STAR HEALTH AND ALLIED INSURANCE COMPANY LIMITED

Regd. & Corporate Office: 1, New Tank Street, Valluvar Kottam High Road, Nungambakkam,
Chennai - 600 034. « Phone : 044 - 28288800 « Email : support@starhealth.in
Website : www.starhealth.in « CIN : L66010TN2005PLC056649 « IRDAI Regn. No. : 129

FAMILY HEALTH OPTIMA INSURANCE PLAN

Unique Identification No.: SHAHLIP23164V072223

PREAMBLE ii) has qualified medical practitioner/s in charge;

The proposal, declaration and other documents given by the proposer shall be the basis of iii) has fully equipped operation theatre of its own where surgical procedures are carried
this Contract and is deemed to be incorporated herein. out;
iv) maintains daily records of patients and will make these accessible to the insurance
1. DEFINITIONS company's authorized personnel.
STANDARD DEFINITIONS Day Care Treatment: Day care treatment means medical treatment, and/or surgical
Accident: An accident means sudden, unforeseen and involuntary event caused by procedure which is:
external, visible and violent means. i. Undertaken under General or Local Anesthesia in a hospital/day care centre in less
Any one illness: Any one illness means continuous period of illness and includes relapse than 24 hrs because of technological advancement, and
within 45 days from the date of last consultation with the Hospital/Nursing Home where ii. which would have otherwise required hospitalization of more than 24 hours
treatment was taken. Treatment normally taken on an out-patient basis is not included in the scope of this
definition
AYUSH Day Care Centre: AYUSH Day Care Centre means and includes Community
Health Centre (CHC), Primary Health Centre (PHC), Dispensary, Clinic, Polyclinic or any Dental Treatment: Dental treatment means a treatment related to teeth or structures
such health centre which is registered with the local authorities, wherever applicable and supporting teeth including examinations, fillings (where appropriate), crowns, extractions
having facilities for carrying out treatment procedures and medical or surgical/para-surgical and surgery.
interventions or both under the supervision of registered AYUSH Medical Practitioner (s) on
day care basis without in-patient services and must comply with all the following criterion: Disclosure to information norm: The policy shall be void and all premium paid thereon
i. Having qualified registered AYUSH Medical Practitioner(s) in charge; shall be forfeited to the Company in the event of misrepresentation, mis-description or non-
disclosure of any material fact.
ii. Having dedicated AYUSH therapy sections as required and/or has equipped
operation theatre where surgical procedures are to be carried out; Domiciliary Hospitalization: Domiciliary hospitalization means medical treatment for an
iii. Maintaining daily records of the patients and making them accessible to the insurance illness/disease/injury which in the normal course would require care and treatment at a
company's authorized representative. hospital but is actually taken while confined at home under any of the following
circumstances:
AYUSH Hospital: An AYUSH Hospital is a healthcare facility wherein medical/surgical/ i) the condition of the patient is such that he/she is not in a condition to be removed to a
para-surgical treatment procedures and interventions are carried out by AYUSH Medical hospital, or
Practitioner(s) comprising of any of the following:
ii) the patient takes treatment at home on account of non-availability of room in a hospital
a. Central or State Government AYUSH Hospital; or
b. Teaching hospital attached to AYUSH College recognized by the Central Grace Period: Grace period means the specified period of time immediately following the
Government/Central Council of Indian Medicine/Central Council for Homeopathy; or premium due date during which a payment can be made to renew or continue a policy in
c. AYUSH Hospital, standalone or co-located with in-patient healthcare facility of any force without loss of continuity benefits such as waiting periods and coverage of
recognized system of medicine, registered with the local authorities, wherever pre-existing diseases. Coverage is not available for the period for which no premium is
applicable, and is under the supervision of a qualified registered AYUSH Medical received.
Practitioner and must comply with all the following criterion: Hospital: A hospital means any institution established for in-patient care and day care
i. Having at least 5 in-patient beds; treatment of illness and/or injuries and which has been registered as a hospital with the
ii. Having qualified AYUSH Medical Practitioner in charge round the clock; local authorities under Clinical Establishments (Registration and Regulation) Act 2010 or
iii. Having dedicated AYUSH therapy sections as required and/or has equipped under enactments specified under the Schedule of Section 56(1) of the said act Or
operation theatre where surgical procedures are to be carried out; complies with all minimum criteria as under:
i) has qualified nursing staff under its employment round the clock;
iv. Maintaining daily records of the patients and making them accessible to the
insurance company's authorized representative. ii) has at least 10 in-patient beds in towns having a population of less than 10,00,000 and
at least 15 in-patient beds in all other places;
AYUSH Treatment: AYUSH Treatment refers to the medical and / or hospitalization iii) has qualified medical practitioner(s) in charge round the clock;
treatments given under 'Ayurveda, Yoga and Naturopathy, Unani, Siddha and
Homeopathy systems’. iv) has a fully equipped operation theatre of its own where surgical procedures are
carried out;
Cashless facility: Cashless facility means a facility extended by the insurer to the insured v) maintains daily records of patients and makes these accessible to the insurance
where the payments, of the costs of treatment undergone by the insured in accordance company's authorized personnel;
with the policy terms and conditions, are directly made to the network provider by the
insurer to the extent pre-authorization is approved. Hospitalization: Hospitalization means admission in a Hospital for a minimum period of
24 consecutive 'In-patient Care' hours except for specified procedures/ treatments, where
Condition Precedent: Condition Precedent means a policy term or condition upon which such admission could be for a period of less than 24 consecutive hours.
the Insurer's liability under the policy is conditional upon.
Illness: Illness means a sickness or a disease or pathological condition leading to the
Congenital Anomaly: Congenital Anomaly means a condition which is present since birth, impairment of normal physiological function and requires medical treatment;
and which is abnormal with reference to form, structure or position. (a) Acute condition - Acute condition is a disease, illness or injury that is likely to
a) Internal Congenital Anomaly: Congenital anomaly which is not in the visible and respond quickly to treatment which aims to return the person to his or her state of
accessible parts of the body health immediately before suffering the disease/ illness/ injury which leads to full
b) External Congenital Anomaly: Congenital anomaly which is in the visible and recovery
accessible parts of the body (b) Chronic condition - A chronic condition is defined as a disease, illness, or injury that
Co-Payment: Co-payment means a cost sharing requirement under a health insurance has one or more of the following characteristics;
policy that provides that the policyholder/insured will bear a specified percentage of the 1. It needs ongoing or long-term monitoring through consultations, examinations,
admissible claims amount. A co-payment does not reduce the Sum Insured. check-ups, and /or tests
2. it needs ongoing or long-term control or relief of symptoms
Cumulative Bonus: Cumulative Bonus means any increase or addition in the Sum
Insured granted by the insurer without an associated increase in premium. 3. it requires rehabilitation for the patient or for the patient to be specially trained to
cope with it
Day Care Centre: A day care centre means any institution established for day care 4. it continues indefinitely
treatment of illness and/or injuries or a medical setup with a hospital and which has been
5. it recurs or is likely to recur
registered with the local authorities, wherever applicable, and is under supervision of a
registered and qualified medical practitioner AND must comply with all minimum criterion Injury: Injury means accidental physical bodily harm excluding illness or disease solely
as under – and directly caused by external, violent, visible and evident means which is verified and
i) has qualified nursing staff under its employment; certified by a Medical Practitioner.
Family Health Optima Insurance Plan Unique Identification No.: SHAHLIP23164V072223 POL / FHO / V.20 / 2023 1 of 14
Inpatient Care: Inpatient care means treatment for which the insured person has to stay in Renewal: Renewal means the terms on which the contract of insurance can be renewed
a hospital for more than 24 hours for a covered event. on mutual consent with a provision of grace period for treating the renewal continuous for
the purpose of gaining credit for pre-existing diseases, time-bound exclusions and for all
Intensive Care Unit: Intensive care unit means an identified section, ward or wing of a
hospital which is under the constant supervision of a dedicated medical practitioner(s), and waiting periods.
which is specially equipped for the continuous monitoring and treatment of patients who Room Rent: Room Rent means the amount charged by a Hospital towards Room and
are in a critical condition, or require life support facilities and where the level of care and Boarding expenses and shall include the associated medical expenses.
supervision is considerably more sophisticated and intensive than in the ordinary and other
wards. Surgery or Surgical Procedure: Surgery or Surgical Procedure means manual and / or
operative procedure(s) required for treatment of an illness or injury, correction of
ICU Charges: ICU (Intensive Care Unit) Charges means the amount charged by a deformities and defects, diagnosis and cure of diseases, relief from suffering and
Hospital towards ICU expenses which shall include the expenses for ICU bed, general prolongation of life, performed in a hospital or day care centre by a medical practitioner.
medical support services provided to any ICU patient including monitoring devices, critical
care nursing and intensivist charges. Unproven/Experimental treatment: Unproven/Experimental treatment means the
treatment including drug experimental therapy which is not based on established medical
Medical Advice: Medical Advice means any consultation or advice from a Medical practice in India, is treatment experimental or unproven.
Practitioner including the issuance of any prescription or follow-up prescription.
SPECIFIC DEFINITIONS
Medical Expenses: Medical Expenses means those expenses that an Insured Person has
Associated medical expenses: Associated medical expenses means medical expenses
necessarily and actually incurred for medical treatment on account of Illness or Accident on
such as Professional fees, OT charges, Procedure charges, etc., which vary based on the
the advice of a Medical Practitioner, as long as these are no more than would have been
room category occupied by the insured person whilst undergoing treatment in some of the
payable if the Insured Person had not been insured and no more than other hospitals or
doctors in the same locality would have charged for the same medical treatment. hospitals. If Policy Holder chooses a higher room category above the eligibility defined in
policy, then proportionate deduction will apply on the Associated Medical Expenses in
Medical Practitioner: Medical Practitioner means a person who holds a valid registration addition to the difference in room rent. Such associated medical expenses do not include
from the Medical Council of any State or Medical Council of India or Council for Indian Cost of pharmacy and consumables, Cost of implants and medical devices and Cost of
Medicine or for Homeopathy set up by the Government of India or a State Government and diagnostics.
is thereby entitled to practice medicine within its jurisdiction; and is acting within its scope
and jurisdiction of license. Assisted Reproduction Treatment: Assisted Reproduction Treatment means
intrauterine insemination (IUI), Intra-Cytoplasmic Sperm Injection (ICSI), In-Vitro
Medically Necessary Treatment: Medically necessary treatment means any treatment, Fertilisation( IVF) and TESA / TESE (Testicular / Epididymal Sperm Aspiration / Extraction).
tests, medication, or stay in hospital or part of a stay in hospital which:
i) is required for the medical management of the illness or injury suffered by the insured; Company: Company means Star Health and Allied Insurance Company Limited.
ii) must not exceed the level of care necessary to provide safe, adequate and Dependent Child: Dependent Child means a child (natural or legally adopted) who is
appropriate medical care in scope, duration, or intensity; financially dependent and does not have his / her independent sources of income and not
iii) must have been prescribed by a medical practitioner; over 25 years.
iv) must conform to the professional standards widely accepted in international medical Diagnosis: Diagnosis means diagnosis by a registered medical practitioner, supported by
practice or by the medical community In India. clinical, radiological, histological, histo-pathological and laboratory evidence and also
Migration: “Migration” means, the right accorded to health insurance policyholders surgical evidence wherever applicable, acceptable to the Company.
(including all members under family cover and members of group health insurance policy), Family: Family includes Insured Person, Spouse / Live in partner / Same Sex partner,
to transfer the credit gained for pre-existing conditions and time bound exclusions, with the dependent children between 16 days and 25 years of age not exceeding 3 in number.
same insurer. Dependent Parent / Parents in law.
Network Provider: Network Provider means hospitals or health care providers enlisted by Insured Person: Insured Person means the name/s of persons named in the schedule of
an insurer, TPA or jointly by an Insurer and TPA to provide medical services to an insured by the Policy.
a cashless facility.
Instalment: Instalment means frequency of Premium amount paid through Quarterly /
New Born Baby: Newborn baby means baby born during the Policy Period and is aged Half-yearly mode by the Policy Holder / Insured.
upto 90 days.
In-Patient: In-Patient means an Insured Person who is admitted to Hospital and stays
Non-Network Provider: Non-Network means any hospital, day care centre or other there for a minimum period of 24 hours for the sole purpose of receiving treatment
provider that is not part of the network.
Limit of Coverage: Limit of Coverage means Sum Insured plus Cumulative Bonus earned
Notification of Claim: Notification of claim means the process of intimating a claim to the wherever applicable.
insurer or TPA through any of the recognized modes of communication.
Shared accommodation: Shared accommodation means a room with two or more patient
Pre-Existing Disease: Pre-existing Disease means any condition, ailment, injury or disease: beds in a Network Hospital.
a) That is/are diagnosed by a physician within 48 months prior to the effective date of the
policy issued by the insurer or its reinstatement Single Standard A/c room: Single Standard A/c room means a single occupancy
or air-conditioned room with attached wash room and a couch for the attendant. The room
b) For which medical advice or treatment was recommended by, or received from, a may have a television and /or a telephone. Such room must be the most economical of all
physician within 48 months prior to the effective date of the policy issued by the insurer accommodations available in that hospital as single occupancy. This does not include a
or its reinstatement deluxe room or a suite.

