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Optima Secure Policy Wording

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Optima Secure Policy Wording

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John Scott

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HDFC ERGO General Insurance Company Limited

Policy Wordings
my: Optima Secure

Section Description Page No.

Preamble 3
Operating Clause 3
Section A. Definitions 3
1.1. Standard Definitions 3
1.2. Specific Definitions 6
Section B. Benefits 7
1. Base Coverage 7
1.1. Hospitalization Expenses 8
1.1.1. Other Expenses 8
1.2. Home Health Care 8
1.3. Domiciliary Hospitalization 8
1.4. AYUSH Treatment 8
1.5. Pre-Hospitalization Expenses 8
1.6. Post-Hospitalization Expenses 8
1.7. Organ Donor Expenses 8
1.8. Cumulative Bonus (CB) [Applicable only to Optima Suraksha plan] 9
2. Optional Covers 9
2.1 Emergency Air Ambulance 9
2.2 Daily Cash for Shared Room 10
2.3 Protect Benefit 10
2.4 Plus Benefit 10
2.5 Secure Benefit 10
2.6 Automatic Restore Benefit 11
2.7 Aggregate Deductible 11
2.7.1 Waiver of Aggregate Deductible 11
2.8 E-Opinion for Critical Illness 11
2.9 Global Health Cover (Emergency Treatments Only) 13
2.10 Global Health Cover (Emergency & Planned Treatments) 13
2.11 Overseas Travel Secure 14
3. Preventive Health Check-up 14
Section C. Exclusions 15
1. Standard Exclusions 15
2. Specific Exclusions: 17
Section D. General Terms and Clauses 17
1. Standard General Terms & Clauses 17

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 - HDFHLIP25011V052425. 2
Preamble c. AYUSH Hospital, standalone or co-located
This Policy is a contract of insurance issued by HDFC ERGO withinpatient healthcare facility of any recognized
General Insurance Company Limited (hereinafter called system of medicine, registered with the local
the ‘Company’) to the proposer mentioned in the Policy authorities, wherever applicable, and is under
Schedule (hereinafter called the ‘Policyholder’) to cover the the supervision of a qualified registered AYUSH
person(s) named in the Policy Schedule (hereinafter called Medical Practitioner and must comply with all the
the ‘Insured Person(s)’). The Policy is based on the statements following criterion:
and declaration provided by the Policyholder in the Proposal i. Having at least 5 in-patient beds;
Form as well as in any welcome or other tele-verification ii. Having qualified AYUSH Medical Practitioner
calls with the Company’s authorized person and is subject to in charge round the clock;;
receipt of the requisite premium.
iii. Having dedicated AYUSH therapy sections
Operating Clause as required and/or has equipped operation
theatre where surgical procedures are to be
If during the Policy Period the Insured Person is required to be carried out;
Hospitalized for treatment of an Illness or Injury at a Hospital/
Day Care Centre or given treatment at Home, following iv. Maintaining daily records of the patients and
Medical Advice of a duly qualified Medical Practitioner, the making them accessible to the insurance
Company shall indemnify Medical Expenses necessarily company’s authorized representative.
incurred towards the Covers in force under the Policy, as Def. 4. AYUSH Day Care Centre means and includes
specified in the Policy Schedule Community Health Centre (CHC), Primary Health
Provided further that, any amount payable under the Policy Centre (PHC), Dispensary, Clinic, Polyclinic or any
shall be subject to the terms of coverage (including Aggregate such health centre which is registered with the local
Deductible, Sub-limits), exclusions, conditions and definitions authorities, wherever applicable and having facilities
contained herein. The maximum, total and cumulative liability for carrying out treatment procedures and medical
of the Company under any and all such claims during each or surgical/para-surgical interventions or both
Policy Year shall be the Sum Insured (Individual or Floater), under the supervision of registered AYUSH Medical
including optional covers and other add on covers in force Practitioner(s) on day care basis without in-patient
under the Policy, and Cumulative Bonus (if any) specified in services and must comply with all the following
the Policy Schedule. criterion:
i. Having qualified registered AYUSH Medical
Section A. Definitions Practitioner (s) in charge;
1.1. Standard Definitions ii. Having dedicated AYUSH therapy sections as
The terms defined below and at other junctures in the required and/or has equipped operation theatre
Policy have the meanings ascribed to them wherever where surgical procedures are to be carried out;
they appear in this Policy and, where, the context so iii. Maintaining daily records of the patients and
requires, references to the singular include references making them accessible to the insurance
to the plural; references to the male includes the female company’s authorized representative.
and references to any statutory enactment includes Def. 5. Cashless facility means a facility extended by the
subsequent changes to the same. insurer to the insured where the payments, of the
Def. 1. Accident means a sudden, unforeseen and costs of treatment undergone by the insured in
involuntary event caused by external, visible and accordance with the policy terms and conditions, are
violent means. directly made to the network provider by the insurer
Def. 2. Any one illness means continuous period of illness to the extent pre-authorization is approved.
and includes relapse within 45 days from the date Def. 6. Condition Precedent means a policy term or
of last consultation with the Hospital/Nursing Home condition upon which the Insurer’s liability under the
where treatment was taken. policy is conditional upon.
Def. 3. AYUSH Hospital is a healthcare facility wherein Def. 7. Congenital Anomaly means a condition which is
medical/surgical/para-surgical treatment procedures present since birth, and which is abnormal with
and interventions are carried out by AYUSH Medical reference to form, structure or position.
Practitioner(s) comprising of any of the following: a) Internal Congenital Anomaly: Congenital
a. Central or State Government AYUSH Hospital; or anomaly which is not in the visible and accessible
b. Teaching hospital attached to AYUSH College parts of the body.
recognized by the Central Government /Central b) External Congenital Anomaly: Congenital
Council of Indian Medicine/Central Council for anomaly which is in the visible and accessible
Homeopathy; or parts of the body.

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 - HDFHLIP25011V052425. 3
Def. 8. Co-Payment means a cost sharing requirement i. the condition of the patient is such that he/she is
under a health insurance policy that provides that the not in a condition to be removed to a hospital, or
policyholder/insured will bear a specified percentage ii. the patient takes treatment at home on account of
of the admissible claims amount. A co-payment does non-availability of room in a hospital.
not reduce the Sum Insured.
Def. 16. Emergency Care means management for an illness
Def. 9. Cumulative Bonus means any increase or addition or injury which results in symptoms which occur
in the Sum Insured granted by the insurer without an suddenly and unexpectedly, and requires immediate
associated increase in premium. care by a medical practitioner to prevent death or
Def. 10. Day Care Centre means any institution established serious long term impairment of the insured person’s
for day care treatment of illness and / or injuries or health.
a medical set -up with a hospital and which has Def. 17. Grace Period means the specified period of time,
been registered with the local authorities, wherever immediately following the premium due date during
applicable, and is under the supervision of a which premium payment can be made to renew or
registered and qualified medical practitioner AND continue a policy in force without loss of continuity
must comply with all minimum criterion asunder: - benefits pertaining to waiting periods and coverage of
i. has qualified nursing staff under its employment; pre-existing diseases. Coverage need not be available
during the period for which no premium is received.
ii. has qualified medical practitioner/s in charge;
The grace period for payment of the premium for
iii. has fully equipped operation theatre of its own all types of insurance policies shall be: fifteen days
where surgical procedures are carried out; where premium payment mode is monthly and thirty
iv. maintains daily records of patients and will make days in all other cases.
these accessible to the insurance company’s Provided the insurers shall offer coverage during the
authorized personnel. grace period, if the premium is paid in instalments
Def. 11. Day Care Treatment means those medical treatment, during the policy period. (Note: In case of non-
and/or surgical procedure which is instalment premium payment, coverage shall not
be available for the period for which no premium is
i) undertaken under General or Local Anaesthesia
received).
in a hospital/day care centre in less than 24 hours
because of technological advancement, and Def. 18.Hospital means any institution established for in
patient care and day care treatment ofIllness and/
ii) which would have otherwise required
or injuries and which has been registered as a
hospitalization of more than 24 hours,
hospital with the local authorities under the Clinical
Treatment normally taken on an out-patient basis is Establishments (Registration and Regulation) Act
not included in the scope of this definition. 2010 or under the enactments specified under the
Def. 12. Deductible means a cost-sharing requirement under Schedule of Section 56(1) of the said act Or complies
a health insurance policy that provides that the insurer with all minimum criteria as under::
will not be liable for a specified rupee amount in case i) has qualified nursing staff under its employment
of indemnity policies and for a specified number of round the clock;
days/hours in case of hospital cash policies which will
ii) has at least 10 in-patient beds in towns having a
apply before any benefits are payable by the insurer.
population of less than 10,00,000 and at least 15
A deductible does not reduce the Sum Insured. The
in-patient beds in all other places;
deductible is separate from any Aggregate Deductible
that may be in-force and applicable under the Policy, iii) has qualified medical practitioner(s) in charge
as specified in the Policy Schedule round the clock;
Def. 13. Dental Treatment mmeans a treatment related iv) has a fully equipped operation theatre of its own
to teeth or structures supporting teeth including where surgical procedures are carried out;
examinations, fillings (where appropriate), crowns, v) maintains daily records of patients and make
extractions and surgery. these accessible to the insurance company’s
Def. 14. Disclosure of information norm means the policy shall authorized personnel;
be void and all premium paid hereon shall be forfeited Def. 19. Hospitalization means admission in a Hospital for a
to the Company in the event of misrepresentation, minimum period of 24consecutive ‘In-patient Care’
mis-description or non-disclosure of any material fact. hours except for specified procedures/treatments,
Def. 15. Domiciliary Hospitalization means medical treatment where such admission could be for a period of less
for an illness/disease/injury which in the normal than 24 consecutive hour.
course would require care and treatment at a hospital Def. 20.Illness means a sickness or a disease or pathological
but is actually taken while confined at home under condition leading to the impairment of normal
any of the following circumstances: physiological function and requires medical treatment.

