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Customer Information Sheet: HDFC ERGO General Insurance Company Limited

The document summarizes the key features of the Optima Restore health insurance policy from HDFC ERGO General Insurance Company. It covers expenses for hospitalization, pre- and post-hospitalization, day care procedures, domiciliary treatment, organ donor expenses, ambulance cover, daily cash for shared accommodation, e-opinion for critical illnesses, emergency air ambulance, and restore benefit. Major exclusions include war, nuclear hazards, intentional self-injury, and alcohol/drug abuse. There is a 30-day waiting period for illnesses and 24 months for specific treatments. The policy renews lifelong subject to payment of renewal premium. Renewal benefits include increased sum insured for claim-free years and preventive health check-

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0% found this document useful (0 votes)

93 views33 pages

Customer Information Sheet: HDFC ERGO General Insurance Company Limited

Uploaded by

Kiran Golwad

We take content rights seriously. If you suspect this is your content, claim it here.

Available Formats

Download as PDF, TXT or read online on Scribd

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HDFC ERGO General Insurance Company Limited

Customer Information Sheet

Optima Restore

DESCRIPTION IS ILLUSTRATIVE AND NOT EXHAUSTIVE

TITLE DESCRIPTION REFER TO POLICY

CLAUSE NUMBER
Product Name Optima Restore
What am I a. In-patient Treatment– Covers hospitalisation expenses for Section B-1.i
covered for: period more than 24 hrs.
b. Pre-Hospitalisation- Medical expenses incurred in 60 Section B-1.ii
days before the hospitalisation.
c. Post-Hospitalisation- Medical expenses incurred in 180 Section B-1.iii
days after the hospitalisation.
d. Day-Care procedures– Medical expenses for day care Section B-1.iv
procedures.
e. Domiciliary Treatment- Medical expenses incurred Section B-1.v
for availing medical treatment at home which would
otherwise have required hospitalisation.
f. Organ Donor- Medical expenses on harvesting the organ Section B-1.vi
from the donor for organ transplantation.
g. Ambulance cover– Upto Rs. 2,000 per hospitalisation Sectio B-1.vii
for utilizing ambulance service for transporting insured
person to hospital in case of an emergency.
h. Daily Cash for choosing shared accommodation- Daily Section B-1.viii
cash amount if hospitalised in shared accommodation in
network hospital and hospitalisation exceeds 48 hrs
i. E-Opinion in respect of a Critical Illness – Second opinion Section B-1.ix
by a Medical Practitioner from Our panel, for a Critical
Illness suffered during the policy period.
j. Emergency Air Ambulance Cover- covers, Expenses for Section B-1.x
ambulance transportation in an airplane or helicopter for
emergency life threatening health conditions.
k. Restore Benefit- Instant addition of 100% Basic Sum Section B-2
Insured on complete or partial utilization of Your existing
Policy Sum Insured and Multiplier Benefit (if applicable)
AUG2021

during the Policy Year. The Restore Sum Insured can be

used for all claims under Inpatient Benefit. If the Restore
Sum Insured is not utilized in a Policy Year, it will expire.
CIS/Ver -1

You must submit a duly filled claim form along with

specified documents under the policy within 30 days from
date of discharge. Any additional information requested
must be submitted within 15 days of Our request
Insured’s Free Look: You have a period of 15 days from the date Section D
Rights of receipt of the Policy document to review the terms and
conditions of this Policy. If You have any objections to any of
the terms and conditions, You have the option of cancelling
the Policy stating the reasons for cancellation and You
will be refunded the premium paid by You after adjusting
the amounts spent on any medical check-up, stamp duty
charges and proportionate risk premium.

The policy shall ordinarily be renewable except on grounds

of fraud, misrepresentation by the insured person.

Claims-
For Cashless Claims: We will check your coverage as per
the eligibility and send an authorization letter to the provider.
In case there is any deficiency in the documents sent, the
same shall be communicated to the hospital within 6 hours
of receipt of documents.

For Reimbursement Claims: On receipt of the complete

set of claim documents, we will make the payment for the
admissible amount, along with a settlement statement
within 30 days.
Insured’s Please disclose all pre-existing disease/s or condition/s Section D
Obligations before buying a policy. Non-disclosure may result in claim
not being paid.
Disclosure of material facts sought to be declared on the
proposal form.

Pre-Policy Check-up at our network may be required based upon the age and Basic Sum Insured. We
will reimburse 100% of the expenses incurred on the acceptance of the proposal. The medical reports
are valid for a period of 90 days from the date of Pre-Policy Check-up.

In order to be eligible for portability benefits you may apply 45 days in advance of the policy renewal
date.

(LEGAL DISCLAIMER) NOTE: The information must be read in conjunction with the product brochure
and policy document. In case of any conflict between the Key featured document and the policy
document the terms and conditions mentioned in the policy document shall prevail.

Premium illustration for Delhi, National Capital Region & Mumbai metropolitan region

Tenure - 1 Year

Age Coverage opted Coverage opted on individual basis Coverage opted on family floater basis
of the on individual ba- covering multiple members of the with overall Sum Insured (only one Sum
members sis covering each family under a single policy (Sum Insured is available for the entire family)
insured member of the Insured is available for each member
(in Years) family separately of the family)
(at a single point
in time)
Premium Sum Premium Family Premium Sum Premium or Floater Premium Sum
(Rs.) Insured (Rs.) Dis- after Insured onsolidated Dis- after Insured
in count of discount in premium count if discount in
Lakhs 10% (Rs.) Lakhs for all any (Rs.) Lakhs
(Rs.) (Rs.) family (Rs.)
members
of the fami-
ly (Rs.)

7 6,279 5 6,279 628 5,651 5 17,108 NA 17,108 5

10 6,279 5 6,279 628 5,651 5 NA

35 7,502 5 7,502 750 6,752 5 NA

40 8,489 5 8,489 849 7,640 5 NA

28,549 25,694 17,108

Total premium for Total premium for all members of the fam- Total premium when policy is opted on
all members of ily is Rs.25,694 when they are covered floater basis is Rs.17,108
the family is Rs. under a single policy.
28,549 when each
member is covered
separately.
Sum Insured Sum Insured available for each individual Sum Insured of Rs. 5 Lakhs is available for
available for each is Rs. 5 Lakhs. the entire family.
individual is Rs. 5
Lakhs

Premium as mentioned above are exclusive of taxes.

Above premium examples are for Illustration purpose only, terms and conditions apply.

Section A Definitions 3
1 Standard Definitions 3
2 Standard Definition: Critical illness 7
3 Specific Definitions 10
Section B Benefits 11
1 In-patient Benefits 11
i In-patient Treatment 11
ii Pre-Hospitalisation 12
iii Post-Hospitalisation 12
iv Day Care Procedures 12
v Domiciliary Treatment 12
vi Organ Donor: 13
vii Ambulance Cover 13
viii Daily Cash 14
ix E-Opinion in respect of a Critical Illness 14
x Emergency Air Ambulance Cover 15
2 Restore Benefit 16
3 Preventive Health Check-up 16
4 Multiplier Benefit 17
Section C Waiting Period & Exclusions 17
1 Standard Waiting Period 17
2 Standard Exclusions 19
Non-Medical Exclusions 21
Medical Exclusions 21
3 Specific Exclusions 22
Medical Exclusions 23
Specific Exclusions 23
Section D Terms & Clauses 24
1 Standard Terms and Conditions 24
2 Specific General Conditions 24
Section E Other Terms & Conditions 36
Contact Us 36
Ombudsman details 36