Pre-hospitalization Medical Expenses: Pre-hospitalization Medical Expenses means Sum Insured: Sum Insured means the Sum Insured Opted for and for which the premium
medical expenses incurred during pre-defined number of days preceding the is paid.
hospitalization of the Insured Person, provided that: Zone A: Delhi, New Delhi, Faridabad, Gurugram, Shahdara, Ahmedabad, Surat,
i. Such Medical Expenses are incurred for the same condition for which the Insured Vadodara, Gautam Buddha Nagar, Ghaziabad, Mewat, Alwar, Baghpat, Bhiwani,
Person's Hospitalization was required, and Bulandshahar, Fatehabad, Hisar, jhajjar, Jind, Kaithal, Karnal, Kurukshetra,
ii. The In-patient Hospitalization claim for such Hospitalization is admissible by the Mahendragarh, Meerut, Muzaffar nagar, Palwal, Panchsheel Nagar, Panipat, Rewari,
Insurance Company Rohtak, Saharanpur, Sirsa and Sonipat.
Portability: “Portability” means, the right accorded to individual health insurance Zone B: Mumbai (Including suburban), Rest of Gujarat, Thane, Palghar and Raigad
policyholders (including all members under family cover), to transfer the credit gained for
pre- existing conditions and time bound exclusions, from one insurer to another insurer. Zone C: Chennai, Ernakulam, Thiruvananthapuram, Bengaluru, Chengalpattu,
Kanchipuram, Nashik, Pune, Tiruvallur, Hyderabad, Kollam, Wayanad, Indore, K V Ranga
Post-hospitalization Medical Expenses: Post-hospitalization Medical Expenses means Reddy, Medchal Malkajgiri, Ahmed Nagar and Gwalior
medical expenses incurred during pre-defined number of days immediately after the
insured person is discharged from the hospital provided that: Zone D: Rest of India
i. Such Medical Expenses are for the same condition for which the insured person's 2. COVERAGE
hospitalization was required, and
ii. The inpatient hospitalization claim for such hospitalization is admissible by the In consideration of the premium paid, subject to the terms, conditions, exclusions and
insurance company. definitions contained herein the Company agrees as under.
If during the period stated in the Policy Schedule the insured person sustains bodily injury
Qualified Nurse: Qualified nurse means a person who holds a valid registration from the or contracts any disease or suffer from any illness and if such disease or injury shall require
Nursing Council of India or the Nursing Council of any state In India. the Insured person, upon the advice of a duly qualified Medical Practitioner to incur
Reasonable and Customary Charges: Reasonable and Customary charges means the Hospitalisation expenses for Medical/Surgical treatment at any Nursing Home / Hospital in
charges for services or supplies, which are the standard charges for the specific provider India as an In-patient, the Company will indemnify the Insured Person such expenses as
and consistent with the prevailing charges in the geographical area for identical or similar are reasonably and necessarily incurred under the Coverage but not exceeding the Limit of
services, taking into account the nature of the illness / injury involved. Coverage stated in the Policy schedule.
Family Health Optima Insurance Plan Unique Identification No.: SHAHLIP23164V072223 POL / FHO / V.20 / 2023 2 of 14
A. Room, Boarding, Nursing Expenses all inclusive as provided by the Hospital / Nursing I. Post Hospitalization medical expenses incurred for a period of 90 days from the date
Home as per the limits given below; of discharge from the hospital towards Consultant fees, Diagnostic charges,
Medicines and Drugs wherever recommended by the Hospital / Medical Practitioner,
Sum Insured (Rs.) Limit (Rs.) where the treatment was taken, following an admissible claim for hospitalization
provided however such expenses so incurred are in respect of ailment for which the
1,00,000/- insured person was hospitalized.
Upto 2,000/- per day
2,00,000/- J. Domiciliary Hospitalization: Coverage for medical treatment (Including AYUSH) for
a period exceeding three days, for an illness/disease/injury, which in the normal
3,00,000/- course, would require care and treatment at a Hospital but, on the advice of the
Upto 5,000/- per day attending Medical Practitioner, is taken whilst confined at home under any of the
4,00,000/- following circumstances;
1. The condition of the patient is such that he/she is not in a condition to be removed
5,00,000/- to a Hospital, or
10,00,000/- 2. The patient takes treatment at home on account of non-availability of room in a
hospital
15,00,000/- Single Standard A/C Room However, this benefit shall not cover Asthma, Bronchitis, Chronic Nephritis and
Nephritic Syndrome, Diarrhoea and all types of Dysenteries including
20,00,000/- Gastro-enteritis, Diabetes Mellitus and Insipidus, Epilepsy, Hypertension, Influenza,
Cough and Cold, all Psychiatric or Psychosomatic Disorders, Pyrexia of unknown
25,00,000/- origin for less than 10 days, Tonsillitis and Upper Respiratory Tract infection including
Note: Expenses relating to Associated medical expenses will be considered in Laryngitis and Pharyngitis, Arthritis, Gout and Rheumatism.
proportion to the eligible room rent/room category stated in the policy schedule K. Organ Donor Expenses for organ transplantation where the insured person is the
or actuals whichever is less. Proportionate deductions are not applied in respect recipient are payable provided the claim for transplantation is payable and subject to
of the hospitals which do not follow differential billing or for those expenses in the availability of the sum insured. Donor screening expenses and post-donation
respect of which differential billing is not adopted based on the room category. complications of the donor are not payable. This cover is subject to a limit of 10% of the
B. Surgeon, Anesthetist, Medical Practitioner, Consultants, Specialist Fees. Sum Insured or Rupees One lakh, whichever is less.

C. Anesthesia, Blood, Oxygen, Operation theatre charges, ICU charges, Surgical L. Cost of Health Checkup: Expenses incurred towards cost of health check-up up to
appliances, Medicines and Drugs, Diagnostic materials and X-ray, Diagnostic the limits mentioned in the table given below for every claim free year provided the
imaging modalities, dialysis, chemotherapy, radiotherapy, cost of pacemaker, stent health checkup is done at network hospitals and the policy is in force. If a claim is
and similar expenses. With regard to coronary stenting, medicines, Implants and such made by any of the insured persons, the health check up benefits will not be available
other similar items the Company will pay cost of stent as per the Drug Price Control under the policy.
Order (DPCO) / National Pharmaceuticals Pricing Authority (NPPA) Capping.
Sum Insured (Rs.) Limit Per Policy Period (Rs.)
D. All day care procedures are covered.
Expenses on Hospitalization for a minimum period of 24 hours only are admissible. 1,00,000/-
However this time limit will not apply for the day care treatments / procedures, where Not Available
treatment is taken in the Hospital / Nursing Home and the Insured is discharged on the 2,00,000/-
same day.
3,00,000/- Up to 750/-
E. Expenses incurred on treatment of Cataract is subject to the limit as per the following
table 4,00,000/- Up to 1,000/-
Sum Insured (Rs.) Limit per eye (in Rs.) Limit per policy period (in Rs.) 5,00,000/- Up to 1,500/-
1,00,000/- 10,00,000/- Up to 2,000/-
Up to 12,000/- per eye, per policy period
2,00,000/- 15,00,000/- Up to 2,500/-
3,00,000/- Up to 25,000/- Up to 35,000/- 20,00,000/- Up to 3,000/-
4,00,000/- Up to 30,000/- Up to 45,000/- 25,00,000/- Up to 3,500/-
5,00,000/- Up to 40,000/- Up to 60,000/- Note
1. This benefit is payable on renewal and when the renewed policy is in force
10,00,000/- 2. Payment under this benefit does not form part of the sum insured and will not
impact the Bonus
15,00,000/-
Up to 50,000/- Up to 75,000/- 3. Payment of any claim under this benefit shall not be construed as a waiver of
20,00,000/- Company's right to repudiate any claim on grounds of non disclosure of material
fact or pre-existing disease, for hospitalization expenses under hospitalization
25,00,000/- provisions of the policy contract
M. Hospitalization expenses for treatment of New Born Baby: The coverage for New
F. Emergency Road ambulance charges up-to a sum of Rs. 750/- per hospitalization Born Baby starts from the 16th day after its birth till the expiry date of the policy and is
and overall limit of Rs.1,500/- per policy period for transportation of the insured person subject to a limit of 10% of the Sum Insured or Rupees Fifty thousand, whichever is
by private ambulance service when this is needed for medical reasons to go to less, subject to the availability of the sum insured, provided the mother is insured
hospital for treatment provided there is an admissible claim for hospitalization under under the policy for a continuous period of 12 months without break.
the policy. Note
G. Air Ambulance charges up to 10% of the Sum Insured during the entire policy period, 1. Intimation about the birth of the New Born Baby should be given to the company
provided that; and policy has to be endorsed for this cover to commence
1. It is for life threatening emergency health condition/s of the insured person which 2. Exclusion no. 3 (Code Excl 03) as stated under this policy shall not apply for the
requires immediate and rapid ambulance transportation to the hospital/medical New Born Baby
centre that ground transportation cannot provide 3. All other terms, conditions and exclusions shall apply for the New Born Baby
2. Necessary medical treatment not being available at the location where the 4. The Exclusion No.1 (Code Excl 01), Exclusion No.2 (Code Excl 02), Exclusion
Insured Person is situated at the time of Emergency No.3 (Code Excl 03) and the above mentioned sublimit will not apply for
3. It is prescribed by a Medical Practitioner and is Medically Necessary treatment related to Congenital Internal disease / defects for the new born.
4. The insured person is in India and the treatment is in India only N. Emergency Domestic Medical Evacuation: Subject to limits mentioned in the table
5. Such Air ambulance should have been duly licensed to operate as such by given below, the Company will reimburse reasonable and necessary expenses
Competent Authorities of the Government/s incurred towards transportation of the insured person from the hospital where the
Note: This benefit is available for sum insured options of Rs.5,00,000/- and above only. insured person is currently undergoing treatment to another hospital for further
H. Relevant Pre-Hospitalization medical expenses incurred for a period not exceeding treatment provided;
60 days prior to the date of hospitalization, for the disease/illness, injury sustained a. The medical condition of the Insured Person is a life threatening emergency.
following an admissible claim for hospitalization under the policy. b. Further treatment facilities are not available in the current hospital.
Family Health Optima Insurance Plan Unique Identification No.: SHAHLIP23164V072223 POL / FHO / V.20 / 2023 3 of 14
 c. The Medical Evacuation is recommended by the treating Medical Practitioner. S. AYUSH Treatment: Inpatient Hospitalizations Expenses incurred on treatment
d. Claim for Hospitalization is admissible under the policy. under Ayurveda, Unani, Siddha and Homeopathy systems of medicines in a
AYUSH Hospital is payable up to the limits given below;
Sum Insured (Rs.) Limit per hospitalization (Rs.)
Sum Insured (Rs.) Limit per policy period (Rs.)
Up to 4,00,000/- Up to 5,000/-
1,00,000/-
5,00,000/- to 15,00,000/- Up to 7,500/-
2,00,000/-
20,00,000/- and 25,00,000/- Up to 10,000/- Up to 10,000/-
3,00,000/-
Note: Payment under this benefit does not form part of the sum insured but will impact
the Bonus. 4,00,000/-
O. Compassionate travel: In the event of the insured person being hospitalized for a life 5,00,000/- to 15,00,000/- Up to 15,000/-
threatening emergency at a place away from his usual place of residence as recorded
in the policy, the Company will reimburse the transportation expenses by air incurred 20,00,000/- and 25,00,000/- Up to 20,000/-
up to Rs. 5,000/- for one immediate family member (other than the travel companion)
for travel towards the place where hospital is located, provided the claim for Note
hospitalization is admissible under the policy. i. Payment under this benefit forms part of the sum insured and will impact the
Note: This benefit is available for sum insured options of Rs.10,00,000/- and above Bonus
only. Payment under this benefit does not form part of the sum insured but will impact ii. Yoga and Naturopathy systems of treatments are excluded from the scope of
the Bonus. coverage under AYUSH treatment.

