HDFC ERGO Health Suraksha Policy

HDFC Ergo Health Suraksha Plan Overview

HDFC Health Suraksha plan is designed to meet the healthcare needs of you and your family. With this health insurance plan, you can offer protection to your family against any unforeseen diseases or accidental injuries in the most affordable manner.

The plan includes both cashless hospitalization in network hospitals and reimbursement of medical expenses incurred on treatment taken in the non-network hospitals. The plan covers hospitalization expenses for the treatment of illnesses or accidental injuries and further extends to ambulance cover, organ donor expenses, domiciliary treatments, day care procedures, and AYUSH benefits.

Features and Benefits of HDFC Ergo Health Suraksha Plan

• Option to choose an Individual Plan or a Family Floater Health Plan
• Option to select an annual health insurance plan or a two-year plan
• No maximum age limit
• Avail cashless hospitalization in more than 6000 empanelled hospitals
• Cumulative bonus for every claim-free year
• Coverage of expenses incurred on health check-ups after completing 4 claim-free years.
• Tax benefits on the premium paid every year
• Quick and hassle free claim settlement with minimum documentation
• No pre-medical checkup required for individuals below 45 years of age (provided pre-existing diseases are declared)
• Sub-limits are not applicable to hospital expenses, doctor fees, hospital room rents, and specific diseases
• Tax benefits on HDFC ERGO Health Insurance premium

Inclusions of HDFC Ergo Health Suraksha Plan

The plan covers the following expenses:

• In-patient hospitalization expenses up to the sum assured limit. This includes boarding expenses, room rent, nursing expenses, intensive care unit, fees charged by the healthcare provider, operation theatre charges, and expenses incurred on surgical appliances, blood, oxygen, anesthesia, medicines, diagnostic procedures
• Reimbursement of pre-hospitalization expenses that are incurred 60 days before hospital admission
• Emergency ambulance charges based on the sum assured
• Reimbursement of 144 day-care procedures that do not require 24-hours of hospitalization
• Reimbursement of organ donor expenses subjected to policy terms and conditions
• Expenses incurred on domiciliary treatment are covered, if it is prescribed by the attending healthcare provider. Either due to unavailability of the beds or as part of the treatment.
• AYUSH benefit is also provided. Expenses incurred on Ayurveda, Homeopathy, Siddha or Unani are covered, provided the treatment is taken in a government hospital
• Cumulative bonus on the sum insured
• On completion of 4 consecutive claim-free years, the medical check-ups are also reimbursed ( either 1% of the sum insured or a up to a limit of Rs. 5000

Optional Benefits

• Maternity Expenses
• Critical Illness Benefit
• Outpatient Dental Care
• Co-payment Benefit

Exclusions of HDFC Ergo Health Suraksha Plan

• A waiting period of 2 years for treatment of internal tumors, tonsils etc.
• 30 days of waiting period to be eligible to make a health insurance claim
• Pre-existing diseases to be covered after 48 months of policy purchase date
• Cost of vaccinations taken as preventive measures including inoculation etc.
• Illness resulting due to war conditions, nuclear radiations, armed conflicts, terrorist activities, rebellion etc.
• Treatment for STDs, HIV, and AIDS
• Claims for illness arising due to an overdose of drugs and alcohol
• Self-inflicted injuries or suicidal attempts
• Loss or damage arising due to criminal intent
• Any kind of cosmetic or plastic surgeries unless required as part of the treatment

Sum Assured (Rs.)

Basic Sum Insured: Rs. 3 lakhs to Rs. 10 lakhs

Claim Procedure of HDFC Ergo Health Suraksha Plan -

The claim procedure varies for cashless claim settlement and reimbursement. Here’s a quick rundown of the plan in detail:

Cashless Claim Settlement

• Cashless hospitalization can only be availed at the network hospitals. The insured is not required to pay the hospitalization bills during admission or discharge.
• Fill the cashless request form provided by the hospital authorities
• For cashless claim settlement hospital authorities usually, coordinate with the Third Party Administrator (TPA) or the insurer to get the pre-authorization.
• The insured needs to submit the health card along with the pre-authorization form to the hospital while taking admission.
• Do not forget to carry an identity proof or photo ID card

If the documents are not submitted timely, the claim can be denied. This does not interrupt the treatment. The insured can pay to the hospital and later on file the claim for reimbursement.

Claim Procedure to Follow In Case Of Emergency Hospitalization

• Once admitted to a network hospital, immediately inform the insurer about the illness and hospitalization
• Submit the patients’ health card to the hospital along with a photo Id proof
• Fill the pre-authorization form and get it signed by the attending medical practitioner
• Medical bills, reports, and the pre-authorization will be emailed by the hospital to the Insurance Company
• The insured or the policyholder will need to sign all the bills, documents, pay-off the expenses that are not covered by the insurance plan.

The insured should keep Xerox copy of all the documents & discharge summary as the original docs will be kept by the hospital.

In the Event of Planned Hospitalization

Select the best network hospital in your vicinity. Intimate the in-house claim team of the insurance provider once the date of treatment and admission are finalized. It is required to intimate the insurer at least 2 to 3 days in advance -

If cashless claim request is approved by the insurance company the process should be as follows -

• At the time of hospital admission submit a photo ID card with the pre-authorization letter to the hospital
• When getting discharged settle the non-reimbursable expenses, check and sign the hospital bills
• Keep a photocopy of all the documents for future records

In Case a Cashless Claim is Denied -

• Get admitted and take treatment
• You need to settle the hospital bills and collect all the original bill documents & reports at the time of discharge.
• Register your claim with HDFC ERGO in-house claims services team (HCS) / Third Party Administrator (TPA) for processing and reimbursement

Procedures for Claim Reimbursement in Non-Network Hospitals -

• Get admitted to the hospital
• As soon as possible, inform the in-house claims team of the insurer or the Third Party Administrator (TPA) about the same
• Clear the hospital bills, collect all the reports, documents and bills at the time of discharge
• File for reimbursement of the claim to the insurance provider or the TPA and submit duly filled claim form with all the required documents

Documents Required for Reimbursement of Insurance Claim

• Sign duly filled claim form
• Original hospital bills, the bill number, receipts and the final bill that is given by the hospital
• Doctor’s prescription is mandatory with medicine bills
• All the lab reports (original copy)
• Discharge summary with the bill, or death certificate in case of death during hospitalization
• Treatment to be followed after discharge with a letter from the medical practitioner
• If it is a non-empanelled hospital, it may be to provide a registration number of the hospital and doctors on the letterhead of the hospital letterhead. This should be signed and stamped by the hospital.