HDFC ERGO General Insurance Company Limited. IRDAI Reg. No.146 CIN: U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor,
HDFC House, 165-166 Backbay Reclamation, H. T. Parekh Marg, Churchgate, Mumbai – 400 020. Trade Logo displayed above belongs to
HDFC Ltd and ERGO International AG and used by the Company under license. UIN: Optima Restore - HDHHLIP21322V062021
1
applicable, and is under the supervision of a
Preamble
registered and qualified medical practitioner AND
HDFC ERGO General Insurance Company Limited will cover must comply with all minimum criteria as under-
all the Insured Persons under this Policy upto the Sum Insured.
- has qualified nursing staff under its
The insurance cover is governed by, and subject to, the terms,
employment;
conditions and exclusions of this Policy.
- has qualified medical practitioner/s in charge;
- has a fully equipped operation theatre of its
Section A. Definitions
own where surgical procedures are carried
out;
The terms defined below and at other junctures in the Policy - maintains daily records of patients and will
Wording have the meanings ascribed to them wherever they make these accessible to the insurance
appear in this Policy and, where appropriate, references to company’s authorized personnel
the singular include references to the plural; references to
Def. 9. Day Care Procedures means those medical
the male include the female and references to any statutory
treatment, and/or surgical procedure
enactment include subsequent changes to the same:
i. which is undertaken under General or Local
Anaesthesia in a Hospital/day care centre in
1. Standard Definitions less than 24 hours because of technological
advancement,
Def. 1. Accident means a sudden, unforeseen and ii. which would have otherwise required a
involuntary event caused by external, visible and Hospitalisation of more than 24 hours.
violent means. Treatment normally taken on an Out-patient
Def. 2. Any one illness means continuous Period of illness basis is not included in the scope of this
and it includes relapse within 45 days from the definition
date of last consultation with the Hospital/Nursing Def.10. Deductible means a cost-sharing requirement under
Home where treatment was been taken. a health insurance policy that provides that the
Def. 3. Cashless facility means a facility extended by the insurer will not be liable for a specified rupee amount
insurer to the insured where the payments, of the in case of indemnity policies and for a specified
costs of treatment undergone by the insured in number of days/hours in case of hospital cash
accordance with the policy terms and conditions, policies which will apply before any benefits are
are directly made to the network provider by the payable by the insurer. A deductible does not reduce
insurer to the extent pre-authorization approved. the Sum Insured.
Def. 4. Condition Precedent means a policy term or Def.11. Dental treatment means a treatment related to
condition upon which the Insurer’s liability under the teeth or structures supporting teeth including
policy is conditional upon. examinations, filings (where appropriate), crowns,
Def. 5. Congenital Anomaly refers to a condition(s) which extractions and surgery.
is present since birth, and which is abnormal with Def.12. Domiciliary Hospitalisation medical treatment for an
reference to form, structure or position illness/disease/injury which in the normal course
(a) Internal Congenital Anomaly - Congenital would require a care and treatment at a Hospital
Anomaly which is not in the visible and but is actually taken while confined at home under
accessible parts of the body any of the following circumstances:
(b) External Congenital Anomaly- Congenital • The condition of the patient is such that he/
Anomaly which is in the visible and accessible she is not in a condition to be removed to a
parts of the body hospital, or
Def. 6. Co-payment means a cost-sharing requirement • The patient takes treatment at home on
under a health insurance policy that provides that account of non-availability of a room in a
the policyholder/insured will bear a specified hospital
percentage of the admissible claim amount. A Def.13. Emergency Care means management for a severe
co-payment does not reduce the Sum Insured. illness or injury which results in symptoms which
PWW/Ver - 1 AUG2021

Def. 7. Cumulative Bonus (Multiplier Benefit) means any occur suddenly and unexpectedly, and requires
increase in the Sum Insured granted by the insurer immediate care by a medical practitioner to prevent
without an associated increase in premium. death or serious long term impairment of the insured
person’s health.
Def. 8. Day Care centre means any institution established
for day care treatment of illness and/or injuries or a Def.14. Grace Period means the specified period of time
medical setup within a hospital and which has been immediately following the premium due date during
registered with the local authorities, wherever which a payment can be made to renew or continue
a Policy in force without loss of continuity benefits

HDFC ERGO General Insurance Company Limited. IRDAI Reg. No.146 CIN: U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor,
HDFC House, 165-166 Backbay Reclamation, H. T. Parekh Marg, Churchgate, Mumbai – 400 020. Trade Logo displayed above belongs to
HDFC Ltd and ERGO International AG and used by the Company under license. UIN:Optima Restore - HDHHLIP21322V062021
2
such as waiting periods and coverage of Pre-Existing - it requires rehabilitation for the patient or for
Diseases. Coverage is not available for the period the patient to be specially trained to cope with
for which no premium is received. it
Def.15. Disclosure of information norm means the policy - it continues indefinitely
shall be void and all premiums paid hereon shall be - it recurs or is likely to recur
forfeited to the Company, in the event of
misrepresentation, mis-description or non-disclosure Def.19. Injury means accidental physical bodily harm
of any material fact. excluding illness or disease solely and directly
caused by external, violent and visible and evident
Def.16. Hospital means any institution established for in- means which is verified and certified by a Medical
patient care and day care treatment of illness Practitioner.
and/or injuries and which has been registered
as a hospital with the local authorities under the Def.20. In-patient Care means treatment for which the
Clinical Establishments (Registration and Insured Person has to stay in a Hospital for more
Regulation) Act, 2010 or under the enactments than 24 hours for a covered event.
specified under the Schedule of Section 56(1) of the Def.21. Intensive Care Unit means an identified section,
said Act OR complies with all minimum criteria as ward or wing of a Hospital which is under the
under: constant supervision of a dedicated Medical
• has qualified nursing staff under its employment Practitioner(s), and which is specially equipped
round the clock, for the continuous monitoring and treatment of
patients who are in a critical condition, or require life
• has at least 10 in-patient beds, in those towns support facilities and where the level of care and
having a population of less than 10,00,000 supervision is considerably more sophisticated and
and 15 in-patient beds in all other places intensive than in the ordinary and other wards.
• has qualified Medical Practitioner(s) in charge Def.22. ICU (Intensive Care Unit) Charges means the
round the clock, amount charged by a Hospital towards ICU
• has a fully equipped operation theatre of its expenses which shall include the coverage for
own where surgical procedures are carried bed, general medical support services provided to
out, any ICU patient including monitoring devices, critical
• maintains daily records of patients and will care nursing and intensive charges.
make these accessible to the insurance Def.23. Maternity expenses means
company’s authorized personnel. i. medical treatment expenses traceable to
Def.17. Hospitalisation means admission in a Hospital for childbirth (including complicated deliveries and
a minimum of 24 consecutive ‘In-patient Care’ hours caesarean sections during hospitalization);
except for specified procedures / treatments,
where such admission could be for a period of less ii. expenses towards lawful medical termination
than 24 consecutive hours. of pregnancy during the Policy Period.
Def.18. Illness means a sickness or a disease or Def.24. Medical Advice means any consultation or advise
pathological condition leading to the impairment of from a Medical Practitioner including the issue of
normal physiological function and requires medical any prescription or repeat prescription.
treatment Def.25. Medical Expenses means those expenses that
a) Acute Condition- Acute condition is a disease, an Insured Person has necessarily and actually
illness or injury that is likely to respond quickly incurred for medical treatment on account of illness
to treatment which aims to return the person or Accident on the advice of a Medical Practitioner,
to his or her state of health immediately before as long as these are no more than would have been
suffering the disease/illness/injury which leads payable if the Insured Person had not been insured
to full recovery. and no more than other Hospitals or doctors in
b) Chronic Condition- A chronic condition is the same locality would have charged for the same
defined as disease, illness, or injury that has medical treatment.
one or more of the following characteristics: Def.26. Medically Necessary Treatment means any
- it needs ongoing or long-term monitoring treatment, test, medication, or stay in Hospital or
through consultations, examinations, check- part of stay in Hospital which
ups, and / or tests • Is required for the medical management of the
- it needs ongoing or long-term control or relief Illness or injury suffered by the Insured ;
of symptoms • Must not exceed the level of care necessary
to provide safe, adequate and appropriate
medical care in scope, duration or intensity.

