HDFC Ergo Optima Secure

Note: When looking for policy features, clause and wording always be sure to look for prospectus with identical UIN number as your policy has. some inclusions and exclusions vary even when the policy is same due to version change. 

Base Benefits Of Policy: (For clarity refer to HDFC Ergo Optima Prospectus Section 3)

• Hospitalisation Expenses:  

  • In Patient Care - Up to Sum Insured. Includes room rent, boarding, and nursing at actuals (No capping). 

    1. 1. Room Rent, Boarding, Nursing: At actuals up to SI. 

       2. Surgeon, Anaesthetist, Medical Practitioner Fees: Up to SI.

       3. Investigations & Diagnostics: Up to SI. 

       4. Medicines & Drugs: Up to SI.

       5. Intravenous Fluids, Blood Transfusion, Surgical Appliances: Up to SI. 

       6. Prosthetics (internal, implanted during surgery): Up to SI

  • Day-Care Treatments - All Day Care treatments (less than 24 hrs hospitalization) covered. 

  • Advance Technology Methods - Up to SI

  • Pre Hospitalisation Medical Expenses - Up to SI (60 Days Prior to Hospitalisation)

  • Post Hospitalisation Medical Expenses - Up to SI (180 Days after Discharge)

  • Ayush Treatment - in-patient treatment under Ayurveda, Yoga, Unani, Siddha, and Homeopathy covered up to SI. Must be in Govt. recognized hospital/NABH Hospital.

  • Domiciliary Treatment - Covered for treatment at home if patient cannot be moved or no beds available. Must exceed 3 consecutive days

  • Home Health Care - Cashless treatment at home for specific illnesses if prescribed by doctor. 

  • Organ Donor Cover - Up to Sum Insured (Covers harvesting costs for the donor). 

• Road Ambulance Cover - Covered, it must be for an emergency transportation to a hospital for an admissible ER claim or for transfer from one hospital to another for better treatment. 

Co-Payment policy: No co-payment mentioned as base benefit in the policy wording 

Individual policy can have multiple persons under one policy number, in this every insured person will have independent sum insured, which will mean it's a multi individual policy. 

Family floater is a policy in which sum insured is shared between all the person insured under the policy. 

Road Ambulance Cover Limit (amount & frequency): Section 3.1.1

Conditions: Medically necessary transfer to nearest hospital, between hospitals, or hospital to home (same city). 

Amount & Frequency: Covered up to Sum Insured (no separate limit/sub-limit noted). 

Pre-Hospitalisation Medical Expenses: Section 3.5

Condition: Must be related to an admissible hospitalization claim. 

Cover: Up to SI, Up to 60 days prior to admission. 

Post-Hospitalisation Medical Expenses: Section 3.6

Condition: Must be related to an admissible hospitalization claim.

Cover: Up to SI, Up to 180 Days after Discharge

Out Patient 

Condition: Not listed as a Base Benefit in this prospectus. 

Cover: Not Covered (unless optional rider purchased). 

Day Care Treatments  Section 3.1.1.iv

Condition: Medical treatment involving less than 24 hours hospitalization due to technological advancement. 

Cover: All Day Care Treatments covered. 

Domiciliary Hospitalisation  Section 3.3

Condition: Medical Expenses incurred during your treatment at home, as long as it involves medical treatment for period exceeding 3 consecutive days. This will be applicable if patients condition dose not allow him/her to move to hospital or in case when hospital room may not be available when patient needs the most. it must be medically necessary.

Cover: Covered up to sum insured

Organ Donor Cover

Condition: Covers harvesting costs for the donor when the insured is the recipient. Donor's pre/post hospitalization excluded. 

Cover: Covered up to sum insured

Advanced Technology Methods

Condition: Procedures as Defined by IRDAI

Cover: up to SI

Accidental Hospitalisation

Hospitalization caused solely and directly due to an accident.  Covered from Day 1

According to HDFC Optima Prospectus Page 20 zones are defined as follows:

• Zone / Tier 1: Delhi, NCR, Mumbai, Thane, Mumbai Suburban, Navi Mumbai, Surat, Ahmedabad, Vadodara 

• Zone  / Tier 2: Rest Of India

Zonal Co-Payment: No co-payment shall apply if Insured Person from Tier 2 avails a treatment in Tier 1 (page 18)

A. Cashless Claim (Network Hospital)

1. Admission: Present the Health Insurance card /  policy card and Aadhaar/PAN at the hospital insurance desk. 

2. Pre-Auth: Pre-authorization request form to be sent by Hospital to your insurance company (within 24 hours for emergency, 48 hours prior for planned).

3. Audit:  Care Health reviews the medical records. 

4. Approval: Insurer sends a "Letter of Approval".

5. Discharge: You pay only the non-medical items (e.g., masks, gloves) unless you have the Claim Shield rider. You pay amount that has not been approved or deducted by insurer. 

B. Reimbursement Claim (Non-Network Hospital)

1. Intimation: Notify your insurer within 24 Hrs. You must call the number mentioned in your policy or go through customer care. Additionally you should also send a email so as to have written proof. 

