Optima Senior Combined PW Cis Hegi

HDFC ERGO General Insurance Company Limited
Policy Wordings
OPTIMA SENIOR
The information mentioned below is illustrative and not exhaustive. Information must be read in conjunction with the
product brochures and policy document. In case of any conflict between the Key Features Document and the policy
document the terms and conditions mentioned in the policy document shall prevail.
TITLE DESCRIPTION REFER TO POLICY

CLAUSE NUMBER
Product Name Optima Senior Insurance
What am I a. In-patient Treatment– Covers hospitalisation expenses in a shared Section B- I, 1 a
covered for: accommodation for period more than 24 hrs. Pre-Hospitalisation-
b. Medical expenses incurred in 30 days before the hospitalisation. Section B- I, 1 b
c. Post-Hospitalisation- Medical expenses incurred in 60 days after the Section B-I,1 c
hospitalisation.
d. Day-Care procedures– Medical expenses for all day care procedures. Section B- I,1 d
e. Domiciliary Treatment-Medical expenses incurred for availing medical Section B- I,1 e
treatment at home which would otherwise have required hospitalisation.
f. Organ Donor- Medical expenses on harvesting the organ from the Section B- I,1 f
donor for organ transplantation.
g. Emergency Ambulance– Upto Rs. 2,000 per hospitalisation for utilizing Section B- I,1 g
ambulance service for transporting insured person to hospital in case
of an emergency.
h. E-Opinion – Second opinion by a Medical Practitioner from Our panel, Section B-I, 2 a
for a Critical Illness suffered during the policy period.
What are Following is a partial list of the policy exclusions. Please refer to the Section C
the major policy wording for the complete list of exclusions.
exclusions in War or similar situations:
the policy: • War or any act of war, invasion, act of foreign enemy, (whether war
be declared or not or caused during service in the armed forces of any
country), civil war, public defence, rebellion, revolution, insurrection,
military or usurped acts, Nuclear, Chemical or Biological attack or
weapons, radiation of any kind.
Breach of law: Code – Excl10
• Expenses for treatment directly arising from or consequent upon any
Insured Person committing or attempting to commit a breach of law
with criminal intent.
• Intentional self-injury or attempted suicide while sane or insane
• Hazardous or Adventure Sports: Code – Excl09
CIS/Ver -1 NOV2021
• Expenses related to any treatment necessitated due to participation as a

professional in hazardous or adventure sports, including but not limited
to, para-jumping, rock climbing, mountaineering, rafting, motor racing,
horse racing or scuba diving, hand gliding, sky diving, deep-sea diving.
Waiting Period We will not pay any claim under the waiting periods for specified benefits
except due to an Accident.
• 30 days waiting periodin the first year and is not applicable in Section C I.i
subsequent renewals.
• 24 months waiting period for specific illness/ surgeriesin the first two Section C-II. ii
years and is not applicable in subsequent renewals.
• Pre-existing conditions will be covered after a waiting period of 36
months. Section C.III. iii
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. Trade Logo displayed above belongs
to HDFC Bank Ltd and ERGO International AG and used by the Company under license. UIN: Optima Senior - HDHHLIP21379V022021. 1
CLAUSE NUMBER
Payout basis Payout on indemnity payment basis. Section B-I-1
Cost Sharing a) Co-Payment applicable on accommodation type Section B-III,A
• Shared Accommodation or any lower accommodation type– 15%
Single occupancy or any higher accommodation type- 30%
• However, the above mentioned Co-payment would not apply in
case of urgent medical and/or surgical treatment is taken for acute
cardiac Illness or Accident to avoid serious impairment of health in
a single occupancy accommodation due to unavailability of Shared
Accommodation or any lower accommodation then only a 15% Co-
Payment would be applicable.
A Co-payment of 15% shall be applicable to all Day Care Procedures;
no additional copay’s shall apply.
Co-Payment applicable on specified Illnesses/surgeries If a claim
has been admitted under Section I in respect of any of the specified
b) illnesses/Surgeries then a co pay of 30% would apply and claim
payment, if any, shall only be in excess of that sum. Section B-III, B
• However, –If we accept a claim for above mentioned specified illnesses/