HDFC ERGO General Insurance Company Limited. IRDAI Reg. No.146 CIN: U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor,
HDFC House, 165-166 Backbay Reclamation, H. T. Parekh Marg, Churchgate, Mumbai – 400 020. Trade Logo displayed above belongs to
HDFC Ltd and ERGO International AG and used by the Company under license. UIN: Optima Restore - HDHHLIP21322V062021
3
• Must have been prescribed by a Medical Hospitalisation was required, and
Practitioner. ii. The In-patient Hospitalization claim for such
• Must conform to the professional standards Hospitalization is admissible by the Insurance
widely accepted in international medical Company
practice or by the medical community in India. Def.37. Post- Hospitalisation Medical Expenses means
Def.27. Medical Practitioner means a person who holds medical expenses incurred during predefined
a valid registration from the medical council of any number of days immediately after the insured person
state or medical council of India or council for Indian is discharged from the hospital provided that:
medicine or for homeopathy set up by the i. Such Medical Expenses are for the same
government of India or a state government and is condition for which the insured person’s
thereby entitled to practice medicine within its hospitalization was required, and
jurisdiction; and is acting within the scope and
jurisdiction of license. ii. The inpatient hospitalization claim for such
hospitalization is admissible by the insurance
Def.28. Migration means the right accorded to individual company
health insurance policyholders (including all
members under family cover and members of group Def.38. Qualified Nurse is a person who holds a valid
health insurance policy) to transfer the credits gained registration from the nursing council of India or the
for pre-existing conditions and time-bound nursing council of any state in India
exclusions, with the same insurer. Def.39. Reasonable & Customary Charges means the
Def.29. Network Provider means Hospital enlisted by an charges for services or supplies, which are the
insurer or a TPA or jointly by an insurer and a TPA to standard charges for a specific provider and
provide medical services to an insured by a cashless consistent with the prevailing charges in the
facility geographical area for identical or similar services,
taking into account the nature of illness/ injury
Def.30. New Born Baby means baby born during the Policy involved.
Period and is aged up to 90 days.
Def.40. Room Rent means the amount charged by a hospital
Def.31. Non Network Provider means any Hospital, day care towards room and boarding expenses and shall
centre or other provider that is not part of the Network include associated medical expenses.
Def.32. Notification of Claim means the process of intimating Def.41. Renewal means the terms on which the contract of
a claim to the insurer or TPA through any of the insurance can be renewed on mutual consent with a
recognized modes of communication. provision of grace period for treating the renewal
Def.33. OPD treatment means the one in which the Insured continuous for the purpose of gaining credit for pre-
visits a clinic / hospital or associated facility like a existing diseases, time bound exclusions and for all
consultation room for diagnosis and treatment based waiting periods.
on the advice of a Medical Practitioner. The Insured Def.42. Surgery or Surgical Procedure means manual and/
is not admitted as a day care or in-patient or operative procedure(s) required for treatment
Def.34. Portability means the right accorded to individual of an Illness or injury, correction of deformities and
health insurance policyholders (including all defects, diagnosis and cure of diseases, relief from
members under family cover) to transfer the credits suffering or prolongation of life, performed in a
gained for pre-existing conditions and time-bound Hospital or day care centre by a Medical Practitioner.
exclusions, from one insurer to another insurer. Def.43. Unproven/Experimental treatment means treatment
Def.35. Pre-existing Disease means any condition, ailment, including drug experimental therapy which is not
injury or disease: based on established medical practice in India, is
a) That is/are diagnosed by a physician within treatment experimental or unproven.
48 months prior to the effective date of the
policy issued by the insurer or its reinstatement
2. Standard Definition: Critical illness
b) For which medical advice or treatment was
recommended by, or received from, a
physician within 48 months prior to the Def.1. Critical Illness means Cancer of specified severity,
effective date of the policy issued by the Open Chest CABG, First Heart Attack of specified
insurer or its reinstatement. severity, Kidney Failure requiring regular dialysis,
Def.36. Pre- Hospitalisation Medical Expenses means the Major Organ/Bone Marrow Transplant, Multiple
medical expenses incurred during predefined Sclerosis with Persisting Symptoms, Permanent
number of days preceding the hospitalization of the Paralysis of Limbs, Stroke resulting in Permanent
Insured Person, provided that: Symptoms as defined below only:

i. Such Medical Expenses are incurred for the

same condition for which the Insured Person’s

• All tumours in the presence of HIV infection. The undergoing of a transplant must be
confirmed by specialist medical practitioner.
Def.3. Open Chest CABG:
The following are excluded:
The actual undergoing of open chest surgery for
the correction of one or more coronary arteries, • Other Stem-cell transplants
which is/are narrowed or blocked, by coronary artery • Where only islets of langerhans are
bypass graft (CABG). The Diagnosis must be transplanted
supported by coronary angiography and realisation Def.7. Multiple Sclerosis with Persisting Symptoms:
of the surgery has to be confirmed by a specialist
The definite occurrence of Multiple Sclerosis.The
Medical Practitioner
diagnosis must be supported by all of the following:
The following are excluded:
• Investigation including typical MRI and CSF
• Angioplasty and / or Any other intra-arterial findings, which unequivocally confirm the
procedures diagnosis to be multiple Sclerosis.
• Any Key-hole surgery or laser surgery • There must be current clinical impairment of
Def.4. First Heart Attack of Specified Severity: motor or sensory function, which must have
The first occurrence of myocardial infarction which persisted for a continuous period of atleast 6
means the death of a portion of the heart muscle as months.
a result of inadequate blood supply to the relevant • We l l d o c u m e n t e d c l i n i c a l h i s t o r y o f
area. exacerbations and remissions of said
The diagnosis for this will be evidenced by all of the symptoms or neurological deficits with atleast
following criteria: two clinically documented episodes atleast 1
month apart.
• A history of typical clinical symptoms
consistent with the diagnosis of Acute Excluded is:
Myocardial Infarction (for e.g. typical chest • Other causes of neurological damage such
pain). as SLE and HIV are excluded
• New characteristic electrocardiogram
changes.

HDFC ERGO General Insurance Company Limited. IRDAI Reg. No.146 CIN: U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor,
HDFC House, 165-166 Backbay Reclamation, H. T. Parekh Marg, Churchgate, Mumbai – 400 020. Trade Logo displayed above belongs to
HDFC Ltd and ERGO International AG and used by the Company under license. UIN: Optima Restore - HDHHLIP21322V062021
5
Def.8. Permanent Paralysis of Limbs: ii) Your children Aged between 91 days and 25
Total and irreversible loss of use of two or more limbs years if they are unmarried
as a result of injury or disease of the brain or spinal iii) Your natural parents or parents that have
cord. A specialist Medical Practitioner (Physician legally adopted You, provided that the parent
/ Neurologist) must be of the opinion that paralysis was below 65 years at his initial participation
will be permanent with no hope of recovery and must in the Optima Restore Policy.
be present for more than 3 months. iv) Your Parent -in-law as long as Your spouse
Def.9. Stroke resulting in Permanent Symptoms: continues to be married to You and were below
Any cerebrovascular incident producing permanent 65 years at his initial participation in the Optima
neurological sequelae. This includes infarction Restore Policy.
of brain tissue, thrombosis in an intra-cranial vessel, All Dependent parents must be financially dependent
haemorrhage and embolisation from an extracranial on You.
source. Def.8. Dependent Child means a child (natural or legally
The diagnosis has to be confirmed by a specialist adopted), who is unmarried, Aged between 91 days
Medical Practitioner and evidenced by typical clinical and 25 years, financially dependent on the primary
symptoms as well as typical findings in CT Scan or Insured or Proposer and does not have his / her
MRI of the brain. independent sources of income.
Evidence of permanent neurological deficit lasting Def.9. Family Floater means a Policy described as such
for atleast 3 months has to be produced. in the Schedule where under You and Your
The following are excluded: Dependents named in the Schedule are insured
under this Policy as at the Commencement Date.
• Transient ischemic attacks (TIA) The Sum Insured for a Family Floater means the
• Traumatic injury of the brain sum shown in the Schedule which represents Our
• Vascular diseases affecting only the eye or maximum liability for any and all claims made by
optic nerve or vestibular functions You and/or all of Your Dependents during the Policy
Period.
Def.10. Insured Person means You and the persons named
3. Specific Definitions
in the Schedule.
Def.11. Material Facts means all relevant information sought
Def.1. Adventurous/Hazardous Sports means any sport or by the Company in the Proposal Form and other
activity involving physical exertion and skill in which connected documents to enable it to take informed
an Insured Person participates or competes for decision in the context of underwriting the risk.
entertainment or as part of his Profession whether
Def.12. Policy means Your statements in the proposal
he / she is trained or not.
form (which are the basis of this Policy), this policy
Def.2. Age or Aged means completed years as at the wording (including endorsements, if any), Annexure
Commencement Date. 1 and the policy schedule (as the same may be
Def.3. Alternative treatments means forms of treatments amended from time to time).
other than treatment “Allopathy” or “modern Def.13. Policy Period means the period between the
medicine” and includes Ayurveda, Unani, Sidha and Commencement Date and the Expiry Date specified
Homeopathy in the Indian context in the Schedule.
Def.4. Bank Rate means the rate fixed by the Reserve Bank Def.14. P o l i c y Ye a r m e a n s a y e a r f o l l o w i n g t h e
of India (RBI) at the beginning of the financial year Commencement Date and its subsequent annual
in which claim has fallen due. anniversary.
Def.5. Commencement Date means the commencement Def.15. TPA means the third party administrator that We
date of this Policy as specified in the Schedule. appoint from time to time as specified in the
Def.6. Contribution means essentially the right of an insurer Schedule.
to call upon other insurers liable to the same insured Def.16. We/Our/Us means the HDFC ERGO General
to share the cost of an indemnity claim on a rateable Insurance Company Limited
proportion of Sum Insured. This clause shall not
Def.17. You/Your/Policyholder means the person named in
apply to any Benefit offered on fixed benefit basis.
the Schedule who has concluded this Policy with
Def.7. Dependents means only the family members listed Us.
below:
i) Your legally married spouse as long as she
continues to be married to You;

