HDFC ERGO Health Insurance

HDFC Ergo Optima Restore Product Page

HDFC Ergo Optima Restore Product Page

HDFC Ergo Optima Restore Plan

Let’s Know The Plan Better!

HDFC Ergo's Optima Restore Plan provides comprehensive coverage that can be customised to meet the unique medical needs of both you and your family. There are several coverage options available with this plan, including Rs 3 lakhs, Rs 5 lakhs, Rs 10 lakhs, Rs 15 lakhs, Rs 20 lakhs, Rs 25 lakhs, and Rs 50 lakhs. With its lifelong renewal feature, you can be assured that you are always protected. The HDFC Ergo Optima Restore Plan offers exceptional discounts and benefits that will cater to all your healthcare needs and those of your family. With such a policy in place, you can be confident knowing that your and your family's health is in good hands.

Any Eligibility Requirements?

  • Minimum Age of Entry: The minimum age of entry is 91 days. In this policy, children between the ages of 91 days and five years can be insured as long as either of the parents is insured under the same policy.

  • Maximum Age of Entry: The maximum age of entry is 65 years.

Key Benefits And Limits!

HDFC Ergo’s Optima Restore Plan covers hospital expenses incurred when you are hospitalised for more than 24 hours including room boarding and nursing charges, medical practitioner’s fees, cost of prescribed medicines and drugs, ICU charges, and other related expenses.

Other than that, HDFC Ergo's Optima Restore Plan covers the following expenses -

  • Pre & Post Hospitalisation Expenses: You may incur certain expenses before and after you are hospitalised. The Optima Restore Plan covers your medical expenses for 60 days before you are hospitalised and 180 days after discharge up to the sum insured, allowing you to confidently manage the financial burden of your medical expenses. Keep in mind that the insurer will cover these expenses only if -

    They are related to the condition for which you are hospitalised, and

    Your claim is approved as an inpatient (when you are hospitalised for medical treatment for 24 hours or more) hospitalisation claim.

  • Daycare Treatment Coverage: Several medical treatments are carried out within 24 hours. No more extended stays in the hospital! These are known as daycare treatments, which provide you with the convenience of a shorter stay and greater flexibility in scheduling. The Optima Restore Plan covers all daycare procedures. No limit is placed on daycare treatment, which means all expenses will be covered up to the sum insured.

  • Domiciliary Treatment Coverage: These are medical treatments for illnesses or injuries that need hospitalisation but have to be carried out at home because -

    The patient is seriously ill/injured due to which they can’t be transported to a hospital, or

    No hospital beds are available in the vicinity. The Optima Restore Plan will cover domiciliary treatment costs up to the sum insured.

  • Organ Donor Coverage: The Optima Restore Plan covers the costs of harvesting an organ from a donor for transplantation (when the insured person is the recipient) up to the sum insured you pick.

  • Modern Treatment Coverage: Some really cool technological advancements are happening in medicine, paving the way for modern treatments that were once regarded as impossible. These treatments have entirely transformed the way diseases and illnesses are treated, providing you with more effective and efficient care. With the Optima Restore Plan, you can claim the expenses associated with modern treatments up to the sum insured.

  • Non-Medical Expenses: Consumable items such as gloves, oxygen masks, nebulizer kits, and other medical supplies are considered non-medical expenses. The Optima Restore Plan covers non-medical expenses up to the sum insured if you opt for an add-on - providing comprehensive protection even for costs beyond medical expenses.

  • Preventative Health Check-Up: The Optima Restore Plan offers a preventative health check-up benefit at renewal. It is a great way to keep a tab on your overall health and well-being, and is available to you, regardless of whether you have made any claims.

    You get the benefit once at -

    The end of every two policy years if your basic sum insured is Rs. 5 lakhs.

    The end of each year if your basic sum insured is Rs. 10 lakhs and above.

  • Multiplier Benefit: If you don't make a claim during a policy year, the Optima Restore Plan will boost your sum insured by 50%, which can go up to a maximum of 100%. When a claim is made during a policy year, the bonus under this benefit will be reduced by 50% for the following year. However, this reduction won’t lower the sum insured below its original level.