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 - HDFHLIP25011V052425. 4
(a) Acute condition – Acute condition means is a any State or Medical Council of India or Council
disease, illness or injury that is likely to respond for Indian Medicine or for Homeopathy set up by
quickly to treatment which aims to return the the Government of India or a State Government
person to his or her state of health immediately and is thereby entitled to practice medicine within
before suffering the disease/illness/injury which its jurisdiction; and is acting within the scope and
leads to full recovery jurisdiction of license.Medical Practitioner who is
(b) Chronic condition – A chronic condition is defined sharing the same residence as the Insured Person
as a disease, illness, or injury that has one or more and is a Family Member of the Insured Person are not
of the following characteristics: considered as Medical Practitioner under the scope
of this Policy.
1. it needs ongoing or long-term monitoring through
consultations, examinations, check-ups, and /or Medical Practitioner (Definition applicable for the
tests treatment taken outside India) means a licensed
medical practitioner acting within the scope of his
2. it needs ongoing or long-term control or relief of
license and who holds a degree of a recognized
symptoms
institution and is registered by the Authorized
3. it requires rehabilitation for the patient or for the Medical Council of the respective country.
patient to be specially trained to cope with it
Def. 28. Medically Necessary Treatment means any
4. it continues indefinitely
treatment, test, medication, or stay in hospital or part
5. it recurs or is likely to recur 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
ii) must not exceed the level of care necessary to
means which is verified and certified by a Medical
provide safe, adequate and appropriate medical
Practitioner.
care in scope, duration or intensity;
Def. 22. Inpatient Care means treatment for which the
iii) must have been prescribed by a medical
insured person has to stay in a hospital for more than
practitioner;
24 hours for a covered event.
iv) must conform to the professional standards
Def. 23. Intensive Care Unit means an identified section,
widely accepted in international medical practice
ward or wing of a hospital which is under the constant
or by the medical community in India.
supervision of a dedicated medical practitioner(s),
and which is specially equipped for the continuous Def. 29. Migration means a facility provided to policyholders
monitoring and treatment of patients who are in a (including all members under family cover and group
critical condition, or require life support facilities policies), to transfer the credits gained for pre-
and where the level of care and supervision is existing diseases and specific waiting periods from
considerably more sophisticated and intensive than one health insurance policy to another with the same
in the ordinary and other wards. 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 expenses providers enlisted by an insurer, TPA or jointly by an
which shall include the expenses for ICU bed, Insurer and TPA to provide medical services to an
general medical support services provided to any insured by a cashless facility.
ICU patient including monitoring devices, critical care Def. 31. Non-Network Provider means any hospital, day
nursing and intensivist charges care centre or other provider that is not part of the
Def. 25. Medical Advice means any consultation or advice network.
from a Medical Practitioner including the issuance of Def. 32. Notification of Claim means the process of
any prescription or follow-up prescription. intimating a claim to the insurer or TPA through any
Def. 26. Medical Expenses means those expenses that of the recognized modes of communication.
an Insured Person has necessarily and actually Def. 33. OPD Treatment means the one in which the Insured
incurred for medical treatment on account of Illness visits a clinic / hospital or associated facility like a
or Accident on the advice of a Medical Practitioner, consultation room for diagnosis and treatment based
as long as these are no more than would have been on the advice of a Medical Practitioner. The Insured
payable if the Insured Person had not been insured is not admitted as a day care patient or in-patient.
and no more than other hospitals or doctors in the
Def. 34. Portability means a facility provided to the health
same locality would have charged for the same
insurance policyholders (including all members
medical treatment.
under family cover), to transfer the credits gained for,
Def. 27. Medical Practitioner means a person who holds pre-existing diseases and specific waiting periods
a valid registration from the Medical Council of

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 - HDFHLIP25011V052425. 5
from one insurer to another insurer. hospital or day care centre by a medical practitioner.
Def. 35. Pre-Existing Disease means any condition, ailment, Def. 43. Unproven/Experimental Treatment means the
injury or disease: treatment including drug experimental therapy which
a) that is/are diagnosed by a physician not more than is based on established medical practice in India, is a
36 months prior to the date of commencement of treatment experimental or unproven.
the policy issued by the insurer; or
1.2. Specific Definitions
b) for which medical advice or treatment was
The terms defined below and at other junctures
recommended by, or received from, a physician,
in the Policy have the meanings ascribed to them
not more than 36 months prior to the date of
wherever they appear in this Policy and, where,
commencement of the policy.
the context so requires, references to the singular
Def. 36. Pre-hospitalization Medical Expenses means iinclude 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 or
same condition for which the Insured Person’s activity involving physical exertion and skill in which
Hospitalization was required, and an Insured Person participates or competes for
ii. The In-patient Hospitalization claim for such entertainment or as part of his profession whether he
Hospitalization is admissible by the Insurance / 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 means a cost-sharing
number of days immediately after the insured person requirement that provides that the Company will
is discharged from the hospital provided that:: not be liable for a specified amount of the covered
i. Such Medical Expenses are for the same condition expenses in respect of all admissible claims made
for which the insured person’s hospitalization was under the Policy in aggregate, and which will apply
required, and before any benefits are payable by the Company.
The 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. AYUSH Treatment refers to the medical and/or
Def. 39. Reasonable and Customary Charges means hospitalisation treatments given under Ayurveda,
the charges for services or supplies, which are Yoga and Naturopathy, Unani, Siddha and
the standard charges for a specific provider and Homeopathy systems.
consistent with the prevailing charges in the
Def. 6. Bank Rate means the rate fixed by the Reserve Bank
geographical area for identical or similar services,
of India (RBI) at the beginning of the financial year,
taking into account the nature of illness/ injury
which shall be applied depending on the year in
involved.
which a claim is due.
Def. 40. Renewal means the terms on which the contract of
Def. 7. Base Sum Insured means the pre-defined limit
insurance can be renewed on mutual consent with
specified in the Policy Schedule which represents
a provision of grace period for treating the renewal Our maximum, total, and cumulative liability under
continuous for the purpose of gaining credit for pre- the Policy for the respective Policy Year, subject to
existing diseases, time-bound exclusions and for all the additional cover amounts which may be available
waiting periods. under any optional covers in-force and specified in
Def. 41. Room Rent means the amount charged by a Hospital the Policy Schedule.
towards Room and Boarding expenses and shall Def. 8. Break in Policy means the period of gap that occurs
include the associated medical expenses. at the end of the existing policy term/installment
Def. 42. Surgery or Surgical Procedure means manual and premium due date, when the premium due for
/ or operative procedure (s) required for treatment renewal on a given policy or installment premium
of an illness or injury, correction of deformities and due is not paid on or before the premium renewal
defects, diagnosis and cure of diseases, relief from date or grace period.
suffering and prolongation of life, performed in a

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 - HDFHLIP25011V052425. 6
Def. 9. 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. 19. 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 any cancellation of this Policy, whichever is earlier.
Illness, incapacitating disablement or death.
Def. 20. Policyholder means person who has proposed the
Def. 10. Chemical attack or weapons mmeans 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, when Def. 21. Policy Schedule means the Policy Schedule attached
suitably distributed, is capable of causing any Illness, to and forming part of this Policyspecifying the details
incapacitating disablement or death. of the Insured Persons, the Sum Insured, the Policy
Period and the Sub-limits to which benefits under the
Def. 11. Commencement Date means the date of Policy are subject to,including any annexures and/or
commencement of insurance coverage under the endorsements, made to or on it from time to time,
Policy as specified in the Policy Schedule. and if more than one, then the latest in time.
Def. 12. Family Members means any one or more of the
Def. 22. Policy Year means a period of twelve months
following family members of the Insured Person:
beginning from the Commencement Date and
i. Legally wedded spouse. ending on the last day of such twelve-month period.
ii. Parents and parents-in-law. For the purpose of subsequent years, Policy Year
shall mean a period of twelve months commencing
iii. Dependent Children (i.e. natural or legally
from the end of the previous Policy Year and lapsing
adopted) between the Age 90 days to Age
on the last day of such twelve-month period, till the
25 years. If the child above 18 years of Age
Expiry Date, as specified in the Policy Schedule.
is financially independent, he or she shall be
ineligible for coverage under this Policy in the Def. 23. Preventive Health Check-up means a package of
subsequent renewals. medical test(s) undertaken for general assessment
of health status, excluding any diagnostic or
Def. 13. Home means the Insured Person’s place of
investigative medical tests for evaluation of Illness or
permanent residence as specified in the Policy
a disease.
Schedule.
Def. 24. E-Opinion for Critical Illness means aa procedure
Def. 14. Insured Person means persons named in the Policy where by upon request of the Insured Person,
Schedule who are insured under the Policyand in
an independent Medical Practitioner reviews
respect of whom the applicable premium has been
and opines on the treating Medical Practitioner’s
received in full.
recommendation as to care and treatment of the
Def. 15. Life threatening situation shall mean a serious Insured Person by reviewing Insured Person’s
medical condition or symptom resulting from Injury or medical status and history.Such an opinion shall
Illness which is not Pre-Existing Disease, which arises not be deemed to substitute the Insured Person’s
suddenly and unexpectedly, and requires immediate physical visit or consultation to an independent
care and treatment by a Medical Practitioner, Medical Practitioner.
generally received within 24 hours of onset to avoid Def. 25. Sub-limit means a cost sharing requirement under
jeopardy to life or serious long term impairment of a health insurance policy in which an insurer would
the Insured Person’s health, until stabilisation at not be liable to pay any amount in excess of the
which time this medical condition or symptom is not predefined limit. The Sub-limit as applicable under
considered an Emergency anymore. the Policy is specified in the Policy Schedule against
Def. 16. Material Facts means all relevant information sought the relevant Cover in force under the Policy.
by the Company in the Proposal Form and other Def. 26. Sum Insured mmeans the aggregate limit of
connected documents to enable it to take informed indemnity consisting of the Base Sum Insured,
decision in the context of underwriting the risk. Cumulative Bonus, Plus Benefit, Secure Benefit
Def. 17. Non-instalment Premium Payment refers to and Automatic Restore Benefit (provided that these
payment of premium for the entire policy period optional covers are in force for the Insured Person),
made in advance as a single premium. which represents the maximum, total and cumulative
Def. 18. Policy means these Policy wordings, the Policy liability of the Company for any and all claims made
Schedule and any applicable endorsements or under the Policy, in respect of that Insured Person
extensions attaching to or forming part thereof, (on Individual basis) or all Insured Persons (on Floater
as amended from time to time, and shall be read basis) during the Policy Year.
together. The Policy contains details of the extent Def. 27. Waiting Period means a period from the inception
of cover available to the Insured Person, applicable of this Policy during which specified diseases/

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 - HDFHLIP25011V052425. 7
treatments are not covered. On completion of the ii. The Hospitalization must be for Medically Necessary
Waiting Period, diseases/treatments shall be covered Treatment, and prescribed in writing by Medical
provided the Policy has been continuously renewed Practitioner.
without any break.
1.2. Home Health Care
Section B. Benefits
The Company shall indemnify the Medical Expenses
1. Base Coverage incurred by the Insured Person on availing treatment at
The Covers listed below are in-built Policy benefits and Home during the Policy Year, if prescribed in writing by
shall be available to all Insured Persons in accordance the treating Medical Practitioner, provided that:
with the procedures set out in this Policy and up to the
a. The treatment in normal course would require
Sub-limits mentioned in the Policy Schedule. Cumulative
In-patient Care at a Hospital, and be admissible
Bonus shall be available only if the Cover is specified to
under Section B-1.1 (Hospitalization Expenses).
be applicable in the Policy Schedule.
b. The treatment is pre-authorized by the Company
Claims made in respect of any of these Covers will
as per procedure given under Claims Procedure -
affect the eligibility for the additional Covers set out in
Section E-1.
Section B-2 and Section B-3 below.
c. Records of the treatment administered, duly
1.1. Hospitalization Expenses
signed by the treating Medical Practitioner,are
The Company shall indemnify Medical Expenses maintained for each day of the Home treatment.
necessarily incurred by the Insured Person for
This Cover is not available on reimbursement basis.
Hospitalization of the Insured Person during the Policy
Year due to Illness or Injury, up to the Sum Insured and
1.3. Domiciliary Hospitalization
Cumulative Bonus specified in the Policy Schedule for:
The Company shall indemnify the Medical Expenses
a. Room Rent, boarding, nursing expenses as
incurred during the Policy Year on Domiciliary
provided by the Hospital / Nursing Home.
Hospitalization of the Insured Person prescribed in
b. Intensive Care Unit (ICU) / Intensive Cardiac Care writing by treating Medical Practitioner, provided that:
Unit (ICCU) expenses.
a. the condition of the Insured Person is such that
c. Surgeon, anaesthetist, Medical Practitioner, he/she could not be removed/admitted to a
consultants, specialist Fees during Hospitalization Hospital.
forming part of Hospital bill.
or,
d. Investigative treatments and diagnostic
b. the Medically Necessary Treatment is taken at
procedures directly related to Hospitalization.
Home on account of non-availability of room in a
e. Medicines and drugs prescribed in writing by Hospital.
Medical Practitioner.
f. Intravenous fluids, blood transfusion, surgical 1.4. AYUSH Treatment
appliances, allowable consumables and/or enteral The Company shall indemnify the Medical Expenses
feedings. Operation theatre charges. incurred by the Insured Person only for Inpatient Care
g. The cost of prosthetics and other devices or under Ayurveda, Yoga and Naturopathy, Unani, Siddha
equipment, if implanted internally during Surgery. and Homeopathy systems of medicines during each
Policy Year up to the Sub-limit specified against this
1.1.1. Other Expenses
Cover in the Policy Schedule, in any AYUSH Hospital.
i. Expenses incurred on road Ambulance if the
Insured Person is required to be transferred to the 1.5. Pre-Hospitalization Expenses
nearest Hospital for Emergency Care or from one The Company shall indemnify the Pre-Hospitalization
Hospital to another Hospital or from Hospital to Medical Expenses incurred by the Insured Person,
Home (within same city) following Hospitalization. related to an admissible Hospitalization under
ii. In patient Care Dental Treatment, necessitated Section B-1.1 (Hospitalization Expenses), for up to
due to disease or Injury 60 days immediately prior to the date of admissible
iii. Plastic Surgery, necessitated due to Injury Hospitalization covered under the Policy.