HDFC ERGO General Insurance Company Limited. IRDAI Reg. No.146 CIN: U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor,
HDFC House, 165-166 Backbay Reclamation, H. T. Parekh Marg, Churchgate, Mumbai – 400 020. Trade Logo displayed above belongs to
HDFC Ltd and ERGO International AG and used by the Company under license. UIN:Optima Restore - HDHHLIP21322V062021
6
Section B. Benefits ii. Pre-Hospitalisation Claims which have NOT
Expenses for been admitted under 1 i)
consultations, and 1 iv).
1. In-patient Benefits investigations and Expenses not related to
medicines incurred upto the admission and not
60 days before the date of incidental to the treatment
This section of benefits is applicable when
admission to the hospital for which the admission
• An insured suffers an Accident or Illness, which is (In-patient OR Day Care has taken place.
covered under this Policy OR Domiciliary treatment).
• Hospitalisation is necessary & is done for treatment iii. Post-Hospitalisation Claims which have NOT
OR Expenses for been admitted under 1 i)
• Day care treatment is necessary and is done OR consultations, and 1 iv).
• Domiciliary treatment is necessary and is done investigations and Expenses not related to
medicines incurred upto the admission and not
180 days after discharge incidental to the treatment
IMPORTANT: Claims made under these benefits will impact
from the Hospital (In- for which the admission
eligibility for Multiplier Benefit.
patient OR Day Care OR has taken place.
We will cover the Medical In addition to the waiting Domiciliary treatment).
Expenses for: periods (Section C1) and iv. Day Care Procedures i) Treatment that can be
general exclusions (Section Medical treatment or and is usually taken on
C2&C3), We will also not surgical procedure which is an out-patient basis is not
cover expenses undertaken under general covered.
i. In-patient Treatment If as per any or all of or local anaesthesia, which ii) Treatment NOT taken
the Medical references require admission in a at a Hospital or Day-care
herein below containing Hospital/Day Care Centre centre.
This includes guidelines and for stay less than 24 hours.
• Hospital room rent or protocols for Evidence Treatment normally taken
boarding; Based Medicines, the on out-patient basis is not
Hospitalisation for included in the scope of
• Nursing; this definition.
treatment under claim is
• Intensive Care Unit
not necessary or the stay v. Domiciliary Treatment 1. Treatment of less than
• Medical Practitioners at the hospital is found Medical treatment for an 3 days (Coverage will be
(Fees) unduly long: Illness/disease/injury which provided for expenses
• Anaesthesia in the normal course would incurred in first three days
• Blood require care and treatment only if treatment period is
Medical text books,
at a Hospital but is actually greater than three days).
• Oxygen Standard treatment taken while confined at
• Operation theatre guidelines as stated in home under any of the
clinical establishment act following circumstances:
• Surgical appliances;
of Government of India,
• Medicines, drugs & The condition of the patient
World Health Organisation is such that he/she is not in
consumables;
(WHO) protocols, a condition to be removed
• Diagnostic procedures
Published guidelines by to a Hospital or,
healthcare providers, The patient takes
Guidelines set by treatment at home on
medical societies like account of non availability
cardiological society of of room in a Hospital. Pre
India, neurological society and Post Hospitalisation
of India etc. expenses for consultations,
investigations and
medicines incurred upto 60
days before hospitalisation
and 180 days after
hospitalization respectively
will be covered in case of
domiciliary treatment.

vii. Ambulance Cover 1. Claims which have -He requests an E-opinion;

Expenses incurred on NOT been admitted under and
transportation of Insured Section B1.i) and Section The Insured Person can
Person to a Hospital for B1.iv). choose one of Our panel
treatment in case of an 2. Healthcare or Medical Practitioners. The
Emergency, subject to Rs. ambulance service opinion will be directly sent
2000 per Hospitalisation. provider not registered with to the Insured Person by
road traffic authority. the Medical Practitioner.
“Critical Illness” includes
viii. Daily Cash Daily Cash Benefit for Cancer, Open Chest
for choosing shared time spent by the Insured CABG, First Heart Attack,
Accommodation Daily Person in an intensive Kidney Failure, Major
cash amount will be care unit Organ/Bone Marrow
payable per day as Claims which have NOT Transplant, Multiple
mentioned in schedule been admitted under B1). Sclerosis, Permanent
of benefits if the Insured Paralysis of Limbs and
Person is hospitalised in Stroke.
Shared Accommodation
in a Network Hospital x. Emergency Air 1. Claims which have NOT
for each continuous and Ambulance Cover been admitted under under
completed period of 24 We will pay for ambulance B1 i) and B1 iv).
hours if the Hospitalisation transportation in an 2. Expenses incurred in
exceeds 48 hours. airplane or helicopter return transportation to
subject to maximum limit the insured’s home by air
prescribed in j (1) , for ambulance is excluded.
emergency life threatening
health conditions which
require immediate
and rapid ambulance
transportation to the
hospital/medical centre
that ground transportation
cannot provide subject to:
• Necessary medical
treatment not being
available at the location
where the Insured Person
is situated at the time of
Emergency;
• The Medical Evacuation
been prescribed by a
Medical Practitioner and is
Medically Necessary;

HDFC ERGO General Insurance Company Limited. IRDAI Reg. No.146 CIN: U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor,
HDFC House, 165-166 Backbay Reclamation, H. T. Parekh Marg, Churchgate, Mumbai – 400 020. Trade Logo displayed above belongs to
HDFC Ltd and ERGO International AG and used by the Company under license. UIN:Optima Restore - HDHHLIP21322V062021
8
2. Restore Benefit
• The insured person is in
India and the treatment
is required in India only Instant addition of 100% Basic Sum Insured on complete
and not overseas in any or partial utilization of Your existing Policy Sum Insured and
condition whatsoever; and Multiplier Benefit (if applicable) during the Policy Year. The
• The air ambulance Total amount (Basic sum insured, Multiplier benefit and
provider being registered Restore sum insured) will be available to all Insured Persons
in India. for all claims under In-patient Benefit during the current Policy
Year and subject to the condition that single claim in a Policy
J(i) The amount payable
Year cannot exceed the sum of Basic Sum Insured and the
in case of Air ambulance
Multiplier Benefit (if applicable).
facility shall be either the
actual expenses or Rs. 2.5
Lacs per hospitalisation, Conditions for Restore benefit:
whichever is lower; upto
i. The Sum Insured will be restored only once in a
basic sum insured limit for
Policy Year.
a year.
ii. If the Restored Sum Insured is not utilized in a Policy
Year, it will expire.
Important terms You should know. In case of a Family Floater Policy, Restore
Sum Insured will be available on floater basis for all
Insured Persons in the Policy.
Sum Insured means the sum shown in the Schedule
which represents Our maximum liability for each Insured
Person for any and all benefits claimed for during 3. Preventive Health Check-up
the Policy Period, and in relation to a Family Floater
represents Our maximum liability for any and all claims This benefit is effective only if mentioned in the schedule of
made by You and all of Your Dependents during the benefits.
Policy Period.
a) If You have maintained an Optima Restore Policy
with Us for the period of time mentioned in the schedule
In-patient Care means treatment for which the Insured of benefits without any break, then at the end of each
Person has to stay in a Hospital for more than 24 hours block of continuous years (as mentioned in the schedule
for a covered event. of benefits) We will pay upto the amount mentioned in the
Schedule of Benefits towards the cost of a preventive
health check-up for those Insured Persons who were
Out-patient Treatment means the medical consultation, insured for the number of previous Policy Years
investigations or treatment taken in a clinic / hospital or mentioned in the Schedule.
associated facility like a consultation room. Important
to note that out-patient treatment does not require Note: If member has changed the plan in subsequent year
admission to day care or in-patient sections of hospital. and in the new plan the waiting period is less than previous
plan then waiting period mentioned in the current plan would
be applicable.
Important terms You should know. IMPORTANT: This benefit does NOT carry forward if it is not
claimed and would not be provided if Optima Restore Policy
Medical Practitioner means a person who holds a valid is not renewed further.
registration from the Medical Council of any State or
Medical Council of India or Council for Indian Medicine Preventive Health Check-up means a package of medical
or for Homeopathy set up by the Government of India or test(s) undertaken for general assessment of health status,
a State Government and is thereby entitled to practice it does not include any diagnostic or investigative medical
medicine within its jurisdiction; and is acting within the tests for evaluation of illness or a disease.
scope and jurisdiction of licence. And is NOT a member
of the Insured Person’s family or stays with him.

Shared accommodation means a Hospital room with two

or more patient beds.

Single occupancy or any higher accommodation n type

means a Hospital room with only one patient bed.

Optima Restore Not Upto a maximum Upto a maximum Upto a maximum Upto Maximum
Individual Applicable of Rs.1,500 per of Rs.2,000 per of Rs.4,000 per of Rs. 5,000 per
insured person, insured person at the insured person, at Insured Person, at
only once at the end of each year at the end of each the end of each
end of a block of renewal. year at renewal year at renewal
every continuous
two Policy Years.
Optima Restore Not Upto a maximum Upto a maximum of Upto a maximum of Upto Maximum
Family Applicable of Rs.2,500 per Rs.5,000 per policy Rs.8,000 per policy, of Rs. 10,000 per
policy, only once at the end of each at the end of each policy, at the end
at the end of a year at renewal year at renewal. of each year at
block of every renewal.
continuous two
Policy Years.

