Regd. & Corporate Office: 1, New Tank Street, Valluvar Kottam High Road,Nungambakkam, Chennai - 600034.

Phone : 044 - 28288800 Telefax : 044 - 28260062 Website :

IRDA Registration No : 129 ; Corporate Identity Number : L66010TN2005PLC056649
www.starhealth.in
Certificate of Insurance
STAR GROUP HEALTH INSURANCE POLICY FOR BANK CUSTOMERS
Unique id : SHAHLGP21290V022021
Master Policy No P/900000/01/2024/000541
Certificate No. P/161132/01/2025/000542
Account Number 2814290103

Name and Address of the Account Holder cum

Insured Person
MOHANI DEVI
W/O MISHRA LAL JAIN E-79 SHASTRI NAGAR
NEAR SCIENCE PARK JAIPUR
Jaipur-302016
Rajasthan
Contact No : 9414047152

Email ID : [email protected]

Fulfiller Code : SH63611

Name and Address of the Proposer M/S.BANK OF BARODA

Baroda Corporate Centre, Plot No. C-26,
Block G, Bandra Kurla Complex,
Bandra (East)
Mumbai-400051

Details of Insured Person(s)

Name of the Insured Gender Date of Birth Relation with

Sl.No Sum Insured Premium ID Card No
Person the Member
1 MOHANI DEVI F 15/05/1948 Self 1000000 17837 CB000005315
300054240473
3

Pre- existing disease: NIL

Issue Office Address: For Star Health and Allied Insurance Co., Ltd.,
CN=NAGARAJAN RANGANATHAN,

C - 100 First floor NAGARAJAN SERIALNUMBER=571a5eb638953f23a816eb6b4ba547263f54f12c3e

b01eeffe482ca5cef2a530, ST=KARNATAKA, OID.2.5.4.17=560097,
OID.2.5.4.20=6790b30666b75b5b38bb63bf7adee63ad3d22e5d7442f
0f2901f2e91fd09c393,

Above United Bank of India RANGANATHAN OID.2.5.4.65=a239b1f28cc54836b0a11b2d664227a3,

O=PERSONAL, C=IN. Date :Fri Jul 05 17:46:26 IST 2024

, Ghaziabad-201002
Noida
Date: 05/07/2024 Authorised Signatory.
 Regd. & Corporate Office: 1, New Tank Street, Valluvar Kottam High Road,Nungambakkam, Chennai - 600034.
Phone : 044 - 28288800 Telefax : 044 - 28260062 Website :
IRDA Registration No : 129 ; Corporate Identity Number : L66010TN2005PLC056649
www.starhealth.in

Period of Insurance From : 03/07/2024 To : 02/07/2025

Scheme Description : 1A

Total Sum Insured (Rs.) Rs.1000000 /-

Premium Rs. 17837 /-

Premium Details GST Rs. 3211 /-
Total Rs. 21048 /-

Nominee Details

Age of the Appointee Appointee Appointee

Sl.No Name of the Nominee Nominee Relation with
Gender ( if Minor) Age Relation
the Member

1 PRADEEP KUMAR JAIN M 55 SON

Coverage Details

Eligible Room Category

Sum Insured Rs Limit Rs

2,00,000/- Up to 2,000/- per day

3,00,000/- & 4,00,000/- Up to 5,000/- per day

5,00,000/ - to 25,00,000/- Single Standard A/C Room

Expenses relating to hospitalization will be considered in proportion to the eligible room category stated in the policy or
actual whichever is less.
b. Cataract: Expenses incurred on treatment of Cataract is subject to the limit as per the following table

Sum Insured Rs Limit per eye Rs. Limit per policy period Rs.