P. Repatriation of Mortal Remains: Following an admissible claim for hospitalization T. Second Medical Opinion: The Insured Person can obtain a Second Medical Opinion
from a Doctor in the Company's network of Medical Practitioners. All the medical
under the policy, the Company shall reimburse up to Rs.5,000/- per policy period
records provided by the Insured Person will be submitted to the Doctor chosen by
towards the cost of repatriation of mortal remains of the insured person (including the
him/her online and the medical opinion will be made available directly to the Insured
cost of embalming and coffin charges) to the residence of the Insured as recorded in by the Doctor. To utilize this benefit, all medical records should be forwarded to the
the policy. Payment under this benefit does not form part of the sum insured but will mail-id “e_medicalopinion@starhealth.in.” or through post/courier.
impact the Bonus.
Special Conditions
Q. Treatment in Valuable Service Provider: In the event of a medical contingency ● This should be specifically requested for by the Insured Person
requiring hospitalization, if the insured seeks advice from the Company, the Company ● This opinion is given based only on the medical records submitted without
may suggest an appropriate hospital from the network for treatment. Where the examining the patient
insured accepts the same and undergoes treatment in the suggested hospital, an ● The second opinion should be only for medical reasons and not for medico-legal
amount calculated at 1% of Sum Insured subject to a maximum of Rs.5,000/- per purposes
policy period is payable as lump sum. ● Any liability due to any errors or omission or consequences of any action taken in
Note reliance of the second opinion provided by the Medical Practitioner is outside the
1. This benefit is applicable for Sum Insured of Rs.3,00,000/- and above only scope of this policy
2. This benefit is payable only if there is an admissible claim for hospitalization ● Utilizing this facility alone will not be considered as a claim
under the policy Note: Medical Records / Documents submitted for utilizing this facility will not
3. This benefit shall be paid if a hospital is a part of the list as on date of admission prejudice the Company's right to reject a claim in terms of policy.
4. Payment under this benefit does not form part of the sum insured but will impact U. Assisted Reproduction Treatment: The Company will reimburse medical expenses
the Bonus incurred on Assisted Reproduction Treatment, where indicated, for sub-fertility
5. The Company shall not be responsible for the quality of the treatment in the subject to;
Valuable Service Provider 1. A waiting period of 36 months from the date of first inception of this policy with the
Company for the insured person. The maximum liability of the Company for such
6. FOR LIST OF VALUABLE SERVICE PROVIDER PLEASE VISIT WEBSITE : treatment shall be limited to Rs.1,00,000/- for Sum Insured of Rs.5,00,000/- and
www.starhealth.in. Rs.2,00,000/- for Sum Insured of Rs.10,00,000/- and above for every block of 36
months and payable on renewal
R. Shared accommodation: If the Insured person occupies, a shared accommodation
2. For the purpose of claiming under this benefit, in-patient treatment is not
during in-patient hospitalization, then amount as per table given below will be payable
mandatory
for each continuous and completed period of 24 hours of stay in such shared
3. Automatic Restoration of Sum Insured, Recharge Benefit shall not be applicable
accommodation.
for this benefit
Sum Insured (Rs.) Limit per day (Rs.) Note: To be eligible for this benefit both husband and spouse should stay insured
continuously without break under this policy for every block. This coverage is
1,00,000/- available only for sum insured options of Rs. 5,00,000/- and above.
Not Available Special Exclusions: The Company shall not be liable to make any payments under
2,00,000/- this policy in respect of any expenses what so ever incurred by the insured person in
connection with or in respect of;
3,00,000/- 1. Pre and Post treatment expenses
2. Sub-fertility services that are deemed to be unproven, experimental or
4,00,000/- investigational
5,00,000/- 800/- per day 3. Services not in accordance with standards of good medical practice and not
uniformly recognized and professionally endorsed by the general medical
10,00,000/- community at the time it is to be provided
4. Reversal of voluntary sterilization
15,00,000/- 5. Treatment undergone for second or subsequent pregnancies except where the
child from the first delivery/ previous deliveries is/are not alive at the time of
20,00,000/- treatment
1000/- per day
25,00,000/- 6. Payment for services rendered to a surrogate
7. Costs associated with cryopreservation and storage of sperm, eggs and
Note embryos
i) This benefit is applicable for Sum Insured of Rs. 3,00,000/- and above only. 8. Selective termination of an embryo.
ii) This benefit is payable only if there is an admissible claim for hospitalization 9. Services done at unrecognized centre
under the policy 10. Surgery / procedures that enhances fertility like Tubal Occlusion, Bariatric
iii) This benefit will not be applicable where the sanction is on package rates Surgery, Diagnostic Laparoscopy with Ovarian Drilling and such other similar
iv) Insured’s stay in Intensive Care Unit or High Dependency Units / wards will not surgery / procedures
be counted for this purpose V. Automatic Restoration of Sum Insured (Applicable for A to K, M, S): There shall
v) Payment under this benefit does not form part of the sum insured but will impact be automatic restoration of the Sum Insured immediately upon exhaustion of the limit
the Bonus of coverage, during the policy period.
Family Health Optima Insurance Plan Unique Identification No.: SHAHLIP23164V072223 POL / FHO / V.20 / 2023 4 of 14
 Such Automatic Restoration is available 3 times at 100% each time, during the policy W. Recharge Benefit (Applicable for A to K, M, S): If the limit of coverage under the
period. Each restoration will operate only after the exhaustion of the earlier one. policy is exhausted/ exceeded during the policy period, additional indemnity up to the
It is made clear that such restored Sum Insured can be utilized only for illness / limits stated in the table given below would be provided once for the remaining policy
disease unrelated to the illness / diseases for which claim/s was / were made. The period. Such additional indemnity can be utilized even for the same hospitalization or
unutilized restored sum insured cannot be carried forward. This Benefit is not for the treatment of diseases / illness / injury / for which claim was paid / payable under
available for Modern Treatment. the policy. The unutilized Recharge amount cannot be carried forward. This benefit is
Note: Automatic Restoration of Sum Insured is available only for sum insured options not available for Modern Treatment.
of Rs.3,00,000/- and above.
Sum Insured (Rs.) Limit (Rs.)
Illustration
Scenario 1 Scenario 2 1,00,000/-
(New Policy) (Renewal) Not Available
2,00,000/-
Sum Insured (SI) Rs.10,00,000/- Rs.10,00,000/-
No Claim Bonus (NCB) 0 Rs.2,50,000/- 3,00,000/- 75,000/-

Recharge Rs.1,50,000/- Rs.1,50,000/- 4,00,000/- 1,00,000/-

Total Cover Available Rs.11,50,000/- Rs.14,00,000/- 5,00,000/-

1st Claim settled Rs.5,00,000/- Rs.5,00,000/- 10,00,000/-

Rs.9,00,000/- 15,00,000/- 1,50,000/-
Rs.6,50,000/-
1st (Balance SI
(Balance SI
Claim Total Coverage available Rs. 5,00,000/- 20,00,000/-
Rs.5,00,000/-
for next claim + Bonus Rs.2,50,000/-
+ Recharge 25,00,000/-
+ Recharge
Rs.1,50,000/-)
Rs.1,50,000/-)
X. Additional Sum Insured for Road Traffic Accident (RTA): If the insured person
meets with a Road Traffic Accident resulting in in-patient hospitalization, then the sum
2nd Hospital Bill Amount Rs.10,00,000/- Rs.10,00,000/-
insured shall be increased by 25% subject to a maximum of Rs.5,00,000/- and subject
Rs.9,00,000/- to the following;
Rs.6,50,000/- 1. It is evidenced that the insured person was wearing helmet and was either riding
(Balance SI
(Balance SI or travelling as pillion rider in a two wheeler at the time of accident as evidenced
Rs.5,00,000/-
Claim Settled Rs.5,00,000/- by Police record and Hospital record
+ Bonus Rs.2,50,000/-
+ Recharge
+ Recharge 2. The additional sum insured shall be available only once during the policy period
Rs.1,50,000/-)
2nd Rs.1,50,000/-) 3. The additional sum insured shall be available after exhaustion of the limit of
Claim Will the restoration kick in? coverage
If yes How Much? 4. The additional sum insured can be utilized only for the particular hospitalization
Rs.10,00,000/- Rs.10,00,000/- following the Road Traffic Accident
Yes, Why - Since there is full
utilization of Sum Insured. 5. Automatic Restoration of Sum Insured and Recharge Benefit shall not apply for
this benefit
Total Coverage available
for next claim (Available Rs.10,00,000/- Rs.10,00,000/- 6. This benefit shall not be applicable for day care treatment
for different illness) 7. The unutilized balance cannot be carried forward for the remaining policy period
or for renewal
Hospital Bill Amount (For 8. Claim under this benefit will impact the Bonus
Rs.5,00,000/- Rs.5,00,000/-
different illness)
Y. Coverage for Modern Treatments: The following expenses are payable during the
Claim Settled Rs.5,00,000/- Rs.5,00,000/- policy period for the treatment/procedure (either as a day care or as an in-patient) is
limited to the amount mentioned in table below. This benefit forms part of sum insured;
Will the restoration kick in ?
3rd If yes How Much? Immunotherapy-Monoclonal
0 0
and Post Hospitalisation)
(Sublimits including Pre

Claim Antibody to be given as

Embolization and HIFU,

Deep Brain Stimulation

No, Why - Since the sum

Intra Vitreal injections

Oral Chemotherapy*

insured is not utilized in full

Uterine artery
Sum Insured in (Rs.)

Sinuplasty,

injection
Balloon

Total Coverage available

for next claim (Available Rs.5,00,000/- Rs.5,00,000/-
for different illness)

Hospital Bill Amount (For

Rs.8,00,000/- Rs.8,00,000/-
Same Illness)
0 0
(Automatic Restoration (Automatic Restoration Limit per policy period
4th Claim Settled for each treatment / procedure (Rs.)
is not available for is not available for
Claim
Same illness) Same illness)
Total Coverage available 1,00,000/- 12,500/- 5,000/- 25,000/- 12,500/- 25,000/- 5,000/-
for next claim (Available Rs.5,00,000/- Rs.5,00,000/-
for different illness) 2,00,000/- 25,000/- 10,000/- 50,000/- 25,000/- 50,000/- 10,000/-

Hospital Bill Amount (For 3,00,000/- 37,500/- 15,000/- 75,000/- 37,500/- 75,000/- 15,000/-
Rs.10,00,000/- Rs.11,00,000/-
Different Illness)
Rs.5,00,000/- Rs.5,00,000/- 4,00,000/- 1,00,000/- 40,000/- 2,00,000/- 1,00,000/- 2,00,000/- 40,000/-
(Since the balance (Since the balance
Claim Settled cover available after cover available after 5,00,000/- 1,25,000/- 50,000/- 2,50,000/- 1,25,000/- 2,50,000/- 50,000/-
settlement of previous settlement of previous
5th claim is Rs.5,00,000/-) claim is Rs.5,00,000/-)
10,00,000/- 1,50,000/- 1,00,000/- 3,00,000/- 2,00,000/- 4,00,000/- 75,000/-
Claim Will the restoration kick in ?
If yes How Much? 15,00,000/- 1,75,000/- 1,25,000/- 4,00,000/- 2,50,000/- 5,00,000/- 1,00,000/-
Rs.10,00,000/- Rs.10,00,000/-
Yes, Why - Since there is full
utilization of Sum Insured.
20,00,000/- 2,00,000/- 1,50,000/- 4,50,000/- 2,75,000/- 5,50,000/- 1,25,000/-
Total Coverage available
for next claim (Available Rs.10,00,000/- Rs.10,00,000/-
25,00,000/- 2,00,000/- 1,50,000/- 5,00,000/- 3,00,000/- 6,00,000/- 1,50,000/-
for different illness)
Family Health Optima Insurance Plan Unique Identification No.: SHAHLIP23164V072223 POL / FHO / V.20 / 2023 5 of 14
 Please refer the Illustrations to understand the calculation of discount in premium,

Hematopoietic stem cells for

Vaporisation of the prostate

bone marrow transplant for

haematological conditions
weightage and the calculation.

