Family Health Optima

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Affordable Premium
Hospitalization Expenses for the Treatment of New Born Baby
Automatic Restoration of Sum Insured
Recharge Benefit

Affordable Premium
Hospitalization Expenses for the Treatment of New Born Baby
Automatic Restoration of Sum Insured
Recharge Benefit

Overview
Features
Eligibility
Disclaimer

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Family Health Optima

Taking care of family needs can be economically challenging. Hence, a super saver policy keeping the expenses to a minimum yet covering the whole family can be your option. The FHO (Floater) Health Insurance Plan is appropriately priced so that you can cope with the most challenging health issues of every family member, even the youngest ones. Protect your newborn from the very start of the 16th day of birth from any medical complications with in-hospitalization charges covered.Read More

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What's Included?

· In-patient hospitalization like room charges, nursing expenses, ICU, surgeon’s fee, etc.

· Domiciliary hospitalization (treatment at home) for a period exceeding three days

· All sorts of day care procedures are covered that take less than 24 hours

· Air ambulance charges up to 10% of the basic sum insured during the policy period

· Pre and post hospitalization expenses 60 days and 90 days respectively

· Affordable Premium - This policy covers family members including self, spouse, up to 3 dependent children, parents and parents-in-law at an affordable premium.

· Policy Type - This policy provides benefits only on a Floater basis.

· Health Check-Up - Health check-up expenses incurred at Network Hospitals are covered up to the specified limits for every claim-free year.

· Organ Donor Expenses - Expenses for organ transplantation where the insured person is the recipient are payable provided the claim for transplantation is payable.

· Automatic Restoration of Sum Insured - On exhaustion of the limit of coverage during the policy period, 100% of the Sum Insured will be restored 3 times in the same policy year.

· Recharge Benefit - On exhaustion of the limit of coverage, an additional indemnity is provided which can be utilised even for the same hospitalisation or for the treatment of disease / illness / injury for which claim was paid / payable under the policy.

· Assisted Reproduction Treatment - Expenses incurred for proven Assisted Reproduction Treatments as listed in the policy clause are covered up to the specified limits.

· Hospitalisation expenses for the treatment of New Born Baby - Cover starts from 16th day after birth and subject to a limit of 10% of the Sum Insured or Rupees Fifty Thousand, whichever is less, provided the mother is insured under the policy for a continuous period of 12 months without break.

· Medical Examination - All people above 50 years of age and those with adverse medical history are required to undergo pre-acceptance medical screening at the Company designated centres. At present 100% of the cost of medical screening will be borne by the company.

· Road Ambulance - Ambulance charges for the transportation of insured person by private ambulance are covered up to Rs. 750/- per hospitalisation and Rs. 1500/- per policy period.

· Air Ambulance - Air ambulance expenses are covered up to 10% of the Sum Insured for the entire policy period.

· Additional Sum Insured for Road Traffic Accident (RTA) - If the insured person meets with a Road Traffic Accident resulting in an in-patient hospitalisation, then the Sum Insured shall be increased by 25% subject to a maximum of Rs.5,00,000/-.

· Assisted Reproduction Treatment - The Company will reimburse medical expenses incurred on Assisted Reproduction Treatment, where indicated, for sub-fertility 1. Waiting period of 36 months from the date of first inception of this policy is applicable. 2. Maximum liability of the Company for such treatment shall be limited to Rs.1 lakh for sum insured of Rs.5 lakh and Rs.2 lakhs for sum insured of Rs.10 lakhs and above for every block of 36 months.

· Hospitalisation Expenses for Treatment of New Born Baby - Cover starts from 16th day after birth and subject to a limit of 10% of the Sum Insured or Rupees Fifty Thousand, whichever is less, provided the mother is insured under the policy for a continuous period of 12 months without break. Note : Exclusions No.1(Code Excl 01), Exclusion No.2(Code Excl 02), Exclusion No.3(Code Excl 03) and the above sublimit will not apply for treatment related to Congenital Internal disease/defects for the new born.

