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.

Health Insurance

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Coverages

Star Health And Allied Insurance Company Ltd. will pay the following expenses

  1. Room, boarding, nursing by the Hospital/Nursing Home
  2. Fees of Surgeon, Anesthetist, Medical Practitioner, Consultants and Specialists
  3. Charges for Anesthesia, blood, oxygen, operation theatre, ICU, surgical appliances, medicines/drugs, diagnostic materials like X-ray, diagnostic imaging modalities like dialysis, chemotherapy, radiotherapy, pacemaker, stent and similar types of expenses.
  4. Ambulance fees
  5. Pre-Hospitalization and Post–Hospitalization expenses
  6. The following treatment costs under Ayurveda, Unani, Sidha and Homeopathy systems of medicines in a Government Hospital or an institute recognized by the government or accredited by the Quality Council of India/National Accreditation Board on Health.
  7. Treatment of the following diseases/conditions (either as daycare or as an in-patient exceeding 24hrs of admission).

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 HIFUBalloon SinuplastyDeep Brain StimulationOral Chemotherapy(Sublimit including pre & Post Hospitalization) Immunotherapy Monoclonal Antibody to be given as an injectionIntravitreal injections
Robotic surgeriesStereotactic radio
surgeries
Bronchial
Thermoplasty,
Vaporization of the
prostate(Green laser
treatment or
holmium laser
treatment), IONM-
(Intra Operative
Neuromonitoring)
Stem cell therapy: Hematopoietic stem cells for bone marrow transplant for hematological conditions
Up to 1 lakh12,5005,00025,00012,50025,0005,00025,00025,000Up to Sum Insured25,000
1 to 2 lakh25,00010,00050,00025,00050,00010,00050,00050,000Up to Sum Insured50,000
2 to 3 lakh37,500 15,000 75,000 37,500 75,00015,00075,00075,000Up to Sum Insured75,000
3 to 4 lakh1,00,00040,0002,00,0001,00,0002,00,0004,00,00020,00001,75,000Up to Sum Insured20,0000
4 to 5 lakh1,25,000 50,000 25,00001,25,00025,0000 50,00025,000020,0000Up to Sum Insured25,0000
5 to 7.5 lakh1,25,000 50,000 2,50,000 1,25,000 2,75,000 60,0002,75,0002,75,000Up to Sum Insured2,75,000
7.5 to 10 lakh1,50,000 1,00,0003,00,0002,00,0004,00,00075,0003,00,0002,25,000Up to Sum Insured4,00,000
10 to 15 lakh1,75,000 1,25,000 4,00,000 2,50,000 2,50,0001,00,0004,00,0002,50,000Up to Sum Insured5,00,000
15 to 20 lakh2,00,000 1,50,000 4,50,000 2,75,000 5,50,000 1,25,0004,50,0002,75,000Up to Sum Insured5,50,000
20 to 25 lakh2,00,000 1,50,000 5,00,000 3,00,000 6,00,000 1,50,0005,00,000

3,00,000 Up to Sum Insured6,00,000
25 to 50 lakh2,25,000 1,75,000 6,00,0004,00,0007,50,0001,75,0006,00,000

3,50,000 Up to Sum Insured7,50,000
50 to 75 lakh2,50,000 2,00,000 7,00,000 5,00,000 9,00,000 2,00,0007,00,000

3,75,000 Up to Sum Insured9,00,000

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.

Exclusions

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:-

Pre-Existing Diseases

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.

  1. Hepato-pancreato-biliary diseases including Gallbladder and Pancreatic calculi
  2. All types of management for kidney and genitourinary tract calculi
  3. All Diseases of Prostate
  4. All types of Hernia
  5. Hydrocele
  6. Congenital Internal disease/defect anomalies (Except to the extent covered under Newborn Baby Cover if specifically opted)
  7. Pilonidal sinus and Fistula/Fissure in the anus
  8. Piles
  9. Sinusitis and related disorders

The following are the listed conditions, surgeries, treatments which would be excluded until the 24 months of continuous coverage.

