HDFC ERGO Optima Super Health Insurance

HDFC ERGO Health Optima Super is a top-up plan designed for your family with unique features. You’ll have the varied sum insured options to choose from. One of the unique features of this plan is the easy conversion of this plan into full-fledged health insurance policy with no deductible. That means while using as a top-up plan you pay the deductibles and when is being converted to indemnity plan, the policy benefits can be enjoyed without paying any deductible.

Key Features of HDFC ERGO Health Optima Super Plan

The policy comes with the following features:

  • Avail cashless access to over 4650+ network hospitals in over 800 cities
  • 10% of cumulative bonus to be paid for not claiming the insurance up to a maximum of 100%
  • The plan comes with no policy ceasing age
  • As per the Section 80D of Income Tax Act, you can enjoy tax benefits for premiums paid towards health insurance of HDFC ERGO Health
  • The offers lifelong renewability with no policy ceasing age
  • Option to opt for a higher sum insured ranging from Rs. 5 lakhs, Rs. 7 lakhs and Rs. 10 lakhs
  • Pre-existing illness covered after 4 years of waiting period
  • A maximum of 2 adults and a maximum of 2 children can be covered under single premium
  • Waiver of the deductible by converting the policy into an indemnity policy
  • Portability benefit with easy access to customised plans

HDFC ERGO Health Optima Super Plan Coverage

Sum Insured Options Rs 500,000; Rs. 700,000; Rs. 10,00, 000
Deductibles 1-7 lakhs and 10 lakhs
In-patient treatment expenses Covered
Pre-hospitalisation Covered
Post-hospitalisation Covered
Day-care procedure Covered
Organ Donor expense Covered
Ambulance expense Covered

HDFC ERGO Health Optima Super Floater Plan: Scope of Cover

  • In-Patient Hospitalisation: The medical expenses incurred during hospitalisation for more than 24 hours including nursing cost, room rent, cost of medicines, doctor’s consultation fee, ICU rent, OP rent, cost of oxygen, X-ray etc.
  • Pre-Hospitalisation: The medical expenses towards doctors’ consultations, investigations and medicines 60 days prior to hospitalisation are covered.
  • Post-Hospitalisation: Expenses incurred for availing treatment at homepost-discharge for 90 days are covered.
  • Day-Care Procedures: 144 day-care procedures are covered which do not require 24 hours hospitalization due to technological advancement
  • Organ Donor: The expenses of organ donor while transplanting an organ are covered
  • Ambulance Service: Up to Rs. 2000 per hospitalisation

Additional Benefits under HDFC ERGO Health Easy Health Plan

  • Waiver of Deductible Benefit: The policy comes with a waiver of deductible benefit where the top-up policy can be converted into a full-fledged policy where no deductible is to be paid. This can be done during renewal between the age 55-60 years, provided you’re enrolled with HDFC ERGO Health before entering the age 50 years and the policy is renewed without a break.
  • Portability Benefit: With HDFC ERGO Health portability benefit, switching the insurer becomes easier. At any point of time, if you feel your existing coverage insufficient or not satisfied with the current insurer, you can opt for HDFC ERGO Health Optima health insurance without losing the current policy benefits such as accrued NCB benefit. Moreover, you don’t need to serve the waiting period all over again to claim your policy.
  • Cashless Service: Keep your savings secured by availing cashless services at more than 4650+ network hospitals of HDFC ERGO Health . Whether it is planned hospitalisation or emergency one, a pre-authorisation letter and health card will be required to get cashless services. The process of applying for cashless services is mentioned in the policy document.
  • Tax Benefits: With Optima Super Plan, you can save on tax under Section 80D of Income Tax Act. The premiums paid towards the policy are exempted from the tax deduction.

Value Added Services

  • Healthline: Under its value-added service, the insurer offers expert advice on health, nutrition and diet. These services can be availed through Healthline by simply call them and mentioning the customer ID. These services are available free of cost, where personalised health and wellness solutions are provided for the needy one.
  • Health Risk Assessment: Now tracking your health becomes easier with HDFC ERGO Health Health Risk Assessment option. It helps to profile the health status of each member on the website. They are offered with recommendations on healthy diet, lifestyle and nutrition regimen.

Waiting Period for HDFC ERGO Health Optima Super Plan

  • Covered after 30 Days: Initial waiting period for paying off a regular claim arising out of a health condition, accept accidental claims
  • Covered after 2 years: Specific illnesses
  • Covered after 4 years: Pre-existing illnesses

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

Exclusions for HDFC ERGO Health Optima Super Plan

While the insurer offers coverage for almost every health condition, the below conditions are just not feasible:

  • The insurer will not entertain any claim in the initial 30 days, except accidental claims
  • Treatment of HIV/AIDS/Mental disorder
  • Intentional injury, suicide or attempt to suicide are excluded
  • War, warlike situation, use of a nuclear weapon, malicious act, riot, terrorism etc. are excluded
  • Violation of law
  • No claim arising out of a health condition for pre-existing illness before 4 years will not be covered
  • Any expenses incurred due to maternity or childbirth
  • Congenital disease or genetic disorder
  • Accidental injury leading to hospitalisation while driving under the influence of alcohol
  • In case of an accident, if the driver is not carrying a valid license and met with an accident
  • Involvement in dangerous activity or adventurous sports
  • Injury while participating in the operation of Army, Navy or Air Force
  • Expenses incurred for cosmetic or plastic surgery

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

Eligibility Criteria of HDFC ERGO Health Optima Super Plan

Feature Age
Minimum entry age Children- 91 days/5 years (if either parent is covered)Adult-18 years 
Maximum entry age 65 years
Renewal age lifelong
Family Definition A maximum of 2 adults and a maximum of 2 children can be included
Calculation of premium Basis of age and the sum insured chosen
Policy Tenure 1 & 2 years

Discount offered under HDFC ERGO Health Optima Super Family Floater Plan

  • 5% discount on purchasing of a long-term policy (2-years plan)

HDFC ERGO Health Easy Health Plan Renewal Terms

In order to enjoy the policy benefits uninterruptedly, you’ll have to ensure timely renewal of HDFC ERGO Health Optima Floater plan. Optima Super plan comes with lifelong renewability, which means no maximum policy ceasing age. As per the renewal terms, a ‘grace period’ of 30 days is offered in case of policy renewal date is missed. The premiums or renewal terms are subjected to change, however, prior notice will be given by the insurer at least 3 months prior to the renewal due date.

Steps to Renew

To renew your existing plan visit the official website of HDFC ERGO Health

  • Go to the ‘policy renewal’ button
  • Login with the registered ID and Password or with the policy number
  • Provide necessary information
  • Calculate the premium and pay it online through credit/debit card or net banking

HDFC ERGO Health Optima Super Floater Plan: Claim Process

Whether it is planned hospitalisation or an emergency, you can claim your insurance policy in two ways- cashless and reimbursement claim. While cashless claims are available at network hospitals only, in case of reimbursement claim you can get the treatment from any of your preferred hospitals. Well, the steps of claiming your insurance include:

Claim Intimation: You’re required to inform the insurer immediately once a claim is raised. You can call on their 24x7 helpline number and write to the email ID, mentioning the nature of the claim. A planned hospitalisation has to be informed 48 hours before the actual hospitalisation date, while in case of emergency hospitalisation such as an accidental case or severe illness leading to hospitalisation is to be informed within 24 hours post hospitalisation.

The below information will be required while registering your claim:

  • Policy number
  • Contact details
  • Name of the insured
  • Nature of the accident/illness
  • Date and time of the occurrence
  • Any previous treatment availed

The claim executive will provide a claim reference number for future use.

Pre-authorisation Request: A pre-authorisation letter obtained from the TPA or insurance help-desk at the hospital shall be submitted seeking approval from the insurer for availing cashless services. The same has to be sent to the insurer along with an Id of the insured.

Claim Settlement: The insurance company will communicate its decision directly to the network hospital authority. If it approves the request, you can avail the treatment free of cost. If the request is rejected, the insurer will notify the reason along with a discrepancy letter within 7 days. In such a case, avail the treatment and pay the expenses on your own. You can register a claim as a reimbursement later.

How to Register Reimbursement Claim?

In case your insurer denies your claim or if you avail the treatment from a non-associated hospital, you pay the medical expenses initially and register a claim under reimbursement claim process. To complete the process smoothly, follow the below steps:

  • Avail the treatment from any of your preferred hospital
  • Pay the medical bills initially, collect the original bills and receipts at the time of discharge
  • Register your claim under reimbursement category with HDFC ERGO Health
  • Duly fill and sign the claim form and submit to the insurer along with the relevant documents
  • After receiving the claim form along with the required documents, the insurance provider will settle the claim up to an approved limit
  • Any discrepancy will be intimated within 7 days with a discrepancy letter
  • In case of claim rejection, you will be informed accordingly

Document Required

To ensure a hassle-free claim settlement with HDFC ERGO Health , the following documents are required

  • Duly filled claim form
  • Police FIR in case of accidental claim
  • Pre-authorisation letter for cashless claim
  • Duly signed doctors report on the nature of the illness
  • 1st Investigation report
  • KYC document of the insured
  • Discharge report
  • A reimbursement claim demands you to submit the original medical bills and receipts while claiming
  • The insurer may ask for other documents supporting the claim

Points to Remember: 

  • You can avail cashless services only at a network hospital of HDFC ERGO Health
  • The settled amount will be transferred in the name of insured only
  • Without a complete claim form, the documentation is incomplete
  • If availing cashless services, a planned hospitalisation is required to informed 48 hours prior to the hospitalisation
  • Emergency hospitalisation requires the insured to inform the insurance provider 24 hours within hospitalisation, with a pre-authorisation letter seeking permission from the insurer.
  • In case of cashless service, the insurer will convey its decision within 6 hours from receiving the pre-authorisation letter
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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