· AYUSH Treatment - Expenses incurred for the treatment under Ayurveda, Unani, Siddha and Homeopathy systems of medicines in AYUSH hospitals are covered.

· Emergency Domestic Medical Evacuation - Expenses incurred towards the transportation of the insured person from the treating hospital to another hospital for treatment are covered as per the limits mentioned in the policy clause.

· Compassionate Travel - The air transportation expenses incurred up to Rs. 5000/- are payable for an immediate family member to travel to the hospital in case of hospitalisation of the insured person for life-threatening emergency times, at the place away from insured’s usual place of residence.

· Second Medical Opinion - The Insured person can avail a Second Medical Opinion from a Doctor in the Company's network of medical practitioners.

· Modern Treatment - Modern treatment expenses are payable up to the limits mentioned in the policy clause.

· Recharge Benefit - Available up to the limits

· Day Care Procedures - Medical treatments and surgical procedures that require less than 24 hours of hospitalisation due to technological advancements are covered.

· Domiciliary Hospitalization - Expenses incurred for domiciliary hospitalisation, including AYUSH on the advice of a medical practitioner for a period exceeding three days are covered.

· Organ Donor Expenses - Expenses incurred for organ transplantation are covered up to a limit of 10% of the Sum Insured subject to the maximum of Rs. 1,00,000/- whichever is less

· Repatriation of Mortal Remains - The expenses incurred for the repatriation of mortal remains of the insured person are covered up to Rs. 5,000/- per policy period.

· Cataract Treatment - Expenses incurred for Cataract treatment are covered up to the limits mentioned in the policy clause.

· Treatment in Valuable Service Providers - If the treatment is undergone in a hospital suggested by the Company, then a lump-sum of 1% of the Sum Insured subject to a maximum of Rs. 5,000/- per policy period is payable.

· Health Check-Up - Health check-up expenses incurred at Network Hospitals are covered up to the specified limits for every claim-free year.

Eligibility

Adults: 18-65 years of age as on last birthday
Children: 16th day of the birth till 25 years
Relationships covered: Self, spouse, dependent parents/ parents-in-law
Renewability: Lifetime

Documentation

Health Insurance Proposal form

KYC Documents: CKYC Detail/ID Proof & address proof (PAN & Aadhar)

For Net banking – Not Applicable

For Mobile banking – Not Applicable

Claims

Condition Precedent to Admission of Liability: The terms and conditions of the policy must be fulfilled by the insured person for the Company to make any payment for claim(s) arising under the policy

Documents for Cashless Treatment

Call the 24 hour help-line for assistance - 1800 425 2255/1800 102 4477, Senior Citizens may call at 044 40020888
Inform the ID number for easy reference
On admission in the hospital, produce the ID Card issued by the Company at the Hospital Helpdesk
Obtain the Pre-authorisation Form from the Hospital Help Desk, complete the Patient Information and resubmit to the Hospital Help Desk
The Treating Doctor will complete the hospitalization/ treatment information and the hospital will fill up expected cost of treatment. This form is submitted to the Company
The Company will process the request and call for additional documents / clarifications if the information furnished is inadequate
Once all the details are furnished, the Company will process the request as per the terms and conditions as well as the exclusions therein and either approve or reject the request based on the merits
In case of emergency hospitalization information to be given within 24 hours after hospitalization
Cashless facility can be availed only in networked Hospitals. For details of Networked Hospitals, the insured may visit www.starhealth.in or contact the nearest branch In non-network hospitals payment must be made up-front and then reimbursement will be effected on submission of documents.
Note: The Company reserves the right to call for additional documents wherever required. Denial of a Pre-authorization request is in no way to be construed as denial of treatment or denial of coverage. The Insured Person can go ahead with the treatment, settle the hospital bills and submit the claim for a possible reimbursement.