iv. All Day Care Treatments. 1.6. Post-Hospitalization Expenses

Note The Company shall indemnify the Post-Hospitalization
i. Expenses of Hospitalization for a minimum period of 24 Medical Expenses incurred by the Insured Person,
consecutive hours only shall be admissible. However, related to an admissible Hospitalization under Section
the time limit shall not apply in respect of Day Care B-1.1 (Hospitalization Expenses), for up to 180 days from
Treatment. the date of discharge from the Hospital, following an

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 - HDFHLIP25011V052425. 8
admissible Hospitalization claim under the Policy. in to two or more floater policies/individual policies or in
cases where the Policy is split due to the child attaining
1.7. Organ Donor Expenses the Age of 25 years, the CB of the expiring policy
The Company shall indemnify the Medical Expenses shall be apportioned to such Renewed Policies in the
covered under Section B-1.1(Hospitalization Expenses) proportion of the Sum Insured of each Renewed Policy
which are incurred by the Insured Person during the f. If the Sum Insured has been reduced at the time of
Policy Year towards the organ donor’s Hospitalization Renewal, the applicable CB shall be reduced in the
for harvesting of the donated organ where an Insured same proportion to the Sum Insured in current Policy.
Person is the recipient, subject to the following
g. If the Sum Insured under the Policy has been increased
conditions:
at the time of Renewal, the CB shall be calculated on the
a. The organ donor is any person whose organ Sum Insured of the last completed Policy Year.
has been made available in accordance and in
h. If the Policy Period is of two/three years, any CB that
compliance with The Transplantation of Human
has accrued for the first/second Policy Year shall be
Organ (amendment) Act, 2011, Transplantation of
credited post completion of each Policy Year.
Human Organs and Tissues Rules, 2014 and other
applicable laws and/or regulations. i. New Insured Person added to the Policy during
subsequent Renewals will be eligible for CB as per their
b. Recipient Insured Person’s claim under Section
Renewal terms.
B-1.1 (Hospitalization Expenses) is admissible
under the Policy. j. CB shall be available only if the Cover is specified to be
applicable in the Policy Schedule.
c. Expenses listed below are excluded from this
Cover:
2. Optional Covers
i. The organ donor’s Pre-Hospitalization
The Covers listed below are optional covers. An
Expenses and Post-Hospitalization Expenses.
optional cover is applicable to an Insured Person only
ii. Expenses related to organ transportation or if it is specified in the Policy Schedule to be in force
preservation. for that Insured Person, and such optional cover will be
iii. Any other Medical Expenses or Hospitalization available in accordance with the procedures set out in
consequent to the organ harvesting. this Policy and up to the Sub-limits mentioned in the
Policy Schedule.
1.8. Cumulative Bonus (CB) [Applicable only to Optima The optional covers shall apply to all Insured Person(s)
Suraksha plan] once selected, without any individual selection.
On Renewal of this Policy with the Company without a Note: Please refer to ‘Annexure C’ for Optional Covers
break, a sum equal to 10% of the Base Sum Insured of which are in-built in Your plan.
the expiring Policy shall be provided as CB irrespective
of any claims and shall be available under the Renewed 2.1 Emergency Air Ambulance
Policy subject to the following conditions:
The Company shall indemnify expenses incurred by
Notes: the Insured Person during the Policy Year towards
a. In case where the Policy is on individual basis as Ambulance transportation in an airplane or helicopter
specified in the Policy Schedule, the CB shall be added for Emergency Care which requires immediate and rapid
and available individually to the Insured Person. Ambulance transportation that ground transportation
cannot provide from the site of first occurrence of the
b. In case where the Policy is on floater basis, the CB shall Illness or Accident to the nearest Hospital. The claim is
be added and available to the family on floater basis. subject to a maximum of Sum Insured as specified in the
c. CB shall be available only if the Policy is renewed/ Policy Schedule against this Cover, and subject to the
premium paid within the Grace Period. following conditions:
d. If the Insured Persons in the expiring policy are a. The air Ambulance transportation is advised in
covered on an individual basis as specified in the Policy writing by a Medical Practitioner.
Schedule and there is an accumulated CB for such b. Medically Necessary Treatment is not available at
Insured Persons under the expiring policy, and such the location where the Insured Person is situated
expiring policy has been Renewed on a floater policy at the time of emergency.
basis as specified in the Policy Schedule then the CB
c. The air Ambulance provider is a registered entity
to be carried forward for credit in such Renewed Policy
in India (except Section B-2.9 (Global Health Cover
shall be the lowest one that is applicable among all the (Emergency Treatments Only)) and Section B-2.10
Insured Persons. (Global Health Cover (Emergency and Planned
e. In case of floater policies where the Insured Persons Treatments Only))
Renew their expiring policy by splitting the Sum Insured d. The Insured Person is in India and the treatment

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 - HDFHLIP25011V052425. 9
is taken in India only(except Section B-2.9 (Global b. The applicable Plus Benefit shall be applied
Health Cover (Emergency Treatments Only)) and annually only on completion of each Policy Year,
Section B-2.10 (Global Health Cover (Emergency and once added, the accumulated amount will
and Planned Treatments Only)). be carried forward to the subsequent Policy Year,
subject to there being no Break in Policy.
e. No return transportation to the Insured Person’s
Home or elsewhere by the air Ambulance will be c. This Cover will be applied irrespective of number
covered under this Cover. of claims made under the expiring Policy.
f. A claim for the same Hospitalization is admissible d. This applicable Plus Benefit under this Cover
under Section B-1.1 (Hospitalization Expenses) OR can be utilized only for claims admissible under
Section B-2.9 (Global Health Cover (Emergency Section B-1 (Base Coverage) and Section B-2.3
Treatments Only)) OR Section B-2.10 (Global (Protect Benefit) of the Policy.
Health Cover (Emergency and Planned Treatments Notes:
Only)).
i. In case where the Policy is issued on an individual
g. The amount specified in the Policy schedule basis, the Plus Benefit shall be added and available
against this benefit denotes the Company’s
individually to the Insured Person. In case where the
maximum liability in respect to the benefit and
Policy is on floater basis, the Plus Benefit shall be added
shall not reduce the Sum Insured of the policy.
and available to all Family Members on a floater basis.
2.2 Daily Cash for Shared Room ii. Plus Benefit shall be available only if the Policy is
renewed and due premium is received within the Grace
The Company shall pay a daily cash amount as
Period.
specified in Policy Schedule for each continuous and
completed 24 hours of Hospitalization during the Policy iii. If the Insured Persons in the expiring policy are covered
Year if the Insured Person is Hospitalised in shared on an individual basis as specified in the Policy Schedule
accommodation in a Network Provider Hospital and and there is an accumulated Plus Benefit for such
such Hospitalization exceeds 48 consecutive hours. Insured Persons under the expiring policy, and such
Specific Exclusions: expiring policy has been Renewed on a floater policy
basis as specified in the Policy Schedule then the Plus
a. The Coveris not available for the time spent by the Benefit to be carried forward for credit in such Renewed
Insured Person in an Intensive Care Unit (ICU). Policy shall be the lowest one that is applicable among
b. The claim for the same Hospitalization is not all the Insured Persons.
admissible under Section B-1.1 (Hospitalization iv. In case of floater policies where Insured Persons Renew
Expenses). their expiring policy by splitting the Sum Insured in to
c. The amount specified in the Policy schedule two or more floater policies/individual policies or in
against this benefit denotes the Company’s cases where the Policy is split due to the child attaining
maximum liability in respect to the benefit and the Age of 25 years, the Plus Benefit of the expiring
shall not reduce the Sum Insured of the policy. policy shall be apportioned to such Renewed Policies
in the proportion of the Sum Insured of each Renewed
2.3 Protect Benefit Policy
The Company shall indemnify the Insured Person for v. If the Sum Insured has been reduced at the time of
the Non-Medical Expenses listed under Annexure B Renewal, the applicable Plus Benefit shall be reduced
to this Policy incurred in relation to a claim admissible in the same proportion to the Sum Insured in current
under Section B-1 (Base Coverage) during the Policy Policy.
Year.
vi. If the Sum Insured under the Policy has been increased
Exclusion (k) of SectionC.2 – Specific Exclusions shall at the time of Renewal, the Plus Benefit shall be
not apply to this Cover. calculated on the Sum Insured of the last completed
Policy Year.
2.4 Plus Benefit
vii. If the Policy Period is of two or three years, the Plus
On Renewal of this Policy with the Company without a
Benefit shall be credited post completion of each Policy
break, a sum equal to 50% of the Base Sum Insured
Year, and will be available for any claims made in the
under the expiring Policy will be added to the Sum
subsequent Policy Year.
Insured available under the Renewed Policy subject to
the following conditions: viii. New Insured Person added to the Policy during
subsequent Renewals will be eligible for the Plus
a. The applicable Plus Benefit under this Cover can
Benefit as per their Renewal terms.
only be accumulated up to 100% of Base Sum
Insured, and will be applicable only to the Insured
2.5 Secure Benefit
Person covered under the expiring Policy and
who continues to remain insured on Renewal. An additional amount as specified in the Policy