4. Multiplier Benefit e) In policies with a two year Policy Period, the application of
above guidelines of Multiplier Benefit shall be post
completion of each policy year.
a) If NO claims have been made in respect of any benefit
listed under Section B-1 in a Policy Year and the Policy
is renewed with Us without any break Section C. Waiting Period & Exclusions
i) We will apply a bonus by enhancing the
renewed policy’s Sum Insured by 50% of the
Basic Sum Insured of the previous year’s Policy
1. Standard Waiting Period
ii) The maximum bonus will not exceed 100% of
the Basic Sum Insured in any Policy Year.
In Family Floater policy, All Illnesses and treatments shall be covered subject to the
waiting periods specified below:
1. The Multiplier Benefit shall be available on
Family Floater basis and accrue only if no i. 30-day waiting period – Code – Excl03
claims have been made in respect of any a) Expenses related to the treatment of any illness
Insured Person during the previous Policy Year. within 30 days from the first policy commencement
2. Accrued Multiplier Benefit is available to all date shall be excluded except claims arising due
Insured Persons under the Policy. to an accident, provided the same are covered.

b) If a Multiplier Benefit has been applied and a claim b) This exclusion shall not, however, apply if the
is made in any Policy Year, then in the subsequent insured person has continuous coverage for more
Policy Year We will automatically decrease the than twelve months.
accrued Multiplier Benefit at the same rate at which it c) The within referred waiting period is made
is accrued. However this reduction will not reduce the applicable to the enhanced sum insured in the
Sum Insured below the Basic Sum Insured of the event of granting higher sum insured subsequently.
policy, and only the accrued multiplier bonus will be
decreased. ii. Specified disease/procedure waiting period – Code –
Excl02
c) If the Insured Persons in the expiring policy are covered
on individual basis and thus have accrued the multiplier a) Expenses related to the treatment of the listed
bonus for each member in the expiring policy, and such Conditions, surgeries/treatments shall be excluded
expiring policy is renewed with Us on a Family Floater until the expiry of 24 months of continuous
basis, then the multiplier bonus to be carried forward coverage after the date of inception of the first
for credit in the Policy would be the lowest accrued policy with us. This exclusion shall not be
multiplier bonus amongst all the Insured Persons from applicable for claims arising due to an accident or
the expiring Policy. underlying cause is cancer(s).

d) Portability/migration benefit will be offered to the extent b) In case of enhancement of sum insured the
of sum of previous sum insured and accrued multiplier exclusion shall apply afresh to the extent of sum
bonus, portability/migration benefit shall not apply to any insured increase.
other additional increased Sum Insured.

HDFC ERGO General Insurance Company Limited. IRDAI Reg. No.146 CIN: U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor,
HDFC House, 165-166 Backbay Reclamation, H. T. Parekh Marg, Churchgate, Mumbai – 400 020. Trade Logo displayed above belongs to
HDFC Ltd and ERGO International AG and used by the Company under license. UIN: Optima Restore - HDHHLIP21322V062021
11
Others • Nil • Surgery of Medical 1. Treatment for Alcoholism, drug or
varicose veins and Exclusions substance abuse or any addictive
varicose ulcers condition and consequences thereof –
Code – Excl12
General • Benign tumors • Nil
2. Obesity/ Weight Control: Code –
(Applicable of Non infectious
Excl06
to all organ etiologye.eg.
Expenses related to the surgical
systems/ cysts, nodules,
treatment of obesity that does not fulfil
organs polyps, lump,
all the below conditions:
whether or growth, etc
i. Surgery to be conducted is upon
not described
the advice of the Doctor
above)
ii. The surgery/Procedure conducted
should be supported by clinical
iii. Pre-Existing Diseases – Code – Excl01 protocols
iii. The member has to be 18 years of
a) Expenses related to the treatment of a pre-existing age or older and
disease (PED) and its direct complications shall be iv. Body Mass Index (BMI);
excluded until the expiry of 36 months of a) greater than or equal to 40 or
continuous coverage after the date of inception of b) greater than or equal to 35 in
the first policy with insurer. conjunction with any of the
b) In case of enhancement of sum insured the following severe co-morbidities
exclusion shall apply afresh to the extent of sum following failure of less invasive
insured increase. methods of weight loss:
i. Obesity-related cardiomyopathy
c) If the insured person is continuously covered ii. Coronary heart disease
without any break as defined under the portability/ iii. Severe Sleep Apnoea
migration norms of the extant IRDAI (Health iv. Uncontrolled Type2 Diabetes
Insurance) Regulations, then waiting period for 3. Expenses related to the treatment for
the same would be reduced to the extent of prior correction of eye sight due to refractive
coverage. error less than 7.5 dioptres. Code –
d) Coverage under the policy after the expiry of 36 Excl15
months for any pre-existing disease is subject 4. Cosmetic or plastic Surgery: Code
to the same being declared at the time of – Excl08
application and accepted by insurer. Expenses for cosmetic or plastic
surgery or any treatment to change
appearance unless for reconstruction
2. Standard Exclusions following an Accident, Burn(s) or
Cancer or as part of medically
We will not pay for any claim which is caused by, arising from necessary treatment to remove a
or attributable to: direct and immediate health risk to the
insured. For this to be considered a
Non Medical 1. Breach of law: Code – Excl10 medical necessity, it must be certified
Exclusions Expenses for treatment directly arising by the attending Medical Practitioner.
from or consequent upon any Insured 5. Change-of-Gender treatments: Code
Person committing or attempting to – Excl07
commit a breach of law with criminal Expenses related to any treatment,
intent. including surgical management, to
2. Hazardous or Adventure sports: change characteristics of the body to
Code – Excl09 those of the opposite sex.
Expenses related to any treatment 6. Unproven Treatments:
necessitated due to participation Expenses related to any unproven
as a professional in Hazardous or treatment, services and supplies for
Adventure Sports, including but not or in connection with any treatment.
limited to, para-jumping, rock climbing, Unproven treatments are treatments,
mountaineering, rafting, motor racing, procedures or supplies that lack
horse racing or scuba diving, hand significant medical documentation to
gliding, sky diving, deep-sea diving. support their effectiveness. Code –
Excl16

HDFC ERGO General Insurance Company Limited. IRDAI Reg. No.146 CIN: U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor,
HDFC House, 165-166 Backbay Reclamation, H. T. Parekh Marg, Churchgate, Mumbai – 400 020. Trade Logo displayed above belongs to
HDFC Ltd and ERGO International AG and used by the Company under license. UIN: Optima Restore - HDHHLIP21322V062021
13
Medical 1. Prosthetic and other devices which 19. Admission for administration
Exclusions are self-detachable /removable without of Intra-articular or Intra-lesional
surgery involving anaesthesia injections, Supplementary medications
2. Treatment availed outside India like Zolendronic acid (Trade
3. Treatment at a healthcare facility name Zometa, Reclast, etc) or IV
which is NOT a Hospital. immunoglobulin infusion
4. Circumcisions (unless necessitated
by Illness or injury and forming part of
treatment)
5. Non allopathic treatment. Section D. Terms & Clauses
6. Conditions for which treatment could
have been done on an outpatient basis
without any Hospitalisation. 1. Standard Terms andConditions
7. Preventive care, vaccination
including inoculation and immunisations
(except in case of post-bite treatment); I. Condition Precedent to admission of Liability
8. Provision or fitting of hearing aids, The terms and conditions of the Policy must be fulfilled
spectacles or contact lenses including by the Insured Person for the Company to make any
optometric therapy, any treatment and payment for claim(s) arising under the Policy.
associated expenses for alopecia,
baldness, wigs, or toupees, medical
supplies including elastic stockings, ii. Claim Settlement (Provision for Penal Interest)
diabetic test strips, and similar
products. i) The Company shall settle or reject a claim, as the
9. Sleep-apnoea case may be, within 30 days from the date of
10. External congenital diseases, receipt of last necessary document.
defects or anomalies ii) In the case of delay in the payment of a claim, the
11. The expense incurred by the Company shall be liable to pay interest to the
insured on organ donation. Policyholder from the date of receipt of last
12. Treatment and supplies for necessary document to the date of payment of
analysis and adjustments of spinal claim at a rate 2% above the Bank Rate.
subluxation, diagnosis and treatment by
manipulation of the skeletal structure; iii) However, where the circumstances of a claim
muscle stimulation by any means warrant an investigation in the opinion of the
except treatment of fractures (excluding Company, it shall initiate and complete such
hairline fractures) and dislocations of investigation at the earliest, in any case not
the mandible and extremities. later than 30 days from the date of receipt of last
13. Any non-medical expenses necessary document. In such cases, the Company
mentioned in Annexure I. shall settle or reject the claim within 45 days from
14. Treatment rendered by a Medical the date of receipt of last necessary document
Practitioner which is outside his iv) In case of delay beyond stipulated 45 days, the
discipline or the discipline for which he Company shall be liable to pay interest to the
is licensed. Policyholder at a rate 2% above the Bank Rate
15. Treatments rendered by a Medical from the date of receipt of last necessary document
Practitioner who is a member of the to the date of payment of claim.
Insured Person’s family or stays with
him, however proven material costs v) We shall be under no obligation to make any
are eligible for reimbursement in payment under this Policy unless We have
accordance with the applicable cover. received all premium payments in full in time and
16. Any treatment or part of a treatment all payments have been realised and We have
that is not of a reasonable charge and been provided with the documentation and
not Medically Necessary. information We have requested to establish the
17. Drugs or treatments which are circumstances of the claim, its quantum or Our
not supported by a prescription. liability for it, and unless the Insured Person has
18.Any specific time bound or lifetime complied with his obligations under this Policy.
exclusion(s) applied by Us and vi) We will only make payment to You under this
specified in the Schedule and accepted Policy. Receipt of paymentby You shall be
by the insured. considered as a complete discharge of Our liability
against the respective claim under this Policy.

