HDFC ERGO Health  Optima Restore plan 

There is nothing better than a health insurance plan you can gift your family. In today’s era where medical emergencies are at the rise and soaring healthcare expenses taking its toll on people’s savings, covering your family against those out of the blue situations. Here comes a health insurance plan like HDFC ERGO Health Optima Restore plan comes in handy in covering your family. This policy is beneficial for those who are explicitly looking for advanced features. This policy comes with 3 basic features- Restoration, Multiplier and Stay Health benefit.  The other features such as lifelong renewability, no claim bonus up to 50%, critical illness cover with E-opinion option, no co-payment etc. have made it worth your money.

Salient Features of HDFC ERGO Health Optima Restore Family Plan

The basic features of HDFC ERGO Health Optima Restore plan are:

  • The plan comes with three prime features- Restore benefit, Multiplier Benefit and Stay Active Benefit
  • Optima restore provides lifelong renewability option
  • Avail cashless services at more than 4500 hospitals across the country
  • No co-payment or premium loading
  • Tax benefits to avail for the premium paid towards HDFC ERGO Health Optima Restore Family Floater plan
  • A maximum of 6 members can be covered, including dependent children, parents and in-laws
  • Options to choose from various sum insured ranging from 3 lakhs to 50 lakhs
  • Annual health check-up facility
  • Critical advantage rider cover for sum insured Rs. 10 lakhs or more

Benefits of HDFC ERGO Health Optima Restore Family Plan

HDFC ERGO Health Optima Restore family plan offers the following benefits:

Category Coverage
In-patient Cover In-patient cover including the cost of nursing, room rent, doctors’ consultation fee, ICU rent, OT rent, cost of medicines and drugs, oxygen, X-ray etc.
Pre-hospitalisation covered up to 60 days
Post-hospitalisation covered up to 180 days
Restore Benefit automatic reinstatement of sum insured in case of exhaustion of sum insured in a policy tenure
Daily Cash Allowance  
Day-care Facility covers all day care procedures which would otherwise have required 24 hours of hospitalisation
Health Check-up Covered by the policy with a sum insured 5 lakhs and more
E-opinion E-opinion in case of critical illness is covered
Emergency Air Ambulance Up to Rs. 2.5 lakhs (Sum Insured: 20/25/50 lakhs)
Multiplier Benefit Bonus for not claiming the policy up to 50%. This can be availed wither increasing the sum insured or reducing the policy premium. In case of a claim, the bonus would be reduced by 50%
Critical Advantage Rider Optional benefit
Emergency Ambulance Rs. 2000 per hospitalisation
Organ Donor Cover Expenses incurred in harvesting an organ during transplantation up to a certain limit
Domiciliary Treatment Expenses for availing treatment at home which otherwise would have required hospitalisation
Daily cash allowance for opting for shared accommodation Rs.800 per day- Rs.4,800 (Sum Insured: 3/5/10/15 lakhs)Rs.1000 per day-Rs.4,800 (Sum Insured: 20/25/25 lakhs)

Additional Benefit to be Availed

  • No Claim Bonus: Cumulative bonus of 50% can be earned by not claiming the insurance. The benefit can be availed once in the renewal time. However, in case of a claim, the NCB reduced by 50%, as per the policy terms and conditions.
  • Cashless Service – Cashless services are offered at more than 4500 network hospitals across the country. To avail this facility, a pre-authorisation
  • Portability – The insurer offers portability benefit as well, where you can switch to HDFC ERGO Health without a hassle. If you are not satisfied with the existing insurance provider, you can check the plans of HDFC ERGO Health and transfer your existing policy without losing the policy benefits such as accumulated NCB benefit or waiting period. With portability, you need not have to serve the waiting period again for covering pre-existing or specific illness, as the insurer will consider the served waiting period as valid.
  • Tax Benefits - With HDFC ERGO Health Optima Restore Family Plan, you can save on tax under Section 80D of Income Tax Act. The premiums paid towards the policy are exempted from the tax
  • Enhancement of Sum Insured: Sum insured can be enhanced at the time of renewal, subject to no claim has been made. However, medical test or waiting period may be applied a fresh depending on the amount up to which the SI has been increased.
  • Stay Active Benefit: By downloading the stay active mobile app of HDFC ERGO Health , you can count the number of steps you take each day and earn up to 8% discount on premium in case of an individual

Add-on Cover under Optima Restore Floater Plan

 With sum insured Rs. 10 lakh or more, you can choose to cover yourself against the listed critical illnesses. The treatment can be availed at the network hospitals for major eight ailments, where a lump sum amount is offered at the time of detection of the illness. This benefit is only covered under sum insured Rs. 10 lakhs or more. You can avail the second opinion in case of critical illness