2,00,000/- Up to 12,000/-per eye, per policy period

3,00,000/- Up to 25,000/- Up to 35,000/-

4,00,000/- Up to 30,000/- Up to 45,000/-

5,00,000/- & 7,00,000/- Up to 40,000/- Up to 60,000/-

10,00,000/- to 25,00,000/- Up to 50,000/- Up to 75,000/-

a.Pre hospitalization expenses up to 60 days prior to date of admission

b.Post hospitalization expenses up to 90 days after date of discharge
c.Road Ambulance expenses up to Rs.750 per hospitalization & maximum of Rs.1500 during entire period of
insurance

Issue Office Address: For Star Health and Allied Insurance Co., Ltd.,
C - 100 First floor
Above United Bank of India
, Ghaziabad-201002
Noida
Date: 05/07/2024 Authorised Signatory.
 Regd. & Corporate Office: 1, New Tank Street, Valluvar Kottam High Road,Nungambakkam, Chennai - 600034.
Phone : 044 - 28288800 Telefax : 044 - 28260062 Website :
IRDA Registration No : 129 ; Corporate Identity Number : L66010TN2005PLC056649
www.starhealth.in
d.Automatic Restoration of Sum Insured: There shall be automatic restoration of the Sum Insured immediately upon
exhaustion of the Sum Insured, which has been defined, during the policy period upto 25% of the Sum Insured.
Restoration will operate only after the exhaustion of the sum insured.
It is made clear that such restored Sum Insured can be utilized only for illness / disease unrelated to the illness / diseases
for which claim/s was / were made. The unutilized restored sum insured cannot be carried forward.
Note: Automatic Restoration of Basic Sum Insured is available only for sum insured options of Rs.3,00,000/- and above.
Not applicable for Sum Insured of Rs.2,00,000/-.
e.All day care treatment covered
f.Organ Donor Expenses for organ transplantation where the insured person is the recipient are payable provided the
claim for transplantation is payable and subject to the availability of the sum insured. Donor screening expenses and
post-donation complications of the donor are not payable. This cover is subject to a limit of 10% of the sum insured or
Rs.1 lakh whichever is less.
g.AYUSH Treatment: In-patient hospitalization expenses incurred on treatment under Ayurveda, Unani, Sidha and
Homeopathy systems of medicines in a Government Hospital or in any institute recognized by the government and / or
accredited by the Quality Council of India / National Accreditation Board on Health is payable up to the limits given below:
Note: Payment under this benefit forms part of the sum insured.

Sum Insured Rs Limit per policy period Rs.

Up to 4,00,000/- Up to 10,000/-

5,00,000/- to 15,00,000/- Up to 15,000/-

20,00,000/- and 25,00,000/ Up to 20,000/-

Cost of Health Checkup: Expenses incurred towards cost of health check-up up to the limits mentioned in the table given
below for every claim free year provided the health checkup is done at network hospitals and the policy is in force. Payment
under this benefit does not form part of the sum insured. If a claim is made by any of the insured persons, the health check
up benefits will not be available under the policy for the other covered members of the family of that insured person who
has made a claim.

Note : Payment of expenses towards cost of health check up will not prejudice the company's right to deal with a claim in
case of non disclosure of material fact and / or Pre-Existing Diseases in terms of the policy.

Sum Insured (Rs.) Limit Per Policy Period (Rs.)

2,00,000/- Not Available

3,00,000/- Up to 750/-

4,00,000/- Up to 1,000/-

5,00,000/- Up to 1,500/-

7,00,000/- Up to 1,750/-

10,00,000/- Up to 2,000/-

15,00,000/- Up to 2,500/-

20,00,000/- Up to 3,000/-

25,00,000/- Up to 3,500/-

Air Ambulance charges up to 10% of the sum insured, provided that

1. It is for life threatening emergency health condition/s of the insured person which requires immediate and rapid ambulance
transportation to the hospital/medical centre that ground transportation cannot provide.

Issue Office Address: For Star Health and Allied Insurance Co., Ltd.,
C - 100 First floor
Above United Bank of India
, Ghaziabad-201002
Noida
Date: 05/07/2024 Authorised Signatory.
 Regd. & Corporate Office: 1, New Tank Street, Valluvar Kottam High Road,Nungambakkam, Chennai - 600034.
Phone : 044 - 28288800 Telefax : 044 - 28260062 Website :
IRDA Registration No : 129 ; Corporate Identity Number : L66010TN2005PLC056649
www.starhealth.in
2. Necessary medical treatment not being available at the location where the Insured Person is situated at the time of
Emergency
3. It is prescribed by a Medical Practitioner and is Medically Necessary;
4. The insured person is in India and the treatment is in India only
5. Such Air ambulance should have been duly licensed to operate as such by Competent Authorities of the Government/s.
Note: This benefit is available for sum insured options of Rs.5,00,000/- and above only.
All other terms and conditions as per Star Group Health Insurance Policy For Bank Customers Policy Clause.

