HDFC Ergo Optima Restore

HDFC Ergo Optima Restore is a health insurance policy offered by HDFC ERGO General Insurance Company Limited.

The HDFC Ergo Optima Restore Plan offers extensive coverage that goes beyond just hospitalisation and related expenses. It also comes with unique benefits such as the ability to increase your sum insured automatically based on the previous year's inflation rate. Our research also revealed that the insurer has received fewer complaints related to claim settlement but a higher number of policy purchase complaints. However, there are some downsides to this plan that you should consider. It comes with a higher price tag compared to other products in the market. 

What are the benefits offered by the HDFC Ergo Optima Restore Plan?

• Inpatient hospitalization coverage: Like all health insurance plans, the HDFC Ergo Optima Restore Plan provides coverage for expenses associated with inpatient hospitalization. These are expenses you incur when you are hospitalized for more than 24 hours such as room and board fees, nursing charges, medical practitioner fees, prescription drugs, ICU expenses, and other relevant expenses.
• Pre-hospitalization coverage: Medical expenses that you incur before hospitalization are referred to as pre-hospitalization charges. These expenses typically include consultation fees, lab tests, checkups, medical reports, etc. However, the insurer will only cover these expenses if they are related to the medical condition that eventually leads to hospitalization and the claim is approved as part of the inpatient hospitalization coverage. The good news is that with the HDFC Ergo Optima Restore Plan, pre-hospitalization expenses are covered for 60 days before hospitalization up to the sum insured.
• Post-hospitalization coverage: After you are discharged from the hospital, you might encounter further medical expenditures referred to as post-hospitalization costs. These expenses may include consultations with your physician, medical check-ups, rehabilitation schemes, physical therapy, etc. To have these costs covered, they must be relevant to your initial hospitalisation, and your claim must be approved under inpatient hospitalisation. The HDFC Ergo Optima Restore Plan provides coverage for post-hospitalization expenses for 180 days after hospitalisation up to the sum insured.
• Daycare treatment coverage: Daycare treatment is a medical procedure or surgery that used to require an extended hospital stay but can now be completed within 24 hours due to advancements in medical technology. With HDFC Ergo Optima Restore Plan, expenses related to all daycare procedures are covered without any limit.
• Domiciliary treatment coverage: Domiciliary treatments are medical treatments for illnesses or injuries that require immediate attention at the hospital but are given at home due to the severity of your medical condition or the absence of hospital beds in the vicinity. With HDFC Ergo Optima Restore Plan, domiciliary treatment expenses are covered up to the sum insured.
• Organ donor coverage: Under the HDFC Ergo Optima Restore Plan, organ donor expenses are covered up to the sum insured. This coverage encompasses organ harvesting expenses in the event of an organ transplantation surgery - where you are the organ recipient.
• Modern treatment coverage: As medical technology advances, innovative treatments that were once deemed impossible are now becoming a reality. These modern treatments, including stem cell therapy, radio surgeries, etc. intend to cure ailments that were once regarded as incurable. The HDFC Ergo Optima Restore Plan is designed to keep up with these advancements by covering expenses related to modern treatments up to the chosen sum insured.
• Non-medical expenses coverage: The HDFC Ergo Optima Restore Plan covers the non-medical expenses that are essential for treatment without any limit - if you opt for an add-on. Such expenses include the cost of gloves, nebulization kits, oxygen masks, etc.
• No Claim Bonus: The HDFC Ergo Optima Restore Plan offers a No-Claim Bonus - a reward given to you if you don’t make any claims in a policy year. This bonus amounts to 50% of the sum insured subject to a maximum of up to 100%. Bonus will be accumulated irrespective of claim history.
• Super No Claim Bonus: The Super No Claim Bonus operates in the same way as the standard No Claim Bonus, but is an accelerated version. It is important to note that the HDFC Ergo Optima Restore Plan does not provide the Super No Claim Bonus feature.
• Restoration Benefit: The Restoration Benefit is an exclusive feature of the HDFC Ergo Optima Restore Plan. It restores the sum insured once it is utilised during a policy year. This benefit applies to both related and unrelated illnesses. The refill benefit kicks in once both the sum insured and No Claim Bonus are partially used up. And, the benefit can be applied an unlimited number of times in a policy year for subsequent claims - if you opt for an add-on.

