Treatment Expenses Claimed

Details of Treatment Expenses Claimed with STAR Health Insurance
Details of Expenses Claimed Amount Details of Expenses Claimed Amount
Hospitalization Expenses Ambulance Charges
Pre-Hospitalization Expenses Lump-Sum Benefit
Post - Hospitalization Expenses Critical Illness Benefit
Health Checkup Expenses Others
Total Total
Details of Bill Enclosed
Sl. No. Bill No. Date Issued by Details of Expenses Claimed Amount
Note: In case of more details, please attach separate sheets

Please submit the required Mandatory Documents listed in the checklist for prompt claim settlement, wherever applicable
List of Mandatory Documents to be submitted Yes / No List of Mandatory Documents to be submitted Yes / No
Doctor’s Prescription for Admission, Medicine,

Duly filled and signed Claim Form
investigations, Surgery (Originals)
Investigation / Diagnostic Reports Including CT / MRI /
Discharge Summary (Originals)
USG / HPE / ECG etc.,) (Originals)
Hospital Final Bill with breakup and Receipts (Originals) Invoice / Sticker for the implants used in the treatment.
Proposer’s Bank Account Details-Cancelled Cheque Leaf

Doctor Consultation Bills (Originals)
/ Passbook / Bank Statement - Self Attested
Pharmacy / Investigation / Diagnostic Bills (Originals) Death Certificate
Legal Heir / Succession Certificate if Nominee is not

Sonography Report - in case of Maternity Claim (Originals)
Registered under the Policy (in case of Proposer’s Death)
Affidavit-NOC from Legal Heirs in Stamp Paper certified
USG / X-Ray / MRI / CT Films (Original)
by Notary Public (In case of settlement to Legal Heir)
Nominee / Legal Heir Bank Account Details-Cancelled
Pre & Post - Hospitalisation Bills (Originals) Cheque Leaf / Passbook / Bank Statement
(in case of Proposer’s Death) - Self Attested
Proposer’s ID Proof, Address Proof, PAN Card & Photo Medico Legal Case (MLC) / Accident Report (AR) /
(If CKYC not registered) Self Attested (In case of Accident)
ID Card issued by Employer (in case of Group Policy) Self Attested First Information Report (FIR) in case of Accident
Proposer’s Bank Account Details
Bank Account
Bank Name IFSC Code
Holder Name
Bank Branch Account

Account Type
Name Number
I / We understand that any payment related to Premium Refund / Claim Amount will be directly deposited to my aforesaid Bank Account.
Verification of Bank Account Details is a mandatory requirement for NEFT transactions. Please enclose either a Cheque Leaf or Bank Passbook
Declaration by the Proposer / Claimant
I hereby declare that the information furnished in this claim form is true & correct to the best of my knowledge and belief. If I have made any false or
untrue statement, suppression or concealment of any material fact with respect to questions asked in relation to this claim, my right to claim
reimbursement shall be forfeited. I hereby declare that I have included all the bills / receipts for the purpose of this claim & that I will not be making
any supplementary claim except the pre/post hospitalisation claim, if any. I / We authorise Star Health Insurance Company / TPA to contact me / us
through SMS / Email / WhatsApp for any update on this claim
I/we agree that the PAN details and other information provided by me/us in the proposal form may be used by the Company to download/ verify /
modify / add my/our KYC documents from the CERSAI* CKYC portal for processing this application. I/We understand that only the acceptable
officially valid documents would be relied upon for processing this application. (*Central Registry of Securitization and Asset Reconstruction and
security Interest of India) I hereby consent to receiving information from Central KYC Registry through SMS / email on the above registered number/
email address. The list of acceptable documents can be referred from website (Download > AML/KYC).
I hereby authorize Star Health & Allied insurance Co to use any information/data provided in any of the documents submitted for this claim for the
purpose of research/training/analytics/ investigations/case studies and to ensure that such information/data do not go outside the insurer and its
authorized representatives and also to be compliant under the relevant laws and regulations and without prejudice to my Personal data privacy.
Date Signature of the Proposer / Claimant
Page No: 2 of 4

Treatment Expenses Claimed

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Treatment Expenses Claimed

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Details of Treatment Expenses Claimed with STAR Health Insurance

Details of Expenses Claimed Amount Details of Expenses Claimed Amount

Hospitalization Expenses Ambulance Charges

Pre-Hospitalization Expenses Lump-Sum Benefit

Post - Hospitalization Expenses Critical Illness Benefit

Health Checkup Expenses Others

Details of Bill Enclosed

Note: In case of more details, please attach separate sheets

Doctor’s Prescription for Admission, Medicine,

Proposer’s Bank Account Details-Cancelled Cheque Leaf

Pharmacy / Investigation / Diagnostic Bills (Originals) Death Certificate

Legal Heir / Succession Certificate if Nominee is not

Proposer’s Bank Account Details

Bank Branch Account

Date Signature of the Proposer / Claimant

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