surgeries then no additional Copayment shall be applicable for the
same claim.
Terms of • The policy shall ordinarily be renewable except on grounds of fraud, Section D-I.h
Renewal misrepresentation by the insured person.
The Company shall endeavor to give notice for renewal. However,
• the Company is not under obligation to give any notice for renewal.
Renewal shall not be denied on the ground that the insured person had
made a claim or claims in the preceding policy years.
• Request for renewal along with requisite premium shall be received by
the Company before the end of the policy period.
• At the end of the policy period, the policy shall terminate and can be
renewed within the Grace Period of 30 days to maintain continuity of
benefits without break in policy. Coverage is not available during the
grace period.
• No loading shall apply on renewals based on individual claims
experience.
Renewal Non Claim Discount:-A 5% non cumulative discount will be offered Section B-II
Benefits on the renewal premium payable under the Policy after every CLAIM
FREE Policy Year, provided that the Policy is renewed with Us and
without a break.
Cancellation The policyholder may cancel this policy by giving 15days’ written Section D I.o
notice and in such an event, the Company shall refund premium for
the unexpired policy period as detailed in Policy Wordings.
Notwithstanding anything contained herein or otherwise, no refunds

of premium shall be made in respect of Cancellation where, any claim
has been admitted or has been lodged or any benefit has been availed
by the insured person under the policy.
The Company may cancel the policy at any time on grounds of

misrepresentation non-disclosure of material facts, fraud by the insured
person by giving 15 days’ written notice. There would be no refund
of premium on cancellation on grounds of misrepresentation, non-
disclosure of material facts or fraud.
CLAUSE NUMBER
How to Claim Kindly contact Us 48 hrs prior for planned hospitalisation or within 24 Section E
hours of hospitalisation in case of emergency hospitalisation on
Toll Free (within India) :022-62346234 / 0120-62346234
Outside India
Toll Free No: 800 08250825
Global Toll Free No: +800 08250825 (accessible from locations
outside India only)
Landline no (Chargeable) : 0120-4507250
Email: [email protected]
You must submit a duly filled claim form along with specified
documents under the policy within 30 days from date of discharge.
Any additional information requested must be submitted within 15
days of Our request
Note
Pre-Policy Check-up at our network is compulsory under this Policy. We will reimburse 50% of the expenses
incurred on the acceptance of the proposal. The medical reports are valid for a period of 30 days from the date of
Pre-Policy Check-up.
HDFC ERGO General Insurance Company Limited
Policy Wordings
OPTIMA SENIOR
CONTENTS
Section Description Page No.

