STAR HEALTH AND ALLIED INSURANCE CO.Ltd.

,
No.15, SRI BALAJI COMPLEX,1st FLOOR, WHITES
LANE,ROYAPETTAH,CHENNAI-600014.
Toll Free No: 1800 425 2255 / Toll Free Fax: 1800 425 5522, www.starhealth.in

DATE 30/03/2019
To
Shaishav Jayeshbhai Mehta
B/1 Ushma Flat Nr Navrangpura Bus Stand ,Navragpura,Ahmedabad,Gujarat,Navranpura,Navrangpura
Ahmedabad
Pincode : 380009
Gujarat

Dear Sir / Madam,

Sub :Repudiation of Claim.

We refer to the mediclaim preferred by you. Details are briefly given below:

Name of the insured : Mr.JAIN INTERNATIONAL ORGANISATION

Member Name : Shaishav Jayeshbhai Mehta
Membership ID : JACID:9100799974454824
Claim Intimation number : CLI/2019/900000/0721340
Name of the insured-Patient : NAYANA JAYESHBHAI MEHTA
Age / Sex : / Female
Relationship with Member : Mother
Product name : Group Health Insurance
Policy number : P/900000/01/2018/000012
Policy period : From : 31-MAR-18 To : 30-MAR-19
Diagnosis : BOTH EYES PRIMARY ANGLE CLOSURE GLAUNOMA

Room Category : Single Room A/C

Date of admission : 20/03/2019
Name of the Hospital and : NETRALAYA THE EYE ASSOCIATES ( DR.MUDIT BANSAL ) -
Location ELLIS BRIDGE,AHMEDABAD - AHMEDABAD
We have processed the claim records relating to the above insured-patient seeking reimbursement of
hospitalization expenses for treatment of both eyes primary angle closure glaunoma.

It is observed from the medical records that the insured patient was admitted for YAG iridotomy.

As per Exclusion No.15 of the above policy, the company is not liable to make any payment in respect of
any expenses incurred on Low level laser therapy and such other therapies.

We are therefore unable to settle your claim under the above policy and we hereby repudiate your claim.

The above decision has been taken as per the terms and conditions of the policy and based on the claim
... 2 ...
IRDA Regn.No.129
Corporate Identity Number U66010TN2005PLC056649
Email ID : info@starhealth.in
 STAR HEALTH AND ALLIED INSURANCE CO.Ltd.,
No.15, SRI BALAJI COMPLEX,1st FLOOR, WHITES
LANE,ROYAPETTAH,CHENNAI-600014.
Toll Free No: 1800 425 2255 / Toll Free Fax: 1800 425 5522, www.starhealth.in

2
details/documents submitted.

We are always at your service.

Yours faithfully,

Authorized signatory
s

PS:
In case you are not satisfied with the above decision, you may wish to represent to our Grievance
Department at the following address:
Grievance Redressal Officer,
Corporate Grievance Department,
Star Health And Allied Insurance Co. Ltd.,
No.1,New Tank Street,
Valluvar Kottam High road, Chennai 600034.
Contact number : 044-2824 3925
Mail ID:- grievances@starhealth.in

Thereafter if you wish to pursue the matter further, you may represent to the Office of the Insurance
Ombudsman in your State.

SM Code / Name : SO900000900000 SO CODE

Intermediary Code / Name : LC0000000010M/S.ALLIANCE
INSURANCE BROKERS PVT LTD

COPY TO : Corporate Office

No. 1, New Tank Street, Valluvar Kottam High Road,,Nungambakkam,,Chennai -
600 034.

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