c. In case of a family floater policy, the Automatic 2.7.1 Waiver of Aggregate Deductible
Restore Benefit will be available on floater basis
for all Insured Persons covered under the Policy The Insured Person will have the option to either
and will operate in accordance with the above reduce or waive the applicable deductible only once
conditions.s. in the lifetime of the Policy and at Renewal, subject
to underwriting and only if all the below mentioned
2.7 Aggregate Deductible conditions are fulfilled:
The Insured Person shall bear an amount equal to the a. Age of eldest Insured Person should be less than
Aggregate Deductible specified on Policy Schedule for 50 years at the time of purchasing this Policy (with
all admissible claims made by the Insured Person and aggregate deductible)
assessed by the Company in a Policy Year. The liability b. Only after completion of 5 continuous Policy Years
of the Company to pay the admissible claim under that with Us in this Policy (with aggregate deductible)
Policy Year will commence only once the specified and the age of eldest Insured Person covered in
Aggregate Deductible has been exhausted. This Cover the Policy should be less than 61 years at the time
shall be subject to the following conditions: of availing this option.
a. This Cover is applicable on annual aggregate c. Continuity benefits of waiting period accrued
basis and can be opted only at inception of the as per expiring Policy Year (with aggregate

d. Availing this benefit shall not have any impact on 28 Bacterial Meningitis
the Sum Insured. 29 Cardiomyopathy
Disclaimer – E - The Insured Person is free to choose
30 Other serious coronary artery disease
whether or not to obtain the E-Opinion for Critical Illness,
and if obtained, it is the Insured Person’s sole and absolute 31 Creutzfeldt-Jakob Disease (CJD)
discretion to follow the suggestion for any advice related
32 Encephalitis
to his/her health. It is understood and agreed that any
information and documentation provided to the Company for 33 End Stage Lung Failure
the purpose of seeking the E-Opinion for Critical Illness shall
34 Fulminant Hepatitis
be shared with the Network Providers
35 Eisenmenger’s Syndrome
Major Medical Illness
36 Major Head Trauma
1 Cancer of specified severity 37 Chronic Adrenal Insufficiency (Addison’s Disease)
2 Open Chest CABG 38 Progressive Scleroderma
3 Kidney failure requiring regular dialysis 39 Progressive Supranuclear Palsy
4 Myocardial Infarction (First Heart Attack of specified 40 Blindness
severity)
41 Chronic Relapsing Pancreatitis
42 Elephantiasis

48 Crohn’s Disease B. Specific Exclusions applicable to Global Health Cover

49 Severe Rheumatoid Arthritis (Emergency Treatments Only)
i. Any Planned treatments
50 Severe Ulcerative Colitis
ii. In case we have paid a Hospitalization claim under this
51 Angioplasty
benefit, Pre-hospitalization Medical Expenses and/or
Post-hospitalization Medical Expenses related to the
2.9 Global Health Cover (Emergency Treatments Only) claim whether incurred overseas or within India are not
On availing this cover, the below mentioned benefits payable under this Policy.
shall be extended for Emergency Medical Expenses iii. Treatment or part of treatment for any condition which
which are diagnosed and incurred outside India: is not Life threatening in nature and can be safely
B-1.1 Hospitalization Expenses postponed till the Insured Person returns to India.

B-1.4 AYUSH Treatment iv. Medical treatment taken outside India if that is the sole
reason or one of the reasons for the journey.
B-1.7 Organ Donor Expenses
v. Any treatment of orthopaedic diseases or conditions
B-2.1 Emergency Air Ambulance
except for fractures, dislocations and / or Injuries
B-2.3 Protect Benefit suffered during the Policy Period.
B-2.4 Plus Benefit
vi. Oncological (Cancer) diseases
B-2.8 E Opinion for Critical Illness
vii. The Company may not be liable to make any payment
under this Policy, wherein the Government of India has
A. Global Health Cover (Emergency Treatments Only) is
laid down territorial restriction.
applicable subject to following terms and conditions
i. Our maximum liability in a Policy Year for claims under 2.10 Global Health Cover (Emergency & Planned
this cover shall not exceed the Base Sum Insured and Treatments)
Plus Benefit (if available).
On availing this cover, the below mentioned benefits
ii. Section B-2.7 (Aggregate Deductible) will not be shall be extended for both planned and Emergency
applicable for any claim under this cover. However, a Medical Expenses outside India:
Per Claim Deductible of Rs. 10,000 will apply separately
for each and every claim (except Section B-2.8 ‘E B-1.1 Hospitalization Expenses
Opinion for Critical Illness’) under this cover. B-1.4 AYUSH Treatment
iii. Claims shall normally be payable on Reimbursement B-1.5 Pre-Hospitalization cover
basis only. Cashless facility may be arranged on case to B-1.6 Post-Hospitalization cover
case basis.
B-1.7 Organ Donor Expenses
iv. The treatment should be taken in a registered Hospital,
B-2.1 Emergency Air Ambulance
as per law, rules and/ or regulations applicable to the
country, where the treatment is taken. B-2.3 Protect Benefit

v. The payment of any Claim under this Benefit will B-2.4 Plus Benefit
be based on the rate of exchange as on the date of B-2.8 E Opinion for Critical Illness
payment to the Hospital published by Reserve Bank of
India (RBI) and shall be used for conversion of Foreign Global Health Cover (Emergency & Planned Treatments) is
Currency into Indian Rupees for payment of Claims. If applicable subject to following terms and conditions
on the Insured Person’s Date of Discharge, if RBI rates i. Our maximum liability in a Policy Year for claims under
are not published, the exchange rate next published by this cover shall not exceed the Base Sum Insured and
RBI shall be considered for conversion. Plus Benefit (if available).
vi. We would not be liable to pay any claim wherein ii. Section B-2.7 (Aggregate Deductible) will not be
the medical treatment taken outside India has not applicable for any claim under this cover. However, a
commenced within the first 45 days of a trip. Per Claim Deductible of Rs. 10,000 will apply separately

iv. The treatment should be taken in a registered Hospital, b. We have accepted a claim under
as per law, rules and/ or regulations applicable to the • Section 2.9 Global Health Cover (Emergency
country, where the treatment is taken. Treatments Only) OR
v. The payment of any Claim under this Benefit will • Section 2.10 Global Health Cover
be based on the rate of exchange as on the date of (Emergency & Planned Treatments)
payment to the Hospital published by Reserve Bank of iii) There is no separate Sum Insured for this optional cover
India (RBI) and shall be used for conversion of Foreign and any claim triggered under this benefit shall reduce
Currency into Indian Rupees for payment of Claims. If the Sum Insured of the opted plan.
on the Insured Person’s Date of Discharge, if RBI rates
iv) We will indemnify the following expenses incurred
are not published, the exchange rate next published by
overseas:
RBI shall be considered for conversion.
vi. The Company may not be liable to make any payment A. Travel Expenses
under this Policy, wherein the Government of India has a. We will indemnify actual expenses incurred on air
laid down territorial restriction. tickets (most basic economy class airfare in a common
vii. There is no separate Sum Insured for this optional cover carrier) for the Hospitalized Insured Person and any one
and any claim triggered under this benefit shall reduce accompanying person to attend to the Insured Person‘s
the Sum Insured of the opted plan. medical treatment overseas.
viii. Pre-hospitalization Medical Expenses and/or i. For Emergency hospitalization cases, we shall
Posthospitalization Medical Expenses incurred and paid indemnify for the following travel expenses
overseas shall be indemnified only if the concerned • For the accompanying person, two way
hospitalization was undertaken overseas and claim expense incurred on air tickets from his
for such hospitalization was admissible under ‘Global City of Residence OR India to the airport
Health Cover (Emergency & Planned Treatments)’. nearest to the site of hospitalization shall be
ix. In case we have accepted an overseas hospitalization provided.
claim under ‘Global Health Cover (Emergency & • For the Hospitalized Insured Person, we
Planned Treatments)’ then shall only indemnify air expenses incurred to
transport him from the airport nearest to the
i) Pre-hospitalization Medical Expenses and/or
site of Hospitalization to India.
Posthospitalization Medical Expenses concerning
such hospitalization shall be paid only if the same ii. For planned hospitalization cases, we shall
have been incurred and paid overseas (as per indemnify for the following travel expenses
details in invoice supporting documents). • For the accompanying person, two way
ii) Any Pre-hospitalization Medical Expenses and/or expense incurred on air tickets from his
Post-hospitalization Medical Expense emanating City of Residence OR India to the airport
from an overseas hospitalization claim but nearest to the site of h ospitalization shall be
incurred in India shall not be payable under the provided.
policy. • For the Hospitalized Insured Person, we shall
indemnify two way expense incurred on air
x. In case of Migration and Portability, all waiting periods
tickets from India to the airport nearest to
shall apply afresh only for planned hospitalization claims
the site of hospitalization shall be provided.
admissible under ‘Global Health Cover (Emergency
& Planned Treatments)’. Such waiting periods shall iii. In case the accompanying person was
commence from the date ‘Global Health Cover already present in that city at the time of such
(Emergency & Planned Treatments) has come into force. hospitalization, we shall only indemnify air
expenses incurred to transport him from the
2.11 Overseas Travel Secure airport nearest to the site of Hospitalization to his
City of Residence OR India.
i) This optional cover can only be opted along with
Optima Secure Global Plan or Optima Secure Global b. Any kind of other transportation expenses except the
expense on airfare is not payable under this optional
Plus Plan on payment of additional premium.
cover
ii) Claim under this benefit shall be payable upto Sum Note – For Insured Person, City of Residence shall
Insured and is admissible only if both the below be considered as declared in the Proposal Form
conditions are fulfilled: and mentioned in the Policy Schedule. Whereas, for

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 - HDFHLIP25011V052425. 14
accompanying person, City of Residence shall be in the Policy:
considered as mentioned in the legal document issued
1. Standard Exclusions
by the Government of that particular country.
All the Waiting Periods and exclusions listed below shall
B. Accommodation Expenses be applicable individually for each Insured Person and
a. We will also indemnify the cost of accomodation, claims shall be assessed accordingly.
at a place near to the site of Hospitalization, for the
a. Pre-Existing Diseases – Code – Excl01
accompanying person, to attend to the Insured Person‘s
medical treatment overseas. i. Expenses related to the treatment of a
b. Cost of accomodation overseas shall be indemnified pre-existing disease (PED) and its direct
upto Rs. 15,000 per day, only for the days wherein the complications shall be excluded until the
Insured person was hospitalized overseas; maximum expiry of 36 months of continuous coverage
upto 30 days in a Policy Year. after the date of inception of the first policy
with insurer.
c. Any other kind of supplementary expenses such as
meals, laundry, transport are not payable under this ii. In case of enhancement of Sum Insured the
cover. exclusion shall apply afresh to the extent of
Sum Insured increase.
3. Preventive Health Check-up iii. If the Insured Person is continuously covered
On each continuous Renewal of the Policy, the Company without any break as defined under the
will indemnify the cost of a Preventive Health Check- portability norms of the extant IRDAI (Health
up for the Insured Person who was insured during the Insurance) Regulations, then waiting period
previous Policy Year, up to the amounts specified in this for the same would be reduced to the extent
Cover below. of prior coverage.
i. This Cover does NOT carry forward if it is not iv. Coverage under the Policy after the expiry
claimed and shall not be provided if the Policy is of 36 months for any pre-existing disease is
not Renewed further. subject to the same being declared at the
ii. The amount specified in the Policy schedule time of application and accepted by Insurer.
against this benefit denotes the Company’s
b. Specified Disease/Procedure waiting period-
maximum liability in respect to the benefit and
Code – Excl02
shall not reduce the Sum Insured of the policy.
i. Expenses related to the treatment of the
iii. For Individual Policies, the below mentioned limits
listed Conditions, surgeries/treatments shall
are applicable for each Insured Person per Policy
be excluded until the expiry of 24 months
Year.
of continuous coverage after the date of
iv. This benefit is available every year post inception of the first Policy with us. This
completion of the first Policy Year exclusion shall not be applicable for claims
Base Sum 5 10 15 20, 100 & arising due to an Accident.
Insured under Lacs Lacs Lacs 25, 50 200 ii. In case of enhancement of sum insured the
the Policy & 75 Lacs exclusion shall apply afresh to the extent of
Lacs Sum Insured increase.
Limit of Cover Rs. Rs. Rs. Rs. Rs. iii. If any of the specified disease/procedure
1,500 2,000 4,000 5,000 8,000 falls under the waiting period specified for
Pre-Existing diseases, then the longer of the
For Family Floater Policies, the below mentioned limits are two waiting periods shall apply.
applicable cumulatively for all Insured Persons per Policy
iv. The waiting period for listed conditions shall
Year.
apply even if contracted after the Policy or
Base Sum 5 Lacs 10 15 20, 100 & declared and accepted without a specific
Insured Lacs Lacs 25, 50 200 exclusion.
under the & 75 Lacs
Policy Lacs v. If the Insured Person is continuously
covered without any break as defined
Limit of Rs. Rs. Rs. Rs. Rs.
under the applicable norms on portability
Cover 2,500 5,000 8,000 10,000 15,000
stipulated by IRDAI, then waiting period for
the same would be reduced to the extent of
Section C. Exclusions
prior coverage.
The Company shall not make payment for any claim in respect
vi. List of specific diseases/procedures is
of any Insured Person caused by, arising from or attributable
to any of the following unless expressly stated to the contrary provided below:

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 - HDFHLIP25011V052425. 15
Illnesses diagnosis and treatment are excluded.
Pancreatitis Non infective Arthritis Pilonidal sinus e. Rest Cure, rehabilitation and respite care: Code
Diseases of gall calculus diseases of Benign tumors, cysts, – Excl05:
bladder including Urogenital system e.g. nodules, polyps Expenses related to any admission primarily for
cholecystitis Kidneystone, Urinary including breast lumps
Bladder Stone enforced bed rest and not for receiving treatment.
This also includes:
All forms of Cirrhosis Ulcer and erosion Polycystic ovarian
of stomach and diseases i. Custodial care either at home or in a nursing
duodenum facility for personal care such as help with
Cataract and other Gastro Esophageal Sinusitis, Rhinitis activities of daily living such as bathing,
disorders of lens and Reflux Disorder (GERD) dressing, moving around either by skilled
Retina
nurses or assistant or non-skilled persons.
Perineal Abscesses Perianal Abscesses Skin tumors
Osteoarthritis and Fissure/fistula in Tonsillitis ii. Any services for people who are terminally
osteoporosis anus, Haemorrhoids ill to address physical, social, emotional and
including Gout and spiritual needs.
rheumatism f. Obesity/Weight control: Code – Excl06:
Fibroids ( fibromyoma) Benign Hyperplasia of
Prostate Expenses related to the surgical treatment of
obesity that does not fulfil all the below conditions:
Surgical Procedures
i. Surgery to be conducted is upon the advice
Adenoidectomy, Tympanoplasty, Hernia of the Doctor
tonsillectomy Mastoidectomy
Dilatation and Nasal concha Surgery for prolapsed ii. The surgery/Procedure conducted should
curettage (D&C) resection inter vertebral disc be supported by clinical protocols
Myomectomy for Surgery of Genito Surgery for varicose iii. The member has to be 18 years of age or
fibroids urinary system unless veins and varicose older and
necessitated by ulcers
Malignancy iv. Body Mass Index (BMI)
Surgery on prostate Cholecystectomy Surgery for Perianal A. greater than or equal to 40 or
Abscesses
B. greater than or equal to 35 in
Hydrocele/Rectocele Joint replacement Surgery for Nasal
surgeries septum deviation conjunction with any of the following
severe co-morbidities following failure
Ligament, Tendon and Hysterectomy Fissurectomy,
Meniscal tear Haemorrhoidectomy, of less invasive methods of weight
Fistulectomy, ENT loss:
surgeries 1) Obesity-related cardiomyopathy
Endometriosis Prolapsed Uterus Rectal Prolapse
2) Coronary heart disease
Varicocele Retinal detachment Glaucoma
Nasal polypectomy 3) Severe sleep apnoea
4) Uncontrolled type 2 diabetes
c. 30-day waiting period – Code – Excl03 g. Change-of-Gender treatments: Code – Excl07:
i. Expenses related to the treatment of any Expenses related to any treatment, including
illness within 30 days from the first Policy surgical management, to change characteristics
commencement date shall be excluded of the body to those of the opposite sex.
except claims arising due to an accident, h. Cosmetic or plastic Surgery: Code – Excl08:
provided the same are covered. Expenses for cosmetic or plastic surgery or any
ii. This exclusion shall not, however, apply if the treatment to change appearance unless for
Insured Person has continuous coverage for reconstruction following an Accident, Burn(s)
more than twelve months. or Cancer or as part of Medically Necessary
iii. The within referred waiting period is made Treatment to remove a direct and immediate
applicable to the enhanced Sum Insured in health risk to the insured. For this to be considered
the event of granting higher Sum Insured a medical necessity, it must be certified by the
subsequently. attending Medical Practitioner.
i. Hazardous or Adventure Sports: Code – Excl09:
d. Investigation & Evaluation: Code Excl04
Expenses related to any treatment necessitated
i. Expenses related to any admission primarily due to participation as a professional in Hazardous
for diagnostics and evaluation purposes or Adventure sports, including but not limited to,
only are excluded. para-jumping, rock climbing, mountaineering,
ii. Any diagnostic expenses which are not rafting, motor racing, horse racing or scuba diving,
related or not incidental to the current hand gliding, sky diving, deep-sea diving.

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 - HDFHLIP25011V052425. 16
j. Breach of Law: Code – Excl10: Expenses for 2. Specific Exclusions:
treatment directly arising from or consequent In addition to the foregoing general exclusions, the
upon any Insured Person committing or attempting Company shall not be liable to make any payment under
to commit a breach of law with criminal intent. this Policy caused by or arising out of or attributable to
k. 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
any Medical Practitioner or any other provider
enemy, (whether war be declared or not or caused
specifically excluded by the Insurer and disclosed
during service in the armed forces of any country),
in its website/notified to the Policyholders are not
civil war, public defence, rebellion, revolution,
admissible. However, in case of Life Threatening
insurrection, military or usurped acts, Nuclear,
Situations or following an Accident, expenses up
Chemical or Biological attack or weapons,
to the stage of stabilization are payable but not
radiation of any kind.
the complete claim.
b. Aggregate Deductible - Claims/claim amount
l. Treatment for Alcoholism, drug or substance abuse
falling within Aggregate Deductible limit if opted
or any addictive condition and consequences
and in force, as specified in the Policy Schedule.
thereof. Code – Excl12.
m. Treatments received in health hydros, nature cure c. Any Insured Person committing or attempting to
clinics, spas or similar establishments or private commit intentional self-injury or attempted suicide
beds registered as a nursing home attached or suicide.
to such establishments or where admission is d. Any Insured Person’s participation or involvement
arranged wholly or partly for domestic reasons. in naval, military or air force operation.
Code – Excl13. e. Investigative treatment for sleep-apnoea, general
n. Dietary supplements and substances that can debility or exhaustion (“run-down condition”).
be purchased without prescription, including f. Congenital external diseases, defects or
but not limited to Vitamins, minerals and organic anomalies.
substances unless prescribed by a Medical
Practitioner as part of Hospitalization claim or Day g. Stem cell harvesting.
Care procedure. Code – Excl14. h. Investigative treatments for analysis and
o. Refractive Error: Code – Excl15: Expenses related adjustments of spinal sub luxation, diagnosis
to the treatment for correction of eye sight due to and treatment by manipulation of the skeletal
refractive error less than 7.5 dioptres. structure or for muscle stimulation by any means
except treatment of fractures (excluding hairline
p. Unproven Treatments: Code – Excl16: Expenses
fractures) and dislocations of the mandible and
related to any unproven treatment, services and
extremities.
supplies for or in connection with any treatment.
Unproven treatments are treatments, procedures i. Circumcisions (unless necessitated by Illness or
or supplies that lack significant medical Injury and forming part of treatment).
documentation to support their effectiveness. j. Vaccination including inoculation and
q. Sterility and Infertility: Code – Excl17: Expenses immunisations (except post animal bite treatment).
related to sterility and infertility. This includes: k. Non-Medical expenses such as food charges
i. Any type of contraception, sterilization (other than patient’s diet provided by hospital),
laundry charges, attendant charges, ambulance
ii. Assisted Reproduction services including
collar, ambulance equipment, baby food, baby
artificial insemination and advanced
utility charges and other such items. Full list of
reproductive technologies such as IVF, ZIFT,
Non-Medical Expenses is attached as ANNEXURE
GIFT, ICSI
B and also available at www.hdfcergo.com.
iii. Gestational Surrogacy
l. Treatment taken on outpatient basis.
iv. Reversal of sterilization.
m. The provision or fitting of hearing aids, spectacles
r. Maternity: Code – Excl18 or contact lenses.
i. Medical treatment expenses traceable to n. Any treatment and associated expenses for
childbirth (including complicated deliveries alopecia, baldness including corticosteroids and
and caesarean sections incurred during topical immunotherapy wigs, toupees, hair pieces,
hospitalization) except ectopic pregnancy; any non-surgical hair replacement methods,
ii. Expenses towards miscarriage (unless optometric therapy.
due to an accident) and lawful medical o. Expenses for Artificial limbs and/or device used
termination of pregnancy during the Policy for diagnosis or treatment (except when used
Period. intra-operatively), prosthesis, corrective devices