Preamble 2
Section A Definitions 2
I Standard Definitions 2
II Specific Definitions 3
Section B Benefits 4
I Coverages 4
II Renewal Benefits 5
III Special terms and conditions 5
Section C Exclusions & Waiting Period 6
I Standard Waiting Period 6
II Standard General exclusions 7
III Specific Exclusions 7
Section D General Terms & Clauses 9
I Standard General Terms & Clauses 9
II Specific General Terms & Clauses 12
Section E Others 14
I Claim Related Information 14
II List of Ombudsman 15
Preamble • has qualified Medical Practitioner(s) in charge
round the clock,
HDFC ERGO General Insurance Company Limited will cover
all Insured Persons under this Policy upto the Sum Insured. • has a fully equipped operation theatre of its
The insurance cover is governed by, and subject to, the terms, own where surgical procedures are carried
conditions and exclusions of this Policy. out,
• maintains daily records of patients and will
make these accessible to the insurance
Section A. Definitions company’s authorized personnel.
Def. 6. Hospitalisation or Hospitalised means admission in
The terms defined below and at other junctures in the Policy a Hospital for a minimum period of 24 consecutive
Wording have the meanings ascribed to them wherever they ‘In-patient Care’ hours except for specified
appear in this Policy and, where appropriate, references to procedures/ treatments, where such admission
the singular include references to the plural; references to could be for a period of less than 24 consecutive
the male include the female and references to any statutory hours.
enactment include subsequent changes to the same: Def. 7. Illness means a sickness or a disease or
pathological condition leading to the impairment
I. Standard Definitions of normal physiological function which manifests
itself during the Policy Period and requires medical
treatment
Def. 1. Accident or Accidental means a sudden, unforeseen
a) Acute Condition- Acute condition is a disease,
and involuntary event caused by external and visible
illness or injury that is likely to respond quickly
means (but does not include any Illness) which
to treatment which aims to return the person
results in physical bodily injury.
to his or her state of health immediately before
Def. 2. Congenital Anomaly means a condition which is suffering the disease/illness/injury which leads
present since birth, and which is abnormal with to full recovery.
reference to form, structure or position
b) Chronic Condition- A chronic condition is
a) Internal Congenital Anomaly - Congenital defined as disease, illness, or injury that has
anomaly which is not in the visible and one or more o f the following characteristics:
accessible parts of the body - it needs ongoing or long-term monitoring
b) External Congenital Anomaly- Congenital through consultations, examinations, check-
anomaly which is in the visible and accessible ups, and / or tests
parts of the body - it needs ongoing or long-term control or relief
Def. 3. Disclosure to information norm means the policy of symptoms
shall be void and all premiums paid hereon shall be - it requires your rehabilitation or for you to be
forfeited to the Company, in the event of specially trained to cope with it
misrepresentation, mis-description or
- it continues indefinitely
non-disclosure of any material fact.
- it recurs or is likely to recur
Def. 4. Grace Period means the specified period of time
immediately following the premium due date during Def.8. In-patient Care means treatment for which the
which a payment can be made to renew or continue Insured Person has to stay in a Hospital for more
a Policy in force without loss of continuity benefits than 24 hours for a covered event.
such as waiting periods and coverage of Def. 9. Intensive Care Unit means an identified section,
Pre-Existing Conditions. Coverage is not available ward or wing of a Hospital which is under the
for the period for which no premium is received. constant supervision of a dedicated Medical
Def. 5. Hospital means any institution established for Practitioner(s), and which is specially equipped
in-patient care and day care treatment of illness for the continuous monitoring and treatment of
and/or injuries and which has been registered patients who are in a critical condition, or require life
as a hospital with the local authorities under the support facilities and where the level of care and
Clinical Establishments (Registration and supervision is considerably more sophisticated and
PWW/Ver - 1 NOV2021
Regulation) Act, 2010 or under the enactments intensive than in the ordinary and other wards.
specified under the Schedule of Section 56(1) of Def. 10. ICU (Intensive Care Unit) Charges means the
the said Act OR complies with all minimum criteria amount charged by a Hospital towards ICU
as under: expenses which shall include the coverage for
• has qualified nursing staff under its employment bed, general medical support services provided
round the clock, to any ICU patient including monitoring devices,
critical care nursing and intensivist charges.
• has at least 10 in-patient beds, in those towns
having a population of less than 10,00,000 and Def. 11. Medical Expenses means those expenses that
15 in-patient beds in all other places, an Insured Person has necessarily and actually
incurred for medical treatment on account of illness
2 to HDFC Bank Ltd and ERGO International AG and used by the Company under license. UIN: Optima Senior - HDHHLIP21379V022021.
or Accident on the advice of a Medical Practitioner, is discharged from the hospital provided that:
as long as these are no more than would have been i. Such Medical Expenses are for the same
payable if the Insured Person had not been insured condition for which the insured person’s
and no more than other Hospitals or doctors in hospitalization was required, and
the same locality would have charged for the same
medical treatment. ii. The inpatient hospitalization claim for such
hospitalization is admissible by the insurance
Def. 12. Medically Necessary means any treatment, test, company
medication, or stay in Hospital or part of stay in
Hospital which Def. 20. Reasonable Charges means the charges for
services or supplies, which are the standard charges
• Is required for the medical management of the for a specific provider and consistent with the
Illness or injury suffered by the Insured Person; prevailing charges in the geographical area for
• Must not exceed the level of care necessary identical or similar services by comparable
to provide safe, adequate and appropriate providers, taking into account the nature of illness/
medical care in scope, duration or intensity. injury involved
• Must have been prescribed by a Medical Def. 21. Renewal means the terms on which the contract of
Practitioner. insurance can be renewed on mutual consent with
• Must conform to the professional standards a provision of grace period for treating the renewal
widely accepted in international medical continuous for the purpose of gaining credit for pre-
practice or by the medical community in India. existing diseases, time bound exclusions and for
all waiting periods.
Def. 13. Migration means, the right accorded to the health
insurance policyholders (including all members Def. 22. Surgery or Surgical Procedure means manual and/
under family cover and members of group health or operative procedure(s) required for treatment
insurance policy), to transfer the credit gained for of an Illness or injury, correction of deformities and
pre-existing conditions and time bound exclusions, defects, diagnosis and cure of diseases, relief of
with the same insurer. suffering or prolongation of life, performed in a
Hospital or day care centre by a Medical Practitioner.
Def. 14. Network means Hospital enlisted by an insurer or
a TPA or jointly by an insurer and a TPA to provide
medical services to an insured by a cashless facility. II. Specific Definitions
Def. 15. Non Network means any Hospital, day care centre
or other provider that is not part of the Network Def. 1. Adventurous/Hazardous Sports means any sport or
Def. 16. Portability means transfer by an individual health activity involving physical exertion and skill in which
insurance policyholder (including family cover) of an