Star Health And Allied Insurance Company Limited

Date : 31-Oct-2023
To, IMPORTANT

RUPESH ANANT POMENDKAR,

ROOM NO 58 MARWADI,WADI SANGH NO 4 G P AMBEKAR MARG
NEAR MANOHAR DEWRAT PAREL VILLAGE
.
Mumbai City,Maharashtra-400012
Mobile : 91XXXXXX09

Dear Customer,

Re: Health Insurance Policy - 11240482502300

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.

Page 1 of 6

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 : L66010TN2005PLC056649 Email :[email protected]
Website :www.starhealth.in IRDAI Regn.no: 129
 Star Health And Allied Insurance Company Limited

Star Super Surplus (Floater) Insurance Policy

Unique Identification No. SHAHLIP22034V062122
POLICY SCHEDULE
Policy No. : 11240482502300 Previous Policy No :
Customer Code : PI0004365881 GSTIN : 27AAJCS4517L1ZY
Customer Name : RUPESH ANANT POMENDKAR SAC Code : 997133 / Accident and Health
Insurance Services
Proposer Code : PI0004365881 Issuing Office Code : 171143
Proposer Name : RUPESH ANANT POMENDKAR Issuing Office Name : Branch Office - Ghatkopar II
Proposer Address : ROOM NO 58 MARWADI,WADI Issuing Office Address : 610, 6th Floor, Neelyog
SANGH NO 4 G P AMBEKAR MARG Square, Patel
NEAR MANOHAR DEWRAT PAREL Chowk, Station road,
VILLAGE Ghatkopar East
. .
Mumbai City Maharashtra 400012 Mumbai City Maharashtra
400077
Phone No : 91XXXXXX09 Phone No : 022-42267000
E-mail Id : [email protected] E-mail Id : [email protected]
Proposer GSTIN : NO Place of Supply : Maharashtra
Proposal date : 30-Oct-2023 Fulfiller Code : SH5757
Date of Inception : 30-Oct-2023
of first policy
Policy Category : New Intermediary : BA0000067467
Collection No : 191661007179
Code
Collection Date : 30-Oct-2023

Premium : Rs. 4,775/-

Name : SARODE ROHIDAS

CGST @ 9% : Rs. 430/-

Phone No :9967399272
:
SGST @ 9% Rs. 430/-
E-mail Id : rohidas.sarode@yaho
o.com
Total Premium : Rs. 5,635/-
Stamp Duty : Re. 1/-

Total Premium In Words : Rupees Five thousand six hundred thirty five only
PERIOD OF INSURANCE : From : 30-Oct-2023 17:46 To : Midnight Of 29-Oct-2024 Policy Term :1 Year
Installment Facility Option:No Premium Payment Frequency :Annual Installment Amount Rs. : 0/-

Plan Type : GOLD Family Size : 2A+1C

Sum Insured : Rs. 15,00,000 Defined Limit (Rs.) : 5,00,000
Sum Insured in words : Indian Rupees Fifteen lakhs only
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
RUPESH ANANT POMENDKAR
1 Male 17-Oct-1983 40 Self PI0004365881 30-Oct-2023

Pre Existing Disease : No PED Declared

RUCHIRA POMENDKAR
2 Female 09-Nov-1986 36 Spouse ME0441087355 30-Oct-2023

Pre Existing Disease : No PED Declared

RKSHA POMENDKAR
3 Female 12-Jul-2012 11 Daughter ME0441087364 30-Oct-2023

Pre Existing Disease : No PED Declared

Entered by : SH55913 For Star Health and Allied Insurance Company Ltd.
Approved by : SH55913
IRDAI Regn.No.129

Corporate Identity Number L66010TN2005PLC056649

Authorised Signatory Page 2 of 6
Email ID: [email protected]

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 : L66010TN2005PLC056649 Email :[email protected]
Website :www.starhealth.in IRDAI Regn.no: 129
 Star Health And Allied Insurance Company Limited

Attached to and forming part of Policy No: 11240482502300

Sector Classification:
Urban

''CONSOLIDATED STAMP DUTY FOR POLICY STAMPS PAID VIDE NO. LOA/CSD/667/2023/1172 DT. 28/MAR/2023''

Please check whether the details given by you about the Insured persons in the Proposal Form are incorporated
correctly in the Policy.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 persons given in the Policy 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.
THE INSURANCE UNDER THIS POLICY IS SUBJECT TO CONDITIONS, CLAUSES, WARRANTIES,
EXCLUSIONS ETC., ATTACHED.
Toll Free No:1800 425 2255/1800 102 4477 Email: [email protected], Fax No: 1800 425 5522.

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.
In witness whereof the undersigned being authorized here in to set his hand at Branch Office - Ghatkopar II on
31st Day of October 2023.

Entered by : SH55913 For Star Health and Allied Insurance Company Ltd.
Approved by : SH55913

Authorised Signatory Page 3 of 6

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 : L66010TN2005PLC056649 Email :[email protected]
Website :www.starhealth.in IRDAI Regn.no: 129
 Star Health And Allied Insurance Company Limited

Star Health and Allied Insurance

Company Limited
Customer Identity Card
Policy No : 11240482502300

Name DOB Gender Customer id

RUPESH ANANT POMENDKAR
17-Oct-1983 Male PI0004365881

RUCHIRA POMENDKAR
09-Nov-1986 Female ME0441087355

RKSHA POMENDKAR
12-Jul-2012 Female ME0441087364

Valid From : 30-Oct-2023 Agent/Broker/TE Code : BA0000067467

Office Code : 171143 TA/SSM/SM Code : SH5757

IRDAI Regn.No:129

Emergency Help Line No.1800 425 2255/1800 102 4477

e-mail : [email protected] Website : www.starhealth.in

Please quote the Customer Id No. for assistance

This Card is valid until otherwise Cancelled.

