Star Health And Allied Insurance Company Limited

Date : 31-Mar-2025
To, IMPORTANT

ANIL KESHAVRAO PAVITRAKAR,

PLOT NO 134, TOSHNIWAL LAYOUT,
NEAR KRUSHI NAGAR TELEPHONE EXCHANGE,
AKOLA
Akola,Maharashtra-444001
Mobile : 9822222224

Dear Customer,

Re: Health Insurance Policy - 5648112500083806

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 30 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

This is an electronically generated document(Policy

Schedule). ORDER NO. LOA/ENF-2/CSD/44/2024 VALIDITY
PERIOD DT. 29-APR-24 TO 31-DEC -2027 /571 GRN NO.
MH017132436202324E DATE:12.3.24 CANARA BANK
DEFACE NO. 0000591537202425 DATE 23-APR-24
Page 1 of 8

Regd.&Corporate Office:1,New Tank Street,Valluvar Kottam High Road,Nungambakkam,Chennai - 600034,Phone : 044 -28302700 / 28288800
Toll Free No:1800-425-2255 / 1800-102-4477,CIN : L66010TN2005PLC056649 Email :support@[Link] Website :[Link]
IRDAI [Link]: 129
 Star Health And Allied Insurance Company Limited

Star Health Assure Insurance Policy

Unique Identification No. SHAHLIP23131V022223
POLICY SCHEDULE
Policy No. : 5648112500083806 Previous Policy No :
Customer Code : PI0008479670 GSTIN : 27AAJCS4517L1ZY
Customer Name : ANIL KESHAVRAO PAVITRAKAR SAC Code : 997133 / Accident and Health
Cust CKYC No : - Insurance Services

Proposer Code : PI0008479670 Issuing Office Code : 151143

Proposer Name : ANIL KESHAVRAO PAVITRAKAR Issuing Office Name : Branch Office - Nashik III
Proposer Address : PLOT NO 134, TOSHNIWAL Issuing Office Address : 1st Floor, F-2,
LAYOUT, Suyojit Modern Point,
NEAR KRUSHI NAGAR TELEPHONE Sharanpur Road
EXCHANGE, NASHIK
AKOLA Nashik Town Maharashtra
Akola Maharashtra 444001 422002
Phone No : 9822222224 Phone No :
E-mail Id : anilpavitrakar925@[Link] E-mail Id : [Link]@starhealth.i
n, [Link]@star
Proposer GSTIN : NO Place of Supply : Maharashtra
Proposal Date : 31-Mar-2025 Fulfiller Code : SO151143
Date of Inception : 31-Mar-2025
of first policy
Policy Category : New Intermediary : BA0000617184
Collection No : 151143/RV/2025/0211268517
Code
Collection Date : 31-Mar-2025
Premium : Rs. 21,864/- Name : SAVITA M
WARUNGASE
CGST @ 9% : Rs. 1,968/-
Phone No :7721930827/772193082
7
:
SGST @ 9% Rs. 1,968/-
E-mail Id : mohanwarungase76@
[Link]
Total Premium : Rs. 25,800/-
Stamp Duty : Re. 1/-

Total Premium In Words : Rupees Twenty Five thousand eight hundred only
Period of Insurance : From : 31-Mar-2025 17:31 Hrs To : Midnight of 30-Mar-2026 Policy Term :1 Year
Installment Facility Option:No Premium Payment Frequency :Annual Installment Amount Rs. : 0/-
(inclusive GST)

Policy Type : FLOATER Scheme Description : 2A+1C

Basic Floater Sum Insured : Rs. 10,00,000/- Bonus : Rs. 0/-
Sum Insured In Words : Rupees Ten lakhs only
Optional Cover (Deductible) : No Deductible : Rs. 0/-