(Green laser treatment or

holmium laser treatment)

IONM-(Intra Operative
Neuro Monitoring)

Stem cell therapy:

Robotic surgeries
The wellness services and activities are categorized as below

radio surgeries

Thermoplasty
Stereotactic
Sum Insured in (Rs.)

Bronchical
Maximum number of
Wellness Points that
Sr.
Activity can be earned under
No.
each activity in a
policy year
1. Sign up points for Enrolling to Wellness Program 100
Limit per policy period Manage and Track Health
for each treatment / procedure (Rs.)
2. a) Online Health Risk Assessment (HRA) 150
1,00,000/- 25,000/- 25,000/- 25,000/- b) Preventive Risk Assessment 200
2,00,000/- 50,000/- 50,000/- 50,000/- Affinity to Wellness
a) Participating in Walkathon, Marathon, Cyclothon and
3,00,000/- 75,000/- 75,000/- 75,000/- 3. 200
similar activities
4,00,000/- 2,00,000/- 1,75,000/- 2,00,000/- b) Membership in a health club 200

5,00,000/- 2,50,000/- 2,00,000/- Up to Sum Insured 2,50,000/- Stay Active - If the Insured member achieves the step
4. 250
count target on mobile app
10,00,000/- 3,00,000/- 2,25,000/- 3,00,000/- Sharing 'Active Life Success Story' through adoption of
5. 50
Star Wellness Program
15,00,000/- 4,00,000/- 2,50,000/- 4,00,000/-
Condition Management Program (CMP): Weight
20,00,000/- 4,50,000/- 2,75,000/- 4,50,000/- 6. Management, Diabetes Management, Hypertension, 150
De-Stress & Mind Body Healing Program.
25,00,000/- 5,00,000/- 3,00,000/- 5,00,000/- For Submission of Vaccination Certificate
7. Eg: Vaccine for Covid, HPV, Pneumoccocal, Swine Flu 20
*Sublimits all inclusive with or without hospitalization where ever hospitalization includes (H1N1), Hepatitis etc..
pre and post hospitalizations.
8. For Submission of Preventive Eye Check-up report 20
Z. Cumulative Bonus (Applicable for [A to K], [M to S], U, and X ): In respect of a
claim free year of Insurance, for the Sum Insured options Rs.3,00,000/- and above, 9. For Submission of Preventive Dental Check-up report 20
the insured would be entitled to benefit of bonus of 25% of the expiring Sum Insured in For Submission of Mammography & PAP Test (for
the second year and additional 10% of the expiring sum Insured for the subsequent 11. 20
Women) report
years. The maximum allowable bonus shall not exceed 100%.
The Bonus will be calculated on the expiring sum insured or on the renewed sum For Submission of Prostate specific antigen (PSA) test
12. 20
insured whichever is less. Bonus will be given on that part of sum insured which is report (for Male persons aged > 50 yrs)
continuously renewed. If the insured opts to reduce the sum insured at the 13. Glaucoma Screening (for persons aged > 50 yrs) 20
subsequent renewal, the limit of indemnity by way of such Bonus shall not exceed
such reduced sum insured. Value Added Services
Bonus shall be available only upon timely renewal without break or upon renewal Star Tele-health services
within the grace period allowed.
Medical Concierge Services
In the event of a claim, such bonus so granted will be reduced at the same rate at
which it has accrued. However the sum insured, will not be reduced. Digital Health Vault
AA Co-payment(Applicable for A to K and S): This policy is subject to co-payment of Wellness Content
20% of each and every claim amount for fresh as well as renewal policies for insured
persons whose age at the time of entry is 61 years and above. Post-Operative Care

AB. Star Wellness Program: This program intends to promote, incentivize and to reward Discounts from Network Providers
the Insured Persons' healthy life style through various wellness activities. The 1. Sign up points for Enrolling to Wellness Program: Insured person(s) can earn
wellness activities as mentioned below are designed to help the Insured person to 100 reward points for enrolling in Star Wellness Program through Star Health Mobile
earn wellness reward points which will be tracked and monitored by the Company. application.
The wellness points earned by the Insured Person(s) under the wellness program,
can be utilized to get discount in premium during the renewal. 2. Manage and Track Health:
This Wellness Program is enabled and administered online through Star Health a) Completion of Health Risk Assessment (HRA): The Health Risk Assessment
Mobile Applications. (HRA) questionnaire is an online tool for evaluation of health and quality of life of
Note: The Wellness Activities mentioned in the table below (from Serial Number 1 to 6) the Insured. It helps the Insured to introspect his/ her personal lifestyle. The Insured
are applicable for the Insured person(s) aged 18 years and above only. The following can log into his/her account on the website www.starhealth.in and complete the
table shows the discount on premium available under the Wellness Program; HRA questionnaire. The Insured can undertake this once per policy year.
On Completion of online HRA questionnaire, the Insured earns 150 wellness
Wellness Points Earned Discount in Premium points.
Note: To get the wellness points mentioned under HRA, the Insured has to
200 to 350 4% complete the entire HRA within one month from the time he/she started HRA
351 to 600 10% Activity.
b) Preventive Risk Assessment: The Insured can also earn wellness points by
601 to 750 14%
undergoing diagnostic / preventive tests during the policy year. These tests
751 and above 20% should include the four mandatory tests mentioned below. Insured can take
these tests at any diagnostic centre at Insured's own expenses.
The weightage is given as per the following table;
- On submission of the test reports, Insured earns 200 reward points.
Family Size Weightage Note: These tests reports should be submitted together and within 30 days from
the date of undergoing such Health Check-Up.
Self, Spouse** 1:1
Self, Spouse** and Dependent Children List of mandatory tests under Preventive Risk Assessment
1:1:0:0:0
(up to 18 years) 1. Complete Haemogram Test
Self, Spouse** and Dependent Children
2:2:1:1:1 2. Blood Sugar (Fasting Blood Sugar (FBS) + Postprandial (PP) [or] HbA1c)
(aged above 18 years)
**Spouse / Live-in Partner / Same Sex Partner 3. Lipid profile (Total cholesterol, HDL, LDL, Triglycerides, Total Cholesterol /
HDL Cholesterol Ratio)
Note: In case of two year policy, total number of wellness points earned in two year
period will be divided by two. 4. Serum Creatinine

Family Health Optima Insurance Plan Unique Identification No.: SHAHLIP23164V072223 POL / FHO / V.20 / 2023 6 of 14
3. Affinity towards wellness: Insured earns wellness reward points for undertaking - These tests reports to be submitted within 1 month from the date of
any of the fitness and health related activities as given below. List of Fitness Initiatives undergoing the Health Check-Up
and Wellness points
Values Criteria to
Name of the Test to be
Wellness Sr.No. get the additional
Initiative Ailment submitted
Points Wellness points

Participating in Walkathon, Marathon, Cyclothon and similar Diabetes(Insured HbA1c £ 6.5

a. can submit either
activities
HbA1c test value
- On submission of BIB Number along with the details of the (or)
200 1.
entry ticket taken to participate in the event and/or Fasting Blood Sugar Fasting Blood Sugar 100 to 125 mg/dl
(FBS) Range and (FBS) Range and
- On Achieving 20,000 Step count on Star Health Mobile Postprandial test Postprandial test below 160 mg/dl
Application value) value
Systolic Range -
Membership in a health club (50 points for each quarter) - In a
Measured with - BP 110 to 140 mmHg
Gym / Yoga Centre / Zumba Classes / Aerobic Exercise/ Sports 2. Hypertension
b. 200 apparatus Diastolic Range -
Club/ Pilates Classes/ Swimming / Tai Chi/ Martial Arts /
70 to 90 mmHg
Gymnastics/ Dance Classes
LDL Cholesterol and
Note: In case if Insured is not a member of any health club, he/she should join into club 100 to 159 mg/dl
Cardiovascular Total Cholesterol /
within 3 months from the date of the policy risk commencement date. Insured person 3.
Disease HDL Cholesterol
should submit the health club membership. £ 4.0
Ratio

4. Stay Active: Insured earns wellness reward points on achieving the step count target FEV1 (PFC) is 75%
on Star Health Mobile Application as mentioned below PFT (Pulmonary or more
4. Asthma
Function Test) FEV1/ FVC is 70%
or more
Criteria to get reward points

