IMPORTANT

To, 30-SEP-21

Tarun Kumar Sethi

Flat No. 205, Sun City Apartment
Dhankauda

Sambalpur (M+OG) (Part),Sambalpur,ODISHA -768001

Mobile : 7205555759.

Dear Customer,

Re: Health Insurance Policy - P/161130/01/2022/081050

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
"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. CN=R Margabandhu,

R Margabandhu
SERIALNUMBER=00f82dcf76fdf6537e3331f8479ef45e7b4f3861b154
75488cdf3b2c3c26c3c9, ST=TAMIL NADU, OID.2.5.4.17=600034,
OID.2.5.4.20=513b7b33f2ce960f23148ea208744690e09638750806c
a65f89e15179f5fe50a, OU=UNDERWRITING - Chief Risk Officer,
O=STAR HEALTH AND ALLIED INSURANCE COMPANY, C=IN.
Date :Thu Sep 30 20:11:55 IST 2021

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@starthealth.in Website :www.starhealth.in IRDAI Regn.no: 129
 STAR COMPREHENSIVE INSURANCE POLICY
SCHEDULE (INDIVIDUAL)
UNIQUE ID:SHAHLIP22028V072122

Policy No. : P/161130/01/2022/081050 Previous Policy No. :

Customer Code : AA0020939977 GSTIN : 06AAJCS4517L1Z2
Customer Name : Tarun Kumar Sethi SAC Code : 997133/Accident and Health Insurance Services
Proposer's Code : 24172768 Issuing Office Code : 161130
Proposer's Name : Tarun Kumar Sethi Issuing Office Name : Branch Office - Gurgaon III
Address : Flat No. 205, Sun City Apartment Address : Ist Floor,, SCO 4, Sector 14
Dhankauda Market
Near Payal Cinema, Gurgaon
Sambalpur (M+OG) Gurgaon-122001
(Part),Sambalpur,ODISHA-768001
Phone No : /7205555759/ Phone No : 0124-4797452
E-mail Id : tarunsethi028@gmail.com E-mail Id : gurgaon3@starhealth.in
Proposer GSTIN : - Place of Supply : -
Proposal date : 30/09/2021 Fulfiller Code : SO161130

Date of Inception of first policy : 01-OCT-2021

Renewal Year : NEW
Collection Number : 1439107495 Intermediary Code : LC0000000619
Receipt Date : 30/09/2021 Name : M/S.POLICYBAZAAR
Premium :Rs 12,862 /- INSURANCE BROKERS
IGST @18% : 2,315 /- PRIVATE LIMITED
Stamp Duty :Rs 1 /- Total Premium :Rs 15,177 /- Phone No : 1800-258-5970/9971552250
E-mail Id : care@policybazaar.com
Total Premium In Words : Rupees Fifteen Thousand One Hundred Seventy Seven Only Installment Facility Optn :No

Premium Payment Frequency :Annual Installment Amount : Rs. 0

Period of Insurance : FROM 01/10/2021 00:00 TO : Midnight Of 30/09/2023 Policy Term: 2 Year
Details of Insured Persons :

Section 1 Section 10 Pre- Inception

Basic Sum Existing Date
Age in ID Card Co-Pay Cumulative Capital Sum Disease
Sl. Name of the Insured Sex Date of Relationshi Insured Bonus Rs Insured (Rs.)
Yrs p with No (Health) (Rs.)
no. Birth
Proposer
1 Tarun Kumar Sethi M 28/01/1994 27 SELF 24172768-1 0 500000 0 500000 No PED 01/10/2021
declared

Buy Back Pre Existing Disease Opted: No

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.

For Star Health and Allied Insurance Company Ltd.

Entered by : STAR_PORTAL
Aproved by : PORTAL

IRDAI Regn. No 129

Authorised Signatory
Corporate Identity Number U66010TN2005PLC056649
Email ID : info@starhealth.in
2 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@starthealth.in Website :www.starhealth.in IRDAI Regn.no: 129
Attached to and forming part of Policy No : P/161130/01/2022/081050

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
AYUSH Hospital means a healthcare facility wherein medical/surgical/para-surgical treatment procedures and interventions are carried out by
AYUSH Medical Practitioner(s) comprising of any of the following:
1. Central or State Government AYUSH Hospital or
2. Teaching hospital attached to AYUSH College recognized by the Central Government / Central Council of Indian
Medicine/Central Council for Homeopathy; or
3. AYUSH Hospital, standalone or co-located with in-patient healthcare facility of any recognized system of medicine,
registered with the local authorities, wherever applicable, and is under the supervision of a qualified registered AYUSH
Medical Practitioner and must comply with all the following criterion:
i. Having at least 5 in-patient beds;
ii. Having qualified AYUSH Medical Practitioner in charge round the clock;
iii. Having dedicated AYUSH therapy sections as required and/or has equipped operation theatre where
surgical procedures are to be carried out;
iv. Maintaining daily records of the patients and making them accessible to the insurance Company's
authorized representative.