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 - HDFHLIP25011V052425. 17
external durable medical equipment of any kind, Any payment to the Policyholder, Insured Person or
wheelchairs, crutches, and oxygen concentrator his/ her nominees or his/ her legal representative or
for bronchial asthma/ COPD conditions, cost of assignee or to the Hospital, as the case may be, for
cochlear implant(s) unless necessitated by an any benefit under the Policy shall be a valid discharge
Accident. towards payment of claim by the Company to the extent
p. Any treatment or part of a treatment that is not of a of that amount for the particular claim.
reasonable charge and not Medically Necessary.
1.5. Multiple Policies
Drugs or treatments which are not supported by a
prescription. a. In case of multiple policies taken by an Insured
Person during a period from one or more insurers
q. Any permanent exclusion applied on any
to indemnify treatment costs, the Insured Person
medical or physical condition or treatment of an
shall have the right to require a settlement of his/
Insured Person as specifically mentioned in the
her claim in terms of any of his/her policies. In
Policy Schedule and as specifically accepted by
all such cases the Insurer chosen by the Insured
Policyholder/Insured Person. Such exclusions
Person shall be obliged to settle the claim as long
shall be applied for the condition(s) or treatment(s)
as the claim is within the limits of and according to
that otherwise would have resulted in rejection
the terms of the chosen Policy.
of insurance coverage under this Policy to such
Insured Person as per Company’s Underwriting b. Insured Person having multiple policies shall also
Policy. have the right to prefer claims under this Policy for
the amounts disallowed under any other policy /
Section D. General Terms and Clauses policies even if the Sum Insured is not exhausted.
Then the insurer shall independently settle the
1. Standard General Terms & Clauses
claim subject to the terms and conditions of this
1.1. Disclosure of Information Policy.
The policy shall be void and all premium paid thereon c. If the amount to be claimed exceeds the Sum
shall be forfeited to the Company in the event of Insured under a single Policy, the Insured Person
misrepresentation, mis-description or non-disclosure of shall have the right to choose Insurer from whom
any material fact by the Policyholder. he/she wants to claim the balance amount.
1.2. Condition Precedent to Admission of Liability d. Where the Insured Person has policies from
The terms and conditions of the policy must be fulfilled more than one Insurer to cover the same risk on
by the insured person for the Company to make any indemnity basis, the Insured Person shall only be
payment for claim(s) arising under the policy. indemnified the treatment costs in accordance
1.3. Claim Settlement (provision for Penal Interest) with the terms and conditions of the chosen
Policy.
a. The Company shall settle or reject a claim, as
the case may be, within 30 days from the date of 1.6. Moratorium Period
receipt of last necessary document.
After completion of sixty continuous months of coverage
b. In the case of delay in the payment of a claim, (including portability and migration) in health insurance
the Company shall be liable to pay interest to policy, no policy and claim shall be contestable by the
the Policyholder from the date of receipt of last insurer on grounds of non-disclosure, misrepresentation,
necessary document to the date of payment of except on grounds of established fraud. This period of
claim at a rate 2% above the bank rate. sixty continuous months is called as moratorium period.
c. However, where the circumstances of a claim The moratorium would be applicable for the sums
warrant an investigation in the opinion of the insured of the first policy. Wherever, the sum insured
Company, it shall initiate and complete such is enhanced, completion of sixty continuous months
investigation at the earliest, in any case not later would be applicable from the date of enhancement of
than 30 days from the date of receipt of last sums insured only on the enhanced limits.
necessary document. In such cases, the Company
shall settle or reject the claim within 45 days from 1.7. Fraud
the date of receipt of last necessary document. If any claim made by the Insured Person, is in any respect
d. In case of delay beyond stipulated 45 days, the fraudulent, or if any false statement, or declaration is
Company shall be liable to pay interest to the made or used in support thereof, or if any fraudulent
Policyholder at a rate 2% above the bank rate from means or devices are used by the Insured Person or
the date of receipt of last necessary document to anyone acting on his/her behalf to obtain any benefit
the date of payment of claim. under this Policy, all benefits under this policy and the
premium paid shall be forfeited.
1.4. Complete Discharge
Any amount already paid against claims made under

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 - HDFHLIP25011V052425. 18
this Policy but which are found fraudulent later shall a) Renewal of a health insurance policy shall not
be repaid by all recipient(s)/Policyholder(s), who have be denied on the ground that the insured had
made that particular claim, who shall be jointly and made a claim or claims in the preceding policy
severally liable for such repayment to the Insurer. years, except for benefit based policies where
For the purpose of this clause, the expression “fraud” the policy terminates following payment of the
means any of the following acts committed by the benefit covered under the policy like critical
Insured Person or by his agent or the hospital/doctor/ illness policies.
any other party acting on behalf of the Insured Person, b) The company shall condone a delay in renewal
with intent to deceive the insurer or to induce the up to the grace period from the due date of
insurer to issue an insurance policy: renewal without considering such condonation as
a. the suggestion, as a fact of that which is not true a break in policy.
and which the Insured Person does not believe to c) No loading shall apply on renewals based on
be true; individual claims experience
b. the active concealment of a fact by the Insured d) The Company shall not resort to fresh
Person having knowledge or belief of the fact; underwriting unless there is an increase in sum
insured. In case increase in sum insured is
c. any other act fitted to deceive; and
requested by the Policyholder, the Insurer may
d. any such act or omission as the law specially underwrite only to the extent of increased sum
declares to be fraudulent. insured.
The Company shall not repudiate the claim and / or e) Renewal premium due can be paid prior to the
forfeit the Policy benefits on the ground of Fraud, if the due date as per norms set out by the Company..
Insured Person / beneficiary can prove that the mis-
statement was true to the best of his knowledge and 1.10. Portability
there was no deliberate intention to suppress the fact The Insured Person will have the option to port the
or that such mis-statement of or suppression of material Policy to other insurers by applying to such Insurer to
fact are within the knowledge of the Insurer. port the entire policy along with all the members of the
family, if any, at least 45 days before, but not earlier
1.8. Free look Period than 60 days from the policy renewal date as per
The Free Look Period shall be applicable on new IRDAI guidelines related to Portability. If such person is
individual health insurance policies and not on renewals presently covered and has been continuously covered
or at the time of porting/migrating the policy. without any lapses under any health insurance policy
The insured person shall be allowed free look period of with an Indian General/Health insurer, the proposed
thirty days from date of receipt of the policy document Insured Person will get the accrued continuity benefits
to review the terms and conditions of the policy, and to in waiting periods as per IRDAI guidelines on portability.
return the same if not acceptable. For Detailed Guidelines on Portability, kindly refer the
link
If the insured has not made any claim during the Free
Look Period, the insured shall be entitled to: https://www.irdai.gov.in/ADMINCMS/cms/frmGuidelines_
Layout.aspx?page=PageNo3987
a. a refund of the premium paid less any expenses
incurred by the Company on medical examination
1.11. Migration
of the insured person and the stamp duty charges
or The Insured Person will have the option to migrate
the Policy to other health insurance products/plans
b. where the risk has already commenced and
offered by the Company by applying for Migration of
the option of return of the policy is exercised
the policyatleast30 days before the policy renewal date
by the insured person, a deduction towards the
as per IRDAI guidelines on Migration. If such person is
proportionate risk premium for period of cover or
presently covered and has been continuously covered
c. Where only a part of the insurance coverage without any lapses under any health insurance product/
has commenced, such proportionate premium plan offered by the Company, the Insured Person will
commensurate with the insurance coverage get the accrued continuity benefits in waiting periods as
during such period. per IRDAI guidelines on Migration.
For Detailed Guidelines on Migration, kindly refer the link
1.9. Renewal of Policy:
https://www.irdai.gov.in/ADMINCMS/cms/frmGuidelines_
A health insurance policy shall be renewable except
Layout.aspx?page=PageNo3987
on grounds of established fraud or non-disclosure or
misrepresentation by the insured, provided the policy 1.12. Cancellation
is not withdrawn and also subject to conditions stated a. The Policyholder may cancel this Policy by giving
under Moratorium clause of this schedule. . 7 days’ written notice and in such an event, the

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 - HDFHLIP25011V052425. 19
Company shall refund to the Insured a pro-rata instalments shall immediately become due and
premium for the unexpired Policy Period. payable
Note: For Policies where premium is paid by g. The Company has the right to recover and deduct
instalment: In case of admissible claim under the all the pending instalments from the claim amount
Policy, future instalment for the current Policy due under the policy.
Year will be adjusted in the claim amount and no
refund of any premium will be applicable during 1.14. Possibility of Revision of terms of the Policy including
the Policy Year the Premium Rates
b. The Company may cancel the Policy at any time The Company, with prior approval of IRDAI, may revise
on grounds of established fraud or non-disclosure or modify the terms of the Policy including the premium
or misrepresentation by the Insured Person rates. The Insured Person shall be notified three months
by giving 15 days’ written notice. There would before the changes are effected.
be no refund of premium on cancellation on
1.15. Withdrawal of Policy
grounds of established fraud or non-disclosure or
misrepresentation. a. In the likelihood of this product being withdrawn
in future, the Company will intimate the Insured
c. Refund of Policy premium in case of death
Person about the same 90 days prior to expiry of
of Insured Person/s: Policy premium shall be
the policy.
refunded proportionately for the deceased
Insured Person, for the unexpired Policy Period in b. Insured Person will have the option to migrate to
case of death of any Insured Person/s similar health insurance product available with
the Company at the time of renewal with all the
d. Notwithstanding anything contained herein or
accrued continuity benefits such as Cumulative
otherwise, no refunds of premium shall be made
Bonus, waiver of waiting period as per IRDAI
in respect of Cancellation where any claim has
guidelines, provided the policy has been
been admitted or any benefit has been availed by
maintained without a break.
the Insured Person under the Policy.
1.16. Nomination
1.13. Premium Payment in Instalments
The Policyholder is required at the inception of the
If the Insured Person has opted for payment of Premium Policy to make a nomination for the purpose of payment
on an instalment basis i.e. Yearly, Half Yearly, Quarterly of claims under the Policy in the event of death of
or Monthly, as mentioned in the Policy Schedule, the the Policyholder. Any change of nomination shall be
following Conditions shall apply (notwithstanding any communicated to the Company in writing and such
terms contrary elsewhere in the Policy): change shall be effective only when an endorsement
a. Grace Period as mentioned in the table below on the Policy is made. In the event of death of the
would be given to pay the instalment premium Policyholder, the Company will pay the nominee
due for the Policy {as named in the Policy Schedule/Policy Certificate/
Endorsement (if any)} and in case there is no subsisting
Options Instalment Grace Period
nominee, to the legal heirs or legal representatives of
Premium Option applicable
the Policyholder whose discharge shall be treated as
Option 1 Multi-Year / Yearly 30 days full and final discharge of its liability under the Policy.
Option 2 Half Yearly 30 days
1.17. Redressal of Grievance
Option 3 Quarterly 30 days
In case of any grievance the insured person may
Option 4 Monthly 15 Days
contact the Company through:
b. If premium is paid in instalments then coverage
will be available during the grace period also. • Website: www.hdfcergo.com
(Note: In case of non-instalment premium • Contact Us: 022 6234 6234 / 0120 6234 6234
payment, coverage shall not be available for the • E-mail: [email protected]
period for which no premium is received). • Contact Details for Senior Citizen: 022 – 6242 –
c. The Insured Person will get the accrued continuity 6226
benefit in respect of the “Waiting Periods”, • E-mail specific for Senior citizens : seniorcitizen@
“Specific Waiting Periods” in the event of payment hdfcergo.com
of premium within the stipulated Grace Period
Insured Person may also approach the grievance cell
d. No interest will be charged If the instalment at any of the Company’s branches with the details of
premium is not paid on due date grievance.
e. In case of instalment premium due not received
within the Grace Period, the Policy will get
cancelled
f. In the event of a claim, all subsequent premium