Entered by : CUSTPORTAL This is an electronically generated document(Policy For Star Health and Allied Insurance Company Ltd.
Approved by : PORTAL Schedule). ORDER NO. LOA/ENF-2/CSD/44/2024 VALIDITY
PERIOD DT. 29-APR-24 TO 31-DEC -2027 /571 GRN NO.
IRDAI [Link].129 MH017132436202324E DATE:12.3.24 CANARA BANK
DEFACE NO. 0000591537202425 DATE 23-APR-24
Authorised Signatory Page 2 of 8
Corporate Identity Number L66010TN2005PLC056649
Email ID: info@[Link]

Regd.&Corporate Office:1,New Tank Street,Valluvar Kottam High Road,Nungambakkam,Chennai - 600034,Phone : 044 -28302700 / 28288800
Toll Free No:1800-425-2255 / 1800-102-4477,CIN : L66010TN2005PLC056649 Email :support@[Link] Website :[Link]
IRDAI [Link]: 129
 Star Health And Allied Insurance Company Limited

Attached to and forming part of Policy No: 5648112500083806

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
ANIL KESHAVRAO PAVITRAKAR
1 Male 19-Jan-1978 47 Self PI0008479670 31-Mar-2025

Pre Existing Disease : No PED Declared

MADHURI PAVITRAKAR
2 Female 04-Sep-1985 39 Spouse ME0466856527 31-Mar-2025

Pre Existing Disease : No PED Declared

RISHI PAVITRAKAR
3 Male 07-Dec-2007 17 Son ME0466856530 31-Mar-2025

Pre Existing Disease : No PED Declared

Nominee Details:
Nominee Details for the Proposer Appointee Details
[Link] Name Relationship Age % of the Appointee Name Appointee Relationship
with proposer claim Age with nominee

1 MADHURI ANIL Spouse 39 100

PAVITRAKAR
Sector Classification:
Urban

''ORDER NO. LOA/ENF-2/CSD/44/2024 VALIDITY PERIOD DT. 29-APR-24 TO 31-DEC -2027 /571 GRN NO.
MH017132436202324E DATE:12.3.24 CANARA BANK DEFACE NO. 0000591537202425 DATE 23-APR-24''

Please check whether the details given by you about the insured person(s) 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 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.
Toll Free No : 1800 425 2255 Email: support@[Link], Fax No: 1800 425 5522.

In witness whereof the undersigned being authorized by and on behalf of the company has set his hand at Branch
Office - Nashik III on 31st Day of March 2025.
As per Section 34 of CGST Act of 2017, Policy Issued in one Financial Year and Cancelled in another Financial Year
on or after 01st of December, then Only Premium Amount will be Refunded to the Customer and GST Amount will
Not be Refunded. Customer has to Claim the Refund of GST Amount from the GST Portal.

Entered by : CUSTPORTAL This is an electronically generated document(Policy For Star Health and Allied Insurance Company Ltd.
Approved by : PORTAL Schedule). ORDER NO. LOA/ENF-2/CSD/44/2024 VALIDITY
PERIOD DT. 29-APR-24 TO 31-DEC -2027 /571 GRN NO.
MH017132436202324E DATE:12.3.24 CANARA BANK
DEFACE NO. 0000591537202425 DATE 23-APR-24
Authorised Signatory Page 3 of 8

Regd.&Corporate Office:1,New Tank Street,Valluvar Kottam High Road,Nungambakkam,Chennai - 600034,Phone : 044 -28302700 / 28288800
Toll Free No:1800-425-2255 / 1800-102-4477,CIN : L66010TN2005PLC056649 Email :support@[Link] Website :[Link]
IRDAI [Link]: 129
 Star Health And Allied Insurance Company Limited

Hospitalisation Benefit Policy

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

Policy No : 5648112500083806 Type of Policy : Assure Insurance-2021

Issue Office : 151143-Branch Office - Nashik III

Address : 1st Floor, F-2,

Suyojit Modern Point, Sharanpur Road
NASHIK
Nashik Town Maharashtra 422002

Tel / Fax :

Email : [Link]@[Link], [Link]@star

This is to certify that ANIL KESHAVRAO PAVITRAKAR has paid Rs 25,800/- (Total Premium : Indian Rupees
Twenty Five thousand eight hundred only ) towards Premium for Hospitalization Insurance vide Policy No:
5648112500083806 for the Period 31-Mar-2025 To 30-Mar-2026 issued on 31-Mar-2025.