For Reimbursement claims: Time limit for submission of:

Sr. No	Type of Claim	Prescribed Time Limit
1	Reimbursement of hospitalization, day care and pre hospitalization expenses	Claim must be filed within 15 days from the date of discharge from the hospital
2	Reimbursement of Post Hospitalization	Within 15 days from completion of 90 days from the date of discharge from hospital

Notification of Claim: Upon the happening of the event, notice with full particulars shall be sent to the Company within 24 hours from the date of occurrence of the event irrespective of whether the event is likely to give rise to a claim under the policy or not.

Note: Above conditions are precedent to admission of liability under the policy. However the Company will examine and relax the time limit mentioned in these conditions depending upon the merits of the case.

Documents to be submitted for Reimbursement: The reimbursement claim is to be supported with the following documents and submitted within the prescribed time limit;

Duly completed claim form, and
Pre Admission investigations and treatment papers
Discharge Summary from the hospital
Cash receipts from hospital, chemists
Cash receipts and reports for tests done
Receipts from doctors, surgeons, anesthetist
Certificate from the attending doctor regarding the diagnosis
Copy of PAN card
Note: Call the 24 hour help-line for assistance - 1800 425 2255 / 1800 102 4477, Senior Citizens may call at 044 40020888

Exclusions

STANDARD EXCLUSIONS

1. Pre-Existing Diseases

·Expenses related to the treatment of a pre-existing Disease (PED) and its direct complications shall be excluded until the expiry of 48 months of continuous coverage after the date of inception of the first policy with insurer

· In case of enhancement of sum insured the exclusion shall apply afresh to the extent of sum insured increase

· If the Insured Person is continuously covered without any break as defined under the portability norms of the extant IRDAI (Health Insurance) Regulations, then for the same would be reduced to the extent of prior coverage

· Coverage under the policy after the expiry of 48 months for any pre-existing disease is subject to the same being declared at the time of application and accepted by Insurer

2. Specified disease / procedure waiting period

·Expenses related to the treatment of the following listed Conditions, surgeries/treatments shall be excluded until the expiry of 24 months of continuous coverage after the date of inception of the first policy with us. This exclusion shall not be applicable for claims arising due to an accident

· In case of enhancement of sum insured the exclusion shall apply afresh to the extent of sum insured increase

· If any of the specified disease/procedure falls under the waiting period specified for pre-existing diseases, then the longer of the two waiting periods shall apply

· The waiting period for listed conditions shall apply even if contracted after the policy or declared and accepted without a specific exclusion

· If the Insured Person is continuously covered without any break as defined under the applicable norms on portability stipulated by IRDAI, then waiting period for the same would be reduced to the extent of prior coverage

· List of specific diseases/procedures;

· Treatment of Cataract and diseases of the anterior and posterior chamber of the Eye, Diseases of ENT,and Diseases related to Thyroid, Benign diseases of the breast.

· Subcutaneous Benign Lumps, Sebaceous cyst, Dermoid cyst, Mucous cyst lip / cheek, Carpal Tunnel Syndrome, Trigger Finger, Lipoma, Neurofibroma, Fibroadenoma, Ganglion and similar pathology

· All treatments (Conservative, Operative treatment) and all types of intervention for Diseases related to Tendon, Ligament, Fascia, Bones and Joint Including Arthroscopy and Arthroplasty / Joint Replacement [other than caused by accident].

· All types of treatment for Degenerative disc and Vertebral diseases including Replacement of bones and joints and Degenerative diseases of the Musculo-skeletal system, Prolapse of Intervertebral Disc (other than caused by accident),

· All treatments (conservative, interventional, laparoscopic and open) relatedto Hepato-pancreato-biliary diseases including Gall bladder and Pancreatic calculi. All types of management for Kidney calculi and Genitourinary tract calculi.

