HDFC ERGO Optima Super Health Insurance Plan

HDFC ERGO Health (formerly known as Apollo Munich) Optima Super - Overview

HDFC ERGO Health (formerly known as Apollo Munich) Optima Super is a top up plan with unique features. The plan comes with varied sum insured & deductible options to choose from. Moreover, the policy also provides the option to convert this into a full-fledged indemnity policy while you approach your retirement age. When it is a top up plan, deductible is there to be applied, when it is converted to an indemnity plan, deductible is waved.

Key Features of HDFC ERGO Health (formerly known as Apollo Munich) Optima Super Plan

The policy comes with the following features:

• Avail cashless access to over 4500+ network hospitals in over 800 cities
• NCB bonus of 10% for every claim-free year, a maximum up to 100%
• The plan comes with no policy ceasing age
• Pre-existing illness covered after 4 years of waiting period
• Tax benefit for the premiums paid towards HDFC ERGO Health (formerly known as Apollo Munich) Optima Super plan
• The policy comes with lifelong renewability
• Opt for a higher coverage with sum insured ranging from Rs. 5 lakhs, Rs. 7 lakhs and Rs. 10 lakhs
• The policy comes with portability benefit as well
• A maximum of 4 adults and a maximum of 5 children can be covered under single premium
• Waiver of the deductible by converting the policy to an indemnity policy
• Portability benefit with easy access to customised plans

Benefits of HDFC ERGO Health (formerly known as Apollo Munich) Optima Super Plan

Sum Insured Option- 5 lakhs/7 lakhs/10 lakhs                                                              Deductible: 1lakh to 10 lakhs
Category	Coverage
In-Patient Treatment	Hospitalisation expenses including room rent, nursing cost, medicine cost, ICU, drugs, surgery, doctor’s consultation etc.
Pre-hospitalisation Expense	Medical expenses for 60 days prior to hospitalisation
Post-Hospitalisation Expense	Medical expenses for 90 days prior to hospitalisation
Ambulance Cover	Rs. 2000 per hospitalisation
Organ Donor Expense	Expenses incurred due to organ transplantation
Day Care Procedure	144-day care procedures that don’t require 24 hours hospitalisation

Additional Benefits under HDFC ERGO Health (formerly known as Apollo Munich) Easy Health Plan

• Waiver of Deductible Benefit - it offers an option to convert the plan into a full-fledged indemnity plan at the time renewal between 55-60 years. The only condition is that you have to be enrolled with the insurer before the age of 50 years. Moreover, the policy should be renewed without a break.
• Portability Benefit: The insurer ensures a smooth portability option in case you are not satisfied with the existing health insurance provider and want to shift to HDFC ERGO Health (formerly known as Apollo Munich). You can browse over the plan according to your comfort and switch without losing the accumulated policy benefits such as NCB bonus or waiting period.
• Cashless Service - You can avail cashless services at more than 4500 network hospitals of the insurance provider. In order to avail so, a pre-authorisation letter and health card will be required. 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

1. Healthline: Under its value-added service, the insurer offers expert advice on health, nutrition and diet. These services can be availed through Healthline by simple 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.
2. Health Risk Assessment: HDFC ERGO Health (formerly known as Apollo Munich) provides its customers with the facility to access their health risk through 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 (formerly known as Apollo Munich) Optima Super Plan

• From day 1: Only accidental claims will be accepted
• Covered after 30 Days: Initial waiting period for paying off a regular claim arising out of a health condition
• 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 (formerly known as Apollo Munich) Optima Super Plan

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

• No claim will be entertained in the initial 30 days, except accidental claims
• Any claim arising out of pre-existing illnesses before completing 4 years of waiting period
• Any expenses incurred due to maternity or childbirth
• Treatment of HIV/AIDS/Mental disorder
• Intentional injury, suicide or attempt to suicide
• 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
• War, warlike situation, malicious act, riot, terrorism, use of a nuclear weapon
• Breach of law
• Involvement in dangerous activity or adventurous sports
• Injury while participating in the operation of Army, Navy or Air Force
• Congenital disease or genetic disorder
• 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 (formerly known as Apollo Munich) 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	Individual Plan - A maximum of 4 adults and a maximum of 5 children can be included
Calculation of premium	Basis of age and the sum insured chosen
Policy Tenure	1 & 2 years