Exclusions: The Company shall not be liable to make any payments under this policy in respect of any expenses what
so ever incurred by the insured person in connection with or in respect of:
1.Any disease contracted by the insured person during the first 30 days from the commencement date of the policy.
2.During the first year of continuous operation of Insurance Policy, any expenses on
a)During the first year of operation of the Insurance cover, the expenses on treatments (conservative, interventional,
laparoscopic and open) related to Hepato-pancreato-biliary diseases including Gall bladder and Pancreatic calculi, all
types of management for kidney and genitourinary tract calculi., all Diseases of Prostate, all types of Hernia,,
Hydrocele, Congenital Internal disease/defect anomalies (Except to the extent covered under Newborn Baby Cover if
specifically opted) Pilonidal sinus and Fistula / Fissure in ano, Piles, Sinusitis and related disorders, If these are Pre-
Existing at the time of proposal they will be covered subject to exclusion number 4 mentioned below.
b)Cataract and diseases of the anterior and posterior chamber of the Eye, Diseases of ENT, Diseases related to
Thyroid, Prolapse of intervertebral disc (other than caused by accident), Varicose veins and Varicose ulcers, all
Stricture Urethra, all Obstructive Uropathies, Epididymal Cyst, Benign Tumours of Epididymis, Spermatocele,
Varicocele, Hemorrhoids, Rectal Prolapse, Stress Incontinence.
c)Desmoid tumour of anterior abdominal wall.
d)All treatments (conservative, interventional, laparoscopic and open) related to all Diseases of Uterus, Fallopian tubes,
Cervix and Ovaries, Uterine bleeding, Pelvic Inflammatory Diseases, Benign breast diseases, Umbilical sinus, Umbilical
fistula.
e)Conservative, operative treatment and all types of intervention for Diseases related to Tendon, Ligament, Fascia,
Bones and Joint Including Arthroscopy and Arthroplasty [other than caused by accident]
f)Degenerative disc and Vertebral diseases including Replacement of bones and joints and Degenerative diseases of
the Musculo-skeletal system
g)Subcutaneous Benign lumps, Sebaceous cyst, Dermoid cyst, Mucous cyst lip / cheek, Carpal tunnel syndrome,
Trigger finger, Lipoma , Neurofibroma, Fibroadenoma, Ganglion and similar pathology
h)Any transplant and related surgery
Note : If these are pre-existing at the time of proposal, they will be covered subject to exclusion number 3 mentioned
below
3.Pre Existing Diseases as defined in the policy until 36 consecutive months of continuous coverage have elapsed
under this Star Group Health Insurance Policy For Bank Customers since inception of the first policy with the Company.
4.Note : In the event of this Star Group Health Insurance Policy For Bank Customers not being renewed or when the
Individual member of the group leaves the group on account of resignation / retirement / termination or otherwise, such
individual member has the option to migrate to any individual health insurance policy on indemnity basis offered by the
Company. In such an event the continuity of benefits with respect to waiting periods under exclusions 1, 2, and 3 will be
given in the individual health insurance policy according to the number of years covered continuously under this Star
Group Health Insurance Policy For Bank Customers Circumcision, Preputioplasty, Frenuloplasty, Preputial Dilatation
and Removal of SMEGMA, Inoculation or Vaccination (except for post-bite treatment and for medical treatment other
than for prevention of diseases)
5.Congenital External diseases/condition defects or anomalies
