HDFC Ergo Optima Secure

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

HDFC ERGO Optima Secure is a comprehensive plan that provides coverage as well as a range of benefits designed to meet your medical needs financially. It offers some standout features like double the sum insured from your first day of coverage, coverage for the costs of consumables, dental coverage, etc. But it is a bit more expensive than the other products in the market. Also, based on our research, the insurer has received a lesser number of claim settlement complaints but a higher number of complaints during policy purchases.

What are the benefits offered by the HDFC ERGO Optima Secure plan? 

• Inpatient hospitalization coverage: HDFC ERGO Optima Secure Plan provides coverage for expenses related to inpatient hospitalization. This includes costs that arise when a patient is admitted to a hospital and stays for more than 24 hours. Inpatient hospitalization expenses involve fees for accommodation, nursing services, medical consultation, prescribed medication, intensive care unit (ICU) fees, and other relevant costs. 
• Pre-hospitalization coverage: These are costs that you incur before hospitalization, like consultations, tests, checkups, etc. These charges will be covered by the insurance company if they are related to the medical condition that led to hospitalization, and if they are approved as part of the inpatient hospitalization coverage. The HDFC ERGO Optima Secure Plan covers pre-hospitalization charges up to 60 days before hospitalization - up to the sum insured. 
• Post-hospitalization coverage: Medical expenses that arise after hospitalization are called post-hospitalization expenses. These may include follow-up consultations with your doctor, medical check-ups, rehabilitation sessions, physiotherapy and other related costs. To be eligible for coverage, the post-hospitalization charges must be related to the medical condition you were hospitalized for, and they must be approved as part of inpatient hospitalization coverage. HDFC ERGO Optima Secure Plan covers post-hospitalization expenses incurred up to 180 days after hospitalization - up to the sum insured. 
• Daycare treatment coverage: A daycare treatment is a medical procedure or surgery that used to require an extended hospital stay but now can be completed within 24 hours due to advancements in medical technology. HDFC ERGO Optima Secure Plan covers all daycare treatments without any limit on expenses. So, these costs will be covered up to the sum insured.   
• Domiciliary treatment coverage: Domiciliary treatments are medical treatments for illnesses or injuries that need immediate assistance at the hospital but are treated at home because the patient is too ill or injured to go to the hospital, or if no hospital beds are available nearby. Under the HDFC ERGO Optima Secure Plan, all types of domiciliary treatments will be covered up to the sum insured, provided that the treating doctor certifies it.
• Organ donor coverage: HDFC ERGO Optima Secure plan also covers organ donor expenses, in which in-patient expenses are covered up to the sum insured.
• Modern treatment coverage: Healthcare is advancing rapidly due to technological developments, resulting in the formulation of modern treatments. These treatments, such as stem cell therapy and radio surgeries, strive to treat the diseases the treatment of which was once impossible. HDFC ERGO Optima Secure plan covers the costs of such modern treatments up to the sum insured. 
• Non-medical expenses coverage: Along with the medical costs, the HDFC ERGO Optima Secure plan offers coverage for non-medical expenses such as gloves, oxygen masks, nebulization kits, and other consumables needed for treatment. Such items add up and can get expensive. This plan offers coverage for these expenses up to the sum insured. 
• No Claim Bonus: Insurance companies offer a No Claim Bonus if no claims are filed during the policy year. However, HDFC ERGO Optima Secure rewards you with a bonus of 50% for every claim-free irrespective of the claims made - up to 100% of the sum insured. And, the accumulated bonus will not reduce even if a claim is filed during the policy year. 
• Super No Claim Bonus: It is an upgraded version of the No Claim Bonus and works just like it. But HDFC ERGO Optima Secure doesn’t have the Super No Claim Bonus feature. 
• Restoration Benefit: This is a feature in which the sum insured is restored after it has been depleted within a policy year. The HDFC ERGO Optima Secure Plan offers the refill benefit for both related and unrelated illnesses and can be used for subsequent claims. It will activate once the sum insured is partially exhausted. You can enjoy the refill benefit unlimited times in a policy year if you opt for an add-on.