  • Restoration Benefit: This feature restores your sum insured once you use it up in the policy year. The Optima Restore Plan restores 100% of your basic sum insured and helps you focus on your health without worrying about running out of coverage. The Restoration Benefit kicks in once the Basic Sum Insured and Multiplier Benefit (if any) have been partially or completely utilised, and will be available for subsequent claims under the inpatient benefit. As long as you renew your policy every year, you can use the Restoration Benefit once every policy year for the rest of your life.

    Furthermore, if you choose the Unlimited Restore (optional benefit), you get access to unlimited restorations in a policy year. At an affordable cost. This ensures that you have unlimited coverage for your hospitalisation expenses. Hello, quality healthcare!

  • Room Rent Limit: This is the maximum amount your insurance will cover for the room you are staying in while you are hospitalised. If you select a room within your plan's room rent limit, you won’t have to pay anything. You will, however, be subject to a proportionate deduction if you choose a room that goes beyond what you are eligible for. So, you will have to pay a proportionate share of the entire bill, not just the difference in room rent. The Optima Restore Plan lets you choose any type of room including shared room, single room, deluxe room, or any room that’s available without any restrictions. Sweet!

Some Other Features You Should Know About!

  • Zero Financial Limits On Treatments/Diseases: Your insurance company won't deny you coverage for any diseases if they don't explicitly state the same otherwise. The policy does not apply sub-limits based on treatment or diseases, like cataract treatments, knee replacement surgery, etc.

  • No Geography-Based Sub-Limits: No matter where you buy the policy, you can get treated anywhere you want without worrying about additional co-pays or sub-limits.

  • Discount For Staying Active: The Optima Restore Plan also offers a discount at each renewal if you maintain a specified average step count on the mobile app provided by the insurer within a given time period. It offers up to a whopping 8% discount, letting you enjoy the benefits of staying active while saving some money.

    The following table shows the renewal discount based on the average number of steps:

    Average Step Count Renewal Discount
    > 5000 steps 0%
    5001 steps to 8000 steps 2%
    8001 steps to 10,000 steps 5%
    < 10,000 steps 8%

Waiting Periods You Should Know About!

Some illnesses and diseases may not be covered for a certain period of time after purchasing a health insurance policy. This is known as the waiting period. These conditions can be claimed once this period ends. Some of the types of waiting periods include -

  • Initial Waiting Period: All medical conditions except accidents have an initial waiting period of 30 days. So, hospitalisation claims will not be accepted for the first 30 days, except in the event of an accident.

  • Waiting Period For Pre-Existing Diseases: A Pre-existing Disease (PED) is any medical condition or illness that you have had in the 48 months prior to issuance of the health insurance policy. The Optima Restore Plan has a 36-month waiting period for pre-existing diseases. Any expenses arising out of such conditions will not be covered during this timeframe.

  • Waiting Period For Specific Diseases: Insurance companies will have a list of medical conditions or illnesses other than PEDs that will be subject to a waiting period regardless of whether or not you have experienced those in the past. This waiting period is set by your insurer and has no bearing on your health status. Specific diseases are subject to a 24-month waiting period under the Optima Restore Plan.

The Optima Restore Plan Won’t Cover This!

Exclusions are those situations where your health insurance policy will not provide coverage under any circumstances. You need to make note of them, as they can significantly impact the scope of your coverage.

Here are some types of exclusions -

  • Standard Permanent Exclusions: All insurance companies are bound to enforce the IRDAI's list of 'standard permanent exclusions'. Here are some of them:

  • Investigation and evaluation: Admission to a hospital for the sole purpose of observation and monitoring.

  • Plastic/cosmetic surgery: Treatment or surgery aimed at changing the appearance or characteristics of the body.

  • Profession in hazardous or adventure sports: Treatment costs associated with engaging in adventure activities as a professional such as river rafting, mountaineering, scuba diving, horse racing, etc.

  • Rehabilitation, rest cure, and respite care: Hospitalisation for bed rest with no active treatment involved.

  • Overweight/obesity: Treatment or surgery intended for weight control or obesity.

  • Change of gender treatment: Treatment developed to modify the body's characteristics to those of the opposing gender.

  • An act of breach of law: Costs associated with treating a person who has committed a criminal act or attempted to do so.

