STAR HEALTH AND ALLIED INSURANCE CO.Ltd.

,
BILL ASSESSMENT SHEET - MEMBER PAYMENT

Intimation No CLI/2020/171222/0961296 Bill Approved Date 03-04-2020

Insured Name Mr.MAHENDRA Policy No P/171222/01/2020/000162

BHAGWANJIBHAI MARADIYA Certificate of Insurance
No.
Claimant Name HEMANSHI MARADIYA Product Name Family Health Optima Insurance - 2017
DOB/Age 07/12/1998 - 20 years
Policy Period 29-05-2019 to 28-05-2020
Address : PARTH VRUJBHUVAN SOCIETY,
B/H INDRA ROAD Hospital Name Global Multispeciality Hospital
PORBANDAR
PORBANDAR Hospital Address Porbandar, Khijadi Plot, Panch Hatdi,
Pincode : 360575 Porbandar, Gujarat 360575
PORBANDAR PORBANDAR (M+OG) - 360575
GUJARAT Gujarat
Telephone : 9427227270 DOA 21-02-2020

DOD 23-02-2020
Sum Insured 400000
Bonus 220000 Final Diagnosis AGE /DKA,
Copay % 0.0%
SM Code / Name SH33713 / Mr.PRAKASH VINAYKANT
PANDYA

Intermediary Code / BA0000265804 / Mr.PANDYA DIPAK ICD Codes Desc K52.9,

Name GUNVANTBHAI SECTION

Hospitalisation Expenses
Amount Disallowed
Approve
Nature of Amount Non Proportionate
SNo Bill No Bill Date d Disallowance Reasons / Remarks
Expenditure Claimed Payable Deduction
Amount
(A) (B)

Room Rent &

1 4200 4200
Nursing Charges

Professional Fees
(Surgeon, Anastheist,
2 1600 1600
Consultation Charges
etc)

Investigation &
3 770 770
Diagnostics

a.ii) Medicines -
4 43 43
outside Hospital

Miscellaneous
5 500 500
Charges

IRDA Regn.No.129
Corporate Identity Number U66010TN2005PLC056649
Email ID : info@starhealth.in
 Amount Disallowed
Approve
Nature of Amount Non Proportionate
SNo Bill No Bill Date d Disallowance Reasons / Remarks
Expenditure Claimed Payable Deduction
Amount
(A) (B)

BMW, RBS AND REGISTRATION

6 Others 1000 1000
CHARGES NOT PAYABLE.

Total 8113

Deductibles (A + B) 1000

Hospital Discounts

Deductions

NET AMOUNT (Total - Deductibles,

Hospital Discounts 7113
& Deductions)

IRDA Regn.No.129
Corporate Identity Number U66010TN2005PLC056649
Email ID : info@starhealth.in
 Amount claimed 8113

Total Deductions 1000

a. Non payable 1000

b. Proportionate Deductions 0

Approved Amount (after Total Deductions) 7113

Less: Hospital Discounts 0

Less: Other deductions 0

Net Amount (Approved amount - Hospital

7113
discounts and other deductions )

Amount considered 7113

Co-Pay Amount 0

Amount considered after co pay 7113

Exceeds sub limit 0

Less: Amount settled by other Insurer 0

Exceeds Sum Insured 0

Amount payable 7113

Claim Restrictions 0

Preauth approved amount 0

Amount payable to Hospital 0

Payable to Insured 7113

Less amount already paid to Insured 0

Balance payable to Insured 7113

Pre Hospitalisation Expenses

Amount Approved
Nature of Non Payable
S.No Bill No Bill Date Claimed Amount Disallowance Reasons / Remarks
Expenditure (B)
(A) (C)

IRDA Regn.No.129
Corporate Identity Number U66010TN2005PLC056649
Email ID : info@starhealth.in
Post Hospitalisation Expenses

Amount
Nature of Non Payable Approved
S.No Bill No Bill Date Claimed Disallowance Reasons / Remarks
Expenditure (B) Amount
(A)
Total 0

Amount payable 0

Co pay Amount 0.0% 0

Net Payable / Eligible Amt * (After Co-pay) 0

Exceeds the limit 0

Amount already paid to insured 0

Balance payable to Insured 0

Consolidation Summary

Section Amount

Total amount claimed 8113

Hospitalisation payable amount 7113

Pre hospitalisation payable amount 0

Post hospitalisation payable amount 0

Add on Benefit(Hospital Cash / Patient
0
care)
Total Claim Payable Amount 7113

IRDA Regn.No.129
Corporate Identity Number U66010TN2005PLC056649
Email ID : info@starhealth.in