Discount Offered under HDFC ERGO Health Optima Restore Plan

  • Avail 7.5% discount by opting for a multi-year policy with 2-years tenure
  • NCB discount up to 50% for every claim-free year

Waiting Period for HDFC ERGO Health Optima Restore Plan

  • Covered after 30 Day: all illnesses, except the specific illnesses, pre-existing illness and other conditions that are in the list of exclusion
  • Covered from day 1: Only accidental claims are entertained
  • Covered after 2 years: specific illnesses
  • Covered after 3 years: Pre-existing illnesses

(Refer the policy document for the complete list of illnesses covered)

Exclusions for HDFC ERGO Health Optima Restore Plan

The policy will not entertain any claim arising out of the following situations:

  • Any claim for pre-existing illness before the policy completes 3 years
  • Mental disorder, congenital diseases, expenses for cosmetic surgery or weight control measures are excluded by the insurer
  • Accident or injury occurred due to consumption of alcohol or other intoxicating drugs
  • Expenses incurred for treating HIV or AIDS or related exclusion
  • Injury due to war or warlike situation, civil war, use of a nuclear weapon, terrorist attack
  • Expenses incurred towards dental treatment, pregnancy etc.
  • Treatment for specific illness before serving the waiting period of 2 years

(For the complete list of exclusion, please refer to the policy document)

Eligibility Criteria of HDFC ERGO Health -Optima Restore

Feature Age
Minimum entry age Children- 91 days/5 years 
Maximum entry age 65 years
Renewal age lifelong
Family Definition A maximum of 4 adults and a maximum of 5 children can be included
Premium calculation Basis of age and the sum insured chosen

HDFC ERGO Health -Optima Restore Plan: Claim Process

In order to ensure a smooth claim with HDFC ERGO Health , make sure you have an approach in the right way. Optima Restore plan can be claimed in two ways-Cashless claim and reimbursement claim. The cashless claim further can be categorised into Planned Cashless and Emergency Cashless.

Cashless Claim:

 Cashless claim facility can be availed only at the network hospitals of the insurance provider. To ensure a smooth claim, the insurer urges you to follow the below claim steps:

Claim Intimation: When it comes to hospitalisation, the claim is categorised into planned and emergency hospitalisation, based on which the insurer further compensates the amount towards cashless and reimbursement claim process. Whether it is a cashless or reimbursement claim, the first thing is to inform the insurer. In case of planned hospitalisation, 48 hours of prior intimation is required while in case of emergency hospitalisation, the insurer has to informed within 24 hours of hospitalisation. You can register a claim by using the 24x7 helpline number of the insurer or sending a mail regarding a claim.

Claim Related Information: At the time of registering your claim, the following information will be required:

  • Policy number
  • Contact details
  • Name of the insured
  • Detail of the incident
  • Date and time of the occurrence
  • Nature of illness or injury

A claim reference number will be provided by the claim executive for future reference.

Pre-authorisation Letter:  in case of a cashless claim, you’ll require a pre-authorisation letter duly approved by the insurer. to do so, approach the insurance help desk in the hospital or TPA, who will further coordinate with the insurer regarding the same.

Claim Settlement: The insurer will convey its decision to the hospital authority. Once the pre-authorisation request has been accepted, you can avail treatment free of cost. The hospital bills will be settled directly by the insurer.

Reimbursement Claim

When you avail treatment from a non-network hospital and register a claim to compensate the incurred amount, it is called reimbursement claim. To ensure a successful claim, the following steps have to be followed:

  • Avail the treatment from a hospital of your choice and pay the medical bills initially
  • Don’t forget to collect the original bills with the receipts
  • Register a claim by filling and submitting the claim form and the supporting documents
  • Post receiving the required documents, the insurer will process the claim within 30 days
  • In case of a discrepancy, the insurer will intimate you within 7 days with a discrepancy letter
  • In case of claim rejection, the insured will be informed about the reason of rejection
  • The admissible amount will be transferred to the registered bank account number

Document Required

While claiming HDFC ERGO Health Optima Restore Floater plan, the following documents are required:

  • Duly filled claim form
  • Police FIR in case of accidental claim
  • Pre-authorisation letter for cashless claim
  • KYC document of the insured
  • 1st Investigation report
  • Duly signed doctors report on the nature of the illness
  • Original medical bills and receipts (reimbursement claim)
  • Discharge report
  • The insurer may ask for other documents supporting the claim
Written By: PolicyBazaar - Updated: 08 January 2021
Disclaimer: Policybazaar does not endorse, rate or recommend any particular insurer or insurance product offered by an insurer.

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