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 hospitalisation,kindly submit any Government approved photo ID

Card.

Corporate Identity Number : L66010TN2005PLC056649

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

Entered by : SH55913 For Star Health and Allied Insurance Company Ltd.
Approved by : SH55913

Authorised Signatory Page 4 of 6

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 : L66010TN2005PLC056649 Email :[email protected]
Website :www.starhealth.in IRDAI Regn.no: 129
 Star Health And Allied Insurance Company Limited

Tax Invoice
Invoice No. : 272310I003254508 Customer ID : PI0004365881
Invoice Date : 30-Oct-2023 Policy No. : 11240482502300
Recipient Supplier
GSTIN : GSTIN : 27AAJCS4517L1ZY
Name : RUPESH ANANT POMENDKAR Name : Star Health and Allied Insurance Co Ltd -
Branch Office - Ghatkopar II
Address : ROOM NO 58 MARWADI,WADI SANGH Address : 610, 6th Floor, Neelyog Square, Patel
NO 4 G P AMBEKAR MARG
NEAR MANOHAR DEWRAT PAREL Chowk, Station road, Ghatkopar East
VILLAGE
. .
City : Mumbai City Pin Code : 400012 City : Mumbai City Pin Code : 400077

State : Maharashtra Client : IND State : Maharashtra Place of : Maharashtra

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 4,775.00 0 4,775.00 0 430.00 430.00 0 5,635.00
Services

Total Invoice Value (in Figures) : Rs. 5,635/-

Total Invoice Value (in Words) : Rupees Five thousand six hundred thirty five 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
"I/We hereby declare that though our aggregate turnover in any preceding financial year from 2017-18 onwards is more than the aggregate
turnover notified under sub-rule (4) of rule 48, we are not required to prepare an invoice in terms of the provisions of the said sub-rule."
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: [email protected]

Entered by : SH55913 For Star Health and Allied Insurance Company Ltd.
Approved by : SH55913

Authorised Signatory Page 5 of 6

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 : L66010TN2005PLC056649 Email :[email protected]
Website :www.starhealth.in IRDAI Regn.no: 129
 Star Health And Allied Insurance Company Limited

Name Of the Product Star Super Surplus (Floater) Insurance Policy

Product UIN No. SHAHLIP22034V062122

Summary of Important Benefits – Gold Plan

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

Sum Insured (in Rs.) 5,00,000 10,00,000 15,00,000 20,00,000 25,00,000 50,00,000 75,00,000 1,00,00,000

Defined Limit (in Rs.) 3,00,000/-, 5,00,000/-, 10,00,000/-, 15,00,00/-, 20,00,000/-, 25,00,000/-

Room Category
*Expenses relating to the hospitalization
1 Single Private A/C Room III (A)
will be considered in proportion to the
room rent stated in the policy

Surgeon, Anesthetist, Medical

Practitioner, Consultants, Specialist Fees,
2 Anesthesia, blood, oxygen, operation Actual III (B)
theatre charges, ICU Charges, Surgical
Appliances, Medicines and Drugs

Ambulance Charges (Per hospitalization)

3 3,000 3,000 3,000 3,000 3,000 3,000 3,000 3,000 III (C)
up to

Air Ambulance Charges (Per Policy

4 N/A Covered up to 10% of Sum Insured III (D)
Period)

Medical Second Opinion

5 E-MAIL: Available Available Available Available Available Available Available Available III (E)
“[email protected]”

6 Pre-Hospitalization Expenses 60 days 60 days 60 days 60 days 60 days 60 days 60 days 60 days III (F)

7 Post-Hospitalization Expenses 90 days 90 days 90 days 90 days 90 days 90 days 90 days 90 days III (G)

Delivery Expenses (Limit Per Policy

8 50,000 50,000 50,000 50,000 50,000 50,000 50,000 50,000 III (H)
Period) up to

9 Organ Donor Expenses Covered up to Sum Insured III (I)

10 Coverage for Modern Treatment Available III (J)

Note
under
11 Day Care Treatments / Procedures All Day Care Procedures are Covered
Coverage
III

Defined Limit Rs. Recharge Limit Rs.

3,00,000/- 50,000/-
12 Recharge Benefit 5,00,000/- 75,000/- III (K)

10,00,000/- 1,00,000/-

15,00,000/- and above 2,50,000/-

13 Wellness Services Available III (L)

14 Instalment options(if opted) Available V(13)

Note: The Company's liability will begin only when the aggregate of the hospitalization expenses admissible under this policy during this policy period exceed
the Defined limit

- Defined Limit means the limit of admissible hospitalization expenses as per the terms of the policy, opted for and mentioned in the Schedule of the policy,
up to which the Company will not be liable during the policy period
- For the purpose of calculating the Defined limit, the pre-hospitalization and post-hospitalization expenses will not be taken into account.

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 : SH55913 For Star Health and Allied Insurance Company Ltd.
Approved by : SH55913

Authorised Signatory Page 6 of 6

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 : L66010TN2005PLC056649 Email :[email protected]
Website :www.starhealth.in IRDAI Regn.no: 129