HDFC ERGO General Insurance Company Limited. IRDAI Reg. No.146 CIN: U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor,
HDFC House, 165-166 Backbay Reclamation, H. T. Parekh Marg, Churchgate, Mumbai – 400 020. Trade Logo displayed above belongs to
HDFC Ltd and ERGO International AG and used by the Company under license. UIN:Optima Restore - HDHHLIP21322V062021
14
In the event of Your death, We will make payment For the purpose of this clause, the expression “fraud”
to the Nominee (as named in the Schedule), means any of the following acts committed by the Insured
payments under this Policy shall only be made in Person or by his agent or the hospital/doctor/any other
Indian Rupees within India. party acting on behalf of the Insured Person, with intent
to deceive the insurer or to induce the insurer to issue
vii) The assignment of benefits of the policy shall be
an insurance policy:
subject to applicable law.
a) the suggestion, as a fact of that which is not true
viii) We are not obliged to make payment for any claim
and which the Insured Person does not believe to
or that part of any claim that could have been
be true;
avoided or reduced if the Insured Person had taken
reasonable care, or that is brought about or b) the active concealment of a fact by the Insured
contributed to by the Insured Person failing to Person having knowledge or belief of the fact;
follow the directions, advice or guidance provided c) any other act fitted to deceive; and
by a Medical Practitioner.
d) any such act or omission as the law specially
ix) Cashless service: If any treatment, consultation declares to be fraudulent
or procedure for which a claim may be made is to
The Company shall not repudiate the claim and / or forfeit
be taken at a Network Hospital, then We will
the Policy benefits on the ground of Fraud, if the Insured
provide a cashless service by making payment
Person / beneficiary can prove that the misstatement
to the extent of Our liability direct to the Network
was true to the best of his knowledge and there was no
Hospital as long as We are given notice that the
deliberate intention to suppress the fact or that such
Insured Person wishes to take advantage of a
misstatement of or suppression of material fact are within
cashless service accompanied by full particulars at
the knowledge of the Insurer.
least 48 hours before any planned treatment or
Hospitalisation or within 24 hours after IV. Multiple Policies
Hospitalisation in the case of an emergency.
i. In case of multiple policies taken by an Insured
x) In an event claim event falls within two Policy Person during a period from one or more insurers
Period then We shall settle claim by taking into to indemnify treatment costs, the Insured Person
consideration the available in the two Policy shall have the right to require a settlement of his/
Periods. Such eligible claim amount to be payable her claim in terms of any of his/her policies. In all
to the Insured shall be reduced to the extent of such cases the Insurer chosen by the Insured
premium to be received for the renewal /due date Person shall be obliged to settle the claim as long
of the premium of health insurance policy, if not as the claim is within the limits of and according
received earlier. to the terms of the chosen Policy.
xi) Healthcare Advisory Benefit: We may suggest ii. Insured Person having multiple policies shall also
alternate Network Provider in specific cases of have the right to prefer claims under this Policy
surgical or medical treatment, should the Insured for the amounts disallowed under any other policy
member accept and utilize one of the alternatives / policies even if the Sum Insured is not exhausted.
suggested he would be eligible for a lumpsum Then the insurer shall independently settle the
benefit of Rs 5000. claim subject to the terms and conditions of
this Policy.
Please note: The acceptance of our
recommendation is not obligatory on the Insure iii. If the amount to be claimed exceeds the Sum
member and We are not liable for any outcome Insured under a single Policy, the Insured Person
of the treatment conducted at the network centre. shall have the right to choose Insurer from whom
he/she wants to claim the balance amount.
III. Fraud
iv. Where an Insured Person has policies from more
If any claim made by the Insured Person, is in any respect
than one Insurer to cover the same risk on
fraudulent, or if any false statement, or declaration is
indemnity basis, the Insured Person shall only be
made or used in support thereof, or if any fraudulent
indemnified the treatment costs in accordance
means or devices are used by the Insured Person or
with the terms and conditions of the chosen Policy.
anyone acting on his/her behalf to obtain any benefit
under this Policy, all benefits under this policy and the V. Renewal of Policy
premium paid shall be forfeited.
The policy shall ordinarily be renewable except on
Any amount already paid against claims made under this grounds of fraud, misrepresentation by the insured
Policy but which are found fraudulent later shall be person.
repaid by all recipient(s)/policyholder(s), who have made
i. The Company shall endeavour to give notice for
that particular claim, who shall be jointly and severally
Renewal. However, the Company is not under
liable for such repayment to the Insurer.

1 Year Policy Period 2 Year Policy Period

Length of time Policy in % of premium refunded Length of time Policy in % of premium refunded
force force
Upto 1 Month 75.00% Upto 1 Month 87.50%
Upto 3 Months 50.00% Upto 3 Months 75.00%
Upto 6 Months 25.00% Upto 6 Months 62.50%
Exceeding 6 Months Nil Upto 12 Months 48.00%
Upto 15 Months 25.00%

Upto 18 Months 12.00%

Exceeding 18 Months Nil

Notwithstanding anything contained herein or The Insured Person shall be allowed free look period of
otherwise, no refunds of premium shall be made fifteen days from date of receipt of the policy document
in respect of Cancellation where, any claim has to review the terms and conditions of the policy, and to
been admitted or has been lodged or any benefit return the same if not acceptable.
has been availed by the Insured Person under the If the Insured has not made any claim during the Free
Policy. Look Period, the insured shall be entitled to
ii. The Company may cancel the policy at any time i. a refund of the premium paid less any expenses
on grounds of misrepresentation nondisclosure of incurred by the Company on medical examination
material facts, fraud by the insured person by of the Insured Person and the stamp duty charges
giving 15 days’ written notice. or
There would be no refund of premium on ii. where the risk has already commenced and the
cancellation on grounds of misrepresentation, option of return of the Policy is exercised by the
nondisclosure of material facts or fraud. Insured Person, a deduction towards the
VII. Free Look Period proportionate risk premium for period of cover
or
The Free Look Period shall be applicable on new
individual health insurance policies and not on renewals iii. Where only a part of the insurance coverage has
or at the time of porting/migrating the Policy. commenced, such proportionate premium