Please note that the restrictions and terms specified in the above-mentioned benefits pertain to a sum insured of Rs. 10 lakhs. 

HDFC ERGO Optima Secure: Financial Limits

• Room rent limit: The maximum amount of hospital room expenses covered by the insurance company during your hospitalization is called the room rent limit. If you opt for a room that is within the limit of your plan’s room rent, you won’t have to pay anything for the room. However, if you choose a room that exceeds your eligibility, you will be responsible for paying a proportional share of the entire bill, not just the difference in the room rent. HDFC ERGO Optima Secure gives you the opportunity to select any kind of room without restrictions. 
• ICU rent limit: The maximum amount that a health insurance policy covers for an intensive care unit (ICU) stay is known as the ICU limit. HDFC Optima Secure plan doesn’t have any limit on the ICU rent, which means that the plan covers the full cost of an ICU stay without any restrictions. 
• Co-payment: A co-payment, also known as a co-pay, is a part of the approved claim amount that you are supposed to pay out of your pocket. Once you have paid the co-pay, the insurance company will cover the remaining amount. The HDFC ERGO Optima Secure plan does not have a copayment limit. 
• Deductible: A deductible is an initial amount that you need to pay from your pocket before your health insurance policy begins covering your medical expenses. HDFC ERGO Optima Secure has optional deductible limits of 25k, 50k and 100k. 
• Limits on surgeries/treatments: It is the maximum amount that a health insurance policy will provide for particular medical procedures or treatments. While some policies may impose restrictions on the amount they will cover for specific procedures, some policies may not. The HDFC ERGO Optima Secure plan has no such limitations on healthcare procedures, including joint replacement surgery and cataract treatment. So, this policy fully covers the expenses of joint replacement surgery and cataract treatment without imposing any limit. 

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 Secure: Waiting Periods & Exclusions

👉Waiting period

Some illnesses and diseases are not covered for a certain period after buying a health insurance policy. This time span is called the waiting period. The completion of this duration enables you to claim for these conditions. The various kinds of waiting periods include - 

• Initial waiting period: An initial waiting period of 30 days applies to all health conditions except accidents. You will not be able to make claims for hospitalization expenses during the first 30 days, except in the case of accidents.
• Waiting period for pre-existing diseases: A pre-existing disease refers to a medical condition that you have suffered from in the 48 months before applying for the health insurance policy. HDFC ERGO Optima Secure plan has a waiting period of 36 months for pre-existing diseases. In this period, you will not be covered by your health insurance policy for the medical expenses incurred due to a pre-existing disease. 
• Waiting period for specific diseases: The insurance companies have a predetermined list of medical conditions apart from your pre-existing diseases which will have a waiting period irrespective of whether you have had those diseases in the past or not. The duration of this waiting period is decided by the insurance company and it is not influenced by your present health condition. HDFC ERGO Optima Secure plan has a waiting period of 24 months for specific diseases. 

👉Exclusions: 

The medical conditions that are not covered by the health insurance policy are called exclusions. They include: 

• Standard Permanent Exclusions: All insurance companies are required to enforce the set of ‘standard permanent exclusions’ as established by IRDAI. Some of them are:

1. Investigation and evaluation: Hospital admission for the sole purpose of monitoring or observation.
2. Rest, rehabilitation, and respite care: Admission to a facility for bed rest without any active treatment provided. 
3. Obesity/weight control: Treatment or surgery related to weight control or obesity.
4. Gender reassignment: Treatment aimed at altering the body’s characteristics to match those of the opposite sex. 
5. Plastic/Cosmetic surgery: Treatment or surgery intended to modify body characteristics or appearance.
6. Profession in hazardous or adventure sports: Treatment expenses incurred while participating as a professional in adventurous activities such as surfing, kayaking, trekking, etc. 
7. Breach of law: 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 addiction to substances such as alcohol or drugs.
10. Treatments in establishments arranged for domestic purposes: Expenses of treatment undERGOne in health spas, nursing homes, or similar establishments arranged entirely or partially for domestic reasons.
11. Dietary supplements, substances purchased without subscription: Vitamins, minerals, etc. not prescribed by a medical practitioner.
12. Refractive error: Expenses associated with correcting refractive errors of up to 7.5 diopters for improved eyesight.
13. Unproven treatments: Surgeries, medical procedures, or treatments that are not proven to be effective.
14. Expenses related to birth control, sterility infertility: Contraception, sterilization, artificial insemination, advanced reproductive technologies such as IVF, ZIFT, GIFT, ICSI, gestational surrogacy, etc. 
15. Maternity expenses: Pre/post-natal costs, childbirth-related hospitalization expenses, etc. 