Please note that the limits and conditions mentioned in the above benefits and features are for Rs. 10 Lakhs sum insured.

HDFC Ergo Optima Restore: Financial Limits

• Room rent limit: The room rent limit is the maximum amount that your insurance provider will cover for the hospital room you stay in during your hospitalization. If you opt for a room that falls within this limit, you won't have to bear any additional expenses. However, if you decide to choose a room with a higher rent than your eligibility, a proportional deduction will apply. This means that you will have to bear a proportionate share of the entire bill, rather than paying only the difference. With the HDFC Ergo Optima Restore Plan, you can select any type of room without restrictions.
• ICU rent limit: The HDFC Ergo Optima Restore Plan provides coverage for expenses incurred during an ICU stay. There is no limit on the amount covered, ensuring that you receive the best possible medical care without any financial burden.
• Copayment: It is a certain percentage of the approved claim amount you need to pay out of your own pocket before your insurer covers the remaining amount. However, the HDFC Ergo Optima Restore Plan doesn’t have a copayment limit.
• Deductible: It is a certain amount that you must pay from your end before your policy starts to cover your medical expenses. However, the HDFC Ergo Optima Restore Plan does not have a deductible limit.
• Limits on surgeries/treatments: It is the maximum amount that the health insurance policy will cover for certain medical procedures or treatments. However, some plans have limitations on the amount they will cover for specific procedures, while others don't. In the case of the HDFC Ergo Optima Restore Plan, it offers coverage for important surgeries and treatments like cataract treatment and joint replacement surgery up to the sum insured without any cap. 

Please note that the above financial limits are taken for a 30-year-old individual, opting for a sum insured of Rs. 10 Lakhs.

HDFC Ergo Optima Restore: Waiting Periods & Exclusions

👉Waiting period

A waiting period is a certain time frame during which specific illnesses and medical conditions are not covered right after buying a health insurance policy. You can only claim for these conditions once the waiting period has ended. The duration of the waiting period varies depending on the policy you choose. Here are some types of waiting periods -

• Initial waiting period: For the HDFC Ergo Optima Restore Plan, an initial waiting period of 30 days is applicable for all medical conditions, except for accidents. During this period, you will not be able to claim any hospitalization expenses unless it is due to an accident. Once the initial waiting period is over, you can claim for all covered medical conditions without any restrictions.
• Waiting period for pre-existing diseases: If you had any medical condition or illness within 36 months before applying for a health insurance policy, it is considered a pre-existing disease. With the HDFC Ergo Optima Restore Plan, you will need to wait for 36 months before the policy covers expenses related to your pre-existing condition. This means that during this waiting period, you will not be able to make any claims for expenses related to your pre-existing disease.
• Waiting period for specific diseases: The HDFC Ergo Optima Restore Plan applies waiting periods for certain medical conditions apart from your pre-existing diseases. These waiting periods are predetermined by the insurer and are not related to your current health status. A waiting period of 24 months is applicable for specific diseases under this plan.

👉Exclusions

Health insurance policies do not cover certain situations or medical conditions called exclusions. These include –

• Standard permanent exclusions: Insurance companies in India are required by the Insurance Regulatory and Development Authority of India (IRDAI) to follow a set of ‘standard permanent exclusions’. These include -

1. Investigation and evaluation: Hospitalisation for monitoring or observation purposes alone.
2. Rest cure, rehabilitation, and respite care: Admission to a facility for rest or respite where no active medical treatment is given.
3. Obesity/weight control: Any surgical or medical procedures intended for weight control or obesity.
4. Change of gender treatment: Medical treatment aimed at altering the body's characteristics to that of the opposite gender is excluded.
5. Plastic/cosmetic surgery: Surgical or medical procedures intended for modifying appearance or body characteristics.
6. Profession in hazardous or adventure sports: Any medical expenses incurred while participating as a professional in adventure activities such as mountaineering, river rafting, scuba diving, horse racing, etc.
7. Breach of law: Any expenses related to the treatment of a person who has committed or attempted to commit a criminal act.
8. Excluded providers: Treatment from medical practitioners or hospitals excluded by the insurance company.
9. Narcotics: Treatment for addictive conditions like alcohol addiction, drug usage, etc.
10. Treatments in establishments arranged for domestic purposes: Treatment expenses incurred in health spas, nursing homes, or similar establishments arranged entirely or partially for domestic reasons.
11. Dietary supplements, substances purchased without prescription: Expenses on vitamins, minerals, and other dietary supplements not prescribed by a medical practitioner.
12. Refractive error: Expenses associated with correcting refractive errors up to 7.5 diopters for improved eyesight.
13. Unproven treatments: Any surgeries, medical procedures, or treatments that are not proven to be effective.
14. Expenses related to birth control, sterility, infertility: Contraception, sterilisation, artificial insemination, advanced reproductive technologies such as IVF, ZIFT, GIFT, ICSI, gestational surrogacy, etc.
15. Maternity expenses: Costs related to pre/post-natal care, childbirth, and other hospitalisation expenses.

