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Optima Secure Revision

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You are on page 1/ 33

HDFC ERGO General Insurance Company Limited

Policy Wordings
my: Optima Secure

Table of contents

Sr. No. Particulars Page No.

Preamble 2

Operating Clause 2

A.1.1 Standard Definitions 2

A.1.2 Specific Definitions 7

B.1 Base Coverages 11

B.2 Optional Coverages 14

B.3 Renewal Benefit 27

C.1 Waiting Periods 29

C.2 Standard Exclusions 30

C.3 Specific Exclusions 32

D.1 Standard General Terms & Clauses 33

E Other Terms & Conditions 42

Annexure A 46

Annexure B 51

Annexure C 53

HDFC ERGO General Insurance Company Limited. IRDAI Reg. No. 146. CIN: U66030MH2007PLC177117. Registered & Corporate
Office: 1st Floor, HDFC House, 165-166 Backbay Reclamation, H. T. Parekh Marg, Churchgate, Mumbai – 400 020. UIN: my: Optima
Secure - HDFHLIP25041V062425.
1
Preamble Council of Indian Medicine/Central Council for
This Policy is a contract of insurance issued by HDFC ERGO Homeopathy; or
General Insurance Company Limited (hereinafter called c. AYUSH Hospital, standalone or co-located
the ‘Company’) to the proposer mentioned in the Policy within-patient healthcare facility of any
Schedule (hereinafter called the ‘Policyholder’) to cover the recognized system of medicine, registered
person(s) named in the Policy Schedule (hereinafter called with the local authorities, wherever applicable,
the ‘Insured Person(s)’). The Policy is based on the statements and is under the supervision of a qualified
and declaration provided by the Policyholder in the Proposal registered AYUSH Medical Practitioner and
Form as well as in any welcome or other tele-verification must comply with all the following criterion:
calls with the Company’s authorized person and is subject to i. Having at least 5 in-patient beds;
receipt of the requisite premium.
ii. Having qualified AYUSH Medical
Operating Clause Practitioner in charge round the clock;
If during the Policy Period the Insured Person is required to be iii. Having dedicated AYUSH therapy sections
Hospitalized for treatment of an Illness or Injury at a Hospital/ as required and/or has equipped operation
Day Care Centre or given treatment at Home, following theatre where surgical procedures are to
Medical Advice of a duly qualified Medical Practitioner, the be carried out;
Company shall indemnify Medical Expenses necessarily iv. Maintaining daily records of the
incurred towards the Covers in force under the Policy, as patients and making them accessible
specified in the Policy Schedule. to the insurance company’s authorized
Provided further that, any amount payable under the Policy representative.
shall be subject to the terms of coverage (including Aggregate Def. 4. AYUSH Day Care Centre means and includes
Deductible, Sub-limits), exclusions, conditions and definitions Community Health Centre (CHC), Primary Health
contained herein. The maximum, total and cumulative liability Centre (PHC), Dispensary, Clinic, Polyclinic or any
of the Company under any and all such claims during each such health centre which is registered with the
Policy Year shall be the Sum Insured (Individual or Floater), local authorities, wherever applicable and having
including optional covers and other add on covers in force facilities for carrying out treatment procedures and
under the Policy, and Cumulative Bonus (if any) specified in medical or surgical/para-surgical interventions or
the Policy Schedule. both under the supervision of registered AYUSH
SECTION A. DEFINITIONS Medical Practitioner(s) on day care basis without
in-patient services and must comply with all the
1.1. Standard Definitions following criterion:
The terms defined below and at other junctures i. Having qualified registered AYUSH Medical
in the Policy have the meanings ascribed to them Practitioner (s) in charge;
wherever they appear in this Policy and, where,
ii. Having dedicated AYUSH therapy sections as
the context so requires, references to the singular
required and/or has equipped operation theatre
include references to the plural; references to the
where surgical procedures are to be carried out;
male includes the female and references to any
statutory enactment includes subsequent changes iii. Maintaining daily records of the patients and
to the same. making them accessible to the insurance
company’s authorized representative.
Def. 1. Accident means a sudden, unforeseen and
involuntary event caused by external, visible and Def. 5. Cashless facility means a facility extended by the
violent means. insurer to the insured where the payments, of the
costs of treatment undergone by the insured in
Def. 2. Any one illness means continuous period of illness
accordance with the policy terms and conditions,
and includes relapse within 45 days from the date
are directly made to the network provider by the
of last consultation with the Hospital/Nursing Home
insurer to the extent pre-authorization is approved.
where treatment was taken.
Def. 6. Condition Precedent means a policy term or
Def. 3. AYUSH Hospital is a healthcare facility wherein
condition upon which the Insurer’s liability under the
medical/surgical/para-surgical treatment
policy is conditional upon.
procedures and interventions are carried out by
AYUSH Medical Practitioner(s) comprising of any of Def. 7. Congenital Anomaly means a condition which
the following: is present since birth, and which is abnormal with
reference to form, structure or position.
a. Central or State Government AYUSH Hospital;
or a) Internal Congenital Anomaly: Congenital
anomaly which is not in the visible and
b. Teaching hospital attached to AYUSH College
accessible parts of the body.
recognized by the Central Government /Central

HDFC ERGO General Insurance Company Limited. IRDAI Reg. No. 146. CIN: U66030MH2007PLC177117. Registered & Corporate
Office: 1st Floor, HDFC House, 165-166 Backbay Reclamation, H. T. Parekh Marg, Churchgate, Mumbai – 400 020. UIN: my: Optima
Secure - HDFHLIP25041V062425.
2
b) External Congenital Anomaly: Congenital shall be forfeited to the Company in the event
anomaly which is in the visible and accessible of misrepresentation, mis-description or non-
parts of the body. disclosure of any material fact.
Def. 8. Co-Payment means a cost sharing requirement Def. 15. Domiciliary Hospitalization means medical
under a health insurance policy that provides treatment for an illness/disease/injury which in the
that the policyholder/insured will bear a specified normal course would require care and treatment
percentage of the admissible claims amount. A co- at a hospital but is actually taken while confined at
payment does not reduce the Sum Insured. home under any of the following circumstances:
Def. 9. Cumulative Bonus means any increase or addition i. the condition of the patient is such that he/
in the Sum Insured granted by the insurer without an she is not in a condition to be removed to a
associated increase in premium. hospital, or
Def. 10. Day Care Centre means any institution established ii. the patient takes treatment at home on account
for day care treatment of illness and / or injuries of non-availability of room in a hospital.
or a medical set -up with a hospital and which has Def. 16. Emergency Care means management for an
been registered with the local authorities, wherever illness or injury which results in symptoms which
applicable, and is under the supervision of a occur suddenly and unexpectedly, and requires
registered and qualified medical practitioner AND immediate care by a medical practitioner to prevent
must comply with all minimum criterion asunder: - death or serious long term impairment of the
i. has qualified nursing staff under its insured person’s health.
employment; Def. 17. Grace Period means the specified period of time,
ii. has qualified medical practitioner/s in charge; immediately following the premium due date during
iii. has fully equipped operation theatre of its own which premium payment can be made to renew or
where surgical procedures are carried out; continue a policy in force without loss of continuity
benefits pertaining to waiting periods and coverage
iv. maintains daily records of patients and will of pre-existing diseases. Coverage need not be
make these accessible to the insurance available during the period for which no premium
company’s authorized personnel. is received. The grace period for payment of the
Def. 11. Day Care Treatment means those medical premium for all types of insurance policies shall
treatment, and/or surgical procedure which is be: fifteen days where premium payment mode is
i) undertaken under General or Local Anaesthesia monthly and thirty days in all other cases.
in a hospital/day care centre in less than 24 Provided the insurers shall offer coverage
hours because of technological advancement, during the grace period, if the premium is paid in
and instalments during the policy period. (Note: In case
ii) which would have otherwise required of non-instalment premium payment, coverage shall
hospitalization of more than 24 hours, not be available for the period for which no premium
is received).
Treatment normally taken on an out-patient
basis is not included in the scope of this Def. 18. Hospital means any institution established for in-
definition. patient care and day care treatment ofIllness and/
or injuries and which has been registered as a
Def. 12. Deductible means a cost-sharing requirement
hospital with the local authorities under the Clinical
under a health insurance policy that provides that
Establishments (Registration and Regulation) Act
the insurer will not be liable for a specified rupee
2010 or under the enactments specified under
amount in case of indemnity policies and for a
the Schedule of Section 56(1) of the said act Or
specified number of days/hours in case of hospital
complies with all minimum criteria as under:
cash policies which will apply before any benefits
are payable by the insurer. A deductible does not i) has qualified nursing staff under its employment
reduce the Sum Insured. The deductible is separate round the clock;
from any Aggregate Deductible that may be in-force ii) has at least 10 in-patient beds in towns having
and applicable under the Policy, as specified in the a population of less than 10,00,000 and at least
Policy Schedule. 15 in-patient beds in all other places;
Def. 13. Dental Treatment means a treatment related to iii) has qualified medical practitioner(s) in charge
teeth or structures supporting teeth including round the clock;
examinations, fillings (where appropriate), crowns, iv) has a fully equipped operation theatre of
extractions and surgery. its own where surgical procedures are carried
Def. 14. Disclosure of information norm means the out;
policy shall be void and all premium paid hereon

(a) Acute condition – Acute condition means is a Def. 27. Medical Practitioner means a person who holds
disease, illness or injury that is likely to respond a valid registration from the Medical Council of
quickly to treatment which aims to return the any State or Medical Council of India or Council
person to his or her state of health immediately for Indian Medicine or for Homeopathy set up by
before suffering the disease/illness/injury the Government of India or a State Government
which leads to full recovery and is thereby entitled to practice medicine within
its jurisdiction; and is acting within the scope and
(b) Chronic condition – A chronic condition is jurisdiction of license.Medical Practitioner who is
defined as a disease, illness, or injury that has sharing the same residence as the Insured Person
one or more of the following characteristics: and is a Family Member of the Insured Person are
1. it needs ongoing or long-term monitoring not considered as Medical Practitioner under the
through consultations, examinations, scope of this Policy.
check-ups, and /or tests Medical Practitioner (Definition applicable for the
2. it needs ongoing or long-term control or treatment taken outside India) means a licensed
relief of symptoms medical practitioner acting within the scope of his
3. it requires rehabilitation for the patient or license and who holds a degree of a recognized
for the patient to be specially trained to institution and is registered by the Authorized
cope with it Medical Council of the respective country.

