Star Family Health Optima
Overview
Star Family Health Optima is an affordable health insurance plan offered by Star Health and Allied Insurance. The plan offers restricted coverage with a few disease-specific limits, along with a mandatory copayment clause for elderly people looking for cover.
Though the coverage is decent for its price, it’s far from comprehensive. We recommend you read the terms and conditions before you purchase this one. Moreover, the insurer faces operational challenges that are indicated by its low claim settlement ratio and high volume of claim complaints. This is also a cause of concern.
Pros and Cons
- The plan is fairly inexpensive. Additionally, it offers multiple ways to get discounts on premium.
- Newborn expenses coverage – It covers newborn baby expenses from the 16th day.
- Monthly premium payment mode is available.
- Room rent limit – Covers up to Single Standard AC Room. Picking a higher room category during hospitalisation leads to proportionate deductions in the claim.
- Copayment clause – Includes a mandatory 20% copay for all lives buying the cover after 60 years of age.
- Disease-specific limits – Includes sub-limits on common treatments like cataract surgery and modern treatments.
- Insurer metrics – The insurer faces operational challenges that are indicated by its low claim settlement ratio and high volume of claim complaints.
Plan Benefits
In-patient hospitalisation expenses covered
The plan covers in-patient hospitalisation and related expenses up to the sum insured. However, the coverage is limited to a single standard AC room. If you choose anything more fancy, you bear the cost of proportionate deductions on all charges, including surgery costs, doctors’ fee, nursing charges, etc.
Mandatory 20% copayment clause
The plan imposes a mandatory 20% copay on every claim in case your age at the time of purchase is 61 or more. This is far from desirable for the elderly looking for health insurance coverage.
Disease-specific limits
The plan includes disease-specific limits on common treatments like cataract surgery and modern treatments.
Pre and post-hospitalisation expenses are covered
The insurer covers treatment-related medical expenses 60 days before and 90 days after hospitalisation. This includes diagnostic tests, followup consultations, medication and more.
Get cover even if you are hospitalised for less than 24 hours
Many treatments and surgeries done under anesthesia now require less than 24 hour hospitalisation. They are called daycare treatments. The insurer covers the cost of such treatments. However, there are some disease-wise limits.
Get coverage for a newborn baby from the 16th day
The plan starts covering a newborn baby under the family floater option from the 16th day onwards. All in-patient care expenses in case of hospitalisation are covered.
Alternative medicine covered
Want to take alternative treatment like Ayurveda or Homeopathy? Don’t worry. Your insurer fully covers your hospitalisation and related expenses.
Get cover even if you are forced to be hospitalised at home
Are you forced to be hospitalised at home? Imagine this. No beds are available in the hospital or the patient’s medical condition does not allow him to be moved to a hospital. This is called domiciliary hospitalisation. Your insurance policy covers the cost of hospitalisation if it happens for at least 3 consecutive days under the supervision of a medical practitioner.
Covers organ harvesting cost in case of an organ transplant
If you are an organ recipient, your insurer will cover the hospitalisation expenses of the organ donor for harvesting the donated organ. However, the maximum limit is 10% of the sum insured or Rs. 1 Lakh, whichever is less.
Get free health check-up every claim-free year
Get a pre-defined free health check-up every claim-free year, subject to limits. You can avail of this benefit only at a network provider centre on a cashless basis. This benefit has a separate limit over and above the base coverage.
Infertility treatment cover available
The plan covers the cost of assisted reproduction treatment, including IVF, in case of indicated infertility. The coverage kicks off after a 3 year waiting period and is subject to limits.
Automatic restoration of sum insured upon exhaustion of base sum insured
The insurer restores 100% of the base sum insured up to 3 times in a policy year upon the exhaustion of the base sum insured. Restored sum insured is only available for unrelated illnesses for subsequent claims. Additionally, the insurer also provides a one-time recharge of Rs. 1.5 Lakh every year upon exhaustion of the base sum insured. This recharge amount can be used for the same hospitalisation and illness.
Guaranteed cumulative bonus available
You get a 10% guaranteed cumulative bonus every year up to a maximum of 100% of the sum insured, irrespective of the claims you make.
Ambulance charges covered
The plan covers road and air ambulance charges subject to limits.
Wellness benefits for staying healthy
Stay healthy and earn reward points from your insurer. You can use these reward points to get up to a 20% discount on subsequent premiums if certain conditions are met.
Opt for a copay to lower the premium
If you find the plan expensive, choose a small copay to lower the premium. Copay options of 10% and 20% are available. However, choose this option with caution as you pay a fixed percentage of each claim out-of-pocket.
Enhance your coverage with Star Protect Extra add-on
This is a many-in-one add-on, as you get multiple benefits. You get an upgrade to any room, coverage for non-medical items and enhanced limits for modern and advanced treatments.
