Star Health Family Health Optima

Star Health Family Health Optima is a health insurance policy offered by Star Health and Allied Insurance Company Limited.

This plan stands out as a cost-effective choice compared to other available products in the market. It offers multiple options to obtain premium discounts, enhancing its affordability. While it covers various expenses, including assisted reproductive treatments and newborns from day 16, it's important to understand that its coverage is not comprehensive. There are sub-limits in place for common treatments like cataract, which may result in notable out-of-pocket expenses.  And, it does not offer the option for monthly premium payments. As per our research, we found that the insurer has received a higher number of claim settlement and policy purchase complaints indicating a poor track record when it comes to both purchase and claims service.

What are the benefits offered by the Star Health Family Health Optima Plan?

• Inpatient hospitalisation coverage: Star Health Family Health Optima Plan provides coverage for inpatient hospitalisation expenses which includes costs you incur when you are hospitalised for more than 24 hours. These include room boarding and nursing charges, the cost of prescribed medications and drugs, medical practitioner fees, ICU charges, and other associated expenses.
• Pre-hospitalisation coverage: Medical expenses that you incur prior to hospitalisation are called pre-hospitalisation expenses. These expenses include the fees for consultations, tests, checkups, lab reports, etc. To be eligible for coverage, the expenses should be related to the medical condition that leads to hospitalisation and your claim for these expenses must be approved as part of inpatient hospitalisation coverage. In the Star Health Family Health Optima Plan, pre-hospitalisation expenses are covered for 60 days before hospitalisation up to the sum insured.                     
• Post-hospitalisation coverage: You may incur medical costs after you are discharged from the hospital. These are called post-hospitalisation expenses such as follow-up consultations with your doctor, medical check-ups, rehabilitation sessions, physiotherapy, and other related costs. To be eligible for coverage, these expenses must be related to the condition that led to your hospitalisation, and your claim must be approved under inpatient hospitalisation coverage. In the Star Health Family Health Optima Plan, post-hospitalisation expenses are covered for 90 days after your hospitalisation up to the sum insured.
• Daycare treatment coverage: Daycare treatments are medical procedures or surgeries that once required prolonged hospitalisation but can now be completed within 24 hours because of groundbreaking advancements in the medical field. In the Star Health Family Health Optima Plan, all daycare procedures are covered up to the sum insured.
• Domiciliary treatment coverage: Domiciliary treatments are medical treatments for illnesses or injuries that require immediate attention at the hospital but are administered at home due to the severity of the patient’s condition or the unavailability of beds in the nearby hospitals. In the Star Health Family Health Optima Plan, domiciliary treatments (except for 15 illnesses) are covered up to the sum insured.
• Organ donor coverage: Star Health Family Health Optima Plan also covers the costs associated with harvesting the organ from the organ donor up to 10% of the sum insured subject to a maximum of Rs 1 lakh – where you are the organ recipient. The insurer will also take care of any complications that may arise in a donor's surgery. 
• Modern treatment coverage: In the dynamic landscape of healthcare, today we’re witnessing treatments that were once considered impossible. Cutting-edge treatments like radio surgeries, stem cell treatments, etc. are bringing new hope and the potential for cures to conditions that were once thought to be beyond medical reach. The Star Health Family Health Optima Plan provides coverage for such modern treatments up to the sum insured – if you opt for an add-on.
• Non-medical expenses coverage: The Star Health Family Health Optima Plan provides non-medical expenses coverage if opted as an add-on. These are costs associated with consumables, such as gloves, nebulization kits, oxygen masks, and other items that are necessary for treatment and are covered up to the sum insured without any limit. 
• No Claim Bonus: No Claim Bonus is a reward offered to you if you do not file any claims during the policy year.  Star Health Family Health Optima Plan offers 25% of the sum insured in the 2^nd policy year and 10% of the sum insured in the subsequent years as a No Claim Bonus. You can accumulate a maximum bonus of up to 100%. You can keep your accumulated bonus amount intact even if you make claims – if you opt for an add-on. No Claim Bonus will not get affected if only the base sum insured is utilised for claim settlement. In case the accumulated bonus is used up, it will reduce at the rate it was earned. 
• Super No Claim Bonus: The Super No Claim Bonus is an enhanced version of the standard No Claim Bonus and operates in the same way. However, the Star Health Family Health Optima Plan does not offer the Super No Claim Bonus feature.
• Restoration benefit: The Restoration Benefit is a feature that replenishes your sum insured once it is used up during a policy year. The Star Health Family Health Optima Plan offers this benefit for unrelated illnesses. The refill benefit becomes active only when both the sum insured and the No Claim Bonus (if any) are entirely exhausted. You can utilise this benefit 3 times in a policy year for subsequent claims.

