HDFC Ergo Health Optima Restore Insurance Plan
HDFC Ergo Health Optima Restore Insurance Plan is a Comprehensive Online Health Insurance Plan that provides comprehensive cover for the entire family.
How it works – This policy can be taken for self, spouse, dependent children and dependent parents. This policy covers all basic hospitalization expenses with the benefit of restoring the initial Basic Sum Assured if it is utilized for claim and upto 100% of Basic Sum Assured as No Claim Bonus is payable in this plan. The plan can be taken for an Individual or as a Family Floater. In a Family Floater policy, a maximum of 2 adults and a maximum of 5 children can be included in a single policy. You can opt for 1 Adult and 3 children also. The plan offer lifelong renewability. There is no claim-based loading. Also you can upgrade to the next higher slab of cover on renewal. Maternity related expenses are excluded in this plan as is the case with most plans.
There are 2 Unique Benefits in this plan:
- Restore Benefit: The Uniqueness in this plan is that in this plan, the Sum Assured is restored if it is exhausted that can be utilized for a future claim for a different illness is made during the same policy year. Thus, if the Initial Sum Assured gets exhausted, the entire amount is restored back into the plan at no extra cost!
Let us explain this with an example. If you have a Sum Assured of Rs 5 lakhs and Claim for Rs 6 lakhs in the first hospitalization, then the entire limit is exhausted and only Rs 5 lakhs would be payable. However, if another claim happens within the same year for a different illness or for a different family member, then the entire Sum Assured of Rs 5 lakhs is available for claim even though the initial Sum Assured has been exhausted.
However, the restore benefit works only if:
- The entire Basic Sum Assured is exhausted
- The claim is for a completely unrelated illness
- Multiplier Benefit: Another Unique Benefit of this plan is that for a claim free year, there is a 50% increase of the Basic Sum Assured as No Claim Bonus and if the consecutive year is also Claim Free then the total No Claim Bonus increases by 100% with a net effect of Double the Basic Sum Assured.
Let us explain this with an example. If you have a 5 lakh policy and don’t claim in the first year, the cover increases to Rs 7.5 lakhs in the second year which rises to Rs 10 lakhs in the third year for another consecutive claim free year while the premium is calculated only for a premium for Rs 5 lakhs of initial Basic Sum Assured.
In case of claim, the No Claim Bonus will be reduced by 50% of the basic sum insured. However this reduction will not reduce the Sum Insured below the basic Sum Insured of the policy.
This plan provides for regular features like pre-hospitalization, hospitalization and post hospitalization expenses without any cap on charges like doctor’s fees, OT charges, etc. as well as Day Care Treatment, Domiciliary Treatment, Organ Donor costs, etc.
- Restoration of the entire Sum Insured if used in the middle of the year at no additional cost
- No claim bonus increases the insurance cover by 50% for one claim free year and then 100% for the consecutive claim free year
- Lifelong renewal to stay insured forever
- No sub-limits on hospital room rent or co-pay required
- No loading on renewal premiums if a claim is made
- Cashless treatment across 4000 hospitals in more than 800 cities
- Wide cover for treatment against illnesses and accident
- Tax benefits
Additional Features of HDFC Ergo Health Optima Restore Insurance Policy
- Cashless Hospitalization
- Policy Term options of 1 or 2 years with a 7.5% Discount on 2 year policy terms
- Tax benefit on premiums paid under Section 80D of the Income Tax Act, 1961
- Free look period of 15 days from the receipt of policy documents
- No caps/limits on doctor/surgery fees, operation theatre, room rent and intensive care unit
- 7.5% Discount on 2 year policy terms and more
- There is No claim based loading in this plan
- Quick turnaround time with 90% of pre-authorization is done within 2 hours of intimation or hospitalization
- Easy upgrade: This health plan also comes with an easy upgrade option on policy renewal
What is covered in HDFC Ergo Health Optima Restore Insurance Plan?
This plan pays for:
- In-patient Treatment
- Pre-Hospitalization Coverage up to 60 Days
- Post-Hospitalization Coverage up to 180 Days
- Day Care Procedures for 140 listed day care procedures
- Domiciliary Treatment
- Organ Donor
- Emergency Ambulance Upto Rs.2,000 per Hospitalisation
Additional Benefits of HDFC Ergo Health Optima Restore Insurance Plan
- Restore Benefit where the Sum Assured is restored if it is exhausted that can be utilized for a future claim for a different illness is made during the same policy year. Thus, if the Initial Sum Assured gets exhausted, the entire amount is restored back into the plan at no extra cost!
- Multiplier Benefit where there is a 50% increase of the Basic Sum Assured as No Claim Bonus and if the consecutive year is also Claim Free then the total No Claim Bonus increases by 100% with a net effect of Double the Basic Sum Assured
Exclusions - What is not covered in HDFC Ergo Health Optima Restore Insurance Plan?
- Any treatment within first 30 days of cover except any accidental injury
- Any Pre-existing diseases/conditions will be covered after a waiting period of 3 years
- 2 years of exclusion for specific diseases like cataract, hernia, hysterectomy, joint replacement etc.