• Additional permanent exclusions: Apart from the standard permanent exclusions, insurance companies may impose additional exclusions for specific medical conditions or situations. If you suffer from certain diseases or severe medical conditions which are risky to cover for the insurer, they may exclude them permanently from the policy. However, it is important to note that insurance companies are restricted to a list of illnesses specified by IRDAI for which they can apply a permanent exclusion. They are not allowed to apply permanent exclusions to illnesses or diseases that are not on this list. 
• Non-standard exclusions (Specific exclusions): These are specific exclusions in addition to the standard permanent exclusions listed by the IRDAI. These exclusions depend on the insurance companies and the policy’s terms and conditions. The specific exclusions under the HDFC ERGO Optima Secure Plan are - 

1. Injury or illness due to participation or involvement in terrorism, war, civil war, nuclear, chemical, biological attack or weapons.
2. Treatment related to intentional self-inflicted injury or attempted suicide by any means.
3. Injury or illness due to participation or involvement in naval, military or air force operations.
4. Treatment for a sleep-related disorder.
5. Expenses related to external birth diseases, defects or anomalies.
6. Expenses related to stem cell harvesting.
7. Treatment related to spinal injuries, skeletal structure, muscle stimulation, except treatment of fractures (excluding hairline fractures).
8. Circumcision unless necessary for treating a disease or injury.
9. Vaccination, inoculation, and immunization costs (except post-animal bite treatment).
10. Treatment for Alopecia and baldness.
11. Prosthesis and external durable equipments of any kind used for diagnosis or treatment, unless necessitated due to accident.

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 Limited has settled 94.61% of claims in less than 30 days. This suggests that you might not experience a long waiting time in receiving the claim amount. 
• Claim-related complaints: Based on our research, it appears that HDFC ERGO General Insurance Company Limited has received fewer complaints regarding claims than other insurance companies. This indicates that their claim settlement process is efficient. 
• Claims incurred ratio: The claims incurred ratio indicates the company’s financial performance. It represents the total amount of claims incurred by the insurance company as compared to the total amount of premiums collected. HDFC ERGO General Insurance Company Limited has a claims incurred ratio of 79.04%
• Claim settlement ratio: The claim settlement ratio is the percentage of claims settled by the insurer as compared to the total number of claims received by them in a financial year. HDFC ERGO General Insurance Company Limited has a claim settlement ratio of 94.32%. 
• Network hospitals: HDFC ERGO General Insurance Company Limited has a network of 12,000+ hospitals, providing a vast range of healthcare providers across various locations. This network of hospitals allows you to conveniently access cashless treatment without concerns about the financial burden. 

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

• Policy purchase-related complaints: Based on research, HDFC ERGO General Insurance Company Limited has received 0.01% of complaints for its after-sales service.
• Response on Toll-Free: As per our research, HDFC ERGO General Insurance Company Limited’s response on the toll-free is quick, which suggests that you can enjoy a smooth experience of your problems getting solved. 
• Response on Twitter: According to our research, HDFC ERGO General Insurance Company Limited’s response on Twitter is slow compared to other insurance companies. 

About HDFC ERGO Insurance Company Limited

HDFC ERGO General Insurance Company Limited, based in Mumbai, Maharashtra, is a collaborative effort between HDFC Ltd. and ERGO International AG. Established in 2002, the company provides a diverse range of general insurance products catering to both retail and corporate sectors. These include Motor, Health, Travel, Home and Personal Accident in the retail space to Property, Marine and Liability Insurance in the corporate space. The CEO of the company is Mr Ritesh Kumar.