· All types of Hernia, Desmoid Tumor, Umbilical Granuloma, Umbilical Sinus, Umbilical Fistula,
All treatments (conservative, interventional, laparoscopic and open) related to all Diseases of Cervix, Uterus, Fallopian tubes, Ovaries (other than due to Cancer), Uterine Bleeding, Pelvic Inflammatory Diseases

· All Diseases of Prostate, Stricture Urethra, all Obstructive Uropathies,

· Benign Tumours of Epididymis, Spermatocele, Varicocele, Hydrocele,

· Fistula, Fissure in Ano, Hemorrhoids, Pilonidal Sinus and Fistula, Rectal Prolapse, Stress Incontinence

· Varicose veins and Varicose ulcers

· All types of transplant and related surgeries.

· Congenital Internal disease / defect

3. 30-day waiting period

·Expenses related to the treatment of any illness within 30 days from the first policy commencement date shall be excluded except claims arising due to an accident, provided the same are covered

· This exclusion shall not, however, apply if the Insured Person has continuous
coverage for more than twelve months

· The within referred waiting period is made applicable to the enhanced sum
insured in the event of granting higher sum insured subsequently

4. Investigation & Evaluation

· Expenses related to any admission primarily for diagnostics and evaluation purposes only are excluded

· Any diagnostic expenses which are not related or not incidental to the current diagnosis and treatment are excluded

5. Rest Cure, rehabilitation and respite care:

Expenses related to any admission primarily for enforced bed rest and not for receiving treatment. This also includes:

· Custodial care either at home or in a nursing facility for personal care such as help with activities of daily living such as bathing, dressing, moving around either by skilled nurses or assistant or non-skilled persons

· Any services for people who are terminally ill to address physical, social, emotional and spiritual needs

6. Obesity / Weight Control:

· Expenses related to the surgical treatment of obesity that does not fulfill all the below conditions;

· Surgery to be conducted is upon the advice of the Doctor

· The surgery/Procedure conducted should be supported by clinical protocols

· The member has to be 18 years of age or older and

· Body Mass Index (BMI);

· greater than or equal to 40 or

· greater than or equal to 35 in conjunction with any of the following severe co morbidities following failure of less invasive methods of weight loss:
a. Obesity-related cardiomyopathy
b. Coronary heart disease
c. Severe Sleep Apnea
d. Uncontrolled Type2 Diabetes

7. Change-of-Gender treatments: Expenses related to any treatment, including surgical management, to change characteristics of the body to those of the opposite sex.

8. Cosmetic or plastic Surgery: Expenses for cosmetic or plastic surgery or any treatment to change appearance unless for reconstruction following an Accident, Burn(s) or Cancer or as part of medically necessary treatment to remove a direct and immediate health risk to the insured. For this to be considered a medical necessity, it must be certified by the attending Medical Practitioner.

9. Hazardous or Adventure sports: Expenses related to any treatment necessitated due to participation as a professional in hazardous or adventure sports, including but not limited to, para-jumping, rock climbing, mountaineering, rafting, motor racing, horse racing or scuba diving, hand gliding, sky diving, deep-sea diving.

10. Breach of law: Expenses for treatment directly arising from or consequent upon any Insured Person committing or attempting to commit a breach of law with criminal intent.

11. Excluded Providers: Expenses incurred towards treatment in any hospital or by any Medical Practitioner or any other provider specifically excluded by the Insurer and disclosed in its website / notified to the policyholders are not admissible. However, in case of life threatening situations or following an accident, expenses up to the stage of stabilization are payable but not the complete claim.

12. Treatment for Alcoholism, drug or substance abuse or any addictive condition and consequences thereof

13. Treatments received in health hydros, nature cure clinics, spas or similar establishments or private beds registered as a nursing home attached to such establishments or where admission is arranged wholly or partly for domestic reasons

14. Dietary supplements and substances that can be purchased without prescription, including but not limited to Vitamins, minerals and organic substances unless prescribed by a medical practitioner as part of hospitalization claim or day care procedure

15. Refractive Error: Expenses related to the treatment for correction of eye sight due to refractive error less than 7. 5 dioptres.

16. Unproven Treatments: Expenses related to any unproven treatment, services and supplies for or in connection with any treatment. Unproven treatments are treatments, procedures or supplies that lack significant medical documentation to support their effectiveness.