4. it continues indefinitely Def. 28. Medically Necessary Treatment means any

treatment, test, medication, or stay in hospital or
5. it recurs or is likely to recur
part of stay in hospital which:
Def. 21. Injury means accidental physical bodily harm
i) is required for the medical management of the
excluding illness or disease solely and directly
illness or injury suffered by the insured;
caused by external, violent and visible and evident
means which is verified and certified by a Medical ii) must not exceed the level of care necessary
Practitioner. to provide safe, adequate and appropriate
medical care in scope, duration or intensity;
Def. 22. Inpatient Care means treatment for which the
insured person has to stay in a hospital for more iii) must have been prescribed by a medical
than 24 hours for a covered event. practitioner;

Def. 23. Intensive Care Unit means an identified section, iv) must conform to the professional standards
ward or wing of a hospital which is under the widely accepted in international medical
constant supervision of a dedicated medical practice or by the medical community in India.
practitioner(s), and which is specially equipped for Def. 29. Migration means a facility provided to policyholders
the continuous monitoring and treatment of patients (including all members under family cover and
who are in a critical condition, or require life support group policies), to transfer the credits gained for
facilities and where the level of care and supervision pre-existing diseases and specific waiting periods
is considerably more sophisticated and intensive from one health insurance policy to another with the
than in the ordinary and other wards. same insurer.
Def. 24. ICU (Intensive Care Unit) Charges means the Def. 30. Network Provider means hospitals or health care
amount charged by a Hospital towards ICU providers enlisted by an insurer, TPA or jointly by an
expenses which shall include the expenses for ICU Insurer and TPA to provide medical services to an
bed, general medical support services provided insured by a cashless facility.
to any ICU patient including monitoring devices, Def. 31. Non-Network Provider means any hospital, day
critical care nursing and intensivist charges care centre or other provider that is not part of the
network.
HDFC ERGO General Insurance Company Limited. IRDAI Reg. No. 146. CIN: U66030MH2007PLC177117. Registered & Corporate
Office: 1st Floor, HDFC House, 165-166 Backbay Reclamation, H. T. Parekh Marg, Churchgate, Mumbai – 400 020. UIN: my: Optima
Secure - HDFHLIP25041V062425.
4
Def. 32. Notification of Claim means the process of Def. 40. Renewal means the terms on which the contract of
intimating a claim to the insurer or TPA through any insurance can be renewed on mutual consent with
of the recognized modes of communication. a provision of grace period for treating the renewal
Def. 33. OPD Treatment means the one in which the Insured continuous for the purpose of gaining credit for pre-
visits a clinic / hospital or associated facility like a existing diseases, time-bound exclusions and for all
consultation room for diagnosis and treatment waiting periods.
based on the advice of a Medical Practitioner. The Def. 41. Room Rent means the amount charged by a
Insured is not admitted as a day care patient or in- Hospital towards Room and Boarding expenses and
patient. shall include the associated medical expenses.
Def. 34. Portability means a facility provided to the health Def. 42. Surgery or Surgical Procedure means manual and
insurance policyholders (including all members / or operative procedure (s) required for treatment
under family cover), to transfer the credits gained of an illness or injury, correction of deformities and
for, pre-existing diseases and specific waiting defects, diagnosis and cure of diseases, relief from
periods from one insurer to another insurer. suffering and prolongation of life, performed in a
Def. 35. Pre-Existing Disease means any condition, ailment, hospital or day care centre by a medical practitioner.
injury or disease: Def. 43. Unproven/Experimental Treatment means the
a) that is/are diagnosed by a physician not treatment including drug experimental therapy
more than 36 months prior to the date of which is based on established medical practice in
commencement of the policy issued by the India, is a treatment experimental or unproven.
insurer; or
1.2. Specific Definitions
b) for which medical advice or treatment
was recommended by, or received from, a The terms defined below and at other junctures
physician, not more than 36 months prior to the in the Policy have the meanings ascribed to them
date of commencement of the policy. wherever they appear in this Policy and, where,
the context so requires, references to the singular
Def. 36. Pre-hospitalization Medical Expenses means include references to the plural; references to the
Medical Expenses incurred during pre-defined male includes the female and references to any
number of days preceding the hospitalization of the statutory enactment includes subsequent changes
Insured Person, provided that: to the same.
i. Such Medical Expenses are incurred for the Def. 1. Adventurous/Hazardous Sports means any sport
same condition for which the Insured Person’s or activity involving physical exertion and skill in
Hospitalization was required, and which an Insured Person participates or competes
ii. The In-patient Hospitalization claim for such for entertainment or as part of his profession
Hospitalization is admissible by the Insurance whether he / she is trained or not.
Company. Def. 2. Age means completed years on last birthday as on
Def. 37. Post-hospitalization Medical Expenses means Commencement Date.
Medical Expenses incurred during pre-defined Def. 3. Aggregate Deductible refers to a cost-sharing
number of days immediately after the insured agreement between the Insurer and the Insured.
person is discharged from the hospital provided The Insured agrees to bear a self-opted amount
that: known as ‘Aggregate Deductible’ once during each
i. Such Medical Expenses are for the same Policy Year post which the Insurer’s liability under
condition for which the insured person’s the Policy shall commence for that Policy Year. The
hospitalization was required, and Aggregate Deductible does not reduce the Sum
ii. The inpatient hospitalization claim for such Insured.
hospitalization is admissible by the insurance Def. 4. Ambulance means a motor vehicle operated by a
company. licenced/authorised service provider and equipped
Def. 38. Qualified Nurse means a person who holds a valid for the transport and paramedical treatment of the
registration from the Nursing Council of India or the person requiring medical attention.
Nursing Council of any state in India. Def. 5. Associated Medical Expenses means Consultation
Def. 39. Reasonable and Customary Charges means fees, charges on Operation theatre, surgical
the charges for services or supplies, which are appliances & nursing, and expenses on Anesthesia,
the standard charges for a specific provider and blood, oxygen incurred during Hospitalization of
consistent with the prevailing charges in the the Insured Person which vary based on the room
geographical area for identical or similar services, category occupied by the insured person whilst
taking into account the nature of illness/ injury undergoing treatment in some of the hospitals.
involved. If Policy Holder chooses a higher room category

HDFC ERGO General Insurance Company Limited. IRDAI Reg. No. 146. CIN: U66030MH2007PLC177117. Registered & Corporate
Office: 1st Floor, HDFC House, 165-166 Backbay Reclamation, H. T. Parekh Marg, Churchgate, Mumbai – 400 020. UIN: my: Optima
Secure - HDFHLIP25041V062425.
5
above the eligibility defined in Policy Schedule, Def. 14. Home means the Insured Person’s place of
then proportionate deduction will apply on the permanent residence as specified in the Policy
Associated Medical Expenses in addition to the Schedule.
difference in room rent. Such associated medical Def. 15. Insured Person means persons named in the Policy
expenses do not include Cost of pharmacy and Schedule who are insured under the Policyand in
consumables, Cost of implants and medical devices respect of whom the applicable premium has been
and Cost of diagnostics. Proportionate deduction received in full.
shall not be applicable to ‘ICU charges’.
Def. 16. Life threatening situation shall mean a serious
Def. 6. AYUSH Treatment refers to the medical and/or medical condition or symptom resulting from Injury
hospitalisation treatments given under Ayurveda, or Illness which is not Pre-Existing Disease, which
Yoga and Naturopathy, Unani, Siddha and arises suddenly and unexpectedly, and requires
Homeopathy systems. immediate care and treatment by a Medical
Def. 7. Bank Rate means the rate fixed by the Reserve Practitioner, generally received within 24 hours of
Bank of India (RBI) at the beginning of the financial onset to avoid jeopardy to life or serious long term
year, which shall be applied depending on the year impairment of the Insured Person’s health, until
in which a claim is due. stabilisation at which time this medical condition or
Def. 8. Base / Basic Sum Insured means the limit opted symptom is not considered an Emergency anymore.
at the time of inception or modified at the time of Def. 17. Material Facts means all relevant information
renewal whichever is later. It forms a part of the Sum sought by the Company in the Proposal Form and
insured for a given Policy Year. It is on per Policy other connected documents to enable it to take
Year basis. In case of Individual Policies Base Sum informed decision in the context of underwriting the
Insured shall be on per Insured Person basis. In risk.
case of Family Floater policies, a common Base Def. 18. Non-instalment Premium Payment refers to
Sum Insured shall be available on a floating basis payment of premium for the entire policy period
amongst all the Insured Persons. made in advance as a single premium.
Def. 9. Break in policy” means the period of gap that Def. 19. Policy means these Policy wordings, the Policy
occurs at the end of the existing policy term/ Schedule and any applicable endorsements or
instalment premium due date, when the premium extensions attaching to or forming part thereof,
due for renewal on a given policy or instalment as amended from time to time, and shall be read
premium due is not paid on or before the premium together. The Policy contains details of the extent
renewal date or grace period. of cover available to the Insured Person, applicable
Def. 10. Biological Attack or Weapons means the emission, exclusions and the terms & conditions applicable
discharge, dispersal, release or escape of any under the Policy.
pathogenic (disease producing) micro-organisms Def. 20. Policy Period means the period between the
and/or biologically produced toxins (including Commencement Date and either the Expiry Date
genetically modified organisms and chemically specified in the Policy Scheduleor the date of
synthesized toxins) which are capable of causing cancellation of this Policy, whichever is earlier.
any Illness, incapacitating disablement or death.
Def. 21. Policyholder means person who has proposed the
Def. 11. Chemical attack or weapons means the emission, Policy and in whose name the Policy is issued.
discharge, dispersal, release or escape of any
solid, liquid or gaseous chemical compound which, Def. 22. Policy Schedule means the Policy Schedule
when suitably distributed, is capable of causing any attached to and forming part of this Policyspecifying
Illness, incapacitating disablement or death. the details of the Insured Persons, the Sum Insured,
the Policy Period and the Sub-limits to which
Def. 12. Commencement Date means the date of benefits under the Policy are subject to, including
commencement of insurance coverage under the any annexures and/or endorsements, made to or on
Policy as specified in the Policy Schedule. it from time to time, and if more than one, then the
Def. 13. Family Members means any one or more of the latest in time.
following family members of the Insured Person: Def. 23. Policy Year means a period of twelve months
i. Legally wedded spouse. beginning from the Commencement Date and
ii. Parents and parents-in-law. ending on the last day of such twelve-month period.
For the purpose of subsequent years, Policy Year
iii. Dependent Children (i.e. natural or legally
shall mean a period of twelve months commencing
adopted) between the Age 90 days to Age
from the end of the previous Policy Year and lapsing
25 years. If the child above 18 years of Age
on the last day of such twelve-month period, till the
is financially independent, he or she shall be
Expiry Date, as specified in the Policy Schedule.
ineligible for coverage under this Policy in the
subsequent renewals.
HDFC ERGO General Insurance Company Limited. IRDAI Reg. No. 146. CIN: U66030MH2007PLC177117. Registered & Corporate
Office: 1st Floor, HDFC House, 165-166 Backbay Reclamation, H. T. Parekh Marg, Churchgate, Mumbai – 400 020. UIN: my: Optima
Secure - HDFHLIP25041V062425.
6
Def. 24. Preventive Health Check-up means a package of Claims made in respect of any of these Covers will
medical test(s) undertaken for general assessment affect the eligibility for the additional Covers set out
of health status, excluding any diagnostic or in Section B-2 and Section B-3 below.
investigative medical tests for evaluation of Illness
or a disease. 1.1. Hospitalization Expenses