Contact Points First Contact Point Escalation level 1 Escalation level 2

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

If Insured Person is not satisfied with the redressal of 2.2. Utilization of Sum Insured
grievance through above methods, the Insured Person may The sequence of utilization of Sum Insured in this Policy,
also approach the office of Insurance Ombudsman of the
subject to the optional covers in force under the Policy,
respective area/region for redressal of grievance as per
will be as follows;
Insurance Ombudsman Rules 2017. Grievance may also be
lodged at IRDAI Integrated Grievance Management System a. Base Sum Insured.
-https://bimabharosa.irdai.gov.in/. b. Cumulative Bonus/Plus Benefit (if applicable).
Latest contact details of Offices of Insurance Ombudsman are c. Secure Benefit (if applicable).
provided at Annexure A.
d. Automatic Restore Benefit (subject to utilization of
2. Specific General Terms and Clauses
the Base Sum Insured in whole or in part).
2.1. Non-Disclosure or Misrepresentation of Pre-Existing
A single claim in a Policy Year cannot exceed the sum of
Disease
Base Sum Insured, Cumulative Bonus (if applicable), Plus
The Company may, notwithstanding and without Benefit (if applicable) and Secure Benefit (if applicable).
prejudice to its rights under the standard general
2.3. Geography
terms and clauses above, also exercise any of the
below listed options for the purpose of continuing the This Policy provides coverage throughout the territory of
health insurance coverage in case of non-disclosure or India, except under Section B-2.8 (E-Opinion for Critical
misrepresentation of Pre-Existing Diseases, subject to Illness) ,Section B-2.9 Global Health Cover (Emergency
prior consent from Policyholder: Treatments Only) ,Section B-2.10 Global Health Cover
(Emergency & Planned Treatments), B-2.11 Overseas
a. Permanently exclude the disease/condition and
Travel Secure and as may be specified in the Schedule
continue with the Policy.
of Coverage in the Policy Schedule.
b. Incorporate additional Waiting Period of not
2.4. Loadings
exceeding 3 years for the said undisclosed disease
or condition from the date the non-disclosed a. The Company may apply loading on the premium,
condition was detected and continue with the Policy specific Waiting Period or permanent exclusions,
based on the declarations made in the Proposal
c. Levy underwriting loading from the first Policy Year
of issuance of Policy or Renewal, whichever is later. Form and the health status, habits and lifestyle, past
medical records, and the results of the pre-Policy
medical examination of the persons proposed to
be insured under the Policy.

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 - HDFHLIP25011V052425. 21
b. The maximum medical underwriting loading shall b. Where there is a change either in the terms and
not exceed 100% for each condition and a total of conditions of the coverage or Policy or in the
150% for each Insured Person. premium rate, the ECS authorization shall be
c. Loadings shall be applied from Commencement obtained afresh.
Date including subsequent Renewal(s), and on c. The Insured Person has the option to withdraw from
increased Sum Insured. 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 d. No additional charges will be levied or recovered
permanent exclusion (if any) through a counter in any manner from the benefits payable towards
offer letter and Policy will be issued only on specific cancellation of the ECS mode.
acceptance within 15 days of the receipt of such 2.9. Dispute Resolution Clause
counter offer letter. In case the Company does not
Any and all disputes or differences under or in relation
receive any response to the counter offer letter
to this Policy shall be determined by the Indian Courts
from the proposer within 15 days, the application
and subject to Indian law
shall be cancelled and any premium received shall
be refunded within 7 days. Section E. Other Terms & Conditions
2.5. Endorsements
1. Claims Procedure
This Policy constitutes the complete contract of insurance.
1.1. Notification of a Claim
This Policy cannot be modified by anyone (including an
insurance agent or broker) except the Company. Any Notice with full particulars shall be sent to the Company
change or modification that the Company makes will be as under:
evidenced by a written endorsement signed and stamped a. Within 24 hours from the date of emergency
by the Company. Hospitalization required or before the Insured
2.6. Communication & Notice Person’s discharge from Hospital, whichever is
earlier.
Policy and any communication related to the Policy shall
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
avail treatment under Section B-1.2 (Home Health
a. The Policyholder’s, at the address/ e-mail address
Care).
specified in the Policy Schedule.
1.2. Procedure for Cashless Claims In India
b. To the Company, at the address specified in the
a. Treatment may be taken in a Network Provider and
Policy Schedule.
is subject to pre authorization by the Company.
c. Insurance agents, brokers, other person or entity
b. Cashless request form is available with the Network
is/are not authorised to receive any notice on the
Provider.
behalf of the Company, unless stated in writing by
the Company. c. The Network Provider shall obtain the relevant
information from the Insured Person / Policyholder
2.7. Premium Tier
and send a Cashless Facility request to the
The premium payable under the Policy will be computed Company for authorization.
basis the city of residence provided by the Insured Person
d. The Company upon getting cashless request
in the Proposal Form. Classification of cities would be as
form and related medical information from the
under:
Insured Person/ Network Provider shall issue pre-
a. Tier 1: Delhi, National Capital Region (NCR), Mumbai, authorization letter to the Network Provider after
Mumbai Suburban, Thane and Navi Mumbai, Surat, verification.
Ahmedabad and Vadodara. e. At the time of discharge, the Insured Person shall
b. Tier 2: Rest of India. verify and sign the discharge papers along with final
No co-payment shall apply if Insured Person from Tier 2 bill, pay for non-medical and inadmissible expenses.
avails a treatment in Tier 1. f. The Company reserves the right to deny pre-
2.8. Instalment Premium payment through Auto Debit/ECS authorization in case the Insured Person is unable
Facility to provide the relevant medical details.
g. In case of denial of cashless access, the Insured
a. If premium payment is opted for by instalments
through auto debit/ECS facility, a separate Person may obtain the treatment as per treating
authorization form shall be submitted by Insured doctor’s advice and submit the claim documents
Person specifying the frequency chosen for to the Company for reimbursement.
premium to be debited. 1.3. Procedure for Cashless Claims Outside India
a. You shall intimate the Claims to us through any

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 - HDFHLIP25011V052425. 22
available mode of communication as specified in 1.6. Procedure for Reimbursement Claims
the Policy, Health Card or our Website For reimbursement of claims, the Insured Person shall
b. Treatment may be taken in a Network Provider and submit the necessary documents to the Company within
is subject to pre authorization by the Company. the prescribed time limit as specified hereunder.
Process for obtaining Pre-Authorization is
mentioned below: Type of Claim Prescribed Time limit
i. We shall send R1the Insured Person for Reimbursement of Within 30 days of date of
signature and consent. Hospitalization, Day discharge from Hospital.
ii. After receiving the signed Release of Care Treatment or Pre-
I n f o r m a t i o n f o r m , We w i l l r e t r i e v e Hospitalization Expenses
hospitalization documents along with invoices
Reimbursement of Post- Within 15 days from
iii. If these details are not provided in full or are
Hospitalization Expenses completion of post
insufficient for Us to consider the request,
Hospitalization treatment.
We will request additional information or
documentation
1.7. List of documents required for a Claim
iv. On receipt of the complete documents We
may The reimbursement claim is to be supported with the
following documents and submitted within the prescribed
• issue the guarantee of payment
time limit.
specifying the sanctioned amount, any
specific limitation on the claim and non- a. Duly Completed claim form,
payable items, if applicable b. Photo ID and Age Proof,
or c. Copy of the Hospital’s Registration Certificate/
• reject the request for pre-authorization Hospital Registration number in case of
specifying reasons for the rejection Hospitalization in any non-Network Provider of
1.4. Procedure for Cashless Claims in case of Home Health the Company or certificate from Hospital authorities
Care (Section B-1.2) providing facilities available including number of
beds
On receipt of duly filled pre authorization form with
other sufficient details to assess a cashless request, d. Discharge Card / Day Care Summary / Transfer
the Company will inform the Home Healthcare service Summary,
provider or Network Provider, who will share the care e. Final Hospital bill with all original deposit and final
plan and treatment cost estimation with the Company. On payment receipt and refund receipt(s), if advance
receipt of the complete documents the Company may: amount refunded,
a. issue the authorization letter specifying the f. Invoice with payment receipt and implant stickers
sanctioned amount, any specific limitation on the for all implants used during Surgeries e.g. lens
claim and non-payable items, if applicable, or sticker and invoice in cataract Surgery, stent invoice
b. reject the request for pre-authorization specifying and sticker in Angioplasty Surgery,
reasons for the rejection.
g. All previous consultation papers indicating history
1.5. Conditions for obtaining Cashless Facility within India and treatment details for current Illness and advice
a. Cashless facility can be availed only at Company’s for current Hospitalization,
Network Provider. The complete list of Network h. All diagnostic reports (including imaging and
Providers and empanelled service providers is laboratory) along with prescription by Medical
available on Company’s website and can also be Practitioner and invoice / bill with receipt from
obtained by contacting the Company. diagnostic centre,
b. The Company reserves the right to modify, add or i. All medicine / pharmacy bills along with prescription
restrict any Network Provider for Cashless facility at by Medical Practitioner,
its sole discretion. The same shall be duly updated
on the Company’s website. The Insured Person j. MLC / FIR Copy – in Accident cases only,
shall check the updated list of Network Providers k. History of alcohol consumption or any intoxication
before applying for cashless claim. certified by first treating doctor in case of Accident
c. Pre-authorization issued by the Company shall be cases,
valid for 15 days from the date of issuance (or expiry l. Copy of Death Summary and copy of Death
of the Policy, whichever is earlier). Certificate (in death claims only),
d. The Company shall make payment for the Cashless m. Copy of indoor case papers with nursing sheet
facility to the authorized amount, directly to the detailing medical history of the Insured Person,
Network Provider. treatment details, and patient’s progress (to be

ii. Flight Tickets and Boarding Pass, if applicable iv. Any delay in notification or submission may be condoned
on merit where delay is proved to be for reasons beyond
iii. Accommodation Invoices, if applicable
the control of the Insured Person.
iv. Written advice from the overseas treating
Medical Practitioner for requirement of an
accompanying person during treatment.
t. Any other relevant document required by Company
for assessment of the claim.

2. Contact Us
Within India Outside India
Claim Intimation: Customer Service No. 022-62346234 / 0120- Global Contact No : +800 08250825
62346234 (accessible from locations outside India only)
Email: [email protected] Landline no (Chargeable) :
Reimbursement Claim Intimation: 0120-4507250
Visit www.hdfcergo.com - > Help - > Claim [email protected]
Registration
Claim document HDFC ERGO General Insurance Co. Ltd. HDFC ERGO General Insurance Co Ltd 6th
submission at address: Stellar IT Park, Tower-15th Floor, C - 25, Floor, Leela Business Park, Andheri Kurla Road,
Sector 62, Noida – 0120 398 8360 Andheri East, Mumbai-400059,
Ph-022 66383600

BENGALURU
Office of the Insurance Ombudsman,
Jeevan Soudha Building, PID No. 57-27-N-19,
Ground Floor, 19/19, 24th Main Road,
Karnataka.
JP Nagar, Ist Phase,
Bengaluru – 560 078.
Tel.: 080 - 26652048 / 26652049
Email: [email protected]

BHOPAL
Office of the Insurance Ombudsman,
1st floor,”Jeevan Shikha”, 60-B,Hoshangabad Road,
Madhya Pradesh, Chattisgarh.
Opp. Gayatri Mandir, Bhopal – 462 011.
Tel.: 0755 - 2769201 / 2769202
Email: [email protected]

BHUBANESHWAR
Office of the Insurance Ombudsman,
62, Forest park, Bhubneshwar – 751 009.
Orissa.
Tel.: 0674 - 2596461 /2596455
Fax: 0674 - 2596429
Email: [email protected]

CHANDIGARH
Office of the Insurance Ombudsman,
State of Punjab, Haryana (excluding 4 districts vizGurugram,
Jeevan Deep Building SCO 20-27,
Faridabad, Sonepat and Bahadurgarh), Himachal Pradesh, Union
Ground Floor Sector- 17 A, Chandigarh – 160 017.
Territories of Jammu &Kashmir, Ladakh and Chandigarh.
Tel.: 0172-2706468
Email: [email protected]