AYUSH Day Care Centre means and includes Community Health Centre (CHC), Primary Health Centre (PHC), Dispensary, Clinic,
Polyclinic or any such health centre which is registered with the local authorities, wherever applicable and having facilities for carrying out
treatment procedures and medical or surgical/para-surgical interventions or both under the supervision of registered AYUSH Medical
Practitioner (s) on day care basis without in-patient services and must comply with all the following criterion:
i. Having qualified registered AYUSH Medical Practitioner(s) in charge;
ii. Having dedicated AYUSH therapy sections as required and/or has equipped operation theatre where surgical procedures
are to be carried out;
iii. Maintaining daily records of the patients and making them accessible to the insurance company's authorized representative.
Nominee Details
Nominee Details for the proposer Appointee Details

S.No. Name Relationship Age % Appointee Relationship

Age
with proposer Name with Nominee

1 Fakir Mohan Sethi Father 27 100

In witness whereof the undersigned being authorised by and on behalf of the company has set his hand at Branch Office - Gurgaon III on 30th
Day of September 2021.

For Star Health and Allied Insurance Company Ltd.

Entered by : STAR_PORTAL
Aproved by : PORTAL

Authorised Signatory

3 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@starthealth.in Website :www.starhealth.in IRDAI Regn.no: 129
Attached to and forming part of Policy No : P/161130/01/2022/081050

Permanent Exclusion Details

Insured Name ID Card Permanent Exclusion Disease

For Star Health and Allied Insurance Company Ltd.

Entered by : STAR_PORTAL
Aproved by : PORTAL

Authorised Signatory

4 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@starthealth.in Website :www.starhealth.in IRDAI Regn.no: 129
 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. : 24172768-1
This Card is valid until otherwise Cancelled. Name : Tarun Kumar Sethi
This ID Card is invalid, if the insurance cover is not in force Date Of Birth : 28-JAN-94 Age : 27 Years
Immediate intimation to 'Star' through above Tel Nos. is a must
Gender : Male Office Code : 161130
in case of Hospitalisation.
At the time of hospitalization, kindly submit any Government Valid From : 01-OCT-21 TA/SSM/SM Code : SO161130
approved photo ID Card. Agent/Broker/TE Code : LC0000000619
Corporate Identity Number: U66010TN2005PLC056649 IRDAI Regn. No:129

For Star Health and Allied Insurance Company Ltd.

Entered by : STAR_PORTAL
Aproved by : PORTAL

Authorised Signatory

5 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@starthealth.in Website :www.starhealth.in IRDAI Regn.no: 129
 TAX Invoice

Invoice No. : 6F439Y22P0015687 Customer ID : AA0020939977

Invoice Date : 30/09/21 Policy No : P/161130/01/2022/081050
Recipient Supplier

GSTIN : - GSTIN : 06AAJCS4517L1Z2

Proposer's : Tarun Kumar Sethi NAME : Star Health and Allied Insurance Co Ltd
Name - Branch Office - Gurgaon III
Address : Flat No. 205, Sun City Apartment Address : Ist Floor,, SCO 4, Sector 14 Market
Dhankauda Near Payal Cinema, Gurgaon
Gurgaon-122001
City : Sambalpur (M+OG) City : GURGAON III
(Part),Sambalpur,ODISHA-768001
State : ODISHA State : Haryana
Pincode : 768001 Pincode : 122001
Client Category : IND Place of Supply : 6 - Haryana

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 13539 677 12862 2315 Rs. 15177

Services
Total Invoice Value (in Figures) : Rs. 15177
Total Invoice Value (in Words) : Rupees: Fifteen thousand one
hundred seventy-seven 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

For Star Health and Allied Insurance Company Ltd.

Entered by : STAR_PORTAL
Aproved by : PORTAL

Authorised Signatory

6 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@starthealth.in Website :www.starhealth.in IRDAI Regn.no: 129
 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 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 Section 1(B & C)
blood, oxygen, operation theatre charges,
Surgical Appliances, Medicines and Drugs

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

4 Air Ambulance charges Up to Rs.2,50,000/- per hospitalization not exceeding Rs.5,00,000/- per policy period Section 1(E)
5 Pre-Hospitalization Expenses Up to 60 days prior to admission Section 1(F)
6 Post-Hospitalization Expenses Up to 90 days from the date of discharge 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 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 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/- Section 2
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/- Section 2
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 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 1Section 4

Hospital Cash Benefit upto 7 days per

15 occurrence & upto 120 days per policy 500/- 750/- 750/- 1000/- 1000/- 1500/- 2500/- 2500/- 2500/-
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 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/- 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.
Section 8

19 AYUSH Treatment Up to Up to Up to Up to Up to Up to Up to Up to Up to
15,000/- 15,000/- 15,000/- 15,000/- 20,000/- 20,000/- 30,000/- 30,000/- 30,000/- Section 9
20 Under Important Note. Point
Day Care Treatments / Procedures All Day Care Procedures No.1
Accidental Death and Permanent Total 1,00,00,000/- 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. Section 11

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

24 Automatic Restoration of Sum Insured 100% (once during policy period) Condition no.15
(Applicable for Section 1 only)

For Star Health and Allied Insurance Company Ltd.

Entered by : STAR_PORTAL
Aproved by : PORTAL

Authorised Signatory

7 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@starthealth.in Website :www.starhealth.in IRDAI Regn.no: 129