If the number of steps per day are minimum 8,000 or above for 16 days in a month, it will b) In case if the Insured is not suffering from Chronic Condition/s (Diabetes,
be considered as one active month and insured will get 20 reward points. Hypertension, Cardiovascular Disease or Asthma) he/she can opt for “De-
Stress & Mind Body Healing Program”. This program helps the Insured to
Note reduce stress caused due to internal (self-generated) & external factors and
· Incase if Insured achieves 10 active months in a policy year, he/ she will get 50 increases the ability to handle stress.
additional points as bonus. - On completion of De-stress & Mind Body Healing Program 150
· First month and last month in each policy year will not be taken into consideration for wellness points will be awarded.
calculation of average number of steps per day under Stay Active. Note: This is a 10 weeks program which insured needs to complete without
· The mobile app must be downloaded within 30 days of the policy risk start date to any break.
avail this benefit. 6. Reward points for Preventive Care: Insured can earn wellness reward points for
· The average step count completed by an Insured member would be tracked on 'Star submitting the following health check-up reports once in a policy year which he/ she
Mobile Application'. had during the policy year.
a. Submission of Vaccination Certificate/s: Insured can earn 20 wellness
5. Condition Management Program reward points by submitting the Vaccination certificate related to vaccine that
he/she have had during the policy year. Eg: Vaccine for Covid, HPV, Swine Flu
(i) Weight Management Program
(H1N1), Hepatitis etc.
a) This Program will help the Insured persons with Over Weight and Obesity to
manage their Body Mass Index (BMI) through the empanelled wellness b. Submission of Preventive Eye Check-up report: Insured can earn
experts who will guide the Insured in losing excess weight and maintain 20 wellness reward points for submitting Eye Check-up report which includes
near and far vision (visual equity) and Colour vision test.
their BMI.
- 150 wellness points will be awarded in case if the results are achieved c. Submission of Preventive Dental Check-up: Insured can earn 20 wellness
reward points for submitting Dental Check-up report which includes screening of
and maintained as mentioned below; oral cavity done by a qualified Dentist.
Name of the Values to be Criteria to get the d. Submission of Mammography & PAP Test report: Insured can earn
Sr.No. 20 wellness reward points for submitting x-ray Mammogramgraphy or coloured
Ailment submitted Wellness points
doppler mammogram for preventive breast screening and PAP smear (biopsy)
report.
Height & Weight
Obesity (If BMI Achieving and maintaining e. Prostate specific antigen (PSA) test (applicable for Males aged > 50 yrs):
1. (to calculate
is above 29) the BMI between 18 and 29 Insured can earn 20 wellness reward points for submitting Prostate specific
BMI)
antigen blood report.
f. Glaucoma Screening (for persons aged > 50 yrs): Insured can earn
Overweight (If Height & Weight Reducing BMI by two points 20 wellness reward points by submitting reports of Glucoma screening test of
2. BMI is between (to calculate and maintaining the same both eyes including tonometery. (slit lamp test), pachymeter test, visual field test,
25 and 29) BMI) BMI in the policy year dilated eye test and gonioscopy examination.
Value Added Services
- Values (for BMI) shall be submitted for every 2 months (up to 5 times a. Star Tele-health Services:Insured can consult with the In-house Medical
in each policy year) Practitioners between 8.00 am and 10.00 pm, who can help the Insured by
providing Medical advice, Second Medical Opinion and consultation on Diet &
b) Incase if the Insured is not Overweight / Obese, the Insured can submit Nutrition through Voice Call, Video Call & Online Chat provided in our Mobile App
his/her 'Active Life Success Story' through adoption of Star Wellness “Talk to Star”and for Consultation by Telephone (between 8.00 am to 10.00 pm)
Activities with us. On submission of Active Life Success Story through Insured can call to the phone number - 7676 905 905
adoption of Star Wellness Activities, Insured earns 50 wellness points. b. Medical Concierge Services: The Insured can also contact Star Health to avail
services like, Emergency assistance information such as nearest ambulance /
(ii) Chronic Condition Management Program
hospital / blood bank etc.
a) This Program will help the Insured suffering from Diabetes, Hypertension,
Cardiovascular Disease or Asthma to track their health through the c. Digital Health Vault: A secured Personal Health records system for Insured to
empanelled wellness experts who will guide the insured in maintaining/ store/access and share health data with trusted recipients. Using this portal,
Insured can store their health documents (prescriptions, lab reports, discharge
improving the health condition.
summaries etc.), track health data add family members.
- The Insured has to submit the test result values for every 3 months
d. Wellness Content: The wellness portal provides rich collection of health
maximum up to 3 times in a policy year.
articles, blogs, tips and other health and wellness content. The contents have
- If the test result values are within +/- 10% range of the values given been written by experts drawn from various fields. Insured will benefit from
below, for at least 2 times in a policy year, 150 wellness points will be having one single and reliable source for learning about various health aspects
awarded. and incorporating positive health changes.
Family Health Optima Insurance Plan Unique Identification No.: SHAHLIP23164V072223 POL / FHO / V.20 / 2023 7 of 14
 e. Post Operative Care: It is done through follow up phone calls (primarily for 3. EXCLUSIONS
surgical cases) for resolving their medical queries.
The Company shall not be liable to make any payments under this policy in respect of any
f. Discounts from Network Providers: The Insured can avail discounts on the
expenses what so ever incurred by the insured person in connection with or in respect of;
services offered by our network providers which will be displayed in our website.
STANDARD EXCLUSIONS
Terms and conditions under wellness activity 1. Pre-Existing Diseases - Code Excl 01
· Any information provided by the Insured in this regard shall be kept confidential. a. Expenses related to the treatment of a pre-existing Disease (PED) and its direct
· There will not be any cash redemption against the wellness reward points. complications shall be excluded until the expiry of 48 months of continuous
· Insured should notify and submit relevant documents, reports, receipts etc for coverage after the date of inception of the first policy with insurer
various wellness activities within 1 month of undertaking such activity/test. b. In case of enhancement of sum insured the exclusion shall apply afresh to the
· For services that are provided through empanelled service provider, Star Health extent of sum insured increase
is only acting as a facilitator; hence would not be liable for any incremental costs c. If the Insured Person is continuously covered without any break as defined under
or the services. the portability norms of the extant IRDAI (Health Insurance) Regulations, then
· All medical services are being provided by empanelled health care service waiting period for the same would be reduced to the extent of prior coverage
provider. We ensure full due diligence before empanelment. However Insured d. Coverage under the policy after the expiry of 48 months for any pre-existing
should consult his/her doctor before availing/taking the medical disease is subject to the same being declared at the time of application and
advices/services. The decision to utilize these advices/services is solely at accepted by Insurer
Insured person's discretion.
2. Specified disease / procedure waiting period - Code Excl 02
· We reserve the right to remove the wellness reward points if found to be achieved a. Expenses related to the treatment of the following listed Conditions,
in unfair manner.
surgeries/treatments shall be excluded until the expiry of 24 months of
· Star Health, its group entities, or affiliates, their respective directors, officers, continuous coverage after the date of inception of the first policy with us. This
employees, agents, vendors, are not responsible or liable for, any actions, exclusion shall not be applicable for claims arising due to an accident
claims, demands, losses, damages, costs, charges and expenses which a
b. In case of enhancement of sum insured the exclusion shall apply afresh to the
Member claims to have suffered, sustained or incurred, by way of and / or on
extent of sum insured increase
account of the Wellness Program.
c. If any of the specified disease/procedure falls under the waiting period specified
· Services offered are subject to guidelines issued by IRDAI from time to time.
for pre-existing diseases, then the longer of the two waiting periods shall apply
Illustration of Benefit d. The waiting period for listed conditions shall apply even if contracted after the
policy or declared and accepted without a specific exclusion
A 51 year old Individual Gopal and his wife Ramya along with their two dependent
children (aged below 18 yrs) buy a Family Health Optima Insurance Plan with Sum e. If the Insured Person is continuously covered without any break as defined under
Insured 10 Lacs, let's understand how they can earn Wellness Points. Gopal has the applicable norms on portability stipulated by IRDAI, then waiting period for
declared that he is suffering from Diabetes. Ramya has declared her BMI as 27. Gopal the same would be reduced to the extent of prior coverage
and Ramya enrolled under the Star wellness program and completed the following f. List of specific diseases/procedures;
wellness activities. 1. Treatment of Cataract and diseases of the anterior and posterior chamber
of the Eye, Diseases of ENT, Diseases related to Thyroid, Benign diseases
Wellness Points Wellness Points of the breast.
Sr.No. Activity
Earned by Gopal Earned by Ramya 2. Subcutaneous Benign Lumps, Sebaceous cyst, Dermoid cyst, Mucous cyst
Sign up points for Enrolling to lip / cheek, Carpal Tunnel Syndrome, Trigger Finger, Lipoma,
1. 100 100 Neurofibroma, Fibroadenoma, Ganglion and similar pathology
Wellness Program
2. Manage and Track Health 3. All treatments (Conservative, Operative treatment) and all types of
intervention for Diseases related to Tendon, Ligament, Fascia, Bones and
a) Online Health Risk Joint Including Arthroscopy and Arthroplasty / Joint Replacement [other
150 150
Assessment (HRA)
than caused by accident].
b) Preventive Risk Assessment 200 200 4. All types of treatment for Degenerative disc and Vertebral diseases
3. Affinity to Wellness including Replacement of bones and joints and Degenerative diseases of
the Musculo-skeletal system, Prolapse of Intervertebral Disc (other than
a) Participating in Walkathon, caused by accident),
Marathon, Cyclothon and 200 0
similar activities 5. All treatments (conservative, interventional, laparoscopic and open) related
to Hepato-pancreato-biliary diseases including Gall bladder and Pancreatic
b) Membership in a health club 100 150 calculi. All types of management for Kidney calculi and Genitourinary tract
Stay Active (Wellness points calculi.
4. 250 120
based on Step Count) 6. All types of Hernia,
For Sharing 'Active Life Success 7. Desmoid Tumor, Umbilical Granuloma, Umbilical Sinus, Umbilical Fistula,
5. 50 0
Story' 8. All treatments (conservative, interventional, laparoscopic and open) related
Condition Management Program to all Diseases of Cervix, Uterus, Fallopian tubes, Ovaries (other than due to
6. 150 150
(CMP) Cancer), Uterine Bleeding, Pelvic Inflammatory Diseases
Submission of Vaccination 9. All Diseases of Prostate, Stricture Urethra, all Obstructive Uropathies,
7. 20 20
Certificate 10. Benign Tumours of Epididymis, Spermatocele, Varicocele, Hydrocele,
For Submission of Preventive Eye 11. Fistula, Fissure in Ano, Hemorrhoids, Pilonidal Sinus and Fistula, Rectal
8. 20 0
Check-up report Prolapse, Stress Incontinence
For Submission of Preventive 12. Varicose veins and Varicose ulcers
9. 0 20
Dental Check-up report 13. All types of transplant and related surgeries.
For Submission of Mammography 14. Congenital Internal disease / defect - (except for coverage 2(M))
10. 0 20
& PAP Test (for Women) report 3. 30-day waiting period - Code Excl 03
For Submission of Prostate A. Expenses related to the treatment of any illness within 30 days from the first
11. specific antigen (PSA) test report 20 0 policy commencement date shall be excluded except claims arising due to an
(for Male persons aged > 50 yrs) accident, provided the same are covered
Glaucoma Screening (for persons B. This exclusion shall not, however, apply if the Insured Person has continuous
12. 20 0
aged > 50 yrs) coverage for more than twelve months
Total Number of Wellness Points C. The within referred waiting period is made applicable to the enhanced sum
1280 930
earned insured in the event of granting higher sum insured subsequently
No of wellness points based upon 640 465 4. Investigation & Evaluation - Code Excl 04
weightage - 1:1:0:0 (1280X1/2) (930X1/2) A. Expenses related to any admission primarily for diagnostics and evaluation
Total Number of Wellness Points earned by Gopal and Ramya = 1105 (640+465) purposes only are excluded
Based on the no of Wellness Points earned, Gopal & Ramya are eligible to get 20% B. Any diagnostic expenses which are not related or not incidental to the current
discount on renewal premium diagnosis and treatment are excluded
Family Health Optima Insurance Plan Unique Identification No.: SHAHLIP23164V072223 POL / FHO / V.20 / 2023 8 of 14
5. Rest Cure, rehabilitation and respite care - Code Excl 05: Expenses related to any 21. Convalescence, general debility, run-down condition, Nutritional deficiency states -
admission primarily for enforced bed rest and not for receiving treatment. This also Code Excl 21
includes:
22. Intentional self-injury - Code Excl 22
1. 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 23. Injury/disease caused by or arising from or attributable to war, invasion, act of foreign
by skilled nurses or assistant or non-skilled persons enemy, warlike operations (whether war be declared or not) - Code Excl 24
2. Any services for people who are terminally ill to address physical, social, 24. Injury or disease caused by or contributed to by nuclear weapons/ materials - Code Excl 25
emotional and spiritual needs
25. Expenses incurred on Enhanced External Counter Pulsation Therapy and related
6. Obesity / Weight Control - Code Excl 06: Expenses related to the surgical treatment therapies, Chelation therapy, Hyperbaric Oxygen Therapy, Rotational Field Quantum
of obesity that does not fulfill all the below conditions; Magnetic Resonance Therapy, VAX-D, Low level laser therapy, Photodynamic
A. Surgery to be conducted is upon the advice of the Doctor therapy and such other therapies similar to those mentioned herein under this
B. The surgery/Procedure conducted should be supported by clinical protocols exclusion - Code Excl 26
C. The member has to be 18 years of age or older and 26. Unconventional, Untested, Experimental therapies - Code Excl 27
D. Body Mass Index (BMI);
27. Autologous derived Stromal vascular fraction, Chondrocyte Implantation, Procedures
1. greater than or equal to 40 or
using Platelet Rich plasma and Intra articular injection therapy - Code Excl 28
2. 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: 28. Biologicals, except when administered as an in-patient, when clinically indicated and
a. Obesity-related cardiomyopathy hospitalization warranted - Code Excl 29
b. Coronary heart disease 29. Inoculation or Vaccination (except for post–bite treatment and for medical treatment
c. Severe Sleep Apnea for therapeutic reasons) - Code Excl 31
d. Uncontrolled Type2 Diabetes 30. Hospital registration charges, admission charges, record charges, telephone charges
and such other charges - Code Excl 34
7. Change-of-Gender treatments - Code Excl 07: Expenses related to any treatment,
including surgical management, to change characteristics of the body to those of the 31. Cost of spectacles and contact lens, hearing aids, Cochlear implants and procedures,
opposite sex. walkers and crutches, wheel chairs, CPAP, BIPAP, Continuous Ambulatory Peritoneal
Dialysis, infusion pump and such other similar aids - Code Excl 35
8. Cosmetic or plastic Surgery - Code Excl 08: Expenses for cosmetic or plastic
surgery or any treatment to change appearance unless for reconstruction following an 32. Any hospitalization which are not medically necessary / does not warrant
Accident, Burn(s) or Cancer or as part of medically necessary treatment to remove a hospitalization - Code Excl 36
direct and immediate health risk to the insured. For this to be considered a medical
33. Other Excluded Expenses as detailed in the website www.starhealth.in - Code Excl 37
necessity, it must be certified by the attending Medical Practitioner.
34. Existing disease/s, disclosed by the insured and mentioned in the policy schedule
9. Hazardous or Adventure sports - Code Excl 09: Expenses related to any treatment (based on insured's consent), for specified ICD codes - Code Excl 38
necessitated due to participation as a professional in hazardous or adventure sports,
including but not limited to, para-jumping, rock climbing, mountaineering, rafting, 4. CONDITIONS
motor racing, horse racing or scuba diving, hand gliding, sky diving, deep-sea diving.
STANDARD CONDITIONS
10. Breach of law - Code Excl 10: Expenses for treatment directly arising from or 1. Disclosure of Information: The policy shall be void and all premium paid thereon
consequent upon any Insured Person committing or attempting to commit a breach of shall be forfeited to the Company, in the event of mis-representation, mis description
law with criminal intent. or non-disclosure of any material fact by the policy holder.
11. Excluded Providers - Code Excl 11: Expenses incurred towards treatment in any 2. Claim Settlement
hospital or by any Medical Practitioner or any other provider specifically excluded by A. Condition Precedent to Admission of Liability: The terms and conditions of
the Insurer and disclosed in its website / notified to the policyholders are not the policy must be fulfilled by the insured person for the Company to make any
admissible. However, in case of life threatening situations or following an accident, payment for claim(s) arising under the policy
expenses up to the stage of stabilization are payable but not the complete claim. B. Documents for Cashless Treatment
12. Treatment for Alcoholism, drug or substance abuse or any addictive condition and a. For assistance call 24 hours help-line 044-69006900 or Toll Free No.
consequences thereof - Code Excl 12 1800 425 2255, Senior Citizens may call at 044-40020888
b. Inform the ID number for easy reference
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 c. On admission in the hospital, produce the ID Card issued by the Company
admission is arranged wholly or partly for domestic reasons - Code Excl 13 at the Hospital Helpdesk
d. Obtain the Pre-authorisation Form from the Hospital Help Desk, complete
14. Dietary supplements and substances that can be purchased without prescription, the Patient Information and resubmit to the Hospital Help Desk
including but not limited to Vitamins, minerals and organic substances unless
e. The Treating Doctor will complete the hospitalisation/ treatment information
prescribed by a medical practitioner as part of hospitalization claim or day care
and the hospital will fill up expected cost of treatment. This form is submitted
procedure - Code Excl 14 to the Company
15. Refractive Error - Code Excl 15: Expenses related to the treatment for correction of f. The Company will process the request and call for additional documents /
eye sight due to refractive error less than 7. 5 dioptres. clarifications if the information furnished is inadequate
16. Unproven Treatments - Code Excl 16: Expenses related to any unproven g. Once all the details are furnished, the Company will process the request as
treatment, services and supplies for or in connection with any treatment. Unproven per the terms and conditions as well as the exclusions therein and either
treatments are treatments, procedures or supplies that lack significant medical approve or reject the request based on the merits
documentation to support their effectiveness. h. In case of emergency hospitalization information to be given within 24 hours
after hospitalization
17. Sterility and Infertility - Code Excl 17: Expenses related to sterility and infertility.
i. Cashless facility can be availed only in networked Hospitals. For details of
This includes; Networked Hospitals, the insured may visit www.starhealth.in or contact the
a. Any type of contraception, sterilization nearest branch
b. Assisted Reproduction services including artificial insemination and advanced j. KYC (Identity proof with Address) of the proposer, as per AML Guidelines
reproductive technologies such as IVF, ZIFT, GIFT, ICSI
In non-network hospitals payment must be made up-front and then
c. Gestational Surrogacy reimbursement will be effected on submission of documents.
d. Reversal of sterilization Note: The Company reserves the right to call for additional documents wherever
Note: Except to the extent covered under Coverage 2(U) required.
18. Maternity - Code Excl 18 Denial of a Pre-authorization request is in no way to be construed as denial of
i. Medical treatment expenses traceable to childbirth (including complicated treatment or denial of coverage. The Insured Person can go ahead with the
deliveries and caesarean sections incurred during hospitalization) except treatment, settle the hospital bills and submit the claim for a possible reimbursement.
ectopic pregnancy C. For Reimbursement claims: Time limit for submission of;
ii. Expenses towards miscarriage (unless due to an accident) and lawful medical Sl.No. Type of Claim Prescribed time limit
termination of pregnancy during the policy period
Reimbursement of hospitalization, Claim must be filed within 15 days
SPECIFIC EXCLUSIONS 1 day care and pre hospitalization from the date of discharge from the
19. Circumcision (unless necessary for treatment of a disease not excluded under this expenses Hospital
