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Group Insurance October 10, 2020
If you contract any disease, illness, or sustain a bodily injury via accident, having this policy will make the insurer pay expenses for the medical or surgical treatment at any Nursing Home/Hospital in India. It has a wide range of sum insured options for you to choose from. The premium and coverage will differ according to the sum insured option you choose. To know more about the Group Health Insurance – Star Health policy, read this page.
Table of Contents
Star Health And Allied Insurance Company Ltd. will pay the following expenses
Check out the table below to know the modern treatment expenses covered by the company as per the policyholder’s sum insured.
|Sum Insured (in INR)||Uterine artery Embolization and HIFU||Balloon Sinuplasty||Deep Brain Stimulation||Oral Chemotherapy(Sublimit including pre & Post Hospitalization)||Immunotherapy Monoclonal Antibody to be given as an injection||Intravitreal injections||Robotic surgeries||Stereotactic radio|
Vaporization of the
|Stem cell therapy: Hematopoietic stem cells for bone marrow transplant for hematological conditions|
|Up to 1 lakh||12,500||5,000||25,000||12,500||25,000||5,000||25,000||25,000||Up to Sum Insured||25,000|
|1 to 2 lakh||25,000||10,000||50,000||25,000||50,000||10,000||50,000||50,000||Up to Sum Insured||50,000|
|2 to 3 lakh||37,500||15,000||75,000||37,500||75,000||15,000||75,000||75,000||Up to Sum Insured||75,000|
|3 to 4 lakh||1,00,000||40,000||2,00,000||1,00,000||2,00,000||4,00,000||20,0000||1,75,000||Up to Sum Insured||20,0000|
|4 to 5 lakh||1,25,000||50,000||25,0000||1,25,000||25,0000||50,000||25,0000||20,0000||Up to Sum Insured||25,0000|
|5 to 7.5 lakh||1,25,000||50,000||2,50,000||1,25,000||2,75,000||60,000||2,75,000||2,75,000||Up to Sum Insured||2,75,000|
|7.5 to 10 lakh||1,50,000||1,00,000||3,00,000||2,00,000||4,00,000||75,000||3,00,000||2,25,000||Up to Sum Insured||4,00,000|
|10 to 15 lakh||1,75,000||1,25,000||4,00,000||2,50,000||2,50,000||1,00,000||4,00,000||2,50,000||Up to Sum Insured||5,00,000|
|15 to 20 lakh||2,00,000||1,50,000||4,50,000||2,75,000||5,50,000||1,25,000||4,50,000||2,75,000||Up to Sum Insured||5,50,000|
|20 to 25 lakh||2,00,000||1,50,000||5,00,000||3,00,000||6,00,000||1,50,000||5,00,000 ||3,00,000||Up to Sum Insured||6,00,000|
|25 to 50 lakh||2,25,000||1,75,000||6,00,000||4,00,000||7,50,000||1,75,000||6,00,000 ||3,50,000||Up to Sum Insured||7,50,000|
|50 to 75 lakh||2,50,000||2,00,000||7,00,000||5,00,000||9,00,000||2,00,000||7,00,000 ||3,75,000||Up to Sum Insured||9,00,000|
Note:- The limit is per person per policy period for each disease or condition.
Expenses on hospitalization are payable only if the patient is admitted to a hospital for a minimum of 24 hours. However, this time limit may not apply to daycare treatments or procedures in the Hospital/Nursing Home. Insurer liability for specific ailment/surgical procedure is up to the limits, as mentioned in the schedule above. The expenses for hospitalization is considered in proportion to the room rent limit as per the policy schedule.
The company will not make any payments under this policy for expenses that are incurred by the insured person in connection with or in respect of the following:-
Your pre-existing Disease and its direct complications will be excluded until the 48 months of continuous coverage since the date of policy inception. In the case of policy enhancement, the exclusion will apply afresh to the extent of the increased sum insured.
If you are covered under the policy without any break under the portability norms of IRDAI (Health Insurance) regulations, the waiting period is reduced to the extent of the previous policy coverage. The coverage under the policy for any pre-existing disease is subject to the same being declared at the time of policy application and the same being accepted by the Insurer.
Disease/Procedure Waiting Period
The following are the listed conditions, surgeries, treatments which would be excluded until 12 months of continuous coverage. The exclusion does not apply to claims arising due to an accident.
The following are the listed conditions, surgeries, treatments which would be excluded until the 24 months of continuous coverage.
In case the sum insured is enhanced, the exclusion shall apply afresh to the extent of your sum insured. If any of the specified disease/procedure falls under a waiting period specified of pre-existing diseases, the longer of the two waiting periods will apply. The waiting period for the listed conditions may apply even if it is contracted after the policy declaration and acceptance of the policy without a specific exclusion.
If the Insured Person is continuously covered, under the applicable norms on portability that are stipulated by the IRDAI, the waiting period for the same is reduced to the extent of prior coverage.
