HDFC Ergo Optima Secure with ABCD Chronic Care Rider

HDFC ERGO General Insurance Company offers a robust health insurance plan called Optima Secure, which can be enhanced further with the ABCD Chronic Care Rider for added coverage. In case you choose this add-on with the Optima Secure policy, you are able to take cover for pre-existing conditions like asthma, blood pressure, cholesterol, and diabetes from day 31 of the policy.

This plan provides a host of features and benefits to help cover the healthcare expenses of you and your family.It is one of the ideal choices for anyone seeking complete protection, along with a range of special benefits. From day one, the plan doubles your base sum insured. It also allows monthly premium payments and includes coverage for several expenses, including the cost of consumables and dental treatment.

On the downside, the plan is more expensive than many others in the market. Additionally, based on our research, the insurer has received fewer complaints related to claim settlement, but a higher number of policy purchase complaints.

Let's now proceed to analyse the features and advantages provided by the HDFC Ergo Optima Secure with ABCD Chronic Care Rider Plan.

What are the benefits offered by the HDFC Ergo Optima Secure with ABCD Chronic Care Rider Plan?

Here are the main features and benefits that make up the HDFC ERGO Optima Secure with ABCD Chronic Care Rider Plan:

• Inpatient hospitalisation benefit: This pays for most of your bill when you are hospitalised for more than 24 hours. This includes room rent, nursing care, prescribed medications, doctor consultation fees, ICU, and other medical costs during your hospital stay. This cover shields you from incurring such costs.
• Pre-hospitalisation cover: Before hospitalisation, you might need to undergo some of the following tests: medical check-ups, blood tests, X-rays, CT scans, or other tests. All these would be pre-hospitalisation costs. This plan pays for these kinds of expenses up to 60 days, up to the sum insured, but only if these are related directly to the sickness that has caused your hospitalisation and your inpatient treatment claim has been sanctioned.
• Post-hospitalisation coverage: After discharge, you may still require follow-up doctor visits, medical tests, or check-ups. These are treated as post-hospitalisation expenses. The plan covers them for up to 180 days, up to the sum insured, but only if they are linked to the illness for which you were hospitalised and your inpatient claim is approved.
• Daycare treatment coverage: Daycare treatments refer to procedures or surgeries that previously required long hospital stays but can now be completed in less than 24 hours, thanks to medical advancements. The HDFC ERGO Optima Secure with ABCD Chronic Care Rider plan covers all daycare treatments up to the sum insured, so you don’t have to worry about these expenses.
• Domiciliary treatment coverage: Domiciliary treatment means receiving medical care at home for a serious illness or injury when hospitalisation is not possible, either due to the patient’s condition or lack of hospital beds. This plan covers domiciliary treatment up to the sum insured.
• Organ donor coverage: The plan includes organ donor expense coverage, provided the insured is the recipient. It pays for the cost of harvesting the donor’s organ, up to the sum insured.
• Modern treatment coverage: Modern treatments refer to advanced and complex medical procedures. Treatments like stem cell therapy and radio surgeries are included, offering hope for conditions that were once believed to be untreatable. These treatments are covered without any financial limit, as long as they are medically necessary and fall under the listed procedures.
• Non-medical expenses cover: Non-medical costs are also covered under this plan, up to the sum insured. This includes the cost of consumables used during treatment, such as nebulisation kits, gloves, oxygen masks, and similar items.
• No Claim Bonus: If you renew your policy continuously without any break, the insurer offers a guaranteed cumulative bonus. Under this plan, you receive a guaranteed 50% bonus each year, regardless of whether a claim is made. This bonus can go up to a maximum of 100% of the base sum insured.
• Super No Claim Bonus: The Super No Claim Bonus is an enhanced version of the standard NCB. However, the HDFC ERGO Optima Secure with ABCD Chronic Care Rider plan does not offer this benefit.
• Restoration benefit: The restoration benefit reinstates your base sum insured if it is used up during the policy year. It is triggered after partial exhaustion of the cover amount and applies to subsequent claims. The unlimited refills within the same year is available as an add-on. This benefit applies to both related and unrelated illnesses, ensuring continued coverage. However, the total amount payable under the restore benefit for a single hospitalisation cannot exceed the base sum insured.