6.Dental treatment or surgery unless necessitated due to accidental injuries and requiring hospitalization. (Dental
implants are not payable)
7.Convalescence, general debility, run-down condition or rest cure, Nutritional deficiency states, Psychiatric, mental and
behavioral disorders, Venereal disease and Sexually transmitted diseases, intentional self injury and use of intoxicating
drugs / alcohol, smoking and tobacco chewing
8.Injury/disease directly or indirectly caused by or arising from or attributable to war, invasion, act of foreign enemy,
warlike operations (whether war be declared or not)
9.Injury or disease directly or indirectly caused by or contributed to by nuclear weapons/materials
10.Treatment arising from or traceable to pregnancy, childbirth, miscarriage, abortion or complications of any of these
(other than ectopic pregnancy), family planning treatment and all types of treatment for infertility and its complications
thereof.
11.Expenses incurred on weight control services including surgical procedures for treatment of obesity, medical
treatment for weight control, treatment for endocrine disorders, treatment for sleep apnea
12.Expenses incurred on High Intensity Focused Ultra Sound, Uterine fibroid embolisation, Balloon Sinoplasty,
Enhanced External Counter Pulsation Therapy and related therapies, Chelation therapy, Deep Brain Stimulation,
Hyperbaric Oxygen Therapy, Rotational Field Quantum Magnetic Resonance Therapy, VAX-D, Low level laser therapy,
Issue Office Address: For Star Health and Allied Insurance Co., Ltd.,
C - 100 First floor
Above United Bank of India
, Ghaziabad-201002
Noida
Date: 05/07/2024 Authorised Signatory.
 Regd. & Corporate Office: 1, New Tank Street, Valluvar Kottam High Road,Nungambakkam, Chennai - 600034.
Phone : 044 - 28288800 Telefax : 044 - 28260062 Website :
IRDA Registration No : 129 ; Corporate Identity Number : L66010TN2005PLC056649
www.starhealth.in
Photodynamic therapy and such other therapies similar to those mentioned herein under exclusion no12
13.Expenses incurred on Lasik Laser or Refractive Error Correction and its complications all treatment for disorders of
eye requiring intra-vitreal injections and related procedures.
14.Charges incurred at Hospital or Nursing Home primarily for diagnostic, Radiology or laboratory Tests not consistent
with or incidental to the diagnosis and treatment of the positive existence or presence of any ailment, sickness or injury,
for which confinement is required at hospital/nursing home.
15.Expenses on vitamins and tonics unless forming part of treatment for injury or disease as certified by the attending
Physician.
16.Naturopathy Treatment, unconventional, untested, unproven, experimental therapies.
17.Stem cell Therapy, Chondrocyte Implantation, Procedures using Platelet Rich plasma and Intra articular injection
therapy. Immunotherapy without proper indication.
18.Oral Chemotherapy, Immuno therapy and Biologicals, except when administered as an in-patient, when clinically
indicated and hospitalization warranted.
19.Hospital registration charges, admission charges, record charges, telephone charges and such other charges
20.Change of sex or cosmetic or aesthetic treatment of any description, plastic surgery (other than as necessitated due
to an accident or as a part of any illness), all treatment for Priapism and erectile dysfunctions.
21.Cost of spectacles and contact lens, hearing aids, Cochlear implants and procedures, walkers and crutches, wheel
chairs, CPAP, BIPAP, Continuous Ambulatory Peritoneal Dialysis, infusion pump and such other similar aids.
22.Other expenses as detailed in the website " www.starhealth.in"