Investigation & Evaluation
Expenses related to admission for diagnostics and evaluation purposes are excluded from the Group Health Insurance – Star Health plan, provided that these diagnostic expenses are not related or not incidental to the current diagnosis and treatment.
Rest Cure, Rehabilitation & Respite Care
Expenses for enforced bed rest that also includes: custodial care either at home or nursing facility for personal care like bathing, dressing, moving around either by a skilled nurse or an assistant or unskilled person. And the services for people who are terminally ill to address physical, social, emotional and spiritual needs.
Expenses for surgical treatment of obesity that does not meet the below conditions:
Expenses including surgical management to change the characteristics of the body.
Expenses for any treatment to change appearance unless reconstruction is needed due to an Accident, Burn, or Cancer or if it is a part of the medically necessary treatment to remove a direct and immediate health risk. This must be certified by the attending Medical Practitioner if such is the case.
Hazardous or Adventure sports
Expenses of injury or illness treatment due to participation in hazardous or adventure sports like para-jumping, rock climbing, mountaineering, rafting, motor racing, horse racing, or scuba diving, hand gliding, skydiving, deep-sea diving.
Breach of law
If you break any law and get injured or infected by a disease the treatment expenses will not be paid by the company.
Expenses incurred in treatment in any hospital or by any Medical Practitioner or any other provider specifically excluded by the insurer and disclosed this on the website and notified it to the policyholder. However, in case of life-threatening situations or an accident, the expenses up to the stage of stabilization will become payable but not the complete claim is possible.
The following are the further exclusions from this policy
After completion of 8 continuous years with Star Health And Allied Insurance Company Ltd. under this policy with no look back, a moratorium period will come. This moratorium would apply to the sums insured of your first policy with the company and subsequently, after completion of 8 continuous years, it applies from the date of enhancement of the sum insured only.
When the Moratorium Period expires, no health insurance claim will be contestable except for the proven fraud and permanent exclusions as specified in the policy contract. Policies are, however, subject to all limits, sub-limits, co-payments, deductibles as per the policy contract.
On the occurrence of injury or illness, a notice with full particulars shall be sent to the company within 24 hours from the date of its occurrence irrespective of whether it is likely to give rise to a claim under the policy or not. However, the company will examine and relax the time limit in claim notification upon the merits of the insured case.
There are certain terms and conditions of the policy that must be fulfilled by the insured person to get the claim –
Note: The company reserves the right to call for additional documents wherever required. The denial of a pre-authorization request is in no way construed as a denial of treatment or denial of coverage. The insured can go ahead with the treatment, settle the hospital bills and submit the claim for possible reimbursement. Any payment to the policyholder, insured person or his/her nominee, legal representative, assignee, or to the hospital, is a valid discharge towards the payment of a claim by the company.
If the insured gets treatment in a non-network hospital, the payment must be made upfront and then reimbursement will take place when the required documents are submitted. The time limit for submission of documents is as follows:-
|Hospitalization, Day Care and|
|Within 15 days from the date of
discharge from the hospital.
|Post-hospitalization||Within 15 days after the date of discharge from the hospital|
The reimbursement claim documents:-
Note:- Organ transplant on the insured must satisfy the requirements of the Transplantation of Human Organs Act of 1994.
Note:- Here “Bank rate”means the rate fixed by the RBI.
Your policy is renewable except for fraud and misrepresentation. The company shall endeavor to give a notice for renewal. However, it is not under an obligation to give any notice for renewal. The renewal can be denied if you have made a claim or claims in the preceding policy years.
Requests for renewal along with the requisite premium is received by the company before the end of the policy period, upon which the policy terminates and can be renewed within 30 days of the Grace Period.
The coverage is not available for the insured during the grace period. If a group policy is discontinued or not renewed or when the members of the group leave the group on account of resignation, retirement or termination, the following provisions may apply.
The insured who is covered under this group policy will be granted to get cover under Indemnity based Individual Health Policy. In respect of that, the person has been covered continuously for one, two or four years under this group policy with the company, and the exclusion will be waived.
The insurance under this policy for each relevant insured person or family shall terminate immediately upon the happening of the following events:
You can cancel this policy by giving a 15-day written notice, and the company shall refund the premium for the unexpired policy period as mentioned in the below table.
|Period on risk||Retained rate of premium|
|Up to 1 month||25% of the annual premium|
|1 to 3 months||40% of the annual premium|
|3 to 6 months||60% of the annual premium|
|6 to 9 months||80% of the annual premium|
|More than 9 months||Full annual premium|
Notwithstanding anything contained herein or otherwise, no refunds of premiums will be made in respect of policy cancellation where any claim has been admitted or has been lodged or any benefit has been availed by the insured. The company can also cancel the policy any time on the grounds of misrepresentation, non-disclosure of material facts, fraud, by giving a 15-day written notice to the insured.
Note:- You will get no refunds on cancellation due to misrepresentation, non-disclosure of material facts, or fraud.
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