- Expenses arising from HIV or AIDS and related diseases
- Abuse of intoxicant or hallucinogenic substance like drugs and alcohol
- Pregnancy, dental treatment, external aids and appliances
- Hospitalization due to war or an act of war or due to nuclear, chemical or biological weapon and radiation of any kind
- Non-allopathic treatment, congenital diseases, mental disorder, cosmetic surgery or weight control treatments
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Eligibility and Restrictions of HDFC Ergo Health Optima Restore Insurance Plan
Sum Assured (in Rs)
Policy Term (in years)
Entry Age of Life Insured (in years)
Renewable till Age (in years)
2 Years Standard Exclusion
For specific diseases like cataract, hernia, hysterectomy, joint replacement etc.
Waiting Period for Pre-existing Illness
After continuous renewal of 3 years
30 days from the date of expiry to renew the policy
Sample illustration of Premium of HDFC Ergo Health Optima Restore Insurance Plan
The below illustration is for an individual of age 30, 40 and 50 years respectively opting for Sum Assured of Rs. 3 and 5 lakh.
What does HDFC Ergo Health Optima Restore Insurance plan cover?
In-patient care: Hospitalization expenses such as room rent, nursing expenses, ICU charges, surgeon’s fees, doctor’s fees, anaesthesia, blood, oxygen, operation theater charges, etc. with no sub-limits
Day care treatment: Medical expenses incurred if hospitalization is less than 24 hours for listed 140 procedures
Pre and Post hospitalization: Medical expenses incurred 60 days immediately before hospitalization will be covered. Expenses incurred up to 180 days after being discharged from the hospital such as follow-up visits to medical practitioner, medication, etc will be covered.
Ambulance charges: Charges of Ambulance provided by the hospital or any service provider will be reimbursed upto Rs 2000 for each hospitalization
Organ Donor Cover: Medical expenses incurred by an organ donor while undergoing the organ transplant surgery if the organ is for the use of the insured person.
Domiciliary Hospitalization: Medical expenses incurred by the insurer for treatment at home will be reimbursed. The medical treatment should be for a period exceeding 3 consecutive days and should merit hospitalization.
Restore of Sum Assured: If the Sum Assured in the policy is exhausted due to claims made, then the company restores the entire sum assured once in the policy year. This restores Sum Assured amount can be used for future claims, not related to the illness / injury for which the claim has already been made during the same year.
Multiplier Benefit: For a Claim Free year, there is a No Claim Bonus of 50% and another 50% of No Claim Bonus for the second consecutive Claim Free year of total 100% of Basic Sum Assured
Treatment anywhere in the country: For select diseases / ailments / treatments, the Company will reimburse the cost of medical expenses, whether the insured gets these treatments anywhere in India.
Family Floater Cover of HDFC Ergo Health Optima Restore Insurance Plan
Under this plan, any number of members of the immediate family (children, spouse and parents) can be covered in a single policy.
Exclusions of HDFC Ergo Health Optima Restore Insurance Plan
The standard policy exclusions are -
- Any pre-existing ailment/injury that was diagnosed/received within 48 months prior to issuance of the first policy
- Any diseases contracted during first 30 days of the policy start date except those arising out of accidents
- Non-allopathic treatment
- Expenses attributable to self-inflicted injury (resulting from suicide, attempted suicide)
- Expenses arising out of or attributable to alcohol or drug use/misuse/abuse
- Cost of spectacles/contact lenses, dental treatment
- Medical expenses incurred for treatment of AIDS
- Treatment arising from or traceable to pregnancy and childbirth, miscarriage, abortion and its consequences
- Congenital disease
- Tests and treatment relating to infertility and in vitro fertilization
- Some treatments such as non-infective arthritis, joint replacement etc., which are covered only after completion of 2 consecutive policy years
Frequently Asked Questions of HDFC Ergo Health Optima Restore Insurance Plan
What is the difference between a family floater and critical illness or hospital cash insurance?
The individual or family floater health insurance works on the principle of indemnity. This means that these insurance policies will pay you only what you have spent for medical treatment in hospital. On the other hand, the critical illness or the hospital cash insurance pays you the amount insured, irrespective of the amount spent for medical treatment. These are a benefit based policies.
Do I need to undergo a medical check-up while buying a health insurance policy?
You may be required to undergo a medical check-up after you buy, in case any member to be insured is above 45 age or for sum insured 7 Lakhs or above.
What is beneficial for me - floater insurance or an individual insurance?
Buying an individual cover or a floater cover is an individual’s perception. However, as a general rule, at younger ages floater cover is advisable. As you grow older, you should go for an individual cover.
What are the documents required for portability?
You can apply for Apollo Munich Optima Restore Plan under portability with following documents:
- Proposal form
- Portability form
- Last 3 year’s copy of expiring health insurance policy
- Copy of renewal notice
Tax Benefits of HDFC Ergo Health Optima Restore Insurance Plan
There is Tax Benefits under section 80D of the Income Tax under the existing tax laws of the Income Tax, 1961:
- Of Rs 15000 on the premium amount paid for Health Insurance Coverage of self, spouse and children
- An additional amount of Rs 15,000 for premium amount paid towards Health Insurance Coverage of parents
- Another additional Rs 5000 of deduction if either or both of the parents are Senior Citizen
Total Amount available for deduction under section 80D of the Income Tax Act, 1961 is Rs 20000 for Senior Citizen parents and Rs 15000 for self, spouse and children.