IMPORTANT

To, 23-MAR-22

Dr RAVEENDRA N M
#502, 4th Floor, SANGAM,
Doctors Quaters, Opp I M A Hall, SIMS Campus

Shimoga,Shimoga, -577201
Mobile : 8095674401.

Dear Customer,

Re: Health Insurance Policy - P/141121/01/2023/000024

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.
If you or any of the insured person(s) have suffered or suffering from any of the diseases which has not been
mentioned in the proposal, the claim that may arise will result in the repudiation of the claim/ cancellation of the
policy. The other option for you is to continue with the previous insurer.

This insurance policy is subject to various exclusions including exclusion for pre-existing diseases and conditions in
this policy.

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
"Let Star Health help you to become healthier and happier. Star Wellness Benefits includes Mind Body healing and other
Condition management programmes (Weight management, Diabetes etc....) Visit www.starhealth.in / customer portal login and
start your journey with us to Better Health".
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.

 STAR COMPREHENSIVE INSURANCE POLICY
SCHEDULE (Floater)
UNIQUE ID:SHAHLIP22028V072122
Policy No. : P/141121/01/2023/000024 Previous Policy No. : 2805203573395601000
Customer Code : AA0024697365 GSTIN : 29AAJCS4517L1ZU
Customer Name : Dr RAVEENDRA N M SAC Code : 997133/Accident and Health Insurance Services
Proposer's Code : 28035215 Issuing Office Code : 141121
Proposer's Name : Dr RAVEENDRA N M Issuing Office Name : Branch Office - Shimoga
Address : #502, 4th Floor, SANGAM, Address : 1st Floor, Karthik Plaza, Durgigudi
Doctors Quaters, Opp I M A Hall, Main Road,
SIMS Campus Gopi Circle,Shimoga - 577 201.

Shimoga,Shimoga, -577201
Phone No : /8095674401/ Phone No : 08182 - 223047 & 404047
E-mail Id : shimogacity1982@gmail.com E-mail Id : shimoga@starhealth.in
Proposer GSTIN : - Place of Supply : -
Proposal date : 23/03/2022 Fulfiller Code : SH4452

Date of Inception of first policy : 05-MAY-2022 Intermediary Code : BA0000259049

Renewal Year : NEW
Collection Number : 1093018236
Receipt Date : 23/03/2022
Name : Mrs.S. VIJAYALAKSHMI

Premium :Rs 10,420 /-

Phone No : 9243314532/9243314532
CGST @9% : 938 /- SGST / UTGST @9% : 938 /- E-mail Id : shivaprasadbhatm06@gma
Stamp Duty :Rs 1 /- Total Premium :Rs 12,296 /-
il.com
Total Premium In Words : Rupees Twelve Thousand Two Hundred Ninety Six Only Installment Facility Optn :No

Premium Payment Frequency :Annual Installment Amount : Rs. 0

Period of Insurance : FROM 05/05/2022 00:00 TO : Midnight Of 04/05/2023
Scheme Description (Family Size) : 2 ADULTS Basic Floater Sum Insured : Rs. 500000 /-
Bonus : Rs. 0 /-
Sum Insured Under Section 1 (Health) Rs. 500000 /- Policy Term : 1 Year
Capital Sum Insured Under Section 10 (For Accidental Death & Permanent Total Disablement) : Rs. 500000 /-
For Mr / Ms. Dr RAVEENDRA N M Only.

Details of Insured Persons :

Sl. Name of the Insured Sex Date of Birth Age in Relationship with ID Card No Co-Pay Buy Back Pre- Inception Date
no. Yrs Proposer PED Opted Existing
Disease/s
1 Dr RAVEENDRA N M M 20/01/1987 35 SELF 28035215-1 0 No No PED 03/05/2019
declared
2 SUPRIYA A S F 16/10/1994 27 SPOUSE 28035215-2 0 No No PED 05/05/2022
declared

For Star Health and Allied Insurance Company Ltd.

Entered by : STAR_PORTAL
Aproved by : SH8705

IRDAI Regn. No 129

Authorised Signatory
Corporate Identity Number L66010TN2005PLC056649
Email ID : info@starhealth.in
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Attached to and forming part of Policy No : P/141121/01/2023/000024

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
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
Toll Free No: 1800 425 2255/1800 102 4477 Email: support@starhealth.in, Fax No: 1800 425 5522
"Consolidated Policy stamp duty paid vide no. CR0122003000808305 DTD 31/01/2022"

Nominee Details
Nominee Details for the proposer Appointee Details

S.No. Name Relationship Age % Appointee Relationship

Age
with proposer Name with Nominee

1 SUPRIYA A S Spouse 27 100

For Star Health and Allied Insurance Company Ltd.