CHENNAI
Office of the Insurance Ombudsman,
Fatima Akhtar Court, 4th Floor, 453,
Anna Salai, Teynampet, Tamil Nadu, Puducherry Town and Karaikal (which are part of
CHENNAI – 600 018. Puducherry).
Tel.: 044 - 24333668 / 24333678
Fax: 044 - 24333664
Email: [email protected]

DELHI
Office of the Insurance Ombudsman,
2/2 A, Universal Insurance Building,
Delhi, 4 districts of Haryana vizGurugram, Faridabad, Sonepat and
Asaf Ali Road,
Bahadurgarh)
New Delhi – 110 002.
Tel.: 011 - 23237539
Email: [email protected]

GUWAHATI
Office of the Insurance Ombudsman,
Jeevan Nivesh, 5th Floor,
Assam, Meghalaya, Manipur, Mizoram, Arunachal Pradesh,
Nr. Panbazar over bridge, S.S. Road,
Nagaland and Tripura.
Guwahati – 781001 (ASSAM).
Tel.: 0361 - 2632204 / 2602205
Email: [email protected]

HYDERABAD
Office of the Insurance Ombudsman,
6-2-46, 1st floor, “Moin Court”,
Lane Opp. Saleem Function Palace, State of Andhra Pradesh, Telangana and Yanam – a part of Union
A. C. Guards, Lakdi-Ka-Pool, Territory of Puducherry
Hyderabad - 500 004.
Tel.: 040 - 23312122
Email: [email protected]

JAIPUR
Office of the Insurance Ombudsman,
Jeevan Nidhi – II Bldg., Gr. Floor,
Bhawani Singh Marg, Rajasthan.
Jaipur - 302 005.
Tel.: 0141 - 2740363 /2740798
Email: [email protected]

KOCH
Office of the Insurance Ombudsman,
10th Floor, Jeevan Prakash,LIC Building,
Opp to Maharaja’s College Ground,M.G.Road, Kerala, Lakshadweep, Mahe-a part of Union Territory of Puducherry.
Kochi - 682 011.
Tel.: 0484 - 2358759
Email: [email protected]

KOLKATA
Office of the Insurance Ombudsman,
Hindustan Bldg. Annexe, 4th Floor,
4, C.R. Avenue, States of West Bengal, Sikkim and Union Territories of Andaman &
KOLKATA - 700 072. Nicobar Islands
Tel.: 033 - 22124339
Fax : 033 - 22124341
Email: [email protected]

Districts of Uttar Pradesh :

LUCKNOW
Lalitpur, Jhansi, Mahoba, Hamirpur, Banda, Chitrakoot, Allahabad,
Office of the Insurance Ombudsman,
Mirzapur, Sonbhabdra, Fatehpur, Pratapgarh, Jaunpur, Varanasi,
6th Floor, Jeevan Bhawan, Phase-II,
Gazipur, Jalaun, Kanpur, Lucknow, Unnao, Sitapur, Lakhimpur,
Nawal Kishore Road, Hazratganj,
Bahraich, Barabanki, Raebareli, Sravasti, Gonda, Faizabad,
Lucknow - 226 001.
Amethi, Kaushambi, Balrampur, Basti, Ambedkarnagar, Sultanpur,
Tel.: 0522 - 4002082 / 3500613
Maharajgang, Santkabirnagar, Azamgarh, Kushinagar, Gorkhpur,
Email: [email protected]
Deoria, Mau, Ghazipur, Chandauli, Ballia, Sidharathnagar.

MUMBAI
Office of the Insurance Ombudsman,
3rd Floor, Jeevan Seva Annexe,
S. V. Road, Santacruz (W), Goa, Mumbai Metropolitan Region excluding Navi Mumbai & Thane.
Mumbai - 400 054.
Tel.: 022 - 69038800/27/29/31/32/33
Email: [email protected]

NOIDA
Office of the Insurance Ombudsman, State of Uttaranchal and the following Districts of Uttar Pradesh:
Bhagwan Sahai Palace Agra, Aligarh, Bagpat, Bareilly, Bijnor, Budaun, Bulandshehar,
4th Floor, Main Road, Etah, Kanooj, Mainpuri, Mathura, Meerut, Moradabad,
Naya Bans, Sector 15, Muzaffarnagar, Oraiyya, Pilibhit, Etawah, Farrukhabad, Firozbad,
Distt: Gautam Buddh Nagar, Gautambodhanagar, Ghaziabad, Hardoi, Shahjahanpur,
U.P - 201301. Hapur, Shamli, Rampur, Kashganj, Sambhal, Amroha, Hathras,
Tel.: 0120-2514252 / 2514253 Kanshiramnagar, Saharanpur.
Email: [email protected]

PATNA
Office of the Insurance Ombudsman,
2nd Floor, Lalit Bhawan,
Bailey Road, Bihar, Jharkhand.
Patna 800 001.
Tel.: 0612-2547068
Email: [email protected]

PUNE
Office of the Insurance Ombudsman,
Jeevan Darshan Bldg.,
3rd Floor,C.T.S. No.s. 195 to 198,
Maharashtra, Area of Navi Mumbai and Thane excluding Mumbai
N.C. Kelkar Road,
Metropolitan Region.
Narayan Peth,
Pune – 411 030.
Tel.: 020-24471175
Email: [email protected]

PUNE - Shri Vinay Sah

Office of the Insurance Ombudsman,
Jeevan Darshan Bldg., 3rd Floor, C.T.S. No.s. 195 to 198, Maharashtra, Area of Navi Mumbai and Thane excluding Mumbai
N.C. Kelkar Road, Narayan Peth, Pune – 411 030. Metropolitan Region.
Tel.: 020-41312555
Email: [email protected]

26 Birth Certificate
27 Certificate Charges
28 Courier Charges
29 Conveyance Charges
30 Medical Certificate
31 Medical Records
32 Photocopies Charges
33 Mortuary Charges
34 Walking Aids Charges
35 Oxygen Cylinder (For Usage outside Hospital)
36 Spacer
37 Spirometre
38 Nebulizer Kit
39 Steam Inhaler
40 Armsling

Base Sum 5/10/15/20/ 5/10/15/20/25/50/ 10/15/20/25/50/ 100/200Lakhs 25/50/75/100/200

Insured 25/50 Lakhs 100/200 Lakhs 100/200 Lakhs Lakhs

^Geography India only India only India only Worldwide Worldwide

including India including India
Base Coverages
1 Hospitalization 100% 100% 100% 100% 100%
Expenses
1.1 Room Rent At Actuals At Actuals At Actuals At Actuals At Actuals
1.2 Road Ambulance Covered Covered Covered Covered Covered
1.3 Dental Treatment Covered Covered Covered Covered Covered
1.4 Plastic surgery Covered Covered Covered Covered Covered
1.5 Day Care Covered Covered Covered Covered Covered
Treatment
2 Home Healthcare Covered Covered Covered Covered Covered
(India only) (India only)
3 Domiciliary Covered Covered Covered Covered Covered
Hospitalization (India only) (India only)
4 AYUSH Treatment Covered Covered Covered Covered Covered
5 Pre- 60 days 60 days 60 days 60 days 60 days
Hospitalization (India only)
6 Post- 180 days 180 days 180 days 180 days 180 days
Hospitalization (India only)
7 Organ Donor Covered Covered Covered Covered Covered
Expenses
8 Cumulative Covered Not Covered Not Covered Not Covered Not Covered
Bonus
Optional Covers
1 Emergency Air Covered Covered Covered Covered Covered
Ambulance Up to 5 L Up to 5 L Up to 5 L Up to 5 L Up to 5 L
2 Daily Cash for Covered Rs. Covered Rs. 800 Covered Rs. 1000 Covered (India Covered (India
Shared Room 800 per day per day max upto per day max up only) Rs. 800 per only) Rs. 800 per
max upto 4800 4800 to 6000 day max upto day max upto
4800 4800
3 Secure Benefit Not Covered Covered 100% Covered 200% Covered Covered
(India only) 100% (India only) 100%
4 Automatic Covered Covered Covered Covered Covered
Restore Benefit (India only) (India only)
5 Protect Benefit Not Covered Covered Covered Covered Covered
6 Plus Benefit Not Covered Covered Covered Covered Covered
7 **Aggregate 225k/50k/100k/ 25k/50k/100k/ 25k/50k/100k/ 25k/50k/100k/ 25k/50k/100k/
Deductible 200K/300K/ 200K/300K/ 200K/300K/ 200K/300K/ 200K/300K/
5L/10L/20L/25L 5L/10L/20L/25L 5L/10L/20L/25L 5L/10L/20L/25L 5L/10L/20L/25L
(India only) (India only)
8 E Opinion for India India Global Global Global
Critical Illness

9 Global Not Covered Not Covered Not Covered Covered Not Covered
Health Cover (Outside India
(Emergency only)
Treatments Only)
10 Global Not Covered Not Covered Not Covered Not Covered Covered
Health Cover (Outside India
(Emergency only)
& Planned
Treatments)
11 **Overseas Travel Not Covered Not Covered Not Covered Covered (Outside Covered (Outside
Secure India only) India only)
Wellbeing Cover
1 Preventive Health Defined Limits Defined Limits Defined Limits Defined Limits Defined Limits
Check-up (India only) (India only)

Note: Optional Covers (except Aggregate Deductible & Overseas Travel Secure) are inbuilt in Plans as per the above table.
Premium of such Optional covers are included in the premium of the respective Plan.
**Aggregate Deductible & Overseas Travel Secure are not an inbuilt feature in any of the above Plans. However, these covers can be
separately opted at inception of the Policy or at subsequent Renewals. Aggregate Deductible if opted, shall apply only for claims arising
in India. However, a Per Claim Deductible of Rs. 10,000 will apply separately for each and every claim arising out of India in Global plans.
5L / 10L Deductible can only be opted with Sum Insured >= 25 L
20L / 25L Deductible can only be opted with Sum Insured >= 50 L
^Claims shall be payable as per geography mentioned unless explicitly stated otherwise in a specific cover.
Preventive Health Check-up benefit will not be available under the policy if Aggregate Deductible of INR 5 Lakhs is in force.
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

Add on – Covers:
‘my: Optima Secure’ offers following Add on Covers:
• 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
• 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.
• 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
• Unlimited Restore (Add on): Provides unlimited restoration in a Policy Year.
• Optima Wellbeing (Add on) : Covers expenses for various outpatient benefits.

(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).

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Optima Secure Policy Wording

Uploaded by

Optima Secure Policy Wording

Uploaded by

HDFC ERGO General Insurance Company Limited

Section Description Page No.

iv. All Day Care Treatments. 1.6. Post-Hospitalization Expenses

48 Crohn’s Disease B. Specific Exclusions applicable to Global Health Cover

Contact Points First Contact Point Escalation level 1 Escalation level 2

Districts of Uttar Pradesh :

PUNE - Shri Vinay Sah

Base Sum 5/10/15/20/ 5/10/15/20/25/50/ 10/15/20/25/50/ 100/200Lakhs 25/50/75/100/200

^Geography India only India only India only Worldwide Worldwide

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