IMPORTANT

To, 30/08/2021

Mr.RAM KUMAR GUPTA,

S/O BASTI RAM GUPTA HOUSE NO-139
SECTOR-31, GURGAON
.
Gurgaon,Gurgaon,Haryana -122001
Mobile : 9810794614.

Dear Customer,

Re: Health Insurance Policy - P/161112/01/2022/015576

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 ab
initio.

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
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.

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 SENIOR CITIZENS RED CARPET HEALTH INSURANCE POLICY
Schedule
Unique Identification No.SHAHLIP22040V052122
Policy No. : P/161112/01/2022/015576 Previous Policy No. :
Customer Code : AA0020343617 GSTIN : 09AAJCS4517L1ZW
Customer Name : Mr.RAM KUMAR GUPTA SAC Code : 997133/Accident and Health Insurance Services
Proposer's Code : 23552562 Issue Office Code : 161112
Proposer's Name : Mr.RAM KUMAR GUPTA Issue Office Name : Branch Office - Vaishali
Address : S/O BASTI RAM GUPTA HOUSE Address : No. 15-16,3rd Floor,Tower
NO-139 C1 & C2,Sector-
SECTOR-31, GURGAON 4,Vaishali,Ghaziabad,
. Uttar Pradesh-201010
Gurgaon,Gurgaon,Haryana-122001
Phone No : ./9810794614/ Phone No : 0120-4127426
E-mail Id : ROYALRITECH@GMAIL.COM E-mail Id : vaishali@starhealth.in
Proposer GSTIN : - Place of Supply : -
Proposal Date : 24/08/2021 Fulfiller Code : SH2327
Date of Inception of first policy : 25-AUG-2021
Renewal Year : NEW
Collection Number : 1112016494
Collection Date : 25/08/2021 Intermediary Code : LC0000000086
Premium :Rs 50,490 /- Name : M/S.A&M INS. BROKERS PVT.
IGST @18% : 9,088 /- LTD.
Stamp Duty :Re 1 /- Total Premium :Rs 59,578 /- Phone No : /9818175705

E-mail Id : support@insurancepandit.com

Total Premium In Words : Rupees Fifty Nine Thousand Five Hundred Seventy Eight Only

Period Of Insurance From : 25/08/2021 00:00 Hrs To : Midnight Of 24/08/2024

Policy Type : Individual
Installment Facility Optn :No Premium Payment Frequency :Annual Installment Amount Rs. : 0
Details of Insured Persons :
Sl. Name Sex Date of Age in Relationship with OP Limit ID Card No Sum Inception Date
No. Birth Proposer Rs. Insured
Yrs
(Rs.)

1 RAM KUMAR GUPTA M 02/04/1946 75 SELF 1000 23552562-1 500000 25/08/2021

Details of Pre Existing Diseases relating to the above person : Diseases of the musculoskeletal System and their complications
Hypertension and its complications
Diseases related to Respiratory System

Entered by : SH49422 For Star Health and Allied Insurance Company Ltd.

Approved by : SH49422

IRDAI Regn. No 129

Corporate Identity Number U66010TN2005PLC056649
Email ID : info@starhealth.in Authorised Signatory

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Attached to and forming part of Policy No. P/161112/01/2022/015576

Co-Payment:
For Sum Insured Options Up to Rs.10,00,000/- :-
Copay for PED Claims : 50%
Copay for Non PED Claims : 30% irrespective of sum insured
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 dishonour of premium cheque(s), the Company shall not be liable under the policy and the policy shall be void abinitio
(from inception).
Expenses relating to the hospitalisation will be considered in proportion to the room rent stated in the policy.

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.

Nominee Details

Nominee Details for the proposer Appointee Details

S.No. Name Relationship Age % Appointee Relationship

Age
with proposer Name with Nominee

In the event of the policy being withdrawn in future, intimation about the withdrawal will be sent 3 months prior to the date when renewal falls
due.The insured will have the option of migrating to any other similar health insurance policy offered by the Company at the relevant time.
Continuity of benefits for waiting period and bonus, if any and if applicable, will be given provided the insured had been renewing the policy
without any break (or renewing within the grace period offered)

In witness whereof the undersigned being authorized by and on behalf of the company has set his hand at Branch Office - Vaishali on
30th Day of August 2021.

Permanent Exclusion Details

Insured Name ID Card Permanent Exclusion Disease

Entered by : SH49422 For Star Health and Allied Insurance Company Ltd.

Approved by : SH49422

Authorised Signatory

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 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. : 23552562-1
This Card is valid until otherwise Cancelled.
Name : RAM KUMAR GUPTA
This ID Card is invalid, if the insurance cover is not in force.
Immediate intimation to 'Star' through above Tel Nos. is a must Date Of Birth : 02-APR-46 Age : 75 Years
in case of Hospitalisation. Gender : Male Office Code : 161112
Valid From : 25-AUG-21 TA/SSM/SM Code: SH2327
At the time of hospitalization, kindly submit any Government
approved photo ID Card. Agent/Broker/TE Code: LC0000000086

Corporate Identity Number: U66010TN2005PLC056649 IRDAI Regn. No:129

*This is a temporary ID card issued along with the policy. Original ID cards will be dispatched shortly.

Entered by : SH49422 For Star Health and Allied Insurance Company Ltd.