HDFC ERGO General Insurance Company Limited. IRDAI Reg. No.146 CIN: U66030MH2007PLC177117. Registered & Corporate Office: 1st Floor,
HDFC House, 165-166 Backbay Reclamation, H. T. Parekh Marg, Churchgate, Mumbai – 400 020. Trade Logo displayed above belongs to
HDFC Ltd and ERGO International AG and used by the Company under license. UIN:Optima Restore - HDHHLIP21322V062021
16
commensurate with the insurance coverage during https://www.irdai.gov.in/ADMINCMS/cms/frmGuidelines_
such period. Layout.aspx?page=PageNo3987
VIII. Disclosure of Information XIII. Possibility of Revision of terms of the Policy including
the Premium Rates
The policy shall be void and all premium paid thereon
shall be forfeited to the Company in the event of The Company, with prior approval of IRDAI, may revise
misrepresentation, mis description or non-disclosure of or modify the terms of the Policy including the premium
any material fact by the policyholder. rates. The Insured Person shall be notified three months
before the changes are effected.
IX. Complete Discharge
XIV. Withdrawal of Policy
Any payment to the Policyholder, Insured Person or his/
her nominees or his/ her legal representative or assignee i. In the likelihood of this product being withdrawn
or to the Hospital, as the case may be, for any benefit in future, the Company will intimate the Insured
under the Policy shall be a valid discharge towards Person about the same 90 days prior to expiry of
payment of claim by the Company to the extent of that the policy.
amount for the particular claim.
ii. Insured Person will have the option to migrate to
X. Moratorium Period similar health insurance product available with the
Company at the time of renewal with all the
After completion of eight continuous years under the
accrued continuity benefits such as Cumulative
policy, no look back to be applied. This period of eight
Bonus, waiver of waiting period as per IRDAI
years is called as Moratorium Period. The moratorium
guidelines, provided the policy has been
would be applicable for the sums insured of the first policy
maintained without a break.
and subsequently completion of 8 continuous years
would be applicable from date of enhancement of sums XV. Nomination:
insured only on the enhanced limits. After the expiry
The Policyholder is required at the inception of the Policy
of Moratorium Period no health insurance claim shall be
to make a nomination for the purpose of payment
contestable except for proven fraud and permanent
of claims under the Policy in the event of death of the
exclusions specified in the policy contract. The policies
Policyholder.
would however be subject to all limits, sub limits,
co-payments, deductibles as per the policy contract Any change of nomination shall be communicated to the
Company in writing and such change shall be effective
XI. Portability
only when an endorsement on the Policy is made. In the
The Insured Person will have the option to port the Policy event of death of the Policyholder, the Company will pay
to other insurers by applying to such Insurer to port the the nominee {as named in the Policy Schedule/Policy
entire policy along with all the members of the family, if Certificate/Endorsement (if any)} and in case there is no
any, at least 45 days before, but not earlier than 60 days subsisting nominee, to the legal heirs or legal
from the policy renewal date as per IRDAI guidelines representatives of the Policyholder whose discharge
related to Portability. If such person is presently covered shall be treated as full and final discharge of its liability
and has been continuously covered without any lapses under the Policy.
under any health insurance policy with an Indian General/
XVI. Redressal of Grievances
Health insurer, the proposed Insured Person will get the
accrued continuity benefits in waiting periods as per In case of any grievance the insured person may contact
IRDAI guidelines on portability. the company through:
For Detailed Guidelines on Portability, kindly refer the • Website: www.hdfcergo.com
link
• Toll free: 022 6234 6234 / 0120 6234 6234
https://www.irdai.gov.in/ADMINCMS/cms/frmGuidelines_
• Contact Details for Senior Citizen: 022 - 6242 - 6226
Layout.aspx?page=PageNo3987
| seniorcitizen@hdfcergo.com
XII. Migration
• E-mail: grievance@hdfcergo.com
The Insured Person will have the option to migrate the
Insured person may also approach the grievance
Policy to other health insurance products/plans offered by
cell at any of the company’s branches with the details of
the Company by applying for Migration of the
grievance.
policyatleast30 days before the policy renewal date as
per IRDAI guidelines on Migration. If such person is If Insured person is not satisfied with the redressal of
presently covered and has been continuously covered grievance through one of the above methods, Insured
without any lapses under any health insurance product/ Person may contact the grievance officer at
plan offered by the Company, the Insured Person will cgo@hdfcergo.com
get the accrued continuity benefits in waiting periods as For updated details of grievance officer, kindly refer the
per IRDAI guidelines on Migration. link: h ttps://www.hdfcergo.com/customer-voice/
For Detailed Guidelines on Migration, kindly refer the link grievances

Email id: seniorcitizen@hdfcergo.com Email id: seniorcitizen@hdfcergo.com Email id: seniorcitizen@hdfcergo.com

Write to care@hdfcergo.com grievance@hdfcergo.com cgo@hdfcergo.com
us at
Visit us Grievance cell of any of our Branch The Grievance Cell, Chief Grievance Officer,
office HDFC ERGO General Insurance HDFC ERGO General Insurance
Company Ltd., D-301, 3rd Floor, Eastern Company Ltd., D-301, 3rd Floor, Eastern
Business District (Magnet Mall), LBS Business District (Magnet Mall), LBS
Marg, Bhandup (West) Mumbai - 400 078. Marg, Bhandup (West) Mumbai - 400 078.

i. If Insured person is not satisfied with the redressal of grievance through above methods, the insured person may also
approach the office of Insurance Ombudsman of the respective area/region for redressal of grievance as per Insurance
Ombudsman Rules 2017.
ii. Grievance may also be lodged at IRDAI Integrated Grievance Management System - https://igms.irda.gov.in/

2. Specific General Conditions application has been accepted by Us and additional

premium has been received. Insurance cover for this
person shall only commence once We have issued an
I. Geography endorsement confirming the addition of such person as
an Insured Person.
This Policy only covers medical treatment taken
within India. All payments under this Policy will only Any Insured Person in the policy has the option to migrate
be made in Indian Rupees within India. For the to similar indemnity health insurance policy available
purpose of policy issuance, the premium will be with us at the time of renewal subject to underwriting
computed basis the city of residence provided by with all the accrued continuity benefits such as
the insured person in the proposal form. cumulative bonus, waiver of waiting period etc. provided
the policy has been maintained without a break as per
The premium that would be applicable zone wise and
portability/migration guidelines.
the cities defined in each zone are as under:
If an Insured Person dies, he will cease to be an Insured
• Delhi NCR/Mumbai MMR- Delhi, Gurgaon, Noida,
Person upon Us receiving all relevant particulars in this
Faridabad, Ghaziabad, Greater Noida ,Mumbai,
regard. We will return a rateable part of the premium
Navi Mumbai , Thane, Kalyan, Dombivali,
received for such person
Bhayandar, Ulhasnagar, Bhiwandi, Vasai,Virar
IF AND ONLY IF there are no claims in respect of that
• Rest of India- All other cities
Insured Person under the Policy.
• The premium will be modified in case of mid term
III. Loadings & Discounts
address change involving migration from one zone
to another and would be calculated on pro-rata We may apply a risk loading on the premium payable
basis. (based upon the declarations made in the proposal form
and the health status of the persons proposed for
II. Insured Person
insurance). The maximum risk loading applicable for
Only those persons named as Insured Persons in the an individual shall not exceed above 100% per diagnosis
Schedule shall be covered under this Policy. Any eligible / medical condition and an overall risk loading of over
person may be added during the Policy Period after his 150% per person. These loadings are applied from

Time Interval (calculated from policy risk start date)

Average Step Risk start date or 91-180 days 181-270 days 271-300 days Maximum
Targe date of download of Discount at the
mobile application end of the year
-90 days
5000 or below 0% 0% 0%

5001 to 8000 0.5% 0.5% 0.5% 0.5% 2%

8001 to 10000 1.25% 1.25% 1.25% 1.25% 5%

Above 10000 2% 2% 2% 2% 8%

Time Interval (calculated from policy risk start date)

Average Risk start 91-180 181-270 271-360 361-450 451-540 541-630 631-660 Maximum
Step date or days days days days days days days Discount
Target date of at the end
download of 2 years
of mobile
application
-90 days
5000 or 0% 0% 0% 0% 0% 0% 0% 0% 0%
below
5001 to 0.25% 0.25% 0.25% 0.25% 0.25% 0.25% 0.25% 0.25% 2%
8000
8001 to 0.625% 0.625% 0.625% 0.625% 0.625% 0.625% 0.625% 0.625% 5%
10000
Above 1% 1% 1% 1% 1% 1% 1% 1% 8%
10000

The mobile app must be downloaded within 30 days of the

policy risk start date to avail this benefit. The average step
count completed by an Insured member would be tracked on
this mobile application.
We reserve the right to remove or reduce any count of steps
if found to be achieved in unfair manner by manipulation.

Illustration

Policy start date 1st Jan 2016

Policy Tenure 1 year
Time Interval
Risk start date or date 91 days - 180 days 181 days - 270 271 - 300 days
of download of mobile days
application - 90 days
average steps 8500 10000 5001 7500
taken in the
defined time
period
Discount % 1.25% 1.25% 0.5% 0.5%
applicable

Total discount applicable on renewal premium = 3.5% ii) If any treatment for Within 24 hours of
which a claim may be the Insured Person’s
made is to be taken and admission to Hospital.
IV. Notification of Claim
that treatment requires
Treatment, Consultation We must be informed: Hospitalisation in an
or Procedure: Emergency.

i) If any treatment for Immediately and in any iii) For all benefits which are Within 7 days of the
which a claim may be event at least 48 hours contingent on Our prior Insured Person’s
made is to be taken and prior to the Insured acceptance of a claim discharge post-
that treatment requires Person’s admission. under Section B1: hospitalisation.
Hospitalisation:

Treatment, Consultation Treatment, Cashless Service is We must be given notice

or Procedure: Consultation or Available: that the Insured Person
Procedure Taken at: wishes to take advantage
of the cashless service
accompanied by full
particulars:
i) If any planned treatment, Network Hospital We will provide cashless At least 48 hours before the
consultation or service by making payment planned treatment or
procedure for which a to the extent of Our liability Hospitalisation
claim may be made: directly to the Network
Hospital.
ii) If any treatment, Network Hospital We will provide cashless Within 24 hours after the
consultation or procedure service by making payment treatment or Hospitalisation
for which a claim may be to the extent of Our liability
made to be taken in an directly to the Network
Emergency: Hospital.