Policy Conditions
| Sum Insured Range | Rs. 5 Lakh – Rs. 25 Lakh |
| Entry Age | 16 Days – 25 Years for dependent children, 18 – 65 Years for adults. |
| Policy Tenure Options | 1 or 2 Years |
| Coverage Types | Family Floater |
| Family Coverage | Up to 6 adults including self, spouse, parents, parents-in-law and 3 dependent children. |
| Premium Payment | Monthly, Quarterly, Half-Yearly and Annual. |
Exclusions
Waiting Periods
- Initial Waiting Period: 30 days (except accidents)
- Specific Illness Waiting Period: 24 months.
- Waiting Period on Pre-Existing Diseases: 36 months.
- Assisted Reproductive Treatment Waiting Period: 36 months
Medical Exclusions
- Change of gender treatment
- Cosmetic surgeries (unless due to accident, cancer, etc.)
- Unproven treatments
- Refractive error correction for less than 7.5 diopters
- Dental OPD treatment
- Maternity and related expenses
Non-Medical Exclusions
- Expenses related to any admission primarily for diagnostics and evaluation purposes
- Expenses related to any admission primarily for enforced bed rest
- Self-injury or attempt to suicide
- Alcoholism, drug or substance abuse
- Treatment necessitated by committing breach of law with criminal intent
- Treatment taken by a medical practitioner outside his discipline
- War, terrorism, nuclear events
- Injuries from hazardous sports
About the Insurer
Star Health and Allied Insurance Company is India’s largest health insurer, offering health insurance solutions for individuals and families. It specialises in health, personal accident and travel insurance solutions. The company was established in 2006 and was promoted by Safecrop Investments India LLP, Westbridge AIF I and Rakesh Jhunjhunwala.
The insurer has a business track record of almost 2 decades. However, the company is facing challenges with its claim settlement and operational processes, which reflect in its relatively low claim settlement ratio. It also has had a very high volume of claim-related complaints that indicates problems in claim handling. Let’s see how the insurer handles these issues in future and wins customers’ trust.
Performance Highlights (FY24)
Turnover – Rs. 16,113 Crore
Claim Settlement Ratio – 86.49%
Incurred Claim Ratio – 64.47%
Volume of Claim Complaints – 55.79
Network Hospitals – 14,000+
Get In Touch
Looking for some insurance related advice? You can book a call with us. It’s absolutely FREE.
Frequently Asked Questions
What is the entry age for Star Family Health Optima plan?
Individuals aged between 18 and 65 years can avail of this policy. Dependent children are covered from the 16th day onwards up to 25 years.
Who can be covered under this policy?
The policy covers self, spouse, up to three dependent children, parents, and parents-in-law.
Does the plan cover pre-existing diseases?
Yes, pre-existing diseases are covered after a waiting period of 36 months.
Is pre-policy medical screening required before purchasing Star Family Health Optima?
Applicants aged above 50 years who declare an adverse medical condition in the policy application need to undergo pre-policy medical screening.
What is the coverage limit for a newborn baby?
Coverage for a newborn baby is offered from the 16th day onwards, up to Rs. 50,000 or 10% of the sum insured, whichever is less.
Is there any copayment in Star Family Health Optima?
Yes, a 20% mandatory copayment applies on every claim if your age at entry is more than 60 years.
What are the pre and post-hospitalisation coverage durations?
The policy covers pre-hospitalisation expenses up to 60 days before admission and post-hospitalisation expenses up to 90 days after discharge.
Does the policy offer a health check-up benefit?
Yes, free health check-ups are available for all insured lives at network hospitals up to specified limits for every claim-free year.
Are day care procedures covered under Star Family Health Optima?
Yes, all day care procedures are included under the policy.
What is the room rent limit under Star Family Health Optima?
Hospitalisation expenses are covered up to a single standard AC room under the plan. If you choose anything more fancy, you bear the cost of proportionate deductions on all charges, including surgery costs, doctors’ fees, nursing charges, etc.
Does Star Family Health Optima cover ambulance charges?
Yes, road ambulance charges are covered up to Rs. 750 per hospitalisation and Rs. 1,500 for every policy period. Air ambulance cover is provided up to 10% of the sum insured.
What is the policy term, and are there any discounts?
Policy tenures of 1 and 2 years are available. If you choose a 2 year policy tenure, a 10% discount on the 2nd year premium is available.
Does Star Health Family Health Optima cover outpatient expenses?
No, the plan does not offer coverage for out-patient (OPD) expenses.
Does Star Family Health Optima offer a restoration benefit?
Yes, 100% of the sum insured is restored thrice in a policy year under the Family Health Optima Insurance Plan. Restored sum insured is only available for unrelated illnesses for subsequent claims. Additionally, the insurer also provides a one-time recharge of Rs. 1.5 Lakh every year upon exhaustion of the base sum insured. This recharge amount can be utilised for the same hospitalisation and illness.
Does the policy cover surgeries like cataract, knee replacement, and liver transplant?
Yes, surgeries such as cataract, knee replacement, and liver transplant are covered under Star Health Family Health Optima after a 2 year waiting period, subject to treatment-specific limits.
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