Approved by : SH49422

Authorised Signatory

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 TAX Invoice

Invoice No. : 9E112Y22P0003033 Customer ID : AA0020343617

Invoice Date : 30/08/21 Policy No : P/161112/01/2022/015576
Recipient Supplier

GSTIN : - GSTIN : 09AAJCS4517L1ZW

Proposer's : Mr.RAM KUMAR GUPTA NAME : Star Health and Allied Insurance Co
Name Ltd - Branch Office - Vaishali
Address : S/O BASTI RAM GUPTA HOUSE Address : No. 15-16,3rd Floor,Tower
NO-139 C1 & C2,Sector-
SECTOR-31, GURGAON 4,Vaishali,Ghaziabad,
. Uttar Pradesh-201010
City : Gurgaon,Gurgaon,Haryana-122001 City : VAISHALI
State : Haryana State : Uttar Pradesh
Pincode : 122001 Pincode : 201010
Client Category : IND Place of Supply : 9 - Uttar Pradesh

HSN / Description of Total Discount TaxableValue IGST @ 18% CGST @9% UT/SGST@9% CESS@1% Total InvoiceValue
SAC Service(s) H=C+D+E+F+G
A B C=A-B D = C * IGST E=C F=C G=C*Cess
Code
*CGST *UTGST or
SGST
997133 Insurance 50490 0 50490 9088 Rs. 59578
Services
Total Invoice Value (in Figures) : Rs. 59578
Total Invoice Value (in Words) : Rupees: Fifty-nine thousand five
hundred seventy-eight 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 U66010TN2005PLC056649 Email ID:stargst@starhealth.in

Entered by : SH49422 For Star Health and Allied Insurance Company Ltd.

Approved by : SH49422

Authorised Signatory

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 Name Of the Product Senior Citizens Red Carpet Health Insurance Policy

Product UIN No. SHAHLIP22040V052122

Summary of Important Benefits-Individual

Refer to
S.No Particulars of Coverage / Benefits Benefit Limits (in Rs.) Policy clause
No.

Sum Insured (in Rs.) 1,00,000 2,00,000 3,00,000 4,00,000 5,00,000 7,50,000 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 proportion to the Room Rent 1,000 2,000 3,000 4,000 5,000 6,000 6,000 7,000 8,500 10,000 1(A)
stated in the policy or actuals whichever is less

2 ICU Charges (Per Day) - Up to 2,000 4,000 6,000 8,000 10,000 15,000 20,000 Actuals Actuals Actuals 1(B)

Surgeon, Anesthetist, Medical Practitioner,

3 Maximum of 25% of the Sum Insured per hospitalization 1(C)
Consultants, Specialist Fees - Up to

Anaesthesia, Blood, Oxygen, Operation Theatre charges, Surgical Appliances,

Maximum of 50% of the Sum Insured per hospitalization
4 Medicines and Drugs, Diagnostic Materials and X-ray, Dialysis, 1(D)
Chemotherapy, Radiotherapy, cost of Pacemaker and similar expenses - Up to

Limit Per hospitalization Up to 600 600 600 600 1,000 1,000 1,000 1,500 1,500 1,500
5 Emergency Ambulance 1(E)
Limit Per policy period Up to 1,200 1,200 1,200 1,200 2,000 2,000 2,000 3,000 3,000 3,000

6 Pre-Hospitalization Medical Expenses Up to 30 days prior to the date of hospitalization 1(F)

Post-Hospitalization Medical Expenses (Limit Per Occurrence) -

7 Equivalent to 7% of the hospitalization expenses comprising of Nursing
Charges, Surgeon / Consultant fees, Diagnostic charges, Medicines and drugs 5,000 5,000 5,000 5,000 5,000 5,000 7,000 7,000 10,000 10,000 1(G)
expenses subject to a maximum of

8 Day Care Procedures / Treatments All Day Care Procedures are Covered Section.1

Out Patient Medical Consultations in a Network Hospital

9 (Limit per policy period) - Up to N/A N/A 600 800 1,000 1,200 1,400 1,800 2,200 2,600
1(H)
(Note: Limit of Rs.200/- is applicable per Consultation)

Cost of Health Check-up - Up to

(for every claim free year provided the health check-up is done at network N/A 2,500 2,500
10 N/A N/A N/A 1,000 1,000 2,000 2,000 1(I)
hospitals and the policy is in force)

11 Cataract (Limit Per person, per policy period) - Up to 15,000 15,000 18,000 20,000 21,500 23,000 25,000 30,000 35,000 40,000

(Limit Per person, per policy period for each disease / condition) - Up to
. Cerebrovascular Accident,
75,000 1,50,000 2,00,000 2,25,000 2,75,000 3,00,000 3,50,000 4,00,000 4,50,000 5,00,000 Refer table
12
. Cardiovascular Diseases, under
. Cancer (Including Chemotherapy / Radiotherapy), Coverage
. Medical Renal Diseases (Including Dialysis),
. Treatment of Breakage of Long Bones

All other major surgeries

60,000 1,20,000 1,50,000 2,00,000 2,25,000 2,50,000 2,75,000 3,00,000 3,25,000 3,50,000
(Limit Per person, per policy period for each disease / condition) - Up to

Co-payment
13 50% for claim arising out of Pre-Existing Diseases and 30% for all Other claims 30% for all claims 1(K)
(Applicable on each and every admissible claim)

14 Coverage for Modern Treatments Covered up to the limits 1(J)

15 Instalment Facility (if Opted) Available

VI (18)

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.

Entered by : SH49422 For Star Health and Allied Insurance Company Ltd.

Approved by : SH49422

Authorised Signatory

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