Please note that the limits and conditions mentioned in the above benefits and features are for a sum insured of Rs. 10 Lakhs.

Star Health Family Health Optima Plan: Financial Limits

• Room rent limit: The room rent limit is the maximum amount that your insurance company will pay for the room you stay in while being hospitalised. Choosing a room that falls within your plan's room rent limit will not lead to any out-of-pocket expenses. But, if you pick an expensive room more than what you are eligible for, you will face a proportionate deduction. This means that you will have to pay a proportionate share of the entire bill, not just the room rent difference. Under Star Health Family Health Optima Plan, you can select any room type except suite and above category if you opt for an add-on.
• ICU rent limit: It is the maximum amount that a health insurance policy covers for the cost of your stay in ICU. The Star Health Family Health Optima Plan does not have an ICU rent limit. Meaning, the insurer covers the entire cost of an ICU stay without any limit.
• Copayment: It is a portion of the approved claim amount that you need to pay from your end. And, the insurer will cover the remaining amount. The Star Health Family Health Optima Plan offers a copayment limit of 20% for individuals aged 60 years and above at the time of enrolment.
• Deductible: A deductible is an amount that you have to pay from your end before your policy steps in to cover the rest of your medical expenses. The Star Health Family Health Optima Plan doesn't provide any deductible options.
• Limits on surgeries/treatments: It is the maximum amount that your insurer will pay for certain medical procedures or treatments. Some policies may place a cap on the amount that they will cover for specific procedures, while others may not. Star Health Family Health Optima Plan applies a limit of Rs 50,000 per eye per policy year, subject to a maximum of Rs 75,000 for cataract treatments. However, joint replacement surgery costs are covered up to the sum insured. So, the insurer will cover the entire cost of joint replacement surgery without any limit.

Please note that the above financial limits are taken for a 30-year-old individual, opting for a sum insured of Rs. 10 Lakhs.

Star Health Family Health Optima Plan: Waiting Periods & Exclusions

👉Waiting period

Some illnesses and diseases may not be covered for a certain duration after you purchase a health insurance policy, which is referred to as the waiting period. You can submit claims for these conditions once the waiting period ends. Here are some types of waiting periods -

• Initial waiting period: Star Health Family Health Optima Plan has an initial waiting period of 30 days for all medical conditions, except for accidents. So, you will not be eligible to make a claim for any hospitalisation, unless it is due to an accident.
• Waiting period for pre-existing diseases: A pre-existing disease is any medical condition or illness that you have experienced within 36 months prior to applying for the health insurance policy. Star Health Family Health Optima Plan has a waiting period of 36 months for pre-existing diseases. During this period, you cannot file any claim for expenses related to pre-existing diseases.
• Waiting period for specific diseases: Insurance companies may apply waiting periods on certain medical conditions or illnesses apart from your pre-existing diseases. These waiting periods are decided by the insurer and are not based on your current state of health. The Star Health Family Health Optima Plan has a waiting period of 24 months for specific diseases.

👉Exclusions
There are certain situations that your insurer will not cover at any cost which are referred to as exclusions. These include –

• Standard permanent exclusions: All insurance companies must stick to a set of “standard permanent exclusions” stipulated by the Insurance Regulatory and Development Authority of India (IRDAI). These exclusions include –  

1. Investigation and evaluation: Hospitalisation for monitoring or observation purposes.
2. Rest cure, rehabilitation, and respite care: Admission to a facility for bed rest where no active medical treatment is administered.
3. Obesity/weight control: Any treatment or surgery designed for weight control or obesity.
4. Change of gender treatment: Any medical treatment designed to alter the characteristics of the body to that of the opposite gender.
5. Plastic/cosmetic surgery: Any surgical or medical procedures for the modification of appearance or body characteristics.
6. Profession in hazardous or adventure sports: Any medical expenses incurred while engaging as a professional in adventure activities such as skydiving, river rafting, scuba diving, horse racing, etc.
7. Breach of law: Any expenses incurred for treating a person who has committed or attempted to commit a criminal act.
8. Excluded providers: Treatment received from a medical practitioner or hospital excluded by the insurance company.
9. Narcotics: Treatment for addictive conditions like alcohol addiction, drug usage, etc.
10. Treatments in establishments arranged for domestic purposes: Expenses related to receiving treatments from health spas, nursing homes, or similar establishments arranged entirely or partially for domestic reasons.
11. Dietary supplements, substances purchased without prescription: Vitamins, minerals, and other dietary supplements not prescribed by a medical practitioner.
12. Refractive error: Expenses related to correcting refractive errors up to 7.5 diopters for improved eyesight.
13. Unproven treatments: Any surgeries, medical procedures, or treatments that are not proven to be effective.
14. Expenses related to birth control, sterility infertility: Expenses related to contraception, sterilisation, artificial insemination, advanced reproductive technologies such as IVF, ZIFT, GIFT, ICSI, gestational surrogacy, etc.
15. Maternity expenses: Pre/post-natal care, childbirth, hospitalisation expenses, etc.