Def. 25. E-Opinion for Critical Illness means a procedure The Company shall indemnify Medical Expenses
where by upon request of the Insured Person, necessarily incurred by the Insured Person for
an independent Medical Practitioner reviews Hospitalization of the Insured Person during the
and opines on the treating Medical Practitioner’s Policy Year due to Illness or Injury, up to the Sum
recommendation as to care and treatment of the Insured specified in the Policy Schedule for:
Insured Person by reviewing Insured Person’s a. Room Rent, boarding, nursing expenses as
medical status and history. Such an opinion shall provided by the Hospital / Nursing Home.
not be deemed to substitute the Insured Person’s Room rent limit shall be ‘At Actuals’ unless
physical visit or consultation to an independent otherwise specified in the Policy Schedule.
Medical Practitioner. b. Intensive Care Unit (ICU) / Intensive Cardiac
Def. 26. Shared Accommodation OR Shared Room Care Unit (ICCU) expenses. ICU limit (including
category means a room in a Hospital with double ICCU) for bed charges shall be ‘At Actuals’
occupancy having shared washroom. This room unless otherwise specified in the Policy
does not include kitchen / dining area. Schedule.
Def. 27. Single Private Room means an air-conditioned c. Surgeon, anaesthetist, Medical Practitioner,
room in a Hospital where a single patient is consultants, specialist Fees during
accommodated and which has an attached toilet Hospitalization forming part of Hospital bill.
(lavatory and bath). Such room type shall be the d. Investigative treatments and diagnostic
most economical of all accommodations available procedures directly related to Hospitalization.
as a single AC room in that Hospital
e. Medicines and drugs prescribed in writing by
Def. 28. Sub-limit means a cost sharing requirement under Medical Practitioner.
a health insurance policy in which an insurer would
f. Intravenous fluids, blood transfusion, surgical
not be liable to pay any amount in excess of the pre-
appliances, allowable consumables and/or
defined limit. The Sub-limit as applicable under the
enteral feedings. Operation theatre charges.
Policy is specified in the Policy Schedule against the
relevant Cover in force under the Policy. g. The cost of prosthetics and other devices
or equipment, if implanted internally during
Def. 29. Sum Insured means the aggregate limit of
Surgery.
indemnity consisting of the Base Sum Insured,
Cumulative Bonus, Plus Benefit, Secure Benefit 1.1.1. Other Expenses
and Automatic Restore Benefit (provided that i. Expenses incurred on road Ambulance if the
these covers are in force for the Insured Person). Insured Person is required to be transferred
Sum Insured represents the maximum, total and to the nearest Hospital for Emergency Care or
cumulative liability of the Company for any and all from one Hospital to another Hospital or from
claims made under the Policy, in respect of that Hospital to Home (within same city) following
Insured Person (on Individual basis) or all Insured Hospitalization.
Persons (on Floater basis) during the Policy Year.
ii. In patient Care Dental Treatment, necessitated
Def. 30. Waiting Period means a period from the inception due to disease or Injury
of this Policy during which specified diseases/
iii. Plastic Surgery, necessitated due to Injury
treatments are not covered. On completion of
the Waiting Period, diseases/treatments shall be iv. All Day Care Treatments.
covered provided the Policy has been continuously Note
renewed without any break.
i. Expenses of Hospitalization for a minimum
SECTION B. BENEFITS period of 24 consecutive hours only shall be
admissible. However, the time limit shall not
1. Base Coverage
apply in respect of Day Care Treatment.
The Covers listed below are in-built Policy benefits
ii. The Hospitalization must be for Medically
and shall be available to all Insured Persons in
Necessary Treatment, and prescribed in writing
accordance with the procedures set out in this Policy
by Medical Practitioner.
and up to the Sub-limits mentioned in the Policy
Schedule. Cumulative Bonus shall be available iii. Proportionate deduction on Room Rent: In case
only if the Cover is specified to be applicable in the the Insured Person is admitted in a room that
Policy Schedule. exceeds the category/limit stipulated in the

b. the Medically Necessary Treatment is taken at ii. Expenses related to organ transportation
Home on account of non-availability of room in or preservation.
a Hospital. iii. Any other Medical Expenses or
Hospitalization consequent to the organ
1.4. AYUSH Treatment harvesting.
The Company shall indemnify the Medical Expenses
incurred by the Insured Person only for Inpatient 1.8. Cumulative Bonus (CB) [Applicable to ‘Optima
Care under Ayurveda, Yoga and Naturopathy, Unani, Suraksha’, ‘Optima Lite’ and ‘Optima Select’ plans]
Siddha and Homeopathy systems of medicines On Renewal of this Policy with the Company without

f. If the Sum Insured has been reduced at the time a. The air Ambulance transportation is advised in
of Renewal, the applicable CB shall be reduced in writing by a Medical Practitioner.
the same proportion to the Sum Insured in current b. Medically Necessary Treatment is not available at
Policy. the location where the Insured Person is situated at
g. If the Sum Insured under the Policy has been the time of emergency.
increased at the time of Renewal, the CB shall be c. The air Ambulance provider is a registered entity
calculated on the Sum Insured of the last completed in India (except Section B-2.9 (Global Health Cover
Policy Year. (Emergency Treatments Only)) and Section B-2.10
h. If the Policy Period is of two/three years, any CB that (Global Health Cover (Emergency and Planned
has accrued for the first/second Policy Year shall be Treatments Only)).
credited post completion of each Policy Year. d. The Insured Person is in India and the treatment
i. New Insured Person added to the Policy during is taken in India only (except Section B-2.9 (Global
subsequent Renewals will be eligible for CB as per Health Cover (Emergency Treatments Only)) and
their Renewal terms. Section B-2.10 (Global Health Cover (Emergency
and Planned Treatments Only)).
j. CB shall be available only if the Cover is specified to
be applicable in the Policy Schedule. e. No return transportation to the Insured Person’s
Home or elsewhere by the air Ambulance will be
k. CB percentage and maximum accrual limit covered under this Cover.
applicable shall be as specified in the Policy
Schedule. f. A claim for the same Hospitalization is admissible
under Section B-1.1 (Hospitalization Expenses) OR
2. Optional Covers Section B-2.9 (Global Health Cover (Emergency
The Covers listed below are optional covers. An Treatments Only)) OR Section B-2.10 (Global Health

HDFC ERGO General Insurance Company Limited. IRDAI Reg. No. 146. CIN: U66030MH2007PLC177117. Registered & Corporate
Office: 1st Floor, HDFC House, 165-166 Backbay Reclamation, H. T. Parekh Marg, Churchgate, Mumbai – 400 020. UIN: my: Optima
Secure - HDFHLIP25041V062425.
9
Cover (Emergency and Planned Treatments Only)). c. This Cover will be applied irrespective of
g. The amount specified in the Policy schedule against number of claims made under the expiring
this benefit denotes the Company’s maximum Policy.
liability in respect to the benefit and shall not reduce d. This applicable Plus Benefit under this Cover
the Sum Insured of the policy. can be utilized only for claims admissible under
Section B-1 (Base Coverage) and Section B-2.3
2.2 Daily Cash for Shared Room (Protect Benefit) of the Policy.
The Company shall pay a daily cash amount as Notes:
specified in Policy Schedule for each continuous
and completed 24 hours of Hospitalization during i. In case where the Policy is issued on an individual
the Policy Year if the Insured Person is Hospitalised basis, the Plus Benefit shall be added and available
in shared accommodation in a Network Provider individually to the Insured Person. In case where
Hospital and such Hospitalization exceeds 48 the Policy is on floater basis, the Plus Benefit shall
consecutive hours. be added and available to all Family Members on a
floater basis.
Specific Conditions:
ii. Plus Benefit shall be available only if the Policy is
a. The Cover is not available for the time spent renewed and due premium is received within the
by the Insured Person in an Intensive Care Unit Grace Period.
(ICU).
iii. If the Insured Persons in the expiring policy are
b. The claim for the same Hospitalization is not covered on an individual basis as specified in the
admissible under Section B-1.1 (Hospitalization Policy Schedule and there is an accumulated Plus
Expenses). Benefit for such Insured Persons under the expiring
c. The amount specified in the Policy schedule policy, and such expiring policy has been Renewed
against this benefit denotes the Company’s on a floater policy basis as specified in the Policy
maximum liability in respect to the benefit and Schedule then the Plus Benefit to be carried forward
shall not reduce the Sum Insured of the policy. for credit in such Renewed Policy shall be the
lowest one that is applicable among all the Insured
2.3 Protect Benefit
Persons.
The Company shall indemnify the Insured Person
iv. In case of floater policies where Insured Persons
for the Non-Medical Expenses listed under
Renew their expiring policy by splitting the Sum
Annexure B to this Policy incurred in relation to a
Insured in to two or more floater policies/individual
claim admissible under Section B-1 (Base Coverage)
policies or in cases where the Policy is split due to
during the Policy Year.
the child attaining the Age of 25 years, the Plus
Exclusion (k) of Section C.2 – Specific Exclusions Benefit of the expiring policy shall be apportioned
shall not apply to this Cover. to such Renewed Policies in the proportion of the
In plans where in Protect Benefit is available as an Sum Insured of each Renewed Policy
optional cover, this benefit can be opted only at v. If the Sum Insured has been reduced at the time
inception or at renewals and once opted the same of Renewal, the applicable Plus Benefit shall be
can be opted out at renewals only. reduced in the same proportion to the Sum Insured
in current Policy.
2.4 Plus Benefit
vi. If the Sum Insured under the Policy has been
On Renewal of this Policy with the Company without
increased at the time of Renewal, the Plus Benefit
a break, a sum equal to 50% of the Base Sum
shall be calculated on the Sum Insured of the last
Insured under the expiring Policy will be added
completed Policy Year.
to the Sum Insured available under the Renewed
Policy subject to the following conditions: vii. If the Policy Period is of two or three years, the Plus
Benefit shall be credited post completion of each
a. The applicable Plus Benefit under this Cover
Policy Year, and will be available for any claims
can only be accumulated up to 100% of Base
made in the subsequent Policy Year.
Sum Insured, and will be applicable only to the
Insured Person covered under the expiring viii. New Insured Person added to the Policy during
Policy and who continues to remain insured on subsequent Renewals will be eligible for the Plus
Renewal. Benefit as per their Renewal terms.
b. The applicable Plus Benefit shall be applied ix. In plans where in Plus Benefit is available as an
annually only on completion of each Policy optional cover, this benefit can be opted only at
Year, and once added, the accumulated amount inception or at renewals and once opted the same
will be carried forward to the subsequent Policy can be opted out only at renewals. Upon opting for
Year, subject to there being no Break in Policy. this benefit, any accrued CB amount shall be carried

HDFC ERGO General Insurance Company Limited. IRDAI Reg. No. 146. CIN: U66030MH2007PLC177117. Registered & Corporate
Office: 1st Floor, HDFC House, 165-166 Backbay Reclamation, H. T. Parekh Marg, Churchgate, Mumbai – 400 020. UIN: my: Optima
Secure - HDFHLIP25041V062425.
10
forward to the renewed Policy and thereafter CB v. The restored Sum Insured can be used by the
benefit shall cease to exist. Insured Person who has already claimed during the
Policy Year and also by any other Insured person
2.5 Secure Benefit under the Policy.
An additional amount as specified in the Policy vi. The restored Sum Insured can be used even for the
Schedule will be available to the Insured Person same illness for which an admissible claim has been
as Sum Insured for all claims admissible under paid during the Policy Year and also for any other
Section B (Base Coverage) and Section B-2.3 Illness covered under the Policy.
(Protect Benefit) during the Policy Year, subject to
the following conditions: vii. The restored Sum Insured if not utilized shall not be
carried forward to subsequent Policy Years.
a. This Secure Benefit shall be applied only once
during each Policy Year and any unutilized viii. In case of a family floater policy, the Automatic
amount, in whole or in part, will not be carried Restore Benefit will be available on floater basis
forward to the subsequent Policy Year. for all Insured Persons covered under the Policy
and will operate in accordance with the above
b. The Secure Benefit can be utilized for any conditions.
number of claims admissible under the Policy
during the Policy Year. 2.7 Aggregate Deductible
c. The Secure Benefit will be applicable only after The Insured Person shall bear an amount equal
exhaustion of Base Sum Insured. to the Aggregate Deductible specified on Policy
d. In case of family floater policy, the Secure Schedule once in a Policy Year post which coverage
Benefit will be available on floater basis for shall commence under this policy for that Policy
all Insured Persons covered under the Policy Year.
and will operate in accordance with the above The Aggregate deductible limit can be exhausted
conditions. by providing any invoices and relevant proof of
one or more hospitalizations of the Insured person
2.6 Automatic Restore Benefit undertaken during the Policy Year. However, such
The company shall instantly add 100% of the Base treatments must be admissible as per terms and
Sum Insured under this benefit in the event of an conditions of this policy. Coverage under the policy
admissible claim during the Policy Year due to which shall be provided post assessment of the above.
Sum Insured was partially or completely exhausted. This Cover shall be subject to the following conditions:
Specific Conditions applicable to Automatic Restore Benefit a. This Cover is applicable on annual aggregate basis
i. Automatic Restore Benefit shall be applied only and can be opted only at inception of the Policy or
once during the Policy Year unless specified at subsequent Renewals. Aggregate Deductible can
otherwise in the Policy Schedule. In case ‘Unlimited be increased at the time of Renewal.
Times’ is specified against this benefit in the Policy b. In case of Individual Policy, the entire amount of
Schedule it shall mean that this benefit shall trigger Aggregate Deductible must first be exhausted on
every time an admissible claim is paid during the per Insured Person basis, once in a Policy Year,
Policy Year. before the Company pays for claims of that Insured
ii. The amount restored under this benefit can only be Person in that Policy Year.
used to pay subsequent claims that arise during the c. In case of family floater Policy, the entire amount of
remainder of the Policy Year. Aggregate Deductible must first be exhausted by
iii. The amount restored under this benefit can only be any one or more of the Insured Persons once in a
used to pay claims that are admissible under Base Policy Year before the Company pays for claims of
Coverage (Section B.1.) and Protect Benefit (Section any Family Member covered under the Policy in that
B.2.3) only. Policy Year.
iv. A single claim in the Policy Year shall never exceed d. The Aggregate Deductible is not applicable to
the cumulative addition of Sections B-2.8 (E-Opinion for Critical Illness), Section
a. Base Sum Insured, B-3 (Preventive Health Check Up), Sections B-2.9
(Global Health Cover (Emergency Treatments Only)),
b. Cumulative Bonus (if applicable and remaining
Section B-2.10 (Global Health Cover (Emergency
during the Policy Year),
and Planned Treatments Only)) and Section B-2.11
c. Plus Benefit (if applicable and remaining during (Overseas Travel Secure). Hence, coverage under
the Policy Year) AND Section B-2.8 (E-opinion for Critical Illness), Section
d. Secure Benefit (if applicable and remaining B-3 (Preventive Health Check Up), Section B-2.9
during the Policy Year). (Global Health Cover (Emergency Treatments Only)),
Section B-2.10 (Global Health Cover (Emergency

HDFC ERGO General Insurance Company Limited. IRDAI Reg. No. 146. CIN: U66030MH2007PLC177117. Registered & Corporate
Office: 1st Floor, HDFC House, 165-166 Backbay Reclamation, H. T. Parekh Marg, Churchgate, Mumbai – 400 020. UIN: my: Optima
Secure - HDFHLIP25041V062425.
11
and Planned Treatments Only)) and Section B-2.11 b. In case of Individual policies, this benefitcan be
(Overseas Travel Secure) can be availed irrespective availed by the Insured Person only once in a Policy
of whether the chosen Aggregate Deductible limit is Year
breached or not, during the Policy Year. c. In case of Family Floater and Multi-individual
e. Preventive Health Check-up benefit will not be policies, This benefit shall be available for once in
available under the policy if Aggregate Deductible the Policy year for each Insured Person under the
of INR 5 Lakhs is in force. policy.
f. Preventive Health Check-up benefit, Secure Benefit, d. The Insured Person is free to choose whether
Cumulative Bonus / Plus Benefit, Automatic Restore or not to obtain the E-Opinion for Critical Illness,
Benefit, Daily Cash for Shared Room and Unlimited and if obtained, it is the Insured Person’s sole and
Restore (Add-on) benefits will not be available under absolute discretion to follow the suggestion for any
the policy if Aggregate Deductible of INR 10 Lakhs advice related to his/her health. It is understood and
or more is in force. agreed that any information and documentation
provided to the Company for the purpose of seeking
2.7.1 Waiver of Aggregate Deductible the E-Opinion for Critical Illness shall be shared with
The Insured Person will have the option to the Network Providers.
either reduce or waive the applicable aggregate e. Availing this benefit shall not have any impact on the
deductible only once in the lifetime of the Policy and Sum Insured.
at Renewal, subject to underwriting and only if all
the below mentioned conditions are fulfilled: Disclaimer – E-Opinion for Critical Illness Services are being
offered by Network Providers through its portal/mail/App
a. Age of eldest Insured Person should be less or any other electronic form to the Policyholders/Insured
than 50 years at the time of purchasing this Person. In no event shall the Company be liable for any
Policy (with aggregate deductible) direct, indirect, punitive, incidental, special, or consequential
b. Only after completion of 5 continuous Policy damages or any other damages whatsoever caused to the
Years with Us in this Policy (with aggregate Policyholders/Insured Person while receiving the services
deductible) and the age of eldest Insured from Network Providers or arising out of or in relation to
Person covered in the Policy should be less any opinion, advice, prescription, actual or alleged errors,
than 61 years at the time of availing this option. omissions and representations made by the Network
c. Continuity benefits of waiting period accrued Provider or treating Medical Practitioner.
as per expiring Policy Year (with aggregate
Major Medical Illness
deductible) shall be offered even after availing
this option. 1 Cancer of specified severity
d. This option shall apply to all Insured Person(s) 2 Open Chest CABG
once selected, without any individual selection. 3 Kidney failure requiring regular dialysis
e. Post availing ‘Waiver of Aggregate Deductible’ 4 Myocardial Infarction (First Heart Attack of
option, premium will be charged as per the specified severity)
modification made.
5 Open Heart Replacement or Repair of Heart Valves
f. In the event that an Aggregate Deductible is 6 Major Organ/Bone Marrow Transplantation
reduced OR is completely waived, at renewal,
the Insured Persons shall be eligible for the 7 Multiple Sclerosis with persisting symptoms
benefits applicable as per the plan / Aggregate 8 Permanent Paralysis of Limbs
Deductible / Sum Insured applicable in the 9 Stroke resulting in permanent symptoms
forthcoming Policy Years post renewal.
10 Benign Brain Tumour
2.8 E-Opinion for Critical Illness 11 Coma of specified severity
The company shall provide E-opinion facility to the 12 Parkinson’s Disease
Insured Person for a Critical Illness listed below. The
13 Alzheimer’s Disease
E-opinion shall be from a Medical Practitioner within
our network 14 Surgery of Aorta
Specific Conditions applicable to E-Opinion for Critical Illness: 15 End Stage Liver Failure
a. Benefit under this cover shall be subject to the 16 Deafness
eligible geography of the Network Provider. The 17 Loss of Speech
Insured Person may contact the Company or
18 Third Degree Burns
refer to its website for details on eligible Network
Provider(s). 19 Medullary Cystic Disease

24 Dissecting Aortic Aneurysm ii. Section B-2.7 (Aggregate Deductible) will not
be applicable for any claim under this cover.
25 Systemic Lupus Erythematous with Lupus Nephritis
However, a Per Claim Deductible of Rs. 10,000
26 Apallic Syndrome will apply separately for each and every claim
27 Aplastic Anaemia (except Section B-2.8 ‘E Opinion for Critical
Illness’) under this cover.
28 Bacterial Meningitis
iii. Claims shall normally be payable on
29 Cardiomyopathy
Reimbursement basis only. Cashless facility
30 Other serious coronary artery disease may be arranged on case to case basis.
31 Creutzfeldt-Jakob Disease (CJD) iv. The treatment should be taken in a registered
32 Encephalitis Hospital, as per law, rules and/ or regulations
applicable to the country, where the treatment
33 End Stage Lung Failure
is taken.
34 Fulminant Hepatitis
v. The payment of any Claim under this Benefit
35 Eisenmenger’s Syndrome will be based on the rate of exchange as on the
36 Major Head Trauma date of payment to the Hospital published by
37 Chronic Adrenal Insufficiency (Addison’s Disease) Reserve Bank of India (RBI) and shall be used
for conversion of Foreign Currency into Indian
38 Progressive Scleroderma Rupees for payment of Claims. If on the Insured
39 Progressive Supranuclear Palsy Person’s Date of Discharge, if RBI rates are not
40 Blindness published, the exchange rate next published by
RBI shall be considered for conversion.
41 Chronic Relapsing Pancreatitis
vi. We would not be liable to pay any claim
42 Elephantiasis
wherein the medical treatment taken outside
43 Brain Surgery India has not commenced within the first 45
44 HIV due to blood transfusion and occupationally days of a trip.
acquired HIV Note: Each trip shall be deemed to start within
45 Terminal Illness the Policy Period and from the date Insured
Person finally boards the flight (scheduled
46 Myelofibrosis
aircraft operated under a valid license for the
47 Pheochromocytoma transportation of fare paying passengers under
48 Crohn’s Disease a valid ticket) to leave from India.
49 Severe Rheumatoid Arthritis vii. There is no separate Sum Insured for this
50 Severe Ulcerative Colitis optional cover and any claim triggered under
this benefit shall reduce the Sum Insured of the
51 Angioplasty opted plan.
2.9 Global Health Cover (Emergency Treatments Only) B. Specific Exclusions applicable to Global Health
On availing this cover, the below mentioned benefits Cover (Emergency Treatments Only)
shall be extended for Emergency Medical Expenses i. Any Planned treatments
which are diagnosed and incurred outside India :
ii. In case we have paid a Hospitalization claim
B-1.1 Hospitalization Expenses under this benefit, Pre-hospitalization Medical
B-1.4 AYUSH Treatment Expenses and/or Post-hospitalization Medical
B-1.7 Organ Donor Expenses Expenses related to the claim whether incurred
overseas or within India are not payable under
B-2.1 Emergency Air Ambulance this Policy.
B-2.3 Protect Benefit iii. Treatment or part of treatment for any condition
B-2.4 Plus Benefit which is not Life threatening in nature and can
B-2.8 E Opinion for Critical Illness be safely postponed till the Insured Person
returns to India.
HDFC ERGO General Insurance Company Limited. IRDAI Reg. No. 146. CIN: U66030MH2007PLC177117. Registered & Corporate
Office: 1st Floor, HDFC House, 165-166 Backbay Reclamation, H. T. Parekh Marg, Churchgate, Mumbai – 400 020. UIN: my: Optima
Secure - HDFHLIP25041V062425.
13
iv. Medical treatment taken outside India if that is vii. There is no separate Sum Insured for this optional cover
the sole reason or one of the reasons for the and any claim triggered under this benefit shall reduce
journey. the Sum Insured of the opted plan.
v. Any treatment of orthopaedic diseases or viii. Pre-hospitalization Medical Expenses and/or Post-
conditions except for fractures, dislocations and hospitalization Medical Expenses incurred and paid
/ or Injuries suffered during the Policy Period. overseas shall be indemnified only if the concerned
vi. Oncological (Cancer) diseases hospitalization was undertaken overseas and claim for
such hospitalization was admissible under ‘Global Health
vii. The Company may not be liable to make Cover (Emergency & Planned Treatments)’.
any payment under this Policy, wherein the
Government of India has laid down territorial ix. In case we have accepted an overseas hospitalization
restriction. claim under ‘Global Health Cover (Emergency & Planned
Treatments)’ then
2.10 Global Health Cover (Emergency & Planned i) Pre-hospitalization Medical Expenses and/or Post-
Treatments) hospitalization Medical Expenses concerning such
On availing this cover, the below mentioned benefits hospitalization shall be paid only if the same have
shall be extended for both planned and Emergency been incurred and paid overseas (as per details in
Medical Expenses outside India: invoice/supporting documents).
B-1.1 Hospitalization Expenses ii) Any Pre-hospitalization Medical Expenses and/or
B-1.4 AYUSH Treatment Post-hospitalization Medical Expense emanating
from an overseas hospitalization claim but incurred
B-1.5 Pre-Hospitalization cover in India shall not be payable under the policy.
B-1.6 Post-Hospitalization cover x. In case customer has initiated Migration or Portability,
B-1.7 Organ Donor Expenses all waiting periods shall apply afresh only for planned
B-2.1 Emergency Air Ambulance hospitalization claims admissible under ‘Global Health
Cover (Emergency & Planned Treatments)’. Such waiting
B-2.3 Protect Benefit
periods shall commence from the date ‘Global Health
B-2.4 Plus Benefit Cover (Emergency & Planned Treatments) has come
B-2.8 E Opinion for Critical Illness into force. In case of forced migration initiated by the
company, this clause shall not apply.
Global Health Cover (Emergency & Planned Treatments) is
applicable subject to following terms and conditions 2.11 Overseas Travel Secure
i. Our maximum liability in a Policy Year for claims under i) This optional cover can only be opted along
this cover shall not exceed the Base Sum Insured and with Optima Secure Global Plan or Optima
Plus Benefit (if available). Secure Global Plus Plan on payment of
additional premium.
ii. Section B-2.7 (Aggregate Deductible) will not be
applicable for any claim under this cover. However, a Per ii) Claim under this benefit shall be payable upto
Claim Deductible of Rs. 10,000 will apply separately for Sum Insured and is admissible only if both the
each and every claim (except Section B-2.8 ‘E Opinion below conditions are fulfilled:
for Critical Illness’) under this cover. a. The overseas treating Medical Practitioner
iii. Claims shall normally be payable on Reimbursement has advised a minimum hospitalization of
basis only. Cashless facility may be arranged on case to 5 consecutive days and has also advised
case basis. the requirement of an accompanying
person during treatment.
iv. The treatment should be taken in a registered Hospital,
as per law, rules and/ or regulations applicable to the b. We have accepted a claim under
country, where the treatment is taken. • Section 2.9 Global Health Cover
v. The payment of any Claim under this Benefit will be (Emergency Treatments Only) OR
based on the rate of exchange as on the date of payment • Section 2.10 Global Health Cover
to the Hospital published by Reserve Bank of India (RBI) (Emergency & Planned Treatments)
and shall be used for conversion of Foreign Currency
iii) There is no separate Sum Insured for this
into Indian Rupees for payment of Claims. If on the
optional cover and any claim triggered under
Insured Person’s Date of Discharge, if RBI rates are not
this benefit shall reduce the Sum Insured of the
published, the exchange rate next published by RBI shall
opted plan.
be considered for conversion.
iv) We will indemnify the following expenses
vi. The Company may not be liable to make any payment
incurred overseas:
under this Policy, wherein the Government of India has
laid down territorial restriction.
HDFC ERGO General Insurance Company Limited. IRDAI Reg. No. 146. CIN: U66030MH2007PLC177117. Registered & Corporate
Office: 1st Floor, HDFC House, 165-166 Backbay Reclamation, H. T. Parekh Marg, Churchgate, Mumbai – 400 020. UIN: my: Optima
Secure - HDFHLIP25041V062425.
14
1. Travel Expenses 2.12 PED waiting period modification
a. We will indemnify actual expenses incurred on air On availing this option, Pre-existing Disease Waiting Period
tickets (most basic economy class airfare in a common shall stand modified and will be as stipulated in the Policy
carrier) for the Hospitalized Insured Person and any one Schedule. All other terms and Conditions of the Policy shall
accompanying person to attend to the Insured Person‘s remain unaltered. This optional cover is allowed to be opted
medical treatment overseas. at channel level only and only at the time of policy inception.
i. For Emergency hospitalization cases, we shall Policyholders will therefore not be able to opt for the same.
indemnify for the following travel expenses This option once selected cannot be opted out in the lifetime
of the Policy.
• For the accompanying person, two way
expense incurred on air tickets from his City of Below mentioned are the options available under this cover
Residence OR India to the airport nearest to the 1. Modification of PED waiting period from 36 months (as
site of hospitalization shall be provided. specified under Section C.1.a – Pre-Existing Diseases) to
• For the Hospitalized Insured Person, we 24 months (2 years)
shall only indemnify air expenses incurred to 2. Modification of PED waiting period from 36 months (as
transport him from the airport nearest to the specified under Section C.1.a – Pre-Existing Diseases) to
site of Hospitalization to India. 12 months (1 year)
ii. For planned hospitalization cases, we shall 2.13 Modification of Room Rent
indemnify for the following travel expenses
On availing this option, Room Rent category shall stand
• For the accompanying person, two way modified and will be as stipulated in the Policy Schedule.
expense incurred on air tickets from his City of Policyholders may re-configure their selection only at the
Residence OR India to the airport nearest to the time of renewals subject to Underwriting. All other terms
site of hospitalization shall be provided. and conditions pertaining to coverage of Room Rent and ICU
• For the Hospitalized Insured Person, we shall / ICCU expenses specified in Section B.1.1. – Hospitalization
indemnify two way expense incurred on air Expenses and Section B.1.1.1. – Other Expenses shall remain
tickets from India to the airport nearest to the unaltered.
site of hospitalization shall be provided. Below mentioned are the options available under this cover
iii. In case the accompanying person was already 1. Modification of Room category coverage from At Actuals
present in that city at the time of such hospitalization, (as specified under Section B.1.1. – Hospitalization
we shall only indemnify air expenses incurred to Expenses) to upto 1% of base sum insured per day AND
transport him from the airport nearest to the site of Modification of ICU / ICCU expenses coverage from At
Hospitalization to his City of Residence OR India. Actuals (as specified under Section B.1.1. – Hospitalization
b. Any kind of other transportation expenses except the Expenses) to upto 2% of base sum insured per day
expense on airfare is not payable under this optional i. This option is inbuilt in Optima Lite plan where in
cover Room rent expenses shall be covered upto 1% of
Note – For Insured Person, City of Residence shall be base sum insured per day and ICU / ICCU expenses
considered as declared in the Proposal Form and mentioned shall be covered 2% of base sum insured per day.
in the Policy Schedule. Whereas, for accompanying person, The same shall also be clearly specified in Policy
City of Residence shall be considered as mentioned in the Schedule against Room Rent and ICU covers under
legal document issued by the Government of that particular Hospitalization Expenses section.
country. ii. This option shall not be available with any other plan
2. Accommodation Expenses of my:Optima Secure product except Optima Lite
a. We will also indemnify the cost of accomodation, plan.
at a place near to the site of Hospitalization, for the 2. Modification of Room category coverage from At Actuals
accompanying person, to attend to the Insured Person‘s (as specified under Section B.1.1. – Hospitalization
medical treatment overseas. Expenses) to upto Single Private room
b. Cost of accomodation overseas shall be indemnified i. This option is inbuilt in Optima Select plan where in
upto Rs. 15,000 per day, only for the days wherein the Room rent expenses shall be covered upto Single
Insured person was hospitalized overseas; maximum Private room and ICU / ICCU expenses shall be
upto 30 days in a Policy Year. covered at Actuals. The same shall also be clearly
c. Any other kind of supplementary expenses such as specified in Policy Schedule against Room Rent and
meals, laundry, transport are not payable under this ICU covers under Hospitalization Expenses section.
cover. ii. This option shall not be available with any other plan
of my:Optima Secure product except Optima Select
plan.

HDFC ERGO General Insurance Company Limited. IRDAI Reg. No. 146. CIN: U66030MH2007PLC177117. Registered & Corporate
Office: 1st Floor, HDFC House, 165-166 Backbay Reclamation, H. T. Parekh Marg, Churchgate, Mumbai – 400 020. UIN: my: Optima
Secure - HDFHLIP25041V062425.
15
3. Modification of Room category coverage from Single Hospitalization expenses (Section B.1.6. – Post-
Private room (default in Optima Select plan) to At Actuals Hospitalization Expenses) shall remain unaltered.
i. This option can be selected only by customers of Below mentioned is the option available under this cover
Optima Select plan. By selecting this Room rent 1. Modification of Post-Hospitalization expenses days
expenses shall be covered at Actuals and ICU / from 180 days (as specified under Section B.1.6. – Post-
ICCU expenses shall also be covered at Actuals. Hospitalization Expenses) to 60 days
The same shall also be clearly specified in Policy
Schedule against Room Rent and ICU covers under i. This option is inbuilt in Optima Lite plan where in
Hospitalization Expenses section. Post-hospitalization medical expenses shall be
indemnified only if the same were incurred upto 180
ii. This option shall not be available with any other plan days immediately post the date of discharge from
of my:Optima Secure product except Optima Select the Hospital. The same shall also be clearly specified
plan. in Policy Schedule against Post-Hospitalization
4. Modification of Room category coverage from Single expenses cover.
Private room (default in Optima Select plan) to Shared ii. This option shall not be available with any other plan
room of my:Optima Secure product except Optima Lite
i. This option can be selected only by customers of plan.
Optima Select plan. By selecting this Room rent
expenses shall be covered upto Shared room 2.16 Modification of Cumulative Bonus
category. However, ICU / ICCU expenses shall be On availing this option, the percentage of
covered at Actuals. The same shall also be clearly cumulative bonus provided shall stand modified
specified in Policy Schedule against Room Rent and and will be as stipulated against Cumulative Bonus
ICU covers under Hospitalization Expenses section. section in the Policy Schedule. All other terms and
This option shall not be available with any other plan of conditions pertaining to Cumulative Bonus (Section
my:Optima Secure product except Optima Select plan. B.1.8. – Cumulative Bonus) shall remain unaltered.
Below mentioned is the option available under this cover
2.14 Modification of Pre-Hospitalization expenses -
Days 1. Modification of Cumulative bonus from 10% of Base Sum
Insured upto 100% (as specified under Section B.1.8. –
On availing this option, the days upto which Pre- Cumulative Bonus) to 25% of Base Sum Insured upto
hospitalization medical expenses shall stand 100%
modified and will be as stipulated against Pre-
Hospitalization section in the Policy Schedule. All i. This option is inbuilt in Optima Select plan where in a
other terms and conditions pertaining to coverage Cumulative Bonus of 25% of Base Sum Insured upto
of Pre-Hospitalization expenses (Section B.1.5. – Pre- 100% shall be provided under the plan. The same
Hospitalization Expenses) shall remain unaltered. shall also be clearly specified in Policy Schedule
against Cumulative Bonus section.
Below mentioned is the option available under this cover
This option shall not be available with any other plan of
1. Modification of Pre-Hospitalization expenses days my:Optima Secure product except Optima Select plan.
from 60 days (as specified under Section B.1.5. – Pre-
Hospitalization Expenses) to 30 days 3. Renewal Benefit - Preventive Health Check-up
i. This option is inbuilt in Optima Lite plan where in On completion of each Policy Year where-in this
Pre-hospitalization medical expenses shall be benefit was in force, the Company will indemnify
indemnified only if the same were incurred upto the cost of a Preventive Health Check-up for the
30 days immediately prior to the date of admission. Insured Persons who were insured during the
The same shall also be clearly specified in Policy previous Policy Year, up to the amounts specified in
Schedule against Pre-Hospitalization expenses this Cover below.
cover. i. This benefit is available every Policy Year post
ii. This option shall not be available with any other plan completion of the first Policy Year irrespective
of my:Optima Secure product except Optima Lite of the policy tenure opted.The tests must
plan. be taken only in the Policy Year where-in the
Insured Person is eligible for this benefit.
2.15 Modification of Post-Hospitalization expenses -
Days ii. This benefit does NOT carry forward if it is
not claimed during the applicable Policy Year
On availing this option, the days upto which Post- and shall not be provided if the Policy is not
hospitalization expenses shall stand modified and Renewed further.
will be as stipulated against Post Hospitalization
section in the Policy Schedule. All other terms iii. The amount specified in the Policy schedule
and conditions pertaining to coverage of Post- against this benefit denotes the Company’s

Surgical Procedures
Adenoidectomy, tonsillectomy Tympanoplasty, Mastoidectomy Hernia
Dilatation and curettage (D&C) Nasal concha resection Surgery for prolapsed inter vertebral
disc
Myomectomy for fibroids Surgery of Genito urinary system unless Surgery for varicose veins and varicose
necessitated by Malignancy ulcers
Surgery on prostate Cholecystectomy Surgery for Perianal Abscesses
Hydrocele/Rectocele Joint replacement surgeries Surgery for Nasal septum deviation
Ligament, Tendon and Meniscal tear Hysterectomy Fissurectomy, Haemorrhoidectomy,
Fistulectomy, ENT surgeries
Endometriosis Prolapsed Uterus Rectal Prolapse
Varicocele Retinal detachment Glaucoma
Nasal polypectomy

c. 30-day waiting period – Code – Excl03 Expenses related to any admission primarily for
i. Expenses related to the treatment of any illness enforced bed rest and not for receiving treatment.
within 30 days from the first Policy commencement This also includes:
date shall be excluded except claims arising due to i. Custodial care either at home or in a nursing
an accident, provided the same are covered. facility for personal care such as help with
ii. This exclusion shall not, however, apply if the activities of daily living such as bathing,
Insured Person has continuous coverage for more dressing, moving around either by skilled
than twelve months. nurses or assistant or non-skilled persons.

iii. The within referred waiting period is made ii. Any services for people who are terminally ill to
applicable to the enhanced Sum Insured in the address physical, social, emotional and spiritual
event of granting higher Sum Insured subsequently. needs.
c. Obesity/Weight control: Code – Excl06:
2. Standard Exclusions
Expenses related to the surgical treatment of
a. Investigation & Evaluation: Code Excl04 obesity that does not fulfil all the below conditions:
i. Expenses related to any admission primarily for i. Surgery to be conducted is upon the advice of
diagnostics and evaluation purposes only are the Doctor
excluded.
ii. The surgery/Procedure conducted should be
ii. Any diagnostic expenses which are not related supported by clinical protocols
or not incidental to the current diagnosis and
treatment are excluded. iii. The member has to be 18 years of age or older
and
b. Rest Cure, rehabilitation and respite care: Code –
Excl05: iv. Body Mass Index (BMI)

g. Breach of Law: Code – Excl10: Expenses for 3. Specific Exclusions:

treatment directly arising from or consequent upon In addition to the foregoing general exclusions, the
any Insured Person committing or attempting to Company shall not be liable to make any payment under
commit a breach of law with criminal intent. this Policy caused by or arising out of or attributable to
h. Excluded Providers: Code – Excl11: Expenses any of the following:
incurred towards treatment in any hospital or by a. War or any act of war, invasion, act of foreign enemy,
any Medical Practitioner or any other provider (whether war be declared or not or caused during
specifically excluded by the Insurer and disclosed service in the armed forces of any country), civil war,
in its website/notified to the Policyholders are not public defence, rebellion, revolution, insurrection,
admissible. However, in case of Life Threatening military or usurped acts, Nuclear, Chemical or
Situations or following an Accident, expenses up Biological attack or weapons, radiation of any kind.
to the stage of stabilization are payable but not the
b. Aggregate Deductible - Claims/claim amount falling
complete claim.
within Aggregate Deductible limit if opted and in
i. Treatment for Alcoholism, drug or substance abuse force, as specified in the Policy Schedule.
or any addictive condition and consequences
c. Any Insured Person committing or attempting to
thereof. Code – Excl12.
commit intentional self-injury or attempted suicide
j. Treatments received in health hydros, nature cure or suicide.
clinics, spas or similar establishments or private
d. Any Insured Person’s participation or involvement in
beds registered as a nursing home attached to such
naval, military or air force operation.
establishments or where admission is arranged
wholly or partly for domestic reasons. Code – e. Investigative treatment for sleep-apnoea, general
Excl13. debility or exhaustion (“run-down condition”).
k. Dietary supplements and substances that can be f. Congenital external diseases, defects or anomalies.
purchased without prescription, including but not g. Stem cell harvesting.
limited to Vitamins, minerals and organic substances
h. Investigative treatments for analysis and
unless prescribed by a Medical Practitioner as part
HDFC ERGO General Insurance Company Limited. IRDAI Reg. No. 146. CIN: U66030MH2007PLC177117. Registered & Corporate
Office: 1st Floor, HDFC House, 165-166 Backbay Reclamation, H. T. Parekh Marg, Churchgate, Mumbai – 400 020. UIN: my: Optima
Secure - HDFHLIP25041V062425.
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adjustments of spinal sub luxation, diagnosis and fulfilled by the insured person for the Company to
treatment by manipulation of the skeletal structure make any payment for claim(s) arising under the
or for muscle stimulation by any means except policy.
treatment of fractures (excluding hairline fractures) 1.3. Claim Settlement (provision for Penal Interest)
and dislocations of the mandible and extremities.
a. The Company shall settle or reject a claim, as
i. Circumcisions (unless necessitated by Illness or the case may be, within 15 days from the date
Injury and forming part of treatment). of receipt of intimation.
j. Vaccination including inoculation and immunisations b. In the case of delay in the payment of a claim,
(except post animal bite treatment). the Company shall be liable to pay interest to
k. Non-Medical expenses such as food charges (other the Policyholder from the date of receipt of
than patient’s diet provided by hospital), laundry intimation to the date of payment of claim at a
charges, attendant charges, ambulance collar, rate 2% above the bank rate.
ambulance equipment, baby food, baby utility 1.4. Complete Discharge
charges and other such items. Full list of Non-
Medical Expenses is attached as ANNEXURE B and Any payment to the Policyholder, Insured Person or
also available at www.hdfcergo.com. his/ her nominees or his/ her legal representative
or assignee or to the Hospital, as the case may
l. Treatment taken on outpatient basis. be, for any benefit under the Policy shall be a
m. The provision or fitting of hearing aids, spectacles or valid discharge towards payment of claim by the
contact lenses. Company to the extent of that amount for the
n. Any treatment and associated expenses for particular claim.
alopecia, baldness including corticosteroids and 1.5. Multiple Policies
topical immunotherapy wigs, toupees, hair pieces, a. In case of multiple policies taken by an Insured
any non-surgical hair replacement methods, Person during a period from one or more
optometric therapy. insurers to indemnify treatment costs, the
o. Expenses for Artificial limbs and/or device used Insured Person shall have the right to require
for diagnosis or treatment (except when used a settlement of his/her claim in terms of any of
intra-operatively), prosthesis, corrective devices his/her policies. In all such cases the Insurer
external durable medical equipment of any kind, chosen by the Insured Person shall be obliged
wheelchairs, crutches, and oxygen concentrator to settle the claim as long as the claim is within
for bronchial asthma/ COPD conditions, cost of the limits of and according to the terms of the
cochlear implant(s) unless necessitated by an chosen Policy.
Accident. b. Insured Person having multiple policies shall
p. Any treatment or part of a treatment that is not of also have the right to prefer claims under
a reasonable charge and not Medically Necessary. this Policy for the amounts disallowed under
Drugs or treatments which are not supported by a any other policy / policies even if the Sum
prescription. Insured is not exhausted. Then the insurer shall
q. Any permanent exclusion applied on any medical or independently settle the claim subject to the
physical condition or treatment of an Insured Person terms and conditions of this Policy.
as specifically mentioned in the Policy Schedule and c. If the amount to be claimed exceeds the Sum
as specifically accepted by Policyholder/Insured Insured under a single Policy, the Insured
Person. Such exclusions shall be applied for the Person shall have the right to choose Insurer
condition(s) or treatment(s) that otherwise would from whom he/she wants to claim the balance
have resulted in rejection of insurance coverage amount.
under this Policy to such Insured Person as per d. Where the Insured Person has policies from
Company’s Underwriting Policy. more than one Insurer to cover the same risk
SECTION D. GENERAL TERMS AND CLAUSES on indemnity basis, the Insured Person shall
only be indemnified the treatment costs in
1. Standard General Terms & Clauses accordance with the terms and conditions of
1.1. Disclosure of Information the chosen Policy.
The policy shall be void and all premium paid 1.6. Moratorium Period
thereon shall be forfeited to the Company in the After completion of sixty continuous months of
event of misrepresentation, mis-description or non- coverage (including portability and migration)
disclosure of any material fact by the Policyholder. in health insurance policy, no policy and claim
1.2. Condition Precedent to Admission of Liability shall be contestable by the insurer on grounds
of non-disclosure, misrepresentation, except on
The terms and conditions of the policy must be
HDFC ERGO General Insurance Company Limited. IRDAI Reg. No. 146. CIN: U66030MH2007PLC177117. Registered & Corporate
Office: 1st Floor, HDFC House, 165-166 Backbay Reclamation, H. T. Parekh Marg, Churchgate, Mumbai – 400 020. UIN: my: Optima
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grounds of established fraud. This period of sixty a. a refund of the premium paid less any
continuous months is called as moratorium period. expenses incurred by the Company on medical
The moratorium would be applicable for the sums examination of the insured person and the
insured of the first policy. Wherever, the sum insured stamp duty charges or
is enhanced, completion of sixty continuous months b. where the risk has already commenced and
would be applicable from the date of enhancement the option of return of the policy is exercised
of sums insured only on the enhanced limits. by the insured person, a deduction towards the
1.7. Fraud proportionate risk premium for period of cover
If any claim made by the Insured Person, is in any or
respect fraudulent, or if any false statement, or c. Where only a part of the insurance coverage
declaration is made or used in support thereof, or has commenced, such proportionate premium
if any fraudulent means or devices are used by the commensurate with the insurance coverage
Insured Person or anyone acting on his/her behalf during such period.
to obtain any benefit under this Policy, all benefits 1.9. Renewal of Policy:
under this policy and the premium paid shall be
forfeited. A health insurance policy shall be renewable except
on grounds of established fraud or non-disclosure
Any amount already paid against claims made under or misrepresentation by the insured, provided
this Policy but which are found fraudulent later the policy is not withdrawn and also subject to
shall be repaid by all recipient(s)/Policyholder(s), conditions stated under Moratorium clause of this
who have made that particular claim, who shall be schedule.
jointly and severally liable for such repayment to the
Insurer. a) Renewal of a health insurance policy shall not
be denied on the ground that the insured had
For the purpose of this clause, the expression made a claim or claims in the preceding policy
“fraud” means any of the following acts committed years, except for benefit based policies where
by the Insured Person or by his agent or the hospital/ the policy terminates following payment of the
doctor/any other party acting on behalf of the benefit covered under the policy like critical
Insured Person, with intent to deceive the insurer or illness policies.
to induce the insurer to issue an insurance policy:
b) The company shall condone a delay in renewal
a. the suggestion, as a fact of that which is not up to the grace period from the due date of
true and which the Insured Person does not renewal without considering such condonation
believe to be true; as a break in policy.
b. the active concealment of a fact by the Insured c) No loading shall apply on renewals based on
Person having knowledge or belief of the fact; individual claims experience
c. any other act fitted to deceive; and d) The Company shall not resort to fresh
d. any such act or omission as the law specially underwriting unless there is an increase in
declares to be fraudulent. sum insured. In case increase in sum insured is
The Company shall not repudiate the claim and / or requested by the Policyholder, the Insurer may
forfeit the Policy benefits on the ground of Fraud, if underwrite only to the extent of increased sum
the Insured Person / beneficiary can prove that the insured.
mis-statement was true to the best of his knowledge e) Renewal premium due can be paid prior to the
and there was no deliberate intention to suppress due date as per norms set out by the Company.
the fact or that such mis-statement of or suppression 1.10. Portability
of material fact are within the knowledge of the
Insurer. The Insured Person will have the option to port the
Policy to other insurers by applying to such Insurer
1.8. Free look Period to port the entire policy along with all the members
The Free Look Period shall be applicable on new of the family, if any, at least 30 days before, but
individual health insurance policies and not on not earlier than 60 days from the policy renewal
renewals or at the time of porting/migrating the date as per IRDAI guidelines related to Portability.
policy. If such person is presently covered and has been
The insured person shall be allowed free look period continuously covered without any lapses under
of thirty days from date of receipt of the policy any health insurance policy with an Indian General/
document to review the terms and conditions of the Health insurer, the proposed Insured Person will get
policy, and to return the same if not acceptable. the accrued continuity benefits in waiting periods as
per IRDAI guidelines on portability.
If the insured has not made any claim during the
Free Look Period, the insured shall be entitled to:
HDFC ERGO General Insurance Company Limited. IRDAI Reg. No. 146. CIN: U66030MH2007PLC177117. Registered & Corporate
Office: 1st Floor, HDFC House, 165-166 Backbay Reclamation, H. T. Parekh Marg, Churchgate, Mumbai – 400 020. UIN: my: Optima
Secure - HDFHLIP25041V062425.
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For Detailed Guidelines on Portability, kindly refer a. Grace Period as mentioned in the table below
the link https://www.irdai.gov.in/ADMINCMS/cms/ would be given to pay the instalment premium
frmGuidelines_Layout.aspx?page=PageNo3987 due for the Policy
1.11. Migration
Options Instalment Grace Period
The Insured Person will have the option to migrate Premium Option applicable
the Policy to other health insurance products/plans
Option 1 Multi-Year / Yearly 30 days
offered by the Company by applying for Migration
of the policyatleast30 days before the policy Option 2 Half Yearly 30 days
renewal date as per IRDAI guidelines on Migration. Option 3 Quarterly 30 days
If such person is presently covered and has been
continuously covered without any lapses under Option 4 Monthly 15 Days
any health insurance product/plan offered by the b. If premium is paid in instalments then coverage
Company, the Insured Person will get the accrued will be available during the grace period also.
continuity benefits in waiting periods as per IRDAI (Note: In case of non-instalment premium
guidelines on Migration. payment, coverage shall not be available for
For Detailed Guidelines on Migration, kindly refer the period for which no premium is received).
the link https://www.irdai.gov.in/ADMINCMS/cms/ c. The Insured Person will get the accrued
frmGuidelines_Layout.aspx?page=PageNo3987 continuity benefit in respect of the “Waiting
1.12. Cancellation Periods”, “Specific Waiting Periods” in the event
of payment of premium within the stipulated
a. The Policyholder may cancel this Policy by
Grace Period
giving 7 days’ written notice and in such an
event, the Company shall refund to the Insured d. No interest will be charged If the instalment
a pro-rata premium for the unexpired Policy premium is not paid on due date
Period. e. In case of instalment premium due not received
Note: For Policies where premium is paid by within the Grace Period, the Policy will get
instalment : In case of admissible claim under cancelled
the Policy, future instalment for the current f. In the event of a claim, all subsequent premium
Policy Year will be adjusted in the claim instalments shall immediately become due and
amount and no refund of any premium will be payable
applicable during the Policy Year.
g. The Company has the right to recover and
b. The Company may cancel the Policy at any deduct all the pending instalments from the
time on grounds of established fraud or non- claim amount due under the policy.
disclosure or misrepresentation by the Insured
1.14. Possibility of Revision of terms of the Policy
Person by giving 15 days’ written notice. There
including the Premium Rates
would be no refund of premium on cancellation
on grounds of established fraud or non- The Company, with prior approval of IRDAI, may
disclosure or misrepresentation. revise or modify the terms of the Policy including the
premium rates. The Insured Person shall be notified
c. Refund of Policy premium in case of death
three months before the changes are effected.
of Insured Person/s: Policy premium shall be
refunded proportionately for the deceased 1.15. Withdrawal of Policy
Insured Person, for the unexpired Policy Period a. In the likelihood of this product being withdrawn
in case of death of any Insured Person/s in future, the Company will intimate the Insured
d. Notwithstanding anything contained herein Person about the same 90 days prior to expiry
or otherwise, no refunds of premium shall be of the policy.
made in respect of Cancellation where any b. Insured Person will have the option to migrate
claim has been admitted or any benefit has to similar health insurance product available
been availed by the Insured Person under the with the Company at the time of renewal with
Policy. all the accrued continuity benefits such as
1.13. Premium Payment in Instalments Cumulative Bonus, waiver of waiting period as
per IRDAI guidelines, provided the policy has
If the Insured Person has opted for payment of
been maintained without a break.
Premium on an instalment basis i.e. Yearly, Half
Yearly, Quarterly or Monthly, as mentioned in the 1.16. Nomination
Policy Schedule, the following Conditions shall apply The Policyholder is required at the inception of
(notwithstanding any terms contrary elsewhere in the Policy to make a nomination for the purpose of
the Policy): payment of claims under the Policy in the event of

For updated details of grievance officer, kindly refer the link: https://www.hdfcergo.com/customer-voice/grievances
Contact Points First Contact Point Escalation level 1 Escalation level 2
Contact us at https://www.hdfcergo.com/ https://www.hdfcergo.com/ https://www.hdfcergo.com/
customer-care/grievances customer-care/grievances/ customer-care/grievances/
Call - : 022 6234 6234 / 0120 escalation level 1 Call - : 022 escalation level 2 Call - : 022
6234 6234 6234 6234 / 0120 6234 6234 6234 6234 / 0120 6234 6234
Contact Point for Senior 022 – 6242 – 6226 | 022 – 6242 – 6226 | 022 – 6242 – 6226 |
Citizen seniorcitizen@hdfcergo.com seniorcitizen@hdfcergo.com seniorcitizen@hdfcergo.com
Write to us at care@hdfcergo.com grievance@hdfcergo.com cgo@hdfcergo.com
Visit us Grievance cell of any of our The Grievance Cell, HDFC The Chief Grievance Officer,
Branch office ERGO General Insurance Registered & Corporate
Company Ltd., D-301, 3rd Office: HDFC House, 1st
Floor, Eastern Business Floor, 165-166 Backbay
District (Magnet Mall), LBS Reclamation, H. T. Parekh
Marg, Bhandup (West) Marg, Churchgate, Mumbai
Mumbai-400078 – 400020

If Insured Person is not satisfied with the redressal of b. Incorporate additional Waiting Period of not
grievance through above methods, the Insured Person may exceeding 3 years for the said undisclosed disease
also approach the office of Insurance Ombudsman of the or condition from the date the non-disclosed
respective area/region for redressal of grievance as per condition was detected and continue with the Policy
Insurance Ombudsman Rules 2017. Grievance may also be c. Levy underwriting loading from the first Policy Year
lodged at IRDAI Integrated Grievance Management System of issuance of Policy or Renewal, whichever is later.
-https://bimabharosa.irdai.gov.in/.
1.2. Utilization of Sum Insured
Latest contact details of Offices of Insurance Ombudsman are
provided at Annexure A. The sequence of utilization of Sum Insured in this Policy
will be as follows, subject to the covers being in force
Specific General Terms and Clauses and amount utilized under each of the below sections
1.1. Non-Disclosure or Misrepresentation of Pre-Existing during the Policy Year;
Disease a. Aggregate Deductible
The Company may, notwithstanding and without b. Base Sum Insured.
prejudice to its rights under the standard general
terms and clauses above, also exercise any of the c. Cumulative Bonus/Plus Benefit
below listed options for the purpose of continuing the d. Secure Benefit
health insurance coverage in case of non-disclosure or e. Automatic Restore Benefit
misrepresentation of Pre-Existing Diseases, subject to
A single claim in the Policy Year shall never exceed the
prior consent from Policyholder:
cumulative addition of
a. Permanently exclude the disease/condition and
a. Base Sum Insured,
continue with the Policy.
b. Cumulative Bonus (if applicable and remaining
during the Policy Year),
HDFC ERGO General Insurance Company Limited. IRDAI Reg. No. 146. CIN: U66030MH2007PLC177117. Registered & Corporate
Office: 1st Floor, HDFC House, 165-166 Backbay Reclamation, H. T. Parekh Marg, Churchgate, Mumbai – 400 020. UIN: my: Optima
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c. Plus Benefit (if applicable and remaining during the behalf of the Company, unless stated in writing by
Policy Year) AND the Company.
d. Secure Benefit (if applicable and remaining during 1.7. Premium Tier
the Policy Year). The premium payable under the Policy will be computed
1.3. Geography basis the city of residence provided by the Insured
This Policy provides coverage throughout the territory of Person in the Proposal Form. Classification of cities
India, except under Section B-2.8 (E-Opinion for Critical would be as under:
Illness), Section B-2.9 Global Health Cover (Emergency a. Tier 1: Delhi, National Capital Region (NCR), Mumbai,
Treatments Only), Section B-2.10 Global Health Cover Mumbai Suburban, Thane and Navi Mumbai, Surat,
(Emergency & Planned Treatments), B-2.11 Overseas Ahmedabad and Vadodara.
Travel Secure and as may be specified in the Schedule b. Tier 2: Rest of India.
of Coverage in the Policy Schedule.
No co-payment shall apply if Insured Person from Tier 2
1.4. Loadings avails a treatment in Tier 1.
a. The Company may apply loading on the premium, 1.8. Instalment Premium payment through Auto Debit/ECS
specific Waiting Period or permanent exclusions, Facility
based on the declarations made in the Proposal
Form and the health status, habits and lifestyle, past a. If premium payment is opted for by instalments
medical records, and the results of the pre-Policy through auto debit/ECS facility, a separate
medical examination of the persons proposed to be authorization form shall be submitted by Insured
insured under the Policy. Person specifying the frequency chosen for
premium to be debited.
b. The maximum medical underwriting loading shall
not exceed 100% for each condition and a total of b. Where there is a change either in the terms and
150% for each Insured Person. conditions of the coverage or Policy or in the
premium rate, the ECS authorization shall be
c. Loadings shall be applied from Commencement obtained afresh.
Date including subsequent Renewal(s), and on
increased Sum Insured. c. The Insured Person has the option to withdraw from
the ECS mode at least fifteen days prior to the due
d. Proposer shall be informed about the proposed date of instalment premium payable.
loading with premium, specific Waiting Period or
permanent exclusion (if any) through a counter d. No additional charges will be levied or recovered
offer letter and Policy will be issued only on specific in any manner from the benefits payable towards
acceptance within 15 days of the receipt of such cancellation of the ECS mode.
counter offer letter. In case the Company does not 1.9. Dispute Resolution Clause
receive any response to the counter offer letter from Any and all disputes or differences under or in relation to
the proposer within 15 days, the application shall this Policy shall be determined by the Indian Courts and
be cancelled and any premium received shall be subject to Indian law
refunded within 7 days.
1.5. Endorsements Section A. Other Terms & Conditions

This Policy constitutes the complete contract of 1. Claims Procedure

insurance. This Policy cannot be modified by anyone 1.1. Notification of a Claim
(including an insurance agent or broker) except the
Notice with full particulars shall be sent to the Company
Company. Any change or modification that the Company
as under:
makes will be evidenced by a written endorsement
signed and stamped by the Company. a. Within 24 hours from the date of emergency
Hospitalization required or before the Insured
1.6. Communication & Notice
Person’s discharge from Hospital, whichever is
Policy and any communication related to the Policy shall earlier.
be sent to through electronic modes or to the address of
b. At least 48 hours prior to admission in Hospital in
the following:
case of a planned Hospitalization or decision to
a. The Policyholder’s, at the address/ e-mail address avail treatment under Section B-1.2 (Home Health
specified in the Policy Schedule. Care).
b. To the Company, at the address specified in the 1.2. Procedure for Cashless Claims In India
Policy Schedule.
a. Treatment may be taken in a Network Provider and
c. Insurance agents, brokers, other person or entity is subject to pre authorization by the Company.
is/are not authorised to receive any notice on the
b. Cashless request form is available with the Network
Provider.
HDFC ERGO General Insurance Company Limited. IRDAI Reg. No. 146. CIN: U66030MH2007PLC177117. Registered & Corporate
Office: 1st Floor, HDFC House, 165-166 Backbay Reclamation, H. T. Parekh Marg, Churchgate, Mumbai – 400 020. UIN: my: Optima
Secure - HDFHLIP25041V062425.
24
c. The Network Provider shall obtain the relevant a. issue the authorization letter specifying the
information from the Insured Person / Policyholder sanctioned amount, any specific limitation on the
and send a Cashless Facility request to the claim and non-payable items, if applicable, or
Company for authorization. b. reject the request for pre-authorization specifying
d. The Company upon getting cashless request reasons for the rejection.
form and related medical information from the 1.5. Conditions for obtaining Cashless Facility within India
Insured Person/ Network Provider shall issue pre-
authorization letter to the Network Provider after a. Cashless facility can be availed only at Company’s
verification. Network Provider. The complete list of Network
Providers and empanelled service providers is
e. At the time of discharge, the Insured Person shall available on Company’s website and can also be
verify and sign the discharge papers along with final obtained by contacting the Company.
bill, pay for non-medical and inadmissible expenses.
b. The Company reserves the right to modify, add or
f. The Company reserves the right to deny pre- restrict any Network Provider for Cashless facility at
authorization in case the Insured Person is unable its sole discretion. The same shall be duly updated
to provide the relevant medical details. on the Company’s website. The Insured Person shall
g. In case of denial of cashless access, the Insured check the updated list of Network Providers before
Person may obtain the treatment as per treating applying for cashless claim.
doctor’s advice and submit the claim documents to c. Pre-authorization issued by the Company shall be
the Company for reimbursement. valid for 15 days from the date of issuance (or expiry
1.3. Procedure for Cashless Claims Outside India of the Policy, whichever is earlier).
a. You shall intimate the Claims to us through any d. The Company shall make payment for the Cashless
available mode of communication as specified in facility to the authorized amount, directly to the
the Policy, Health Card or our Website Network Provider.
b. Treatment may be taken in a Network Provider and 1.6. Procedure for Reimbursement Claims
is subject to pre authorization by the Company. For reimbursement of claims, the Insured Person shall
Process for obtaining Pre-Authorization is submit the necessary documents to the Company within
mentioned below: the prescribed time limit as specified hereunder.
I. We shall send Release of Information form to
Type of Claim Prescribed Time limit
the Insured Person for signature and consent.
Reimbursement of Within 30 days of date of
ii. After receiving the signed Release of
Hospitalization, Day discharge from Hospital.
Information form, We will retrieve hospitalization
Care Treatment or Pre-
documents along with invoices
Hospitalization Expenses
iii. If these details are not provided in full or are
Reimbursement of Post- Within 15 days from
insufficient for Us to consider the request,
Hospitalization Expenses completion of post
We will request additional information or
Hospitalization treatment.
documentation
iv. On receipt of the complete documents We may 1.7. List of documents required for a Claim
• issue the guarantee of payment specifying The reimbursement claim is to be supported with
the sanctioned amount, any specific the following documents and submitted within the
limitation on the claim and non-payable prescribed time limit.
items, if applicable a. Duly Completed claim form,
or b. Photo ID and Age Proof,
• reject the request for pre-authorization c. Copy of the Hospital’s Registration Certificate/
specifying reasons for the rejection Hospital Registration number in case of
1.4. Procedure for Cashless Claims in case of Home Health Hospitalization in any non-Network Provider of the
Care (Section B-1.2) Company or certificate from Hospital authorities
providing facilities available including number of
On receipt of duly filled pre authorization form with
beds,
other sufficient details to assess a cashless request,
the Company will inform the Home Healthcare service d. Discharge Card / Day Care Summary / Transfer
provider or Network Provider, who will share the care Summary,
plan and treatment cost estimation with the Company. e. Final Hospital bill with all original deposit and final
On receipt of the complete documents the Company payment receipt and refund receipt(s), if advance
may: amount refunded,

k. History of alcohol consumption or any intoxication Note:

certified by first treating doctor in case of Accident i. The Company shall only accept bills/invoices/medical
cases, treatment related documents only in the Insured
l. Copy of Death Summary and copy of Death Person’s name for whom the claim is submitted.
Certificate (in death claims only), ii. In the event of a claim lodged under the Policy and
m. Copy of indoor case papers with nursing sheet the original documents having been submitted to any
detailing medical history of the Insured Person, other insurer, the Company shall accept the copy of the
treatment details, and patient’s progress (to be documents and claim settlement advice, duly certified by
submitted wherever required by the Company). the other insurer subject to satisfaction of the Company.

n. Invoice for vaccination and payment receipt, iii. If requested by the Company, at the Company’s cost,
the Insured Person must submit to medical examination
o. Original invoices for the expenses incurred towards by Medical Practitioner appointed by the Company as
ambulance facility along with details of loss in the often as it is considered reasonable and necessary and
Company’s prescribed format, Company’s representatives must be permitted to inspect
p. KYC documents (in all claims above Rs. 1 lakh) of the the medical and Hospitalization records pertaining to
Policyholder as per AML guidelines, the Insured Person’s treatment, and to investigate the
q. Duly filled NEFT form with cancelled blank cheque circumstances pertaining to the claim.
(with IFSC code, A/C number, and name mentioned iv. Any delay in notification or submission may be condoned
on cheque leaf), on merit where delay is proved to be for reasons beyond
the control of the Insured Person.

2. Contact Us
Within India Outside India
Claim Intimation: Customer Service No. 022-62346234 / Global Contact No : +800 08250825
0120-62346234 (accessible from locations outside India only)
Email: healthclaims@hdfcergo.com Landline no (Chargeable) : 0120-4507250

Reimbursement Claim Intimation: Visit www. Emailtravelclaims@hdfcergo.com

hdfcergo.com - > Help - > Claim Registration
Claim document HDFC ERGO General Insurance Co. Ltd. HDFC ERGO General Insurance Co. Ltd.
submission at address: Stellar IT Park, Tower-1 5th Floor, 6th Floor, Leela Business Park,
C - 25, Sector 62 Andheri Kurla Road, Andheri East,
Noida – 0120 398 8360 Mumbai-400059, Ph - 022 66383600

Key to read above table

d. ‘Covered’ means that particular benefit is an inbuilt feature in that particular plan- and the premium of such benefits are
included in the premium of the respective Plan.
e. ‘Not Covered’ means that particular benefit is NOT available either as an inbuilt feature or as an optional feature in that
particular plan
f. ‘Optional’ means that particular benefit is NOT an inbuilt feature BUT can be opted by the Proposer/Policyholder either
at inception or at renewal. However, ‘PED wait period modification’ optional cover is allowed to be opted at channel level
only. Individual customer will not be able to opt for the same.
Notes:
a. Preventive Health Check-up benefit will not be available under the policy if Aggregate Deductible of INR 5 Lakhs is in force.
b. Preventive Health Check-up, Secure Benefit, Cumulative Bonus / Plus Benefit, Automatic Restore Benefit, Daily Cash for
Shared Room and Unlimited Restore (Add-on) benefits will not be available under the policy if Aggregate Deductible of INR
10 Lakhs or more is in force.
c. **For Individual policy sum insured and limits mentioned in the table are applicable on per Insured Person per Policy Year
basis and for Family Floater policy sum insured and limits apply on per policy per Policy Year basis
d. ^Claims shall be payable as per geography mentioned in the above table unless explicitly stated otherwise in a specific
cover.

Add on – Covers:
‘my: Optima Secure’ offers following Add on Covers:
1. my: health Critical Illness Add On: Provides comprehensive coverage by offering a Lumpsum payout on diagnosis of any
of the listed 51 critical Illnesses. Sum Insured options range from Rs. 100,000 to Rs. 500,00,000 in multiples of Rs. 100,000
2. my: health Hospital Cash Benefit Add On: Per day hospital cash benefit for each continuous and completed 24 hours
of hospitalization. Per day Sum Insured options of Rs. 500/ 1000/ 1500 / 2000/ 2500 / 3000 / 5000/ 7500/ 10,000 are
available.
3. lndividual Personal Accident Rider: Provides Lumpsum pay out in case of Accidental Death, Permanent Total Disablement
and Permanent Partial Disablement. Sum Insured shall be 5 (five) times the Sum Insured of Base Plan up to a maximum of
Rs. 1 Crore
4. Unlimited Restore (Add on): Provides unlimited restoration in a Policy Year.
5. Optima Wellbeing (Add on) : Covers expenses for various outpatient benefits.

Notes:
For in depth details on terms and conditions applicable to add-ons, Kindly refer to the Prospectus & Policy wording documents
of the respective add-on available under downloads section on our website.
Coverage and Sum Insured offered under the add-on’s are subject to declaration in proposal forms and internal underwriting
guidelines.

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Optima Secure Revision

Uploaded by

Optima Secure Revision

Uploaded by

HDFC ERGO General Insurance Company Limited

Sr. No. Particulars Page No.

A.1.1 Standard Definitions 2

A.1.2 Specific Definitions 7

B.1 Base Coverages 11

B.2 Optional Coverages 14

B.3 Renewal Benefit 27

C.1 Waiting Periods 29

C.2 Standard Exclusions 30

C.3 Specific Exclusions 32

D.1 Standard General Terms & Clauses 33

E Other Terms & Conditions 42

4. it continues indefinitely Def. 28. Medically Necessary Treatment means any

g. Breach of Law: Code – Excl10: Expenses for 3. Specific Exclusions:

This Policy constitutes the complete contract of 1. Claims Procedure

k. History of alcohol consumption or any intoxication Note:

Reimbursement Claim Intimation: Visit www. Emailtravelclaims@hdfcergo.com

Key to read above table

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