Entered by : STAR_PORTAL
Aproved by : SH8705

Authorised Signatory

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Attached to and forming part of Policy No : P/141121/01/2023/000024

Continuity Benefits applicable is as follows

30 Days 1st Year First Two

S.No. Name Of the Insured Id Card No Pre Existing
Waiting Period Exclusions Year Disease
Exclusion

1 Dr RAVEENDRA N M 28035215-1 Waived Not Applicable Waived Covered

2 SUPRIYA A S 28035215-2 Not Waived Not Applicable Not Waived Not Covered
"A waiting period apply as fresh from the date of enhancement for the increase in the sum insured, that is, the difference between the
expiring policy sum insured and the increased current sum insured".

In witness whereof the undersigned being authorised by and on behalf of the company has set his hand at Branch Office - Shimoga on 23rd
Day of March 2022.

Permanent Exclusion Details

Insured Name ID Card Permanent Exclusion Disease

For Star Health and Allied Insurance Company Ltd.

Entered by : STAR_PORTAL
Aproved by : SH8705

Authorised Signatory

4 of 7
 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. : 28035215-1
This Card is valid until otherwise Cancelled. Name : Dr RAVEENDRA N M
This ID Card is invalid, if the insurance cover is not in force Date Of Birth : 20-JAN-87 Age : 35 Years
Immediate intimation to 'Star' through above Tel Nos. is a must
Gender : Male Office Code : 141121
in case of Hospitalisation.
At the time of hospitalization, kindly submit any Government Valid From : 05-MAY-22 TA/SSM/SM Code : SH4452
approved photo ID Card. Agent/Broker/TE Code : BA0000259049
Corporate Identity Number: L66010TN2005PLC056649 IRDAI Regn. No:129

Star Health and Allied Insurance

Company Limited
Customer Identity Card

Customer ID No. : 28035215-2

Name : SUPRIYA A S
Date Of Birth : 16-OCT-94 Age : 27 Years
Gender : Female Office Code : 141121
Valid From : 05-MAY-22 TA/SSM/SM Code : SH4452
Agent/Broker/TE Code : BA0000259049
IRDAI Regn. No:129

For Star Health and Allied Insurance Company Ltd.

Entered by : STAR_PORTAL
Aproved by : SH8705

Authorised Signatory

5 of 7
 TAX Invoice

Invoice No. : 29L093Y22P001948 Customer ID : AA0024697365

Invoice Date : 23/03/22 Policy No : P/141121/01/2023/000024
Recipient Supplier

GSTIN : - GSTIN : 29AAJCS4517L1ZU

Proposer's : Dr RAVEENDRA N M NAME : Star Health and Allied Insurance Co Ltd
Name - Branch Office - Shimoga
Address : #502, 4th Floor, SANGAM, Address : 1st Floor, Karthik Plaza, Durgigudi
Doctors Quaters, Opp I M A Hall, Main Road,
SIMS Campus Gopi Circle,Shimoga - 577 201.

City : City : SHIMOGA

State : Karnataka State : Karnataka
Pincode : 577201 Pincode : 577 201
Client Category : IND Place of Supply : 29 - Karnataka

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

997133 Insurance 10420 0 10420 938 938 Rs. 12296

Services
Total Invoice Value (in Figures) : Rs. 12296
Total Invoice Value (in Words) : Rupees: Twelve thousand two
hundred ninety-six 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 L66010TN2005PLC056649 Email ID : stargst@starhealth.in

For Star Health and Allied Insurance Company Ltd.

Entered by : STAR_PORTAL
Aproved by : SH8705

Authorised Signatory

6 of 7
 Name Of the Product Star Comprehensive Insurance Policy

Product UIN No. SHAHLIP22028V072122

Summary of Important Benefits
Refer to Policy clause No.
S.No Particulars of Coverage / Benefits Benefit Limits (in Rs.)
Sum Insured (in Rs.) 5,00,000 7,50,000 10,00,000 15,00,000 20,00,000 25,00,000 50,00,000 75,00,000 1,00,00,000

Room Rent (Per Day) - Up to Private Single A/c Room

1 II.Section 1(A)
*Hospitalization expenses will be considered in
proportion to the eligible Room Rent
Surgeon, Anesthetist, Medical Practitioner,
2 Consultants, Specialist Fees, Anesthesia, Actual II. Section 1(B & C)
blood, oxygen, operation theatre charges,
Surgical Appliances, Medicines and Drugs