  1. Cataract
  2. Diseases of the anterior and posterior chamber of the Eye
  3. Diseases of ENT
  4. Thyroid related disease
  5. Prolapse of an intervertebral disc (if not the cause of an accident)
  6. Varicose veins and Varicose ulcers
  7. All Stricture Urethra,
  8. All Obstructive Uropathies
  9. Epididymal Cyst
  10. Benign Tumours of Epididymis
  11. Spermatocele
  12. Varicocele
  13. Hemorrhoids
  14. Rectal Prolapse
  15. Stress Incontinence.
  16. Desmoid tumor of the anterior abdominal wall
  17. Treatments (conservative, interventional, laparoscopic and open) of all related diseases of Uterus, Fallopian tubes, Cervix, Ovaries, Uterine bleeding, Pelvic Inflammatory, Benign breast, Umbilical sinus and Umbilical fistula
  18. Conservative or operative treatment for all types of intervention diseases which is related to Tendon, Ligament, Fascia, Bones and Joint Including Arthroscopy and Arthroplasty (if not caused by accident)
  19. Degenerative disc
  20. Vertebral disease including bone replacement
  21. Joints and Degenerative diseases of the Musculoskeletal system
  22. Subcutaneous Benign lumps
  23. Sebaceous cyst
  24. Dermoid cyst
  25. Mucous cyst lip/cheek
  26. Carpal tunnel syndrome
  27. Trigger finger
  28. Lipoma
  29. Neurofibroma
  30. Fibroadenoma
  31. Ganglion and similar pathology
  32. Transplant and its related surgery

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.

Obesity/Weight Control

Expenses for surgical treatment of obesity that does not meet the below conditions:

  1. Surgery performed with the advice of the doctor
  2. Surgery/Procedure conducted or supported by clinical protocols
  3. The insured should be of a minimum of 18 years
  4. Body Mass Index (BMI) of the insured who is taking the treatment should be as follows:-
  5. >=40%
  6. >=35% in conjunction with these severe comorbidities and failure of less invasive methods of weight loss: Obesity-related cardiomyopathy, Coronary heart disease, Severe Sleep Apnea and Uncontrolled Type2 Diabetes.

Change-of-Gender Treatments

Expenses including surgical management to change the characteristics of the body.

Cosmetic/Plastic Surgery

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.

Excluded Providers

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 

  1. Treatment for Alcoholism, drug, or substances of abuse
  2. Addictive condition and its consequences
  3. Treatments received in health hydros, nature cure clinics, spas, or similar type of establishments
  4. Private beds are registered in a nursing home or where admission is arranged due to domestic reasons
  5. Dietary supplements and substances that are purchased without any prescription, including vitamins, minerals and organic substances
  6. Hospitalization claim or daycare procedure
  7. Refractive Error
  8. Expenses of treatment for correction of eyesight due to refractive error < 7. 5 dioptres
  9. Unproven treatments include any unproven treatment, services and supplies for or in connection with any treatment. Unproven treatments are the treatments, procedures, or supplies that lack significant medical documentation.
  10. Sterility and Infertility expenses like any type of contraception, sterilization, assisted reproduction services including artificial insemination and advanced reproductive technologies such as IVF, ZIFT, GIFT, ICSI, Gestational Surrogacy and Reversal of sterilization
  11. Medical expenses traceable to childbirth except for ectopic pregnancy
  12. Expenses for miscarriage (unless it is caused due to an accident)
  13. Circumcision unless necessary for treatment
  14. Preputioplasty
  15. Frenuloplasty
  16. Preputial Dilatation
  17. Removal of SMEGMA
  18. Congenital External diseases/conditions
  19. Convalescence, general debility, run-down condition and nutritional deficiency states
  20. Intentional self-injury
  21. Venereal disease and Sexually transmitted diseases (Other than HIV)
  22. Injury/disease due to war, invasion, an act of a foreign enemy or war like operations
  23. Injury or disease directly or indirectly caused by or contributed to nuclear weapons/materials
  24. Expenses incurred on Enhanced External Counterpulsation Therapy and its related therapies, Chelation therapy, Hyperbaric Oxygen Therapy, Rotational Field Quantum Magnetic Resonance Therapy, VAX-D, Low-level laser therapy, Photodynamic therapy and such other similar therapies
  25. Unconventional, untested, experimental therapies
  26. Autologous derived Stromal vascular fraction
  27. Chondrocyte Implantation
  28. Procedures using Platelet Rich
  29. Plasma and Intra Articular injection therapy
  30. Immunotherapy without proper indication
  31. Biologicals, except if treated as an in-patient
  32. All treatments for Priapism and erectile dysfunctions
  33. Inoculation or Vaccination (except post–bite treatment)
  34. Dental treatment or surgery unless caused due to an accident
  35. Medical/Surgical treatment of Sleep apnea
  36. Treatment for endocrine disorders
  37. Hospital registration charges
  38. Admission charges
  39. Record charges
  40. Telephone charges
  41. Cost of spectacles, contact lens, hearing aids, cochlear implants and procedures, walkers and crutches, wheelchairs, CPAP, BIPAP, Continuous Ambulatory Peritoneal Dialysis, infusion pump and such other similar aids
  42. Hospitalizations which are not medically necessary for the treatment
  43. Existing diseases that are disclosed by the insured and mentioned in the policy schedule, for specified ICD codes.
  44. Naturopathy Treatment

Moratorium Period of the Group Health Insurance – Star Health Plan

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.