  • Refractive error: The cost of correcting up to 7.5 diopters of refractive error in order to improve vision.

  • Unproven treatments: Procedures, surgeries, or treatments that have not been proven successful.

  • Costs related to birth control and infertility: Contraception, sterilisation, artificial insemination, advanced reproductive technologies such as IVF, ZIFT, GIFT, ICSI, gestational surrogacy, etc.

  • Excluded providers: Treatment or services provided by doctors or hospitals excluded from the insurance policy.

  • Dietary supplements, substances purchased without a prescription: Supplements such as vitamins and minerals that are not prescribed by a physician.

  • Narcotics: Addiction treatment for alcoholism, drug abuse, etc.

  • Treatment in domestic establishments: The cost of treatment received in health spas, nursing homes, or similar establishments - primarily for domestic purposes.

  • Expenses associated with maternity care: Pre/post-natal costs, childbirth-related hospitalisation expenses, etc.

  • Additional Permanent Exclusions: Some insurance companies may lay down additional exclusions for particular situations or medical conditions. In case you suffer from a condition or disease that the insurer thinks to be too risky to cover, they can exclude the same from your plan’s coverage. Insurers can, however, apply permanent exclusions only to illnesses listed by the Insurance Regulatory and Development Authority of India (IRDAI).

  • Non-Standard Exclusions (Specific Exclusions): Exclusions that go beyond the IRDAI's standard permanent exclusions are specific exclusions. It is important to note that these exclusions may vary among insurance companies and may also be determined by the policy terms and conditions. These are some of the top specific exclusions under the Optima Restore Plan:

  • Any treatment caused by an act of war, invasion, nuclear weapon usage, etc.

  • Non-allopathic treatment.

  • Expenses associated with prosthetics and other devices that can be detached or removed without requiring anaesthesia.

  • Treatments for intentional self-injury or attempted suicide.

  • Treatment for injuries/illness arising out of participating or involving in a naval, military, or air force operation.

  • Treatment received outside of India.

  • Treatment for sleep apnoea.

  • Treatments related to external congenital diseases, defects, or anomalies.

  • Healthcare provided in a facility that is not a hospital.

  • Any dental treatment or surgery, unless it requires hospitalisation.

  • Circumcision (unless it is a medical necessity and is part of the treatment).

  • Costs associated with preventive care, vaccination including inoculation and immunisations (except in case of post-bite treatment).

  • Any costs you incur that are associated with donating an organ.

A Quick Recap Of The Benefits & Limits!

Check out this table showing the product benefits and their respective coverage limits:

Product Benefits Coverage Limits
Pre-Hospitalisation Expenses 60 days up to the sum insured
Post-Hospitalisation Expenses 180 days up to the sum insured
Daycare Treatment Coverage Up to the sum insured
Domiciliary Treatment Coverage Up to the sum insured
Organ Donor Coverage Harvesting expenses up to the sum insured
Non-Medical Expenses Covered up to the sum insured, if you opt for an add-on
Preventive Health Check-Up Once at the end of every two policy years on a sum insured of Rs 5 lakhs; Once at the end of each year on a sum insured of Rs 10 lakhs and above
Modern Treatment Coverage Up to the sum insured
Room Rent Limit No limit
Restoration Benefit Up to 100% of the sum insured
Multiplier Benefit A bonus of 50% of the sum insured for every policy year without a claim, max up to 100%.
Pre-existing Disease Covered after a 36-month waiting period
Specified Treatment Covered after a 24-month waiting period
Questions about Car Insurance

FAQs

The Optima Restore Plan offers you health insurance coverage up to Rs 50 lakhs, giving you the assurance of a high level of protection during medical treatments.

No. The Optima Restore Plan does not impose any restrictions on the room type you choose. You are free to go with the one that best suits your needs, be it a single private room, a deluxe room, etc.

No. The Optima Restore Plan does not cover AYUSH or alternative or non-allopathic treatments.

Yes. But, the consumable coverage is available as an add-on at an extra cost.

You can use the restore benefit once every year for the rest of your life as long as you keep renewing your policy. Moreover, you will receive unlimited restorations in a policy year if you choose the Unlimited Restore (optional benefit). This allows you to have complete peace of mind knowing that you'll never be without coverage.