3 Road Ambulance charges(per policy period) Actual II.Section 1(D)

4 Air Ambulance charges Up to Rs.2,50,000/- per hospitalization not exceeding Rs.5,00,000/- per policy period II.Section 1(E)
5 Pre-Hospitalization Expenses Up to 60 days prior to admission II.Section 1(F)
6 Post-Hospitalization Expenses Up to 90 days from the date of discharge II.Section 1(G)
Up to Up to Up to Up to Up to Up to Up to 5,000/- Up to 5,000/- Up to
Out Patient Medical Consultation Coverage
7 1,200/- (per 1,500/-(per 2,100/- (per 2,400/-(per 3,000/-(per 3,300/-(per (per (per 5,000/-(per
other than Out Patient Dental/ Ophthal consultation consultation
Consultation consultation consultation consultation consultation consultation consultation II.Section 1(H)
limit limit limit limit limit limit limit limit Rs.300/- limit
Rs.300/-) Rs.300/-) Rs.300/-) Rs.300/-) Rs.300/-) Rs.300/-) Rs.300/-) ) Rs.300/-)
8 Domiciliary hospitalization Coverage for medical treatment for a period exceeding three days II.Section 1(I)
9a. Delivery Charges(Normal Delivery) 15,000/- 25000/- 30000/- 30000/- 30000/- 50000/- 50000/- 50000/-
30000/-
9b. 20000/- 40000/- 50000/- 50000/- 50000/- 100000/- 100000/- II. Section 2.B
Delivery Charges(Caesarean Delivery) 50000/- 100000/-
10 New Born Cover 100000/- 100000/- 100000/- 100000/- 100000/- 100000/- 200000/- 200000/- 200000/-

11 Vaccination Expenses for New Born (Subject 5,000/- 5,000/- 5,000/- 5,000/- 5,000/- 5,000/- 10,000/- 10,000/- 10,000/- II. Section 2.C
to a valid claim under 9a or 9b above)
24 months for first delivery from first inception of the policy Special condition no.1-
12 Waiting Period for Delivery
24 months from claim under 9a or 9b for next delivery Under Section 2
Out-patient Dental and Ophthalmic Treatment Up to Up to Up to Up to Up to Up to Up to Up to Up to
13 Coverage- Once in a block of every 3 years II Section 3
5,000/- 5,000/- 10,000/- 10,000/- 10,000/- 10,000/- 15,000/- 15,000/- 15,000/-
of continuous renewal

14 Organ Donor Expenses Payable up to the Basic Sum Insured II.Section 4

Hospital Cash Benefit upto 7 days per

15 occurrence & upto 120 days per policy 500/- 750/- 750/- 1000/- 1000/- 1500/- 2500/- 2500/- 2500/-
II.Section 5
period. (1 day time excess) per day per day per day per day per day per day per day per day per day

Health Check Up for every claim free Up to Up to Up to Up to Up to Up to Up to Up to

16 Up to II.Section 6
years of continuous renewal 2,000/- 2,500/- 3,000/- 4,000/- 4,500/- 4,500/ 5,000/- 5,000/-
5,000/-

17 Bariatric Surgery(per policy period) 2,50,000/- 2,50,000/- 2,50,000/- 2,50,000/- 5,00,000/- 5,00,000/- 5,00,000/- 5,00,000/- 5,00,000/- II.Section 7

18 Second Medical Opinion The Insured Person is given the facility of obtaining a medical Second Opinion from a Doctor in the Company's network of
Medical Practitioners.
II. Section 8
Up to Up to Up to Up to Up to Up to Up to Up to Up to II.Section 9
19 AYUSH Treatment(Per Policy Period)
15,000/- 15,000/- 15,000/- 15,000/- 20,000/- 20,000/- 30,000/- 30,000/- 30,000/-
20 Under Important Note. Point
Day Care Treatments / Procedures All Day Care Procedures No.1
Accidental Death and Permanent Total 1,00,00,000/- II. Section 10
21 5,00,000/- 7,50,000/- 10,00,000/- 15,00,000/- 20,00,000/- 25,00,000/- 50,00,000/- 75,00,000/-
Disablement

22 Star Wellness Program Discount in the Renewal premium for healthy life style through wellness activities. II. Section 11

23 Buy Back Pre Existing Disease(Optional Waiting Period of Pre Existing Disease reduces from 36 months to 12 months
II.Section 12
Cover)

24 Automatic Restoration of Sum Insured 100% (once during policy period) IV.30a
(Applicable for Section 1 only)

25 Coverage for Modern Treatment Covered up to limits mentioned in the policy clause II.Section 13

26 Instalment Facility (If Opted) Available IV.13

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

For Star Health and Allied Insurance Company Ltd.

Entered by : STAR_PORTAL
Aproved by : SH8705

Authorised Signatory

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