• Additional permanent exclusions: Besides the standard permanent exclusions defined by the IRDAI, insurance companies can also apply “specific exclusions'' based on certain medical conditions or situations. If the insurer regards certain diseases or severe medical conditions as too risky, they may permanently exclude them from coverage under your policy. It is worth noting that insurers can only apply permanent exclusions to a list of pre-approved illnesses outlined by the IRDAI. They cannot permanently exclude any disease or medical condition beyond this list.
• Non-standard exclusions (Specific exclusions): These exclusions extend beyond the standard permanent exclusions established by the IRDAI and can differ between insurers based on their individual policies and conditions. These are some of the specific exclusions under the Star Health Family Health Optima Plan –

1. Circumcision, unless medically necessary for treating a disease or injury.
2. Expenses related to the treatment of external birth defects.
3. Expenses related to convalescence, general debility, run-down conditions, and nutritional deficiency states.
4. Treatment linked to intentional self-inflicted injury or attempted suicide by any means.
5. Injuries or diseases resulting from war, invasion, acts of foreign enemies, warlike operations, etc.
6. Injury or illness caused by nuclear weapons or materials.
7. Expenses associated with specific therapies like hyperbaric oxygen therapy, low-level laser therapy, photodynamic therapy, etc.
8. Expenses related to therapies that are untested, unconventional, or experimental.
9. Expenses related to biologicals, except when administered during in-patient hospitalisation.
10. Costs associated with vaccinations and inoculations, except for post-animal bite treatment and medically necessary therapeutic purposes.
11. Expenses related to spectacles and contact lenses, hearing aids, walkers, crutches, wheelchairs, and similar equipment.

What to expect in terms of claims experience if you buy from Star Health and Allied Insurance Company Limited?

• Speed of claims: Star Health and Allied Insurance Company has settled 98.86% of claims, in less than 30 days. This suggests that they provide a prompt and efficient claim settlement process.
• Claim-related complaints: As per our research, Star Health and Allied Insurance Company Limited has received a higher number of complaints related to claims, when compared to other insurers, accounting for 0.56%.
• Claims incurred ratio: It is a measure of the financial performance of an insurer. It is the ratio of the total claims incurred by the insurer to the total premiums collected. Star Health and Allied Insurance Company’s claims incurred ratio is 66.47%.
• Claim settlement ratio Star Health and Allied Insurance Company’s claim settlement ratio of 85.32%. It is the percentage of claims settled by the insurer compared to the total claims received in a financial year.
• Network hospitals: Star Health and Allied Insurance Company offers a vast network of over 14,000+ hospitals. The extensive network ensures that customers can access a diverse array of healthcare providers across various locations, allowing them to receive cashless treatment without any financial constraints.

How is the customer service of Star Health and Allied Insurance Company Limited?

• Policy purchase-related complaints: As per our research, Star Health and Allied Insurance Company have received a higher number of complaints related to their after-sales service, compared to other insurers, accounting for 0.06%.
• Response on toll-free: In our research, we observed that the service response on Star Health and Allied Insurance Company's toll-free number is quick, as compared to other insurers. 
• Response on Twitter: As per our research, Star Health and Allied Insurance Company’s response time on Twitter is slow.

About Star Health and Allied Insurance Company Limited

Star Health and Allied Insurance Company Limited, established in 2006, is India's pioneer standalone health insurance provider. The company offers a diverse range of products designed to serve the needs of individuals, families, and corporations. Headquartered in Chennai, Tamil Nadu, the company is led by Mr. V. Jagannathan, who serves as both the chairman and CEO.