Payment received by Payment Gateway vide Receipt No: 151143/RV/2025/0211268517/1 Receipt

Date: 31-Mar-2025

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.

Date : 31-Mar-2025 For and on behalf of

Place : Branch Office - Nashik III Star Health and Allied Insurance Company Ltd.

IRDAI [Link].129

Corporate Identity Number L66010TN2005PLC056649 Authorised Signatory

Email ID: info@[Link]

Entered by : CUSTPORTAL This is an electronically generated document(Policy For Star Health and Allied Insurance Company Ltd.
Approved by : PORTAL Schedule). ORDER NO. LOA/ENF-2/CSD/44/2024 VALIDITY
PERIOD DT. 29-APR-24 TO 31-DEC -2027 /571 GRN NO.
MH017132436202324E DATE:12.3.24 CANARA BANK
DEFACE NO. 0000591537202425 DATE 23-APR-24
Authorised Signatory Page 4 of 8

Regd.&Corporate Office:1,New Tank Street,Valluvar Kottam High Road,Nungambakkam,Chennai - 600034,Phone : 044 -28302700 / 28288800
Toll Free No:1800-425-2255 / 1800-102-4477,CIN : L66010TN2005PLC056649 Email :support@[Link] Website :[Link]
IRDAI [Link]: 129
 Star Health And Allied Insurance Company Limited

Star Health and Allied Insurance

Company Limited
Customer Identity Card
Policy No : 5648112500083806

Name DOB Gender Customer id

ANIL KESHAVRAO
PAVITRAKAR 19-Jan-1978 Male PI0008479670

MADHURI PAVITRAKAR
04-Sep-1985 Female ME0466856527

RISHI PAVITRAKAR
07-Dec-2007 Male ME0466856530

Valid From : 31-Mar-2025 Valid Till : 30-Mar-2026

Office Code : 151143 Agent/Broker/TE Code : BA0000617184

TA/SSM/SM Code : SO151143

IRDAI [Link]

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

e-mail : support@[Link] Website : [Link]

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 hospitalisation,kindly submit any Government approved photo ID

Card.

Corporate Identity Number : L66010TN2005PLC056649

Entered by : CUSTPORTAL This is an electronically generated document(Policy For Star Health and Allied Insurance Company Ltd.
Approved by : PORTAL Schedule). ORDER NO. LOA/ENF-2/CSD/44/2024 VALIDITY
PERIOD DT. 29-APR-24 TO 31-DEC -2027 /571 GRN NO.
MH017132436202324E DATE:12.3.24 CANARA BANK
DEFACE NO. 0000591537202425 DATE 23-APR-24
Authorised Signatory Page 5 of 8

Regd.&Corporate Office:1,New Tank Street,Valluvar Kottam High Road,Nungambakkam,Chennai - 600034,Phone : 044 -28302700 / 28288800
Toll Free No:1800-425-2255 / 1800-102-4477,CIN : L66010TN2005PLC056649 Email :support@[Link] Website :[Link]
IRDAI [Link]: 129
 Star Health And Allied Insurance Company Limited

Tax Invoice
Invoice No. : 272503I022387696 Customer ID : PI0008479670
Invoice Date : 31-Mar-2025 Policy No. : 5648112500083806
Recipient Supplier
GSTIN : GSTIN : 27AAJCS4517L1ZY
Name : ANIL KESHAVRAO PAVITRAKAR Name : Star Health and Allied Insurance Co Ltd -
Branch Office - Nashik III
Address : PLOT NO 134, TOSHNIWAL LAYOUT, Address : 1st Floor, F-2,
NEAR KRUSHI NAGAR TELEPHONE Suyojit Modern Point, Sharanpur Road
EXCHANGE,
AKOLA NASHIK
City : Akola Pin Code : 444001 City : Nashik Town Pin Code : 422002

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 21,864.00 0 21,864.00 0 1,968.00 1,968.00 0 25,800.00
Services

