HDFC Ergo Optima Restore
HDFC Ergo Optima Restore
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Optima Restore Individual Plan

Optima Restore Individual is the most suitable form of health plan that gives you restoration benefit when your sum insured get consumed fully or partly. Optima Restore not only gives you financial protection from minor to major illness but also provide you with health rewards for maintaining sound health throughout the policy tenure. With features like stay active benefit and multiplier benefit, makes Optima Restore health plan distinguishable from all the other health insurances.

Features of the Policy

Sum InsuredRs 3/ 5/ 10/ 15/ 20/ 25/ 50 lakhs
Age limit18 to 65 years for adults and 91 days to 25 years for dependent children
Lifelong RenewabilityLifetime
Tenure of the PolicyOne/ Two years
Pre Policy Check-upRequired for 46 years and above/ taking 15 lakh or more as the sum insured
Sub-limitsNo sub-limits on room and location for taking treatment at any network hospitals
Tax BenefitsTax deduction while filing income tax on the annual salary under section 80 D of Income Tax Act due to the premium paid
Claim Settlement98% claim settlement ratio with regard to proper representation of documents.
Free Look Period15 days given to review the policy’s terms and conditions
Portability Available (transfer all your previous policy’s accrued benefits to new optima restore individual)

Optima Restore Individual Coverage Provided

Coverage ProvidedAmount of Sum Insured
3 lakhs5 lakhs10 lakhs15 lakhs20/25/50 lakhs
In-Patient TreatmentCovered up to the amount of sum insured
Pre-HospitalizationUp to 60 days
Post-HospitalizationUp to 180 days
Domiciliary HospitalisationCovered up to the amount of sum insured
Day Care Procedure140+ daycare treatments
Cashless treatmentAvailable at network hospitals
Ambulance CoverProvided up to Rs 2000 per Hospitalisation for all types of sum insured
Room RentNo Sub Limit
E-opinion on the investigation of critical illnessCan avail One time in a policy period
Air AmbulanceNot CoveredNot CoveredMinimum of 2.5 lakhs per Hospitalisation and the maximum should not exceed the amount of sum insured in a policy year.
Daily Cash limit on selecting shared roomsRs 800 per day and maximum up to Rs 4,800Rs 1000 per day and maximum up to Rs 6,000
Pre-existing diseasesCovered after a waiting period of 36 months
Restoration of sum insured100% reload of sum insured on complete or partial consumption due to claims.
Health check-upNot CoveredUp to Rs 1500 once in every 2 years of the policyUp to Rs 2000 once in every year of the policyUp to Rs 4000 once in every year of the policyUp to Rs 5000 once in every year of the policy
Multiplier BenefitA minimum bonus addition of 50% to the sum insured on one claim free year and a maximum of 100%. The bonus received may subject to a reduction of 50%, if any claim is made in the succeeding year. While the basic sum insured will remain untouched.
Critical Advantage RiderNot providedProvided

Additional Coverage

Critical Advantage Rider

By choosing this additional cover, the insured can enjoy never-ending benefits attached. This cover gives you a treatment facility at network hospital present globally. In addition, it also gives coverage transportation expenses of insured and the attending member, accommodation expenses, post-hospitalization, and second opinion expenses. The illnesses covered under this rider are-

  • Cancer
  • Heart Valve Replacement/repair
  • Aorta Graft Surgery
  • Bone Marrow Transplant
  • Live Donor Organ Transplant
  • Neurosurgery
  • Pulmonary Artery
  • Coronary Artery by-pass Surgery

Benefits on Renewal

  1. Stay Active Benefit - Optim Restore health plan enables the insured to gather health rewards in the shape of discounts. The simple requirement to avail this benefit is to walk as far as possible to gain a healthy body in complimentary to 8% discount on the premium paid on every renewal.
  2. Preventive Health check-up - This benefit will permit you to keep an eye on the health record with the help of health check-ups. If the amount of sum insured is 5 lakhs, then you can avail this facility only once in every two years. However, if the sum insured is 10 lakhs or more, then the check-up limit is once every year.
  3. Multiplier Benefit - Lets takes an example of Sheela who took Optima Restore individual plan for Rs 5 lakhs wherein the first year she didn’t apply for any claim. Consequently, the insurance provider increased her basic sum insured of Rs 5 lakhs by 50% i.e. 7.5 lakhs. In the second year, the sum insured amount will be 7.5 lakhs while the premium paid will be on 5 lakh sum insured.