• Additional permanent exclusions: Apart from the permanent exclusions mandated by the IRDAI, insurance companies have the authority to impose ‘specific exclusions'. If a particular illness is regarded as high-risk, insurers can opt to permanently exclude it from coverage. Nevertheless, insurers are restricted to those diseases on the pre-approved list of illnesses established by the IRDAI for applying permanent exclusions. 
• Non-standard exclusions (Specific exclusions): The HDFC Ergo Optima Restore Plan has specific exclusions in addition to the standard exclusions specified by the IRDAI. These exclusions may vary among insurance providers and are dependent upon the plan’s terms and conditions. Here are some specific exclusions under this plan -

1. Any injury or illness caused directly or indirectly by acts of terrorism, nuclear emissions, war, civil war, etc.
2. Treatment for intentional self-inflicted injury or attempted suicide by any means.
3. Injury or illness resulting from participation or involvement in naval, military, air force operations, etc.
4. Self-detachable or removable prosthetics and other devices that do not require surgery or anaesthesia.
5. Treatment associated with spinal injuries, skeletal structure, muscle stimulation, except treatment of fractures (excluding hairline fractures)
6. Treatment received at a non-hospital healthcare facility.
7. Circumcision unless it is necessary for treating a disease or injury.
8.  Any non-allopathic treatment.
9. Expenses for preventive care, vaccination, inoculation, and immunisation costs (except for post-animal bite treatment).
10. The provision or fitting of hearing aids, spectacles, contact lenses, and similar products.
11. Expenses related to external birth defects.
12.  Expenses incurred for organ donation.

What to expect in terms of claims experience if you buy from HDFC ERGO General Insurance Company Limited?

• Speed of claims: HDFC ERGO General Insurance Company has shown a satisfactory level of efficiency in claim settlement, processing 95.31% of claims within 30 days. This indicates that you can expect a seamless claim settlement process.
• Claim-related complaints: Based on our research, HDFC ERGO General Insurance Company has a lower frequency of complaints related to claims compared to other insurance providers accounting for just 0.07%. This suggests that their claim settlement process is efficient and streamlined.
• Claims incurred ratio: It represents an insurer's financial performance. It is the total claims paid out in proportion to the premiums received in a given fiscal year. HDFC ERGO General Insurance Company boasts a claim incurred ratio of 80.98%.
• Claim settlement ratio: HDFC ERGO General Insurance Company has a claim settlement ratio of 95.30%. It represents the ratio of total claims received to the total claims settled by the company in a given fiscal year.
• Network hospitals: HDFC ERGO General Insurance Company offers access to a vast network of over 13,000+ hospitals. This extensive network enables customers to receive cashless treatment without any financial constraints.

How is the customer service of HDFC ERGO General Insurance Company Limited?

• Policy purchase-related complaints: Based on our research, HDFC ERGO General Insurance Company has received a higher number of complaints regarding their post-sales service as compared to other insurers, accounting for 0.01%.
• Response on Toll-Free: During our research, we found that HDFC ERGO General Insurance Company’s response rate on their toll-free number is average compared to other insurance providers.
• Response on Twitter: HDFC ERGO General Insurance Company’s response rate on Twitter is also average.

About HDFC ERGO General Insurance Company Limited

HDFC ERGO General Insurance Company Limited was established in 2002 and is headquartered in Mumbai, Maharashtra. It is a joint venture between HDFC Limited and ERGO International AG. The company offers a diverse range of general insurance products, including motor insurance, health insurance, travel insurance, home insurance, and personal accident insurance for retail customers. Other products include property insurance, marine insurance, and liability insurance for corporate clients. The company's CEO is Mr. Ritesh Kumar.