policy or necessitated due to an accident), Preputioplasty, Frenuloplasty, Preputial within 15 days after completion of
Dilatation and Removal of SMEGMA - Code Excl 19 Reimbursement of
2 90 days from the date of discharge
Post hospitalization
20. Congenital External Condition / Defects / Anomalies - Code Excl 20 from hospital
Family Health Optima Insurance Plan Unique Identification No.: SHAHLIP23164V072223 POL / FHO / V.20 / 2023 9 of 14
 D. Notification of Claim: Upon the happening of the event, notice with full The Company shall not repudiate the claim and / or forfeit the policy benefits on the
particulars shall be sent to the Company within 24 hours from the date of ground of Fraud, if the insured person / beneficiary can prove that the misstatement
occurrence of the event irrespective of whether the event is likely to give rise to a was true to the best of his knowledge and there was no deliberate intention to
claim under the policy or not. suppress the fact or that such misstatement of or suppression of material fact are
Note: Conditions C and D are precedent to admission of liability under the policy. within the knowledge of the insurer.
However the Company will examine and relax the time limit mentioned in these
7. Cancellation
conditions depending upon the merits of the case.
i. The policyholder may cancel this policy by giving 15 days' written notice and in
E. Documents to be submitted for Reimbursement: The reimbursement claim is such an event, the Company shall refund premium for the unexpired policy
to be supported with the following documents and submitted within the period as detailed below;
prescribed time limit;
a. Duly completed claim form, and Cancellation table applicable for Policy Term 1 Year without installment option
b. Pre Admission investigations and treatment papers.
c. Discharge Summary from the hospital
Period on risk Rate of premium to be retained
d. Cash receipts from hospital, chemists
e. Cash receipts and reports for tests done Up to 1 mth 25% of the policy premium
f. Receipts from doctors, surgeons, anesthetist
g. Certificate from the attending doctor regarding the diagnosis Exceeding 1 mth up to 3 mths 37.5% of the policy premium
h. KYC (Identity proof with Address) of the proposer, as per AML Guidelines
Exceeding 3 mths up to 6 mths 57.5% of the policy premium
Note: For assistance call 24 hours help-line 044-69006900 or Toll Free No.
1800 425 2255, Senior Citizens may call at 044-40020888 Exceeding 6 mths up to 9 mths 80% of the policy premium
3. Provision for Penal Interest
i) The Company shall settle or reject a claim, as the case may be, within 30 days Exceeding 9 mths 100% of the policy premium
from the date of receipt of last necessary document
Cancellation table applicable for installment option of Half-yearly premium
ii) ln the case of delay in the payment of a claim, the Company shall be liable to pay payment for Policy Term 1 Year
interest to the policyholder from the date of receipt of last necessary document to
the date of payment of claim at a rate 2% above the bank rate Period on risk Rate of premium to be retained
iii) However, where the circumstances of a claim warrant an investigation in the
opinion of the Company, it shall initiate and complete such investigation at the Up to 1 Mth 47.5% of the total premium received
earliest, in any case not later than 30 days from the date of receipt of last
necessary document. ln such cases, the Company shall settle or reject the claim Exceeding 1 mth up to 4 mths 90% of the total premium received
within 45 days from the date of receipt of last necessary document
iv) ln case of delay beyond stipulated 45 days, the Company shall be liable to pay Exceeding 4 mths up to 6 mths 100% of the total premium received
interest to the policyholder at a rate 2% above the bank rate from the date of
Exceeding 6 mths up to 7 mths 65% of the total premium received
receipt of last necessary document to the date of payment of claim
v) "Bank rate" shall mean the rate fixed by the Reserve Bank of lndia (RBI) at the Exceeding 7 mths up to 10 mths 85% of the total premium received
beginning of the financial year in which claim has fallen due.
4. Complete Discharge: Any payment to the policyholder, insured person or his/ her Exceeding 10 mths 100% of the total premium received
nominees or his/ her legal representative or assignee or to the Hospital, as the case Cancellation table applicable for installment option of Quarterly premium
may be, for any benefit under the policy shall be a valid discharge towards payment of payment for Policy Term 1 Year
claim by the Company to the extent of that amount for the particular claim
5. Multiple Policies Period on risk Rate of premium to be retained
i. ln case of multiple policies taken by an insured person during a period from one
or more insurers to indemnify treatment costs, the insured person shall have the Up to 1 Mth 95% of the total premium received
right to require a settlement of his/her claim in terms of any of his/her policies. ln
all such cases the insurer chosen by the insured person shall be obliged to settle Exceeding 1 mth up to 3 mths 100% of the total premium received
the claim as long as the claim is within the limits of and according to the terms of
Exceeding 3 mths up to 4 mths 90% of the total premium received
the chosen policy
ii. lnsured person having multiple policies shall also have the right to prefer claims Exceeding 4 mths up to 6 mths 100% of the total premium received
under this policy for the amounts disallowed under any other policy / policies
even if the sum insured is not exhausted. Then the insurer shall independently Exceeding 6 mths up to 7 mths 87.5% of the total premium received
settle the claim subject to the terms and conditions of this policy
iii. If the amount to be claimed exceeds the sum insured under a single policy, the Exceeding 7 mths up to 9 mths 100% of the total premium received
insured person shall have the right to choose insurer from whom he/she wants to
claim the balance amount Exceeding 9 mths up to 10 mths 85% of the total premium received
iv. Where an insured person has policies from more than one insurer to cover the Exceeding 10 mths 100% of the total premium received
same risk on indemnity basis, the insured person shall only be indemnified the
treatment costs in accordance with the terms and conditions of the chosen policy
Cancellation table applicable for Policy Term 2 Year without installment option
6. Fraud: lf any claim made by the insured person, is in any respect fraudulent, or if any
false statement, or declaration is made or used in support thereof, or if any fraudulent
Period on risk Rate of premium to be retained
means or devices are used by the insured person or anyone acting on his/her behalf to
obtain any benefit under this policy, all benefits under this policy and the premium paid
Up to 1 Mth 12.5% of the policy premium
shall be forfeited.
Any amount already paid against claims made under this policy but which are found Exceeding 1 mth up to 3 mths 20% of the policy premium
fraudulent later shall be repaid by all recipient(s)/policyholder(s), who has made that
particular claim, who shall be jointly and severally liable for such repayment to the Exceeding 3 mths up to 6 mths 30% of the policy premium
insurer.
For the purpose of this clause, the expression "fraud" means any of the following acts Exceeding 6 mths up to 9 mths 40% of the policy premium
committed by the insured person or by his agent or the hospital/doctor/any other party
Exceeding 9 mths up to 12 mths 50% of the policy premium
acting on behalf of the insured person, with intent to deceive the insurer or to induce
the insurer to issue an insurance policy: Exceeding 12 mths up to 15 mths 70% of the policy premium
a) the suggestion, as a fact of that which is not true and which the insured person
does not believe to be true; Exceeding 15 mths up to 18 mths 80% of the policy premium
b) the active concealment of a fact by the insured person having knowledge or
belief of the fact; Exceeding 18 mths up to 21 mths 90% of the policy premium
c) any other act fitted to deceive; and
Exceeding 21 mths 100% of the policy premium
d) any such act or omission as the law specially declares to be fraudulent
Family Health Optima Insurance Plan Unique Identification No.: SHAHLIP23164V072223 POL / FHO / V.20 / 2023 10 of 14
 ii. Renewal shall not be denied on the ground that the insured person had made a
Cancellation table applicable for installment option of Half-yearly premium
claim or claims in the preceding policy years
payment for Policy Term 2 Year
iii. Request for renewal along with requisite premium shall be received by the
Period on risk Rate of premium to be retained Company before the end of the policy period
iv. At the end of the policy period, the policy shall terminate and can be renewed
Up to 1 Mth 24% of the total premium received within the Grace Period of 120 days to maintain continuity of benefits without
break in policy
Exceeding 1 mth up to 4 mths 44.5% of the total premium received v. Coverage is not available during the grace period
vi. No loading shall apply on renewals based on individual claims experience
Exceeding 4 mths up to 6 mths 58.5% of the total premium received
11. Withdrawal of policy
Exceeding 6 mths up to 7 mths 32.5% of the total premium received i. In the likelihood of this product being withdrawn in future, the Company will
intimate the insured person about the same 90 days prior to expiry of the policy
Exceeding 7 mths up to 10 mths 43% of the total premium received
ii. lnsured Person will have the option to migrate to similar health insurance product
Exceeding 10 mths up to 12 mths 50% of the total premium received available with the Company at the time of renewal with all the accrued continuity
benefits such as cumulative bonus, waiver of waiting period as per IRDAI
Exceeding 12 mths up to 16 mths 72.5% of the total premium received guidelines, provided the policy has been maintained without a break
12. Moratorium Period: After completion of eight continuous years under the policy no
Exceeding 16 mths up to 19 mths 82.5% of the total premium received look back to be applied. This period of eight years is called as moratorium period. The
moratorium would be applicable for the sums insured of the first policy and
Exceeding 19 mths up to 22 mths 93% of the total premium received subsequently completion of 8 continuous years would be applicable from date of
enhancement of sums insured only on the enhanced limits. After the expiry of
Exceeding 22 mths 100% of the total premium received
Moratorium Period no health insurance claim shall be contestable except for proven
Cancellation table applicable for installment option of Quarterly premium fraud and permanent exclusions specified in the policy contract. The policies would
payment for Policy Term 2 Year however be subject to all limits, sub limits, co-payments, deductibles as per the policy
contract.
Period on risk Rate of premium to be retained 13. Premium Payment in Instalments: lf the insured person has opted for Payment of
Premium on an instalment basis i.e. Half Yearly or Quarterly as mentioned in the
Up to 1 Mth 47.5% of the total premium received policy Schedule/Certificate of Insurance, the following Conditions shall apply
(notwithstanding any terms contrary elsewhere in the policy)
Exceeding 1 mth up to 3 mths 75% of the total premium received i. Grace Period of 7 days would be given to pay the instalment premium due for the
policy.
Exceeding 3 mths up to 4 mths 45% of the total premium received
ii. During such grace period, coverage will not be available from the due date of
Exceeding 4 mths up to 6 mths 57.5% of the total premium received instalment premium till the date of receipt of premium by Company.
iii. The insured person will get the accrued continuity benefit in respect of the
Exceeding 6 mths up to 7 mths 42.5% of the total premium received "Waiting Periods", "Specific Waiting Periods" in the event of payment of premium
within the stipulated grace Period.
Exceeding 7 mths up to 9 mths 52.5% of the total premium received iv. No interest will be charged lf the instalment premium is not paid on due date.
Exceeding 9 mths up to 10 mths 42.5% of the total premium received v. ln case of instalment premium due not received within the grace period, the
policy will get cancelled.
Exceeding 10 mths up to 12 mths 50% of the total premium received vi. ln the event of a claim, all subsequent premium instalments shall immediately
become due and payable.
Exceeding 12 mths up to 13 mths 62.5% of the total premium received vii. The company has the right to recover and deduct all the pending installments
from the claim amount due under the policy.
Exceeding 13 mths up to 15 mths 70% of the total premium received Note
· In case of policy cancellation, due to non-payment of the instalment within grace
Exceeding 15 mths up to 18 mths 80% of the total premium received
period, Company will refund the premium as per the cancellation table.
Exceeding 18 mths up to 21 mths 90% of the total premium received · If Instalment Facility is opted for 2 year term policies, the full premium applicable
for 2 year terms should be paid in quarterly or half yearly within the expiry of the
Exceeding 21 mths 100% of the total premium received first year.
14. Possibility of Revision of Terms of the Policy lncluding the Premium Rates: The
Notwithstanding anything contained herein or otherwise, no refunds of premium shall Company, with prior approval of lRDAl, may revise or modify the terms of the policy
be made in respect of Cancellation where, any claim has been admitted or has been including the premium rates. The insured person shall be notified three months before
lodged or any benefit has been availed by the insured person under the policy. the changes are effected.
ii. The Company may cancel the policy at any time on grounds of misrepresentation,
non-disclosure of material facts, fraud by the insured person by giving 15 days' 15. Free Look Period: The Free Look Period shall be applicable on new individual health
written notice. There would be no refund of premium on cancellation on grounds insurance policies and not on renewals or at the time of porting/migrating the policy.
of misrepresentation, non-disclosure of material facts or fraud The insured person shall be allowed free look period of fifteen days from date of
receipt of the policy document to review the terms and conditions of the policy, and to
8. Migration: The insured person will have the option to migrate the policy to other return the same if not acceptable.
health insurance products/plans offered by the company by applying for migration of
the Policy atleast 30 days before the policy renewal date as per IRDAI guidelines on lf the insured has not made any claim during the Free Look Period, the insured shall be
Migration. lf such person is presently covered and has been continuously covered entitled to
without any lapses under any health insurance product/plan offered by the company, i. a refund of the premium paid less any expenses incurred by the Company on
the insured person will get the accrued continuity benefits in waiting periods as per medical examination of the insured person and the stamp duty charges or
IRDAI guidelines on migration. ii. where the risk has already commenced and the option of return of the policy is
For Detailed Guidelines on migration, kindly refer the link exercised by the insured person, a deduction towards the proportionate risk
https://www.irdai.gov.in/ADMINCMS/cms/frmGuidelines_Layout.aspx?page=PageNo3987 premium for period of cover or
iii. where only a part of the insurance coverage has commenced, such
9. Portability: The insured person will have the option to port the policy to other insurers proportionate premium commensurate with the insurance coverage during such
by applying to such insurer to port the entire policy along with all the members of the period
family, if any, at least 45 days before, but not earlier than 60 days from the policy renewal
date as per IRDAI guidelines related to portability. lf such person is presently covered 16. Redressal of Grievance: Incase of any grievance the insured person may contact
and has been continuously covered without any lapses under any health insurance the Company through
policy with an lndian General/Health insurer, the proposed insured person will get the Website : www.starhealth.in
accrued continuity benefits in waiting periods as per IRDAI guidelines on portability. E-mail : gro@starhealth.in, grievances@starhealth.in
For Detailed Guidelines on portability, kindly refer the link Ph. No. : 044-69006900 | Toll Free No. 1800 425 2255
https://www.irdai.gov.in/ADMINCMS/cms/frmGuidelines_Layout.aspx?page=PageNo3987 Senior Citizens may call at 044-69007500
10. Renewal of policy: The policy shall ordinarily be renewable except on grounds of Courier : 4th Floor, Balaji Complex, No.15, Whites Lane, Whites Road,
fraud, misrepresentation by the Insured Person; Royapettah, Chennai- 600014
i. The Company shall endeavor to give notice for renewal. However, the Company lnsured person may also approach the grievance cell at any of the company's
is not under obligation to give any notice for renewal branches with the details of grievance.
Family Health Optima Insurance Plan Unique Identification No.: SHAHLIP23164V072223 POL / FHO / V.20 / 2023 11 of 14
 lf lnsured person is not satisfied with the redressal of grievance through one of the 24. Automatic Termination: The insurance under this policy with respect to each relevant
above methods, insured person may contact the grievance officer at 044-43664600. Insured Person policy shall expire immediately on the earlier of the following events
For updated details of grievance officer, kindly refer the link ü Upon the death of the Insured Person. This means that, the cover for the
https://www.starhealth.in/grievance-redressal surviving members of the family will continue, subject to other terms of the policy.
lf lnsured person is not satisfied with the redressal of grievance through above ü Upon exhaustion of the Sum Insured, Limit of Coverage, Limit of Coverage plus
methods, the insured person may also approach the office of lnsurance Ombudsman Restore and / or Recharge Sum Insured.
of the respective area/region for redressal of grievance as per lnsurance Ombudsman 25. Policy disputes: Any dispute concerning the interpretation of the terms, conditions,
Rules 2017. limitations and/or exclusions contained herein is understood and agreed to by both
Grievance may also be lodged at IRDAI lntegrated Grievance Management System - the Insured and the Company to be subject to Indian Law.
https://bimabharosa.irdai.gov.in/ 26. Arbitration: If any dispute or difference shall arise as to the quantum to be paid under
17. Nomination: The policyholder is required at the inception of the policy to make a this Policy (liability being otherwise admitted) such difference shall independently of
nomination for the purpose of payment of claims under the policy in the event of death all other questions be referred to the decision of a sole arbitrator to be appointed in
of the policyholder. Any change of nomination shall be communicated to the company writing by the parties to the dispute/difference, or if they cannot agree upon a single
in writing and such change shall be effective only when an endorsement on the policy arbitrator within 30 days of any party invoking arbitration, the same shall be referred to
is made. ln the event of death of the policyholder, the Company will pay the nominee a panel of three arbitrators, comprising of two arbitrators, one to be appointed by each
of the parties to the dispute/difference and the third arbitrator to be appointed by such
{as named in the Policy Schedule/Policy Certificate/Endorsement (if any)} and in case
two arbitrators. Arbitration shall be conducted under and in accordance with the
there is no subsisting nominee, to the legal heirs or legal representatives of the
provisions of the Arbitration and Conciliation Act, 1996.
policyholder whose discharge shall be treated as full and final discharge of its liability
It is clearly agreed and understood that no difference or dispute shall be referable to
under the policy.
arbitration, as hereinbefore provided, if the Company has disputed or not accepted
SPECIFIC CONDITIONS liability under or in respect of this Policy.
18. The Insured Person/s shall obtain and furnish the Company with all original bills, It is hereby expressly stipulated and declared that it shall be a condition precedent to
receipts and other documents upon which a claim is based and shall also give the any right of action or suit upon this Policy that the award by such arbitrator/ arbitrators
Company such additional information and assistance as the Company may require in of the amount of the loss or damage shall be first obtained.
dealing with the claim. It is also further expressly agreed and declared that if the Company shall disclaim
liability to the Insured for any claim hereunder and such claim shall not, within three
19. All claims under this policy shall be payable in Indian currency.
years from the date of such disclaimer have been made the subject matter of a suit in a
20. The premium under this policy shall be payable in advance. No receipt of premium Court of Law, then the claim shall for all purposes be deemed to have been
shall be valid except on the official form of the company signed by a duly authorized abandoned and shall not thereafter be recoverable hereunder.
official of the company. The due payment of premium and the observance of fulfillment
27. Revision of Sum Insured: Reduction or enhancement of Sum Insured is permissible
of the terms, provision, conditions and endorsements of this policy by the Insured
only at the time of renewal. The acceptance for enhancement and the amount of
Person/s, in so far as they relate to anything to be done or complied with by the enhancement will be at the discretion of the Company and subject to Exclusion Code
Insured Person/s, shall be a condition precedent to any liability of the Company to Excl 01, Exclusion Code Excl 02 and Exclusion Code Excl 03.
make any payment under this policy. No waiver of any terms, provisions, conditions,
and endorsements of this policy shall be valid unless made in writing and signed by an 28. Relief under Section 80-D: Insured Person is eligible for relief under Section 80-D of
authorized official of the Company. the IT Act in respect of the premium paid by any mode other than cash.