17. Sterility and Infertility: Expenses related to sterility and infertility.

This includes;

· Any type of contraception, sterilization

· Assisted Reproduction services including artificial insemination and advanced reproductive technologies such as IVF, ZIFT, GIFT, ICSI

· Gestational Surrogacy

· Reversal of sterilization
Note: Except to the extent covered under Coverage 2(U)

18. Maternity –

Medical treatment expenses traceable to childbirth (including complicated deliveries
and caesarean sections incurred during hospitalization) except ectopic pregnancy

· Expenses towards miscarriage (unless due to an accident) and lawful medical
termination of pregnancy during the policy period

SPECIFIC EXCLUSIONS

19. Circumcision (unless necessary for treatment of a disease not excluded under this policy or necessitated due to an accident), Preputioplasty, Frenuloplasty, Preputial Dilatation and Removal of SMEGMA
20. Congenital External Condition / Defects / Anomalies
21. Convalescence, general debility, run-down condition, Nutritional deficiency states
22. Intentional self-injury
23. Injury/disease directly or indirectly caused by or arising from or attributable to war, invasion, act of foreign enemy, warlike operations (whether war be declared or not)
24. Injury or disease directly or indirectly caused by or contributed to by nuclear weapons/ materials
25. Expenses incurred on Enhanced External Counter Pulsation Therapy and related therapies, Chelation therapy, Hyperbaric Oxygen Therapy, Rotational Field Quantum Magnetic Resonance Therapy, VAX-D, Low level laser therapy, Photodynamic therapy and such other therapies similar to those mentioned herein under this exclusion
26. Unconventional, Untested, Experimental therapies
27. Autologous derived Stromal vascular fraction, Chondrocyte Implantation, Procedures using Platelet Rich plasma and Intra articular injection therapy
28. Biologicals, except when administered as an in-patient, when clinically indicated and hospitalization warranted
29. All treatment for Priapism and erectile dysfunctions
30. Inoculation or Vaccination (except for post–bite treatment and for medical treatment for therapeutic reasons)
31. Dental treatment or surgery unless necessitated due to accidental injuries and requiring hospitalization. (Dental implants are not payable)
32. Medical and / or surgical treatment of Sleep apnea, treatment for endocrine disorders
33. Hospital registration charges, admission charges, record charges, telephone charges and such other charges
34. Cost of spectacles and contact lens, hearing aids, Cochlear implants and procedures, walkers and crutches, wheel chairs, CPAP, BIPAP, Continuous Ambulatory Peritoneal Dialysis, infusion pump and such other similar aids
35. Any hospitalization which are not medically necessary / does not warrant
hospitalization
36. Other Excluded Expenses as detailed in the website www.starhealth.
37. Existing disease/s, disclosed by the insured and mentioned in the policy schedule (based on insured's consent), for specified ICD codes

Disclaimer

This website is a user interface platform owned and maintained by IDFC FIRST Bank to provide information and to communicate better with the user who may be interested in knowing about the products and services offered by the company & buying them.
Star Health product details are mentioned solely for information and educational purposes. Neither this website nor the contents available can be construed as a professional advice and before making any decision based on the information the user shall consult a professional advisor.
Star Health has taken all necessary precautions to ensure that the information contained in this website is current, accurate and complete as on the date of Publication. No representations or warranties are made (express or implied) as to the reliability, accuracy or completeness of such information. Star Health cannot be held liable for any loss arising directly or indirectly from the use of, or any action taken in on any information appearing on this website.
Insurance is the subject matter of solicitation. "IDFC FIRST Bank having its registered office at KRM Tower, 7th Floor, No. 1, Harrington Road, Chetpet, Chennai – 600031, is authorized by the Insurance Regulatory and Development Authority of India to act as a Corporate Agent of Star Health & Allied Insurance Co. Ltd. for procuring or soliciting health insurance business under license number CA0106”. The purchase of Insurance products by IDFC FIRST Bank customers is purely on voluntary and not linked to availing of any other services from the bank.Read More

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