Please note: The limitations and conditions mentioned above apply to a sum insured of Rs. 10 lakhs.

HDFC Ergo Optima Secure with ABCD Chronic Care Rider: Financial Limits

• Room rent limit: The room rent limit is the maximum amount your insurance will pay towards hospital room charges. If you choose a room within this limit, you won’t have to pay anything extra. However, if the room costs more than your eligible limit, a proportionate deduction will apply to the associated medical expenses. Under the HDFC ERGO Optima Secure with ABCD Chronic Care Rider plan, there is no room rent limit.
• ICU rent limit: The ICU rent limit refers to the maximum amount the insurer will cover for your stay in the Intensive Care Unit. With this plan, there is no limit on ICU rent. ICU charges are covered in full, up to the total sum insured.
• Copayment: Copayment means paying a fixed portion of the claim amount out of your pocket, while the rest is paid by the insurer. Under this plan, copayment is not required.
• Deductible: Deductible is the amount you pay out of your pocket before the insurance company begins to pay for your medical bills. Deductible choices of Rs. 25,000 / Rs. 50,000 / Rs. 1,00,000 / Rs. 2,00,000 / Rs. 3,00,000 are available as options in HDFC ERGO Optima Secure with ABCD Chronic Care Rider plan.
• Limits on surgeries/treatments: This refers to the maximum coverage for certain medical procedures. While some plans impose restrictions here, the HDFC ERGO Optima Secure with ABCD Chronic Care Rider plan covers cataract treatments and joint replacement surgeries up to the full sum insured.

Please note: The financial limits mentioned above apply to a 30-year-old individual with a sum insured of Rs. 10 lakhs.

HDFC ERGO Optima Secure with ABCD Chronic Care Rider: Waiting Periods & Exclusions

👉 Waiting period

The waiting period is the initial duration after buying a health insurance policy during which certain illnesses or treatments are not covered. You can only raise claims for these conditions after the waiting period ends.

Here are the key types of waiting periods:

• Initial waiting period: All sicknesses, except those resulting from accidents, are subject to a 30-day waiting period. You are not able to claim hospitalisation during this time, except in the case of an accident.
• Pre-existing disease waiting period: Any sickness or medical condition that you suffered from during the 36 months preceding the policy purchase is considered a pre-existing condition. For this plan, the waiting period for pre-existing conditions is 36 months. Asthma, blood pressure, cholesterol, and diabetes are, however, covered from Day 31 if you have the add-on.
• Waiting period for specified diseases: Aside from pre-existing conditions, there is also a waiting period for a list of specified diseases or procedures, no matter what your current state of health is. For HDFC ERGO Optima Secure with ABCD Chronic Care Rider, the specific treatment waiting period is 24 months.

👉 Exclusions

Exclusions refer to specific situations or conditions that are not covered under a health insurance policy. Below are some of the common exclusions:

• Standard Permanent Exclusions: As per the guidelines of the Insurance Regulatory and Development Authority of India (IRDAI), every health insurance provider must follow a defined list of standard permanent exclusions. Some of these include:
  • Investigation and evaluation: Hospital stays are done only for observation or monitoring.
  • Rest, rehabilitation, and respite care: Admission to a facility solely for rest or recovery, without active treatment.
  • Obesity/weight control: Surgeries, treatments, or procedures aimed at weight loss.
  • Gender reassignment: Medical interventions undergone in order to alter physical features in accordance with a different gender identity.
  • Plastic/Cosmetic surgery: Procedures or operations performed to modify or improve looks.
  • Adventure sports profession: Injuries sustained when engaged professionally in sporting activities like river rafting, mountaineering, scuba diving, etc.
  • Violation of law: Treatment for injuries sustained in attempting to commit an offense.
  • Excluded providers: Care received from hospitals or doctors not included in your plan.
  • Narcotics: Treatment or rehabilitation for dependency on alcohol, drugs, or allied substances.
  • Treatments in establishments arranged for domestic purposes: Treatment received in centres such as nursing homes, spas, or other home-based care arrangements not meant for medical treatment.
  • Dietary supplements bought over the counter: Vitamins, minerals, or other supplements that have not been prescribed by a registered medical practitioner.
  • Refractive error: Costs to treat refractive errors up to 7.5 diopters for vision correction.
  • Unproven treatments: Any medical intervention, surgery, or procedure that is not proven effective.
  • Sterilisation, conception, and infertility costs: Costs associated with sterilisation, contraceptives, artificial insemination, and high-tech fertility treatments such as IVF, GIFT, ZIFT, ICSI, and gestational surrogacy.
  • Maternity costs: Fees for maternity services, such as prenatal, postnatal, and delivery costs.
• Additional Permanent Exclusions: In addition to the standard exclusions, insurers can apply additional permanent exclusions for certain diseases or conditions they consider too risky to insure. However, these exclusions must be chosen from the approved list provided by IRDAI. Insurers cannot permanently exclude any illness or condition that is not included on this list.
• Non-standard exclusions (Specific exclusions): Non-standard exclusions go beyond the standard permanent exclusions defined by IRDAI. These exclusions are specific to each insurer and are based on the detailed terms and conditions outlined in the policy. Here are some of the specific exclusions under the HDFC ERGO Optima Secure with ABCD Chronic Care Rider plan: 
  • Investigative treatment for sleep apnoea, general debility, or exhaustion (commonly referred to as a "run-down condition")
  • Expenses related to external birth diseases, defects, or anomalies
  • Costs associated with stem cell harvesting
  • Investigative treatment related to spinal injuries, skeletal structure, or muscle stimulation, except when used for treating fractures (excluding hairline fractures)
  • Circumcision, unless it is necessary for treating a disease or injury
  • Vaccination, inoculation, and immunisation costs, except when administered for post-animal bite treatment
  • Treatment for alopecia and baldness
  • Prosthesis and external durable medical equipment used for diagnosis or treatment, unless required due to an accident

What can you expect in terms of Claims Experience if you buy from HDFC ERGO General Insurance Company?

• Speed of claims: HDFC ERGO General Insurance Company settles 95.31% of its claims in 30 days, reflecting a fast and hassle-free claim settlement experience for insureds.
• Complaints related to claims: According to our research, the company has received fewer complaints regarding claims, with a rate of complaint at 0.07%, which is lower compared to the other insurers.
• Claims incurred ratio: The claims incurred ratio is the total amount of claims paid by the insurance company as compared to the total amount of premiums collected in a fiscal year. In the case of HDFC ERGO General Insurance Company, this is 80.98%, indicating how efficiently the company pays out claims in comparison with its revenue.
• Claim settlement ratio: The claim settlement ratio indicates the percentage of claims settled by the insurance company out of the total claims received during a financial year. HDFC ERGO General Insurance Company had a claim settlement ratio of 95.30%.
• Network hospitals: HDFC ERGO General Insurance Company provides access to cashless treatment from a wide network of more than 16,000 hospitals. With this wide reach, customers are ensured access to cashless medical care from various locations around the nation.

How is the Customer Service of HDFC ERGO General Insurance Company?

• Policy purchase complaints: Our research shows that HDFC ERGO General Insurance Company has a complaint ratio of 0.01% for its after-sales service, which is significantly higher than that of other insurance companies.
• Response on Toll-Free: Based on our research, the response time on toll-free for HDFC ERGO General Insurance Company is average when compared with other companies.
• Twitter response time: According to our studies, HDFC ERGO General Insurance Company’s Twitter response time is average in comparison to other insurers.

About HDFC ERGO General Insurance Company

HDFC ERGO General Insurance Company Limited has been established through a joint venture of HDFC Ltd. and ERGO International AG. The company offers Motor, Health, Travel, Home, and Personal Accident Insurance in the retail segment and Property, Marine, and Liability Insurance in the corporate sector. The company was incorporated in the year 2002 and has its headquarters in Mumbai, Maharashtra. Mr. Ritesh Kumar has been appointed as the CEO of the company.