Total Invoice Value (in Figures) : Rs. 25,800/-

Total Invoice Value (in Words) : Rupees Twenty Five thousand eight hundred 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 [Link].129 Corporate Identity Number L66010TN2005PLC056649 Email ID: stargst@[Link]

Entered by : CUSTPORTAL This is an electronically generated document(Policy For Star Health and Allied Insurance Company Ltd.
Approved by : PORTAL Schedule). ORDER NO. LOA/ENF-2/CSD/44/2024 VALIDITY
PERIOD DT. 29-APR-24 TO 31-DEC -2027 /571 GRN NO.
MH017132436202324E DATE:12.3.24 CANARA BANK
DEFACE NO. 0000591537202425 DATE 23-APR-24
Authorised Signatory Page 6 of 8

Regd.&Corporate Office:1,New Tank Street,Valluvar Kottam High Road,Nungambakkam,Chennai - 600034,Phone : 044 -28302700 / 28288800
Toll Free No:1800-425-2255 / 1800-102-4477,CIN : L66010TN2005PLC056649 Email :support@[Link] Website :[Link]
IRDAI [Link]: 129
 Star Health And Allied Insurance Company Limited

Name Of the Product Star Health Assure Insurance Policy

Product UIN No. SHAHLIP23131V022223
Summary of Important Benefits
Refer to
[Link] Particulars of Coverage / Benefits Benefit Limits (in Rs.) Policy
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 2,00,00,000

Room Category
*Associated Medical expenses which vary based on
the room occupied by the insured person will be Up to
considered in proportion to the room rent stated in 1% of
Any room
1 the policy schedule or actuals whichever is less. Sum Any room B. 1
(Except suite or above category)
Proportionate deductions are not applied in respect Insured
of the hospitals which do not follow differential billing per day
or for those expenses in respect of which differential
billing is not adopted based on the room rent.

Surgeon, Anesthetist, Medical Practitioner,

2 Actual B. 2
Consultants, Specialist Fees

Anesthesia, blood, oxygen, operation theatre

3 charges, ICU Charges, Surgical Appliances, Actual B. 3
Medicines and Drugs

4 Day care procedures All Day Care Procedures are Covered B. 4

5 Coverage for Non-medical Items (Consumables) Actual B. 5

6 Emergency Road Ambulance Actual B. 6

7 Air Ambulance Expenses incurred towards the cost of air ambulance service up to 10% of sum insured per policy year B. 7

8 Pre-Hospitalization Expenses Up to 60 days prior to the date of hospitalization B. 8

9 Post-Hospitalization Expenses Up to 180 days from the date of discharge from the hospital B. 9

10 Domiciliary Hospitalization Coverage for medical treatment (Including AYUSH) for a period exceeding three days B. 10

11 Organ Donor Expenses Up to the Sum Insured B. 11

Individual SI 1,500 2,000 4,000 5,000 5,000 5,000 8,000 8,000 8,000
12 Health Checkup Assure B. 12
Floater SI 2,500 5,000 8,000 10,000 10,000 10,000 15,000 15,000 15,000

13 Home Care Treatment Payable up to 10% of the sum insured subject to maximum of Rs.5 lakhs in a policy year B. 13

Expenses for a Delivery including Delivery by Caesarean section (including pre-natal and post natal
14 Delivery Expenses B. 14
expenses) up-to 10% of the Sum Insured is payable

Expenses incurred for list of In Utero Fetal Surgeries and Procedures after the waiting period of 24
15 In Utero Fetal Surgery/Intervention B. 15
months from the date of inception of this policy

Assisted Reproduction Treatment- Limit of Liability

16 1,00,000 2,00,000 2,00,000 2,00,000 2,00,000 4,00,000 4,00,000 4,00,000 4,00,000 B. 16
in a policy year (Rs.)

Hospitalization expenses for treatment of New Born

17 2,00,000 2,00,000 2,00,000 2,00,000 2,00,000 4,00,000 4,00,000 4,00,000 4,00,000 B. 17
Baby- Limit Per Policy Period (Rs.)