Discount to be Availed under HDFC ERGO Health (formerly known as Apollo Munich) Optima Super Plan

• 10% discount if 3 or more family members are covered
• 5% discount on purchasing of a long-term policy

HDFC ERGO Health (formerly known as Apollo Munich) Easy Health Plan Renewal Terms

The insurer offers lifelong renewability where the policy has to be renewed every year or two, depending on the type of policy. The insurer also offers a grace period of 30 days in case the renewal date is missed. The insured has to renew the policy during this period to avoid a lapsed policy. There is n maximum policy ceasing age on renewal. The waiting period will tend to reduce by 1 year with every continuous renewal. The insured can renew the policy online by paying the premiums through debit/credit card or net banking or by visiting the nearest branch. One can renew by approaching an authorised broker as well.

Moreover, any change is sum insured can only be done at the time of renewal, subject to no claim have been registered. While increasing or decreasing the sum insured, the insurer may ask for a fresh medical test and the waiting period might be applied afresh in relation to the amount by which the SI has been increased.

Moreover, renewal is the only time when one can switch or port to a similar indemnity policy of HDFC ERGO Health (formerly known as Apollo Munich), with all the accrued benefits provided by the existing insurer.

HDFC ERGO Health (formerly known as Apollo Munich) Optima Super: Claim Process

In order to claim the HDFC ERGO Health (formerly known as Apollo Munich) Optima Super plan, you will have to follow the below claim steps:

1. Cashless Claim:

Claim Intimation: Claim intimation is the first step towards claiming your insurance. To register claim call on their 24x7 helpline or write to their official email ID. In case of planned hospitalisation, intimate the insurer 48 hours prior to the actual hospitalisation day. If it is an emergency case, inform the insurer within 24 hours of hospitalisation.

While registering a claim, you’ll need to provide the following information:

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

A claim reference number will be provided for future use.

Cashless Claim Request:  In order to avail cashless services, you’ll require to submit a pre-authorisation letter along with ID proof, seeking permission from the insurer. Upon receiving the request, the insurer will convey its decision to the hospital authority.

Claim Settlement: Once the insurer approves the cashless request, you can avail the treatment free of cost, while the expenses are settled directly with the hospital authority. In case the insurer rejects the cashless request, avail the treatment and pay the bills on your own. Later, register a claim under reimbursement category.

2. Reimbursement Claim

When your insurer denies your cashless request due to insufficient documentation or other related reasons, or if you avail the healthcare services from a non-network hospital, the incurred expenses can be compensated through reimbursement claim. In order to ensure a smooth claim process:

• Approach any of the non-network hospitals as per your convenience and avail the treatment
• Pay the hospital expenses and collect the original bills and receipts at the time of discharge
• Register a claim by approaching the customer care or writing an email directly to HDFC ERGO Health (formerly known as Apollo Munich)
• Duly fill and sign the claim form and submit to the insurer along with the relevant documents
• Upon receiving the claim form along with the supporting documents, the insurer will analyse the case and process the claim
• In case of any discrepancy, the insurer will intimate the same within 7 days
• If everything is at par, the claim will be settled within 30 days by transferring the amount to the registered bank account
• In case of claim rejection, you will be informed accordingly

Document Required

 The following documents are to be furnished to claim HDFC ERGO Health (formerly known as Apollo Munich) Optima Super Plan:

• 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
• 1^st Investigation report
• KYC document of the insured
• Discharge report
• In case of reimbursement claim, original medical bills and receipts are required
• The insurer may ask for other documents supporting the claim

Points to Remember: 

• Cashless services can be availed only at a network hospital
• The settlement will be done in the name of policyholder only
• Without a complete claim form, the documentation is incomplete
• Planned hospitalisation requires 48 hours intimation before hospitalisation
• In case of emergency hospitalisation, the insurer has to be informed 24 hours before hospitalisation
• In case of cashless service, the insurer will convey its decision within 6 hours from receiving the pre-authorisation letter