IMPORTANT: The insurance coverage is subject to terms, conditions, exclusions stated in the master policy
<<P/900000/01/2024/000541>> available with the group administrator / proposer.

Claim Procedure
In the event of any claim, intimation should be given to Star Health immediately, through toll free no: 1800 425 2255 or
1800 102 4477, or email: [email protected] or fax - 1800 425 5522.
For Cashless Treatment:
a.Call the 24 hour toll free no. for assistance - 1800 425 2255 / 1800 102 4477
b.Inform the ID number for easy reference
c.On admission in the hospital, produce the ID Card issued by Star Health at the Hospital Helpdesk

d.Obtain the Pre-authorisation Form from the Hospital Help Desk, complete the Patient Information and resubmit to the
Hospital Help Desk.
e.The Treating Doctor will complete the hospitalisation/ treatment information and the hospital will fill up expected cost of
treatment.
f.This form should be submitted to Star Health
g.Star Health will process the request and call for additional documents/ clarifications if the information furnished is
inadequate.
h.Once all the details are furnished, Star Health will process the request as per the terms and conditions as well as the
exclusions therein and either approve or reject the request based on the merits.
i.In case of emergency hospitalization information to be given within 24 hours after hospitalization
j.Cashless facility can be availed only in Networked Hospitals. Please visit www.starhealth.in for information on Networked
Hospitals.
k.In non-network hospitals payment must be made up-front and then reimbursement will be effected on submission of
documents
Please note that denial of cashless is in no way to be construed as denial of treatment or denial of coverage. The Insured
Person can go ahead with the treatment, settle the hospital bills and submit the claim for a possible reimbursement.
Documents to be submitted for Reimbursement claims:
a.Duly completed claim form, and
b.Pre Admission investigations and treatment papers.
c.Discharge Summary from the hospital in original
d.Cash receipts from hospital, chemists
e.Cash receipts and reports for tests done
f.Receipts from doctors, surgeons, anesthetist
g.Certificate from the attending doctor regarding the diagnosis.
h.Copy of PAN Card

Note: Star Health reserves the right to call for additional documents wherever required.

Issue Office Address: For Star Health and Allied Insurance Co., Ltd.,
C - 100 First floor
Above United Bank of India
, Ghaziabad-201002
Noida
Date: 05/07/2024 Authorised Signatory.
 Regd. & Corporate Office: 1, New Tank Street, Valluvar Kottam High Road,Nungambakkam, Chennai - 600034.
Phone : 044 - 28288800 Telefax : 044 - 28260062 Website :
IRDA Registration No : 129 ; Corporate Identity Number : L66010TN2005PLC056649
www.starhealth.in

Permanent Exclusion Details Of Insured Person

Insured Name ID Card Permanent Exclusion Disease

Permanent Exclusion Details Of Dependent

Insured Name ID Card Permanent Exclusion Disease

Star Health and Allied Insurance

Company Limited
Customer Identity Card

Policy No. : P/900000/01/2024/000541 Valid From: 03/07/2024

Certificate No: P/161132/01/2025/000542
S.No. Name Age(Yrs) Relationship Sum Insured ID Card No
1 MOHANI DEVI 76 Self 1000000 CB000005315300054
2404733

IRDAI Regn. No:129

Emergency Help Line No. 1800 425 2255 or 1800 102 4477
e-mail : [email protected] Website : www.starhealth.in

Please quote the Customer Id No. for assistance

This ID Card is invalid, if the insurance cover is not in force.
Immediate intimation to 'Star' through above Tel Nos. is a must in case of
Hospitalisation.

At the time of hospitalization, kindly submit any Government

approved photo ID Card.

Personal and Caring

Issue Office Address: For Star Health and Allied Insurance Co., Ltd.,
C - 100 First floor
Above United Bank of India
, Ghaziabad-201002
Noida
Date: 05/07/2024 Authorised Signatory.
 Regd. & Corporate Office: 1, New Tank Street, Valluvar Kottam High Road,Nungambakkam, Chennai - 600034.
Phone : 044 - 28288800 Telefax : 044 - 28260062 Website :
IRDA Registration No : 129 ; Corporate Identity Number : L66010TN2005PLC056649
www.starhealth.in

Hospitalisation Benefit Policy

Premium Certificate for the purpose of deduction under Section 80 D of Income Tax (Amendment) Act,1986

Policy No : P/161132/01/2025/000542 Type of Policy : Star Group Health Insurance

Issue Office : Branch Office - Ghaziabad Policy For Bank Customers -
Certificate
Address : C - 100 First floor
Above United Bank of India
, Ghaziabad-201002
Tel / Fax : 0120-4522224/4522205 /
Email : [email protected]

This is to certify that MOHANI DEVI has paid Rs.21048 /-( Rupees: Twenty-One Thousand Forty-Eight Only ) towards
Premium for Hospitalization Insurance vide Policy No: P/161132/01/2025/000542 for the Period 03/07/2024 To 02/07/2025
issued on 05-JUL-24
Payment received by Cheque/Credit/Debit Card vide Receipt No: 1441002441 Receipt Date: 05/07/2024
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.

Issue Office Address: For Star Health and Allied Insurance Co., Ltd.,
C - 100 First floor
Above United Bank of India
, Ghaziabad-201002
Noida
Date: 05/07/2024 Authorised Signatory.