18 Treatment for Chronic Severe Refractory Asthma Payable up to 10% of sum insured not exceeding Rs.5 lakhs per policy period B. 18

Expenses by air incurred upto Rs.10,000/- for one immediate family member(other than the travel
19 Compassionate travel B. 19
companion) for travel towards the place where hospital is located

Payable up to Rs.15,000/- in a policy year towards the cost of repatriation of mortal remains of the
20 Repatriation of Mortal Remains insured person (including the cost of embalming and coffin charges) to the residence of the Insured as B. 20
recorded in the policy.

21 Treatment in Valuable service providers network 1% of Sum Insured subject to a maximum of Rs.5,000/- per policy period is payable as lump sum B. 21

Rs.1,000/- per day will be payable for each continuous and completed period of 24 hours of stay in
22 Shared accommodation B. 22
shared accommodation.

23 AYUSH Treatment Payable up to the sum insured. B. 23

24 Second Medical Opinion e_medicalopinion@[Link]. B. 24

25 Coverage for Modern Treatment Upto sum insured B. 25

The insured person will be eligible for Cumulative bonus calculated at 25% of sum insured for each claim
26 Cumulative Bonus B. 26
free year and maximum upto 100% of the sum insured

Entered by : CUSTPORTAL This is an electronically generated document(Policy For Star Health and Allied Insurance Company Ltd.
Approved by : PORTAL Schedule). ORDER NO. LOA/ENF-2/CSD/44/2024 VALIDITY
PERIOD DT. 29-APR-24 TO 31-DEC -2027 /571 GRN NO.
MH017132436202324E DATE:12.3.24 CANARA BANK
DEFACE NO. 0000591537202425 DATE 23-APR-24
Authorised Signatory Page 7 of 8

Regd.&Corporate Office:1,New Tank Street,Valluvar Kottam High Road,Nungambakkam,Chennai - 600034,Phone : 044 -28302700 / 28288800
Toll Free No:1800-425-2255 / 1800-102-4477,CIN : L66010TN2005PLC056649 Email :support@[Link] Website :[Link]
IRDAI [Link]: 129
 Star Health And Allied Insurance Company Limited

The policy provides automatic restoration of sum insured for unlimited number of times and maximum
27 Automatic Restoration of Sum Insured B. 27
upto 100% each time.

28 Rehabilitation and Pain Management Up to the sub-limit (or) maximum up to 20% of the sum insured whichever is less, per policy year. B. 28

This program intends to promote, incentivize and to reward the Insured Persons' healthy life style
29 Star Wellness Program B. 29
through various wellness activities.

10% of each and every claim amount for fresh as well as renewal policies for insured person whose age
30 Co-payment B. 30
at the time of entry is 61 years and above

Sum Insured Aggregate Deductible Option Discount offered

Rs. 50,000/- 45%

Up to Rs. 20 lakhs
31 Optional Cover to choose deductible Rs. 1,00,000/- 55% B. 31

Rs. 50,000/- 35%

Above Rs. 20 lakhs
Rs. 1,00,000/- 50%

Note: The above information is only indicative. For complete details of the Terms & Conditions kindly read the policy wordings attached.

Entered by : CUSTPORTAL This is an electronically generated document(Policy For Star Health and Allied Insurance Company Ltd.
Approved by : PORTAL Schedule). ORDER NO. LOA/ENF-2/CSD/44/2024 VALIDITY
PERIOD DT. 29-APR-24 TO 31-DEC -2027 /571 GRN NO.
MH017132436202324E DATE:12.3.24 CANARA BANK
DEFACE NO. 0000591537202425 DATE 23-APR-24
Authorised Signatory Page 8 of 8

Regd.&Corporate Office:1,New Tank Street,Valluvar Kottam High Road,Nungambakkam,Chennai - 600034,Phone : 044 -28302700 / 28288800
Toll Free No:1800-425-2255 / 1800-102-4477,CIN : L66010TN2005PLC056649 Email :support@[Link] Website :[Link]
IRDAI [Link]: 129