Available from a Doctor in the Company’s network of Medical Practitioners.

Assisted Reproduction Treatment (Limit for every

Additional Sum Insured for Road Traffic Accident

28 Installment facility (if Opted) Available 4(13)

N/A = Benefits not available to the respective Sum Insured.

Authorised Signatory Page 7 of 7

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