Exclusions

  • Injuries due to war, nuclear and chemical weapons, radioactivities, criminal act, suicide, adventure sports, participation in military or naval force.
  • Treatment of obesity, dental problems, mental disorder, genetic disorders, abnormalities, congenital illness.
  • Treatment of infertility, birth control, vicarious pregnancy, circumcision
  • Cosmetic or plastic surgery, burns, correction of refractive error
  • HIV/AIDS, sterility or illness due to excessive incorporation of hallucinogenic substance(alcohol or drugs).
  • Non-Allopathic treatment or Ayush treatment

Illustration of the Plan

Here is the presentation of premium paid annually based on the age and sum insured value of the policyholder. The premium may change with regard to any medical conditions like pre-existing illness, smoking or drinking habits, and other illnesses. In the graph given below, it is assumed that the individual has no smoking habits and no pre-existing disease.

chart map

About The Company

HDFC Ergo Health was formed with joint cooperation between two health leaders HDFC Ltd. and Munich Health. They conglomerated to bestow unprecedented health insurance services to individuals and their family.

HDFC ERGO Health Insurance (formerly known as Apollo Munich Health Insurance) keeps on launching new plans into the health insurance market like Optima Restore, Optima Vital, Easy health, Health Wallet etc.

The company also deals in travel insurance and individual personal Accident.

FAQs

1. Does Appollo Munich pay for the claim made in the starting 30 days of the policy?

If any claim made during the starting 30 days, the company will not cover the expenses. But in case of accidental injuries to the body, the insurance provider will cover the expenses incurred.

2. What is the grace period in the policy?

The grace period is regarded as a period of 30 days where the policyholder is allotted a time limit to renew the existing policy. The grace period is used when the renewal date get elapsed due to negligence in the payment of premium by the policyholder.

3. Can we port our previous policy with Appolo Munich Optima Restore?

Yes, a policyholder can port or transfer all the benefits of previous policy to newly bought health plan after due allowances for waiting periods. Moreover, if you want to utilize portability benefit you have to inform the insurer 45 days prior to the renewal date of the policy.

4. Do we get reimbursement for the pre-policy check-up?

The company promises to pay or reimburse 100% of the expenses raised on medical check-up before buying the policy by the insured. The report of health check-up will be valid for 90 days maximum within which the policyholder submit the proposal of claim to get reimbursement.

5. What are the renewal discounts under Stay Active Benefit?

The discounts offered to insured on staying fit and healthy will be examined from the number of steps walked in a day. The count of steps will be tracked and calculated by a mobile application which should get downloaded from the inception of the policy within a period of 30 days. Look at the table to get precise information -

Number of Steps on an averageRenewal Discount
5000 or below0%
5001 to 80002%
8001 to 100005%
Above 100008%

6. What is the notification period to make a claim?

The insured has to inform the insurance provider at least 48 hours before in case of planned hospitalization which claims may become important. In case of emergency hospitalization or any other medical issue, the insurer has to be notified within 24 hours after the happening of an event. No delay will be entertained by the company.

7. What is the procedure to avail a cashless claim?

  1. Inform your insurance provider.
  2. Submit all the required documents and the pre-authorization form filled by your doctor. You can upload the information on Health Jinn App to get a quick settlement.
  3. After correct submission of documents, the insurer will approve your cashless claim within 60 minutes, as in 90% of cases.

8. What is the procedure for the reimbursement of claim?

  1. Submit duly filled and attested claim intimation form in combination with the required documents. All the documents must get deposited within 15 days after treatment has been accomplished.
  2. If you fail to submit complete documents, you will be issued a deficiency letter within 7 days of receipt of claim documents.
  3. After the submission of the required documents, the company will pay the requisite amount within 30 days.
  4. A settlement statement is also issued with the name of the proposer.

9. What is the list of documents for settlement of claim?

For cashless settlement, the process is simple -

  1. Claim Intimation Form (attested and filled)
  2. Original Bills like diagnostic bills, consultation bills and attachments like prescriptions.
  3. Medical reports, history of the patient, investigation report, discharge summaries etc.
  4. Records of pre and post-hospitalization treatment.
  5. ID proofs and address proof.
  6. Settlement letter from TPA or insurance provider.
  7. FIR and MLC (Medico-Legal Case) in case of an accident claim.

Last updated on 23-10-2020