21. Any medical practitioner authorized by the Company shall be allowed to examine the 29. Important Note
a) The Sum Insured, Cumulative Bonus and other related benefits floats amongst
Insured Person in case of any alleged injury or diseases requiring Hospitalization
the insured members
when and as often as the same may reasonably be required on behalf of the Company
b) The Policy Schedule and any Endorsement are to be read together and any word
at Company's cost.
or such meaning wherever it appears shall have the meaning as stated in the Act
22. Notice and communication: Any notice, direction or instruction given under this / Indian Laws
Policy shall be in writing and delivered by hand, post, or facsimile/email to Star Health c) The terms, conditions and exceptions that appear in the Policy or in any
and Allied Insurance Company Limited, No.1, New Tank Street, Valluvar Kottam Endorsement are part of the contract, must be complied with and applies to each
High Road, Nungambakkam, Chennai 600034. Customer Care No. 044-69006900 or relevant insured person. Failure to comply with may result in the claim being denied
Toll Free No. 1800 425 2255, e-mail: support@starhealth.in d) The attention of the policy holder is drawn to our website www.starhealth.in for
Notice and instructions will be deemed served 7 days after posting or immediately anti fraud policy of the company for necessary compliance by all stake holders
upon receipt in the case of hand delivery, facsimile or e-mail. 30. Customer Service: If at any time the Insured Person requires any clarification or
23. Territorial Limit: All investigations/treatments under this policy shall have to be taken assistance, the insured may contact No.1, New Tank Street, Valluvar Kottam High
in India. Road, Nungambakkam, Chennai 600034, during normal business hours.