Claim Settlement

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.

Cashless Claim for the Group Health Insurance – Star Health Plan

There are certain terms and conditions of the policy that must be fulfilled by the insured person to get the claim –

  1. Documents for Cashless Treatment
  2. Call the company helpline number – 1800 425 2255 or 1800 102 4477
  3. Inform the ID number for reference
  4. Upon admission to the hospital, show your ID card issued by the company
  5. Obtain the pre-authorization form from the Hospital Help Desk, fill up the information and resubmit to the Hospital Help Desk
  6. After the completion of hospitalization/treatment, the hospital will fill up the expected cost of treatment. And later, this form is submitted to the company.
  7. The company will then request and call for additional documents to clarify whether the information furnished is inadequate
  8. Once all the details are furnished, the company processes the claim request and either approves or rejects the request based on the merits
  9. In case of emergency hospitalization, the information must be given within 24 hours
  10. Cashless facilities are available only at network Hospitals. For the details of network hospitals, you may visit www.starhealth.in or contact the nearest branch.

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.

Reimbursement for the Group Health Insurance – Star Health Plan

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:-

ClaimsTime Limit
Hospitalization, Day Care and
Pre-hospitalization Expenses
Within 15 days from the date of
discharge from the hospital.
Post-hospitalizationWithin 15 days after the date of discharge from the hospital

The reimbursement claim documents:-

  1. Duly completed claim form
  2. Pre Admission investigations and treatment papers
  3. Discharge Summary from the hospital
  4. Cash receipts from hospitals/chemists
  5. Cash receipts and reports for tests
  6. Receipts of fees from doctors, surgeons, anesthetist
  7. Certificate from the attending doctor regarding the diagnosis
  8. Copy of PAN card

Note:- Organ transplant on the insured must satisfy the requirements of the Transplantation of Human Organs Act of 1994.

Provisions of Penal Interest On Star Health Group Insurance Plan

  1. The company will settle or reject a claim within 30 days from the date of its receipt
  2. In the case of delay, the company will be liable to pay penalty interest to the policyholder from the date of receipt of the last necessary document to the date of claim payment at 2% above the bank rate.
  3. However, if the circumstances of a claim warrant an investigation in the opinion of the company, it shall initiate and complete such investigation at the earliest, not later than 30 days from the date of receipt of the last necessary document. in such a case, the company shall settle or reject the claim within 45 days from the date of receipt of the last necessary document.
  4. In the case of delay beyond 45 days of the stipulated period, the company pays the 2% penalty interest above the bank rate.

Note:- Here “Bank rate”means the rate fixed by the RBI.

Group Health Insurance – Star Health Plan Renewal

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.

Group Health Insurance – Star Health Plan Auto Termination

The insurance under this policy for each relevant insured person or family shall terminate immediately upon the happening of the following events:

  1. Death of the Insured Person (In the case of family floater policy, the cover for the other surviving members of the family will continue, subject to the terms of the policy).
  2. Exhaustion of the sum insured

Group Health Insurance – Star Health Plan Cancellation Clause

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 riskRetained rate of premium
Up to 1 month25% of the annual premium
1 to 3 months40% of the annual premium
3 to 6 months60% of the annual premium
6 to 9 months80% of the annual premium
More than 9 monthsFull 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.

Important Notes:-

  1. If the policy is on a floater basis, the sum insured and sub-limits float amongst the family members covered
  2. The Policy Schedule, Certificate of Insurance and Endorsement needs to be read together and any word or such meaning wherever it appears the meaning as stated in the Act/Indian Laws. Special Conditions as stated in the schedule supersede these policy wordings (if any).
  3. Terms, conditions and exceptions in the policy or endorsement are part of the contract and must be complied with. Failure to comply may result in the claim being denied by the insurer
  4. The policyholder/Insured Person must visit the official website of www.starhealth.in for the anti-fraud policy of the company for necessary compliance by all stakeholders

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