VI. Supporting Documentation & Examination ix) Treating doctor’s certificate regarding missing
The Insured Person or someone claiming on Your behalf information in case histories e.g. Circumstance of
shall provide Us with any documentation, medical injury and Alcohol or drug influence at the time of
records and information We may request to establish the accident
circumstances of the claim, its quantum or Our liability x) Copy of settlement letter from other insurance
for the claim within 15 days of the earlier of Our request company or TPA
or the Insured Person’s discharge from Hospitalisation xi) Stickers and invoice of implants used during surgery
or completion of treatment. The Company may accept xii) Copy of MLC (Medico legal case) records and FIR
claims where documents have been provided after a (First information report), in case of claims arising
delayed interval only in special circumstances and for out of an accident
the reasons beyond the control of the insured. Such
documentation will include but is not limited to the xiii) Regulatory requirements as amended from time to
following: time, currently mandatory NEFT (to enable direct
credit of claim amount in bank account) and KYC
i) Our claim form, duly completed and signed for on (recent ID/Address proof and photograph)
behalf of the Insured Person. requirements
ii) Original Bills (including but not limited to pharmacy xiv) Legal heir certificate
purchase bill, consultation bill, diagnostic bill) and
any attachments thereto like receipts or prescriptions
in support of any amount claimed which will then VII. The Insured Person shall have to undergo medical
become Our property. examination by Our authorised Medical Practitioner,
iii) All reports and records, including but not limited to as and when We may reasonably require, to obtain an
all medical reports, case histories/indoor case independent opinion for the purpose of processing any
papers, investigation reports, treatment papers, claim. We will bear the cost towards performing such
discharge summaries. medical examination (at the specified location) of the
Insured Person.
iv) A precise diagnosis of the treatment for which a
claim is made.
v) A detailed list of the individual medical services and VIII. Endorsements
treatments provided and a unit price for each This Policy constitutes the complete contract of
(detailed break up). insurance. This Policy cannot be changed by anyone
vi) Prescriptions that name the Insured Person andin (including an insurance agent or broker) except Us..
the case of drugs: the drugs prescribed, their price
and a receipt for payment.Prescriptions must be IX. Change of Policyholder
submitted with the corresponding Doctor’s invoice.
vii) All pre and post investigation, treatment and follow The Policyholder may be changed only at the time of
up (consultation) records pertaining to the present renewal. The new policyholder must be a member of the
ailment for which claim is being made Insured Person’s immediate family. Such change would
be subject to Our acceptance and payment of premium
viii) All investigation, treatment and follow up records (if any). The renewed Policy shall be treated as having
pertaining to the past ailment(s) since their first
diagnoses or detection

Section E. Other Terms & Conditions

Contact Us
Within India Outside India
Claim Intimation: Customer Service No. 022-62346234 / 0120- 62346234 Toll Free No: 800 08250825
Email: healthclaims@hdfcergo.com Global Toll Free No : +800 08250825
(accessible from locations outside India only)
Landline no (Chargeable) : 0120-4507250
Email: travelclaims@hdfcergo.com
Claim document HDFC ERGO General Insurance Co. Ltd. HDFC ERGO General Insurance Co. Ltd.
submission at Stellar IT Park, Tower-1, 5th Floor, C - 25, Stellar IT Park, Tower-1, 5th Floor, C - 25,
address Noida, Sector 62, 201301, Uttar Pradesh Noida, Sector 62, 201301,Uttar Pradesh

Annexure I – List of Non-Medical Expenses

S. No. Item S. No Item

1 BABY FOOD 26 BIRTH CERTIFICATE
2 BABY UTILITIES CHARGES 27 CERTIFICATE CHARGES
3 BEAUTY SERVICES 28 COURIER CHARGES
4 BELTS/ BRACES 29 CONVEYANCE CHARGES
5 BUDS 30 MEDICAL CERTIFICATE
6 COLD PACK/HOT PACK 31 MEDICAL RECORDS
7 CARRY BAGS 32 PHOTOCOPIES CHARGES
8 EMAIL / INTERNET CHARGES 33 MORTUARY CHARGES
9 FOOD CHARGES (OTHER THAN PATIENT'S 34 WALKING AIDS CHARGES
DIET PROVIDED BY HOSPITAL)
10 LEGGINGS 35 OXYGEN CYLINDER (FOR USAGE OUTSIDE THE
HOSPITAL)
11 LAUNDRY CHARGES 36 SPACER
12 MINERAL WATER 37 SPIROMETRE
13 SANITARY PAD 38 NEBULIZER KIT
14 TELEPHONE CHARGES 39 STEAM INHALER
15 GUEST SERVICES 40 ARMSLING
16 CREPE BANDAGE 41 THERMOMETER
17 DIAPER OF ANY TYPE 42 CERVICAL COLLAR
18 EYELET COLLAR 43 SPLINT
19 SLINGS 44 DIABETIC FOOT WEAR
20 BLOOD GROUPING AND CROSS MATCHING 45 KNEE BRACES (LONG/ SHORT/ HINGED)
OF DONORS SAMPLES
21 SERVICE CHARGES WHERE NURSING 46 KNEE IMMOBILIZER/SHOULDER IMMOBILIZER
CHARGE ALSO CHARGED
22 TELEVISION CHARGES 47 LUMBO SACRAL BELT
23 SURCHARGES 48 NIMBUS BED OR WATER OR AIR BED CHARGES
24 ATTENDANT CHARGES 49 AMBULANCE COLLAR
25 EXTRA DIET OF PATIENT (OTHER THAN 50 AMBULANCE EQUIPMENT
THAT WHICH FORMS PART OF BED
CHARGE)

Schedule of benefits

Optima Restore Individual

Basic Sum 3.00 5.00 10.00 15.00 20.00,25.00,50.00
Insured per
Insured Person
per Policy Year
(Rs. in Lakh)
1a) In-patient Covered Covered Covered Covered Covered
Treatment
1b) Pre- Covered, Covered, Covered, Covered, Covered,
Hospitalization upto 60 Days upto 60 Days upto 60 Days upto 60 Days upto 60 Days
1c) Post- Covered, Covered, Covered, Covered, Covered,
Hospitalization upto 180 Days upto 180 Days upto 180 Days upto 180 Days upto 180 Days
1d) Day Care Covered Covered Covered Covered Covered
Procedures
1e) Domiciliary Covered Covered Covered Covered Covered
Treatment
1f) Organ Donor Covered Covered Covered Covered Covered

1g) Ambulance Upto Upto Upto Upto Upto

Cover Rs.2,000 per Rs.2,000 per Rs.2,000 per Rs.2,000 per Rs.2,000 per
Hospitalisation Hospitalisation Hospitalisation Hospitalisation Hospitalisation
1h) Daily Cash Rs.800 per day, Rs.800 per day, Rs.800 per day, Rs.800 per day, Rs.1000 per day,
for choosing Maximum Maximum Maximum Maximum Maximum
Shared Rs.4,800 Rs.4,800 Rs.4,800 Rs.4,800 Rs.6,000
Accommodation
1i) E-Opinion Covered Covered Covered Covered Covered
in respect of a
Critical Illness
1j) Emergency Not Covered Not Covered Covered Covered Covered
Air Ambulance
Cover

Optima Restore Family

1g) Ambulance Upto Upto Upto Upto Upto

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Customer Information Sheet: HDFC ERGO General Insurance Company Limited

Uploaded by

Customer Information Sheet: HDFC ERGO General Insurance Company Limited

Uploaded by

HDFC ERGO General Insurance Company Limited

Customer Information Sheet

DESCRIPTION IS ILLUSTRATIVE AND NOT EXHAUSTIVE

TITLE DESCRIPTION REFER TO POLICY

during the Policy Year. The Restore Sum Insured can be

You must submit a duly filled claim form along with

The policy shall ordinarily be renewable except on grounds

For Reimbursement Claims: On receipt of the complete

7 6,279 5 6,279 628 5,651 5 17,108 NA 17,108 5

10 6,279 5 6,279 628 5,651 5 NA

35 7,502 5 7,502 750 6,752 5 NA

40 8,489 5 8,489 849 7,640 5 NA

28,549 25,694 17,108

Premium as mentioned above are exclusive of taxes.

i. Such Medical Expenses are incurred for the

vii. Ambulance Cover 1. Claims which have -He requests an E-opinion;

Shared accommodation means a Hospital room with two

Single occupancy or any higher accommodation n type

1 Year Policy Period 2 Year Policy Period

Upto 18 Months 12.00%

Exceeding 18 Months Nil

Email id: seniorcitizen@hdfcergo.com Email id: seniorcitizen@hdfcergo.com Email id: seniorcitizen@hdfcergo.com

2. Specific General Conditions application has been accepted by Us and additional

Time Interval (calculated from policy risk start date)

5001 to 8000 0.5% 0.5% 0.5% 0.5% 2%

Time Interval (calculated from policy risk start date)

The mobile app must be downloaded within 30 days of the

Policy start date 1st Jan 2016

Treatment, Consultation Treatment, Cashless Service is We must be given notice

Section E. Other Terms & Conditions

Annexure I – List of Non-Medical Expenses

S. No. Item S. No Item

Optima Restore Individual

1g) Ambulance Upto Upto Upto Upto Upto

Optima Restore Family

1g) Ambulance Upto Upto Upto Upto Upto

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