Family Health Optima Insurance Plan Unique Identification No.: SHAHLIP23164V072223 POL / FHO / V.20 / 2023 12 of 14
 List of Insurance Ombudsman

AHMEDABAD BENGALURU BHOPAL

Office of the Insurance Ombudsman, Office of the Insurance Ombudsman, Office of the Insurance Ombudsman, BHUBANESWAR
Jeevan Prakash Building, 6th floor, Jeevan Soudha Building, 1st floor, "Jeevan Shikha",
Office of the Insurance Ombudsman,
Tilak Marg, Relief Road, PID No. 57-27-N-19 Ground Floor, 19/19, 60-B, Hoshangabad Road,
62, Forest park, Bhubaneswar – 751 009.
Ahmedabad – 380 001. 24th Main Road, JP Nagar, Ist Phase, Opp. Gayatri Mandir, Bhopal – 462 011.
Tel.: 0674 - 2596461 /2596455
Tel.: 079 - 25501201/02/05/06 Bengaluru – 560 078. Tel.: 0755 - 2769201 / 2769202
Email: bimalokpal.bhubaneswar@cioins.co.in
Email: bimalokpal.ahmedabad@cioins.co.in Tel.: 080 - 26652048 / 26652049 Email: bimalokpal.bhopal@cioins.co.in
Email: bimalokpal.bengaluru@cioins.co.in JURISDICTION: Odisha.
JURISDICTION: Gujarat, Dadra & Nagar JURISDICTION: Madhya Pradesh
Haveli, Daman and Diu. JURISDICTION: Karnataka. Chattisgarh.

CHANDIGARH
CHENNAI DELHI ERNAKULAM
Office of the Insurance Ombudsman,
S.C.O. No. 101, 102 & 103, 2nd Floor, Office of the Insurance Ombudsman, Office of the Insurance Ombudsman, Office of the Insurance Ombudsman,
Batra Building, Sector 17 – D, Fatima Akhtar Court, 4th Floor, 453, 2/2 A, Universal Insurance Building, 2nd Floor, Pulinat Bldg.,
Chandigarh – 160 017. Anna Salai, Teynampet, Asaf Ali Road, Opp. Cochin Shipyard, M. G. Road,
Tel.: 0172 - 2706196 / 2706468 Chennai – 600 018. New Delhi – 110 002. Ernakulam - 682 015.
Email: bimalokpal.chandigarh@cioins.co.in Tel.: 044 - 24333668 / 24335284 Tel.: 011 - 23232481/23213504 Tel.: 0484 - 2358759 / 2359338
Email: bimalokpal.chennai@cioins.co.in Email: bimalokpal.delhi@cioins.co.in Email: bimalokpal.ernakulam@cioins.co.in
JURISDICTION: Punjab, Haryana
(excluding Gurugram, Faridabad, Sonepat JURISDICTION: Tamil Nadu, JURISDICTION: Delhi & following Districts JURISDICTION: Kerala, Lakshadweep,
and Bahadurgarh), Himachal Pradesh, Puducherry Town and Karaikal of Haryana - Gurugram, Faridabad, Mahe-a part of Union Territory of
Union Territories of Jammu & (which are part of Puducherry). Sonepat & Bahadurgarh. Puducherry.
Kashmir,Ladakh & Chandigarh.

HYDERABAD
GUWAHATI
Office of the Insurance Ombudsman, JAIPUR KOLKATA
Office of the Insurance Ombudsman,
6-2-46, 1st floor, "Moin Court",
Jeevan Nivesh, 5th Floor, Office of the Insurance Ombudsman, Office of the Insurance Ombudsman,
Lane Opp. Saleem Function Palace,
Nr. Panbazar over bridge, S.S. Road, Jeevan Nidhi – II Bldg., Gr. Floor, Hindustan Bldg. Annexe, 7th Floor,
A. C. Guards, Lakdi-Ka-Pool,
Guwahati – 781001(ASSAM). Bhawani Singh Marg, 4, C.R. Avenue, Kolkata - 700 072.
Hyderabad - 500 004.
Tel.: 0361 - 2632204 / 2602205 Jaipur - 302 005. Tel.: 033 - 22124339 / 22124340
Tel.: 040 - 23312122
Email: bimalokpal.guwahati@cioins.co.in Tel.: 0141 - 2740363 Email: bimalokpal.kolkata@cioins.co.in
Email: bimalokpal.hyderabad@cioins.co.in
Email: bimalokpal.jaipur@cioins.co.in
JURISDICTION: Assam, Meghalaya, JURISDICTION: West Bengal, Sikkim,
JURISDICTION: Andhra Pradesh,
Manipur, Mizoram, Arunachal Pradesh, JURISDICTION: Rajasthan. Andaman & Nicobar Islands.
Telangana, Yanam and part of Union
Nagaland and Tripura.
Territory of Puducherry.

PATNA
LUCKNOW Office of the Insurance Ombudsman,
NOIDA 2nd Floor, Lalit Bhawan,
Office of the Insurance Ombudsman,
Bailey Road, Patna 800 001.
6th Floor, Jeevan Bhawan, Phase-II, Office of the Insurance Ombudsman,
Tel.: 0612-2547068
Nawal Kishore Road, Hazratganj, Bhagwan Sahai Palace
Email: bimalokpal.patna@cioins.co.in
Lucknow - 226 001. 4th Floor, Main Road, Naya Bans, Sector 15,
MUMBAI
Tel.: 0522 - 2231330 / 2231331 Distt: Gautam Buddh Nagar, U.P-201301. JURISDICTION: Bihar, Jharkhand.
Email: bimalokpal.lucknow@cioins.co.in Office of the Insurance Ombudsman, Tel.: 0120-2514252 / 2514253
3rd Floor, Jeevan Seva Annexe, Email: bimalokpal.noida@cioins.co.in
JURISDICTION: Districts of Uttar Pradesh:
S. V. Road, Santacruz (W),
Lalitpur, Jhansi, Mahoba, Hamirpur, JURISDICTION: State of Uttarakhand and
Mumbai - 400 054.
Banda, Chitrakoot, Allahabad, Mirzapur, the following Districts of Uttar Pradesh:
Tel.: 69038821/23/24/25/26/27/28/29/30/31
Sonbhabdra, Fatehpur, Pratapgarh, Agra, Aligarh, Bagpat, Bareilly, Bijnor,
Email: bimalokpal.mumbai@cioins.co.in
Jaunpur,Varanasi, Gazipur, Jalaun, Budaun, Bulandshehar, Etah, Kannauj,
Kanpur, Lucknow, Unnao, Sitapur, JURISDICTION: Goa, Mumbai Mainpuri, Mathura, Meerut, Moradabad, PUNE
Lakhimpur, Bahraich, Barabanki, Metropolitan Region (excluding Navi Muzaffarnagar, Oraiyya, Pilibhit, Etawah,
Office of the Insurance Ombudsman,
Raebareli, Sravasti, Gonda, Faizabad, Mumbai & Thane). Farrukhabad, Firozbad, Gautam Buddh
Jeevan Darshan Bldg., 3rd Floor,
Amethi, Kaushambi, Balrampur, Basti, nagar, Ghaziabad, Hardoi, Shahjahanpur,
C.T.S. No.s. 195 to 198, N.C. Kelkar Road,
Ambedkarnagar, Sultanpur, Maharajgang, Hapur, Shamli, Rampur, Kashganj,
Narayan Peth, Pune – 411 030.
Santkabirnagar, Azamgarh, Kushinagar, Sambhal, Amroha, Hathras,
Tel.: 020-41312555
Gorkhpur, Deoria, Mau, Ghazipur, Kanshiramnagar, Saharanpur.
Email: bimalokpal.pune@cioins.co.in
Chandauli, Ballia, Sidharathnagar.
JURISDICTION: Maharashtra, Areas of
Navi Mumbai and Thane (excluding
Mumbai Metropolitan Region).

Kindly refer our website, for future updates in Ombudsman address

Family Health Optima Insurance Plan Unique Identification No.: SHAHLIP23164V072223 POL / FHO / V.20 / 2023 13 of 14
 ITEMS THAT ARE TO BE SUBSUMED INTO ROOM CHARGES

SI.NO. ITEM SI.NO. ITEM

1 BABY CHARGES (UNLESS SPECIFIED/INDICATED) 20 LUXURY TAX

2 HAND WASH 21 HVAC
3 SHOE COVER 22 HOUSE KEEPING CHARGES
4 CAPS 23 AIR CONDITIONER CHARGES
5 CRADLE CHARGES 24 IM IV INJECTION CHARGES
6 COMB 25 CLEAN SHEET
7 EAU-DE-COLOGNE / ROOM FRESHNERS 26 BLANKET / WARMER BLANKET
8 FOOT COVER 27 ADMISSION KIT
9 GOWN 28 DIABETIC CHART CHARGES
10 SLIPPERS 29 DOCUMENTATION CHARGES / ADMINISTRATIVE EXPENSES
11 TISSUE PAPER 30 DISCHARGE PROCEDURE CHARGES
12 TOOTH PASTE 31 DAILY CHART CHARGES
13 TOOTH BRUSH 32 ENTRANCE PASS / VISITORS PASS CHARGES
14 BED PAN 33 EXPENSES RELATED TO PRESCRIPTION ON DISCHARGE
15 FACE MASK 34 FILE OPENING CHARGES
16 FLEXI MASK 35 INCIDENTAL EXPENSES / MISC. CHARGES (NOT EXPLAINED)
17 HAND HOLDER 36 PATIENT IDENTIFICATION BAND / NAME TAG
18 SPUTUM CUP
37 PULSEOXYMETER CHARGES
19 DISINFECTANT LOTIONS

ITEMS THAT ARE TO BE SUBSUMED INTO PROCEDURE CHARGES

SI.NO. ITEM SI.NO. ITEM

1 HAIR REMOVAL CREAM 13 SURGICAL DRILL

2 DISPOSABLES RAZORS CHARGES (for site preparations) 14 EYE KIT
3 EYE PAD 15 EYE DRAPE
4 EYE SHEILD 16 X-RAY FILM
5 CAMERA COVER 17 BOYLES APPARATUS CHARGES
6 DVD, CD CHARGES 18 COTTON
7 GAUSE SOFT 19 COTTON BANDAGE
8 GAUZE 20 SURGICAL TAPE
9 WARD AND THEATRE BOOKING CHARGES 21 APRON
10 ARTHROSCOPY AND ENDOSCOPY INSTRUMENTS 22 TORNIQUET
11 MICROSCOPE COVER
23 ORTHOBUNDLE, GYNAEC BUNDLE
12 SURGICAL BLADES, HARMONICSCALPEL,SHAVER

ITEMS THAT ARE TO BE SUBSUMED INTO COSTS OF TREATMENT

SI.NO. ITEM SI.NO. ITEM

1 ADMISSION / REGISTRATION CHARGES 10 HIV KIT

2 HOSPITALISATION FOR EVALUATION / DIAGNOSTIC PURPOSE 11 ANTISEPTIC MOUTHWASH
3 URINE CONTAINER 12 LOZENGES
4 BLOOD RESERVATION CHARGES AND ANTE NATAL BOOKING CHARGES 13 MOUTH PAINT
5 BIPAP MACHINE 14 VACCINATION CHARGES
6 CPAP / CAPD EQUIPMENTS 15 ALCOHOL SWABS
7 INFUSION PUMP — COST 16 SCRUB SOLUTION / STERILLIUM
8 HYDROGEN PEROXIDE / SPIRIT / DISINFECTANTS ETC 17 GLUCOMETER & STRIPS
9 NUTRITION PLANNING CHARGES - DIETICIAN CHARGES - DIET CHARGES 18 URINE BAG

Family Health Optima Insurance Plan Unique Identification No.: SHAHLIP23164V072223 POL / FHO / V.20 / 2023 14 of 14