Introduction
Before we start comparing these two policies we have to set out some ground rules.
Both products are marketed by different insurance companies. Health Gain is sold by Star Health and Optima Restore is sold by HDFC Ergo. So any meaningful comparison should include a comparison of the product alongside the insurers themselves.
Second, we know that both products have massive differences in their core structure. Health Gain is specifically designed for those seeking outpatient coverage. However, Optima Restore is quite comprehensive. It offers considerable protection and it doesn’t impose as many restrictions. So in many ways, you’re comparing apples and oranges here.
And finally, any comparison is ultimately futile without considering the use case. Who are you buying this policy for? You, your family, your parents?
That’s something you’ll need to answer before using this guide. So with that introduction out of the way, we can get to comparing the actual policies themselves.
Let’s start with Health Gain. The product comes from Star Health’s stable:
Star Health Insurance is India's first standalone health insurance firm. And with an army of retail advisors pushing their products across the country, they’ve managed to capture a fair share of the Indian market.
The company also boasts a network of over 14,000+ hospitals and a decent claim settlement ratio of 83%.
Optima Restore meanwhile comes from HDFC Ergo’s stable:
Founded in the year 2002, the company is a joint venture between India’s HDFC and Germany’s ERGO International AG. It offers policies across motor, travel, health and other sectors. And it also happens to be one of the largest insurers in the country.
More importantly, HDFC Ergo boasts a claim settlement ratio of 98%, with a network of 11,500+ hospitals
All in all, an impressive resume.
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Compare Insurances Insurance Parameters Recommended Not Recommended |  Health Gain |  Optima Restore |
|---|---|---|
| Network hospitals | 14,000+ | 11,500+ |
| Claim settlement ratio (avg. of last 3 years) | 83% | 98% |
| Co-payment | 20% (if purchased after turning 61) | No |
| Room rent | Any Room (up to 1% of sum insured) | Any Room |
| Disease sub-limit | Yes | No |
| Pre existing diseases waiting | 3 years | 3 years |
| Pre/Post hospitalization | 30/60 days | 60/180 days |
| No claim bonus | 50% per year (up to 100%) | |
| Domiciliary | ||
| Ayush treatments | ||
| Restoration benefit | 100% restoration (once for any illness) | |
| Health check-up | Once every year | |
| Maternity | ||
| Out Patient Department | Available | |
| Day care |
Feature Comparison
Co payment
With a co-payment clause, the insurer will mandate that you pay a part of the bill. So if the bill adds up to Rs. 2,00,000 and the co-payment is set at 20% then you could be asked to pay Rs. 40,000 from the bill. In this case, however, Health Gain requires you to co-pay a part of the bill 20% if you purchase after turning 61 whereas Optima Restore doesn’t impose a co-payment clause
Room rent
If the policy does impose room rent restrictions then the insurer may only let you stay in a room of a certain specification or impose a cap on the total room rent. If you were to breach either criterion then the insurance company may ask you to pay a portion of all the expenses you incurred while staying in the room. In this case, however, Health Gain only lets you stay in a room whose rent doesn’t exceed 1% of the total sum insured but you can pick any room you want with Optima Restore.
Sub limits
Some policies will tell you that they will cover all medical expenses up until the sum insured, but then impose caps on the total costs you can incur while dealing with a very specific list of diseases. We call these caps “Disease Wise Sub Limits.” In this case, Health Gain imposes disease-wise sub-limits on Cataracts, Modern Treatments whereas Optima Restore doesn’t impose a disease wise sub-limit.
Waiting periods for pre-existing diseases
If you’re suffering from a lifestyle condition or if you’ve had surgery in the past, or if you’re dealing with an acute or chronic illness at the time of buying the policy, then the insurer may classify this as a pre-existing disease. And they may tell you that they will only cover these illnesses after some time. This cooling period is referred to as the Pre-existing-disease waiting period. In this case, Health Gain imposes a 3 year waiting period on pre-existing diseases and Optima Restore will similarly tell you to wait 3 years before making a claim related to your pre-existing diseases
Pre and post Hospitalization expenses
Most people aren’t hospitalized right off the bat. Instead, they’ll have to go through a whole series of diagnostic tests before hospitalization and take medication post-discharge. These costs are outlined as pre-hospitalization expenses and post-hospitalization expenses respectively. In this case, Health Gain covers expenses incurred 30 days before hospitalization and expenses incurred 60 days post-hospitalization. Meanwhile, Optima Restore covers expenses incurred 60 days before hospitalization and expenses incurred 180 after hospitalization, although there may be different sub-limits
No claim bonus
Some policies will tell you that they will incentivize you for not making a claim in any given year. And they offer such incentives by offering extra cover on top of the existing sum insured. This extra cover is categorized as a no-claim bonus. In this case, however, Health Gain doesn’t offer a no-claim bonus whereas Optima Restore offers a no-claim bonus.
Domiciliary
Imagine you are forced to treat yourself at home because you don’t find a hospital bed, or you have a chronic condition that prevents you from visiting one, then, insurers may choose to cover your treatment even if you’re hospitalized at home. And such costs are collectively categorized as domiciliary treatment costs. In this case, however, Health Gain doesn’t offer domiciliary protection whereas Optima Restore offers domiciliary cover.
Ayush treatments
Most policies only cover treatments administered in a registered medical facility. However, on some occasions, you may want to pursue alternative treatments including homoeopathy, Ayurveda, Unani and Siddha. These treatments are collectively categorized as Ayush treatments. And in this case, Health Gain covers Ayush procedures and Optima Restore also extends coverage for Ayush treatments.
Maternity benefits
If you’re hospitalized during childbirth, then you may have to incur significant costs during delivery of your newborn, child care and other related matters during the course of the hospitalization. These costs are collectively termed maternity costs. And in this case, neither Health Gain offers maternity cover nor does Optima Restore.
Out Patient Department (OPD)
Doctor visits and regular consultations aren’t usually covered by health insurance policies. They are categorized as Outpatient consultations (or OPD treatments) and patients have to bear the cost on their own. In this case, however, Health Gain offers OPD cover whereas Optima Restore doesn’t offer OPD protection.
Final Conclusion
If you’re specifically looking to buy a policy for those seeking outpatient coverage, Health Gain makes a lot of sense. But considering Star Health has a claim settlement ratio that can only be considered sub-par at best, we would still recommend going with anything that HDFC Ergo has to offer, if the policy is made available to you.
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