2. Payment:  You pay the full bill at the hospital. 

3. Submission: Submit original documents within 15-30 days of Discharge

4. Verification: The company may send an investigator to the hospital to verify the case. 

5. Settlement: Money is credited to your bank via NEFT within 30 days of receiving the last "complete" document. 

List of Documents Required:

• Claim Form: Generally Part A (filled by you) and Part B (filled by the hospital).

• Discharge Summary: Must mention the history and line of treatment.

• Final Bill & Receipts: Itemized bill with original payment receipts.
  Note: Bills & receipts are different bills have details of expenses and receipts confirms the amount paid. 

• Test Reports: All X-rays, Blood reports, Scans with doctor’s prescription.

• KYC: Cancelled cheque (with name printed) and ID proof.

Permanent Exclusions in Health Insurance Policy 

1. Investigation & Evaluation only (Hospitalized only for tests).

2. Rest Cure, Rehabilitation, and Respite Care.

3. Obesity/Weight Control.

4. Change-of-Gender treatments.

5. Plastic/Cosmetic Surgery.

6. Breach of law / Hazardous sports / War / Nuclear acts.

Specific Exclusions in Health Insurance Policy 

1. Expenses for lenses, spectacles, hearing aids.

2. Dental treatment (unless requiring hospitalization due to accident).

3. Unproven treatments.

HDFC ERGO Optima Secure is a premium "flagship" product that attempts to eliminate the concept of "No Claim Bonus" by replacing it with the "Secure Benefit" (2x cover from Day 1) and "Plus Benefit" (increasing cover regardless of claims). The Protect Benefit (covering consumables) is a massive advantage as it reduces out-of-pocket expenses to near zero for cashless claims. 

The 36-month PED wait is standard, though some competitors like Care Supreme offers 24 months. It is ideal for families looking for a high-coverage, "fill-it-shut-it-forget-it" type of policy where room rent capping or consumable deductions are not a worry. 

If you are not looking for HDFC only policies you should consider Care Supreme as it will give you more for lesser premium , it offers multiple restoration of SI even for same illness. 

1. Major Medical Conditions

(Stroke, Bypass, Heart Diseases, Major Organ Transplant, Cancer, Renal Failure, etc.)

• Standard Initial Waiting Period: 30 Days (Clause C.1.b).

• Pre-Existing Disease (PED) Wait: 36 Months (3 years).

• Sum Covered: Up to Sum Insured.

• Key Advantage: The Secure Benefit provides 2X coverage from Day 1. For example, if you buy ₹10 Lakhs, you effectively have ₹20 Lakhs available for these conditions after the first 30 days.

• Add-on: There is no specific retail rider in the standard Optima Secure prospectus to reduce the 36-month PED wait for these major illnesses.

2. Chronic Lifestyle Conditions

(Diabetes, Hypertension, Asthma, Epilepsy)

• Standard Initial Waiting Period: 30 Days (if not a PED).

• If declared as PED: 36 Months.

• Critical Note: Unlike Care Supreme, HDFC ERGO Optima Secure does not have an "Instant Cover" rider for these specific diseases. The client must serve the 36-month wait if these are pre-existing.

3. Specific Ailments (Named Ailments)

(Stones, Hernia, Piles, BPH, Varicose Veins, Hysterectomy, etc.)

• Waiting Period: 24 Months (Clause C.1.a).

• If declared as PED: The 36-month wait applies.

• Condition: If the surgery (like Hysterectomy) is due to Malignancy (Cancer), the 24-month wait is waived.

4. Joint Replacement

• Waiting Period: 24 Months.

• Accident Exception: Covered from Day 1 if required due to an accidental injury.

• If declared as PED: 36 Months.

5. Dental, Psychiatric, and Sleep Apnea

• Dental Treatment: Unique Benefit. Covers medical expenses for treatment of both Injury and Disease to natural teeth, provided it requires at least 24 hours of hospitalization or is a listed Day Care procedure.

• Psychiatric Care: Covered up to the Sum Insured after a 30-day initial wait (provided it is not a PED).

• Sleep Apnea: Generally excluded if related to Obesity (Excl06). If medically necessary and not related to obesity, it is covered under Modern Treatments, but check for a 50% SI cap depending on the specific robotic/advanced technology used.

6. Cataract Details

• Waiting Period: 24 Months.

• Monetary Limit: No Sub-limit. You can claim up to the full Sum Insured (Base + Secure Benefit).

• Lens & Room Rent: No specific lens cap. HDFC ERGO covers the cost of "Surgical Appliances" as medically necessary. Since there is No Room Rent Capping, there are no proportionate deductions on the bill.

7. The "4X Coverage" Ecosystem

1. Secure Benefit: Doubles your base cover from Day 1.

2. Plus Benefit: Increases base cover by 50% after 1 year and 100% after 2 years (irrespective of claims).

3. Restore Benefit: 100% of base cover is restored automatically for every claim in the year.

4. Protect Benefit: Built-in cover for Consumables (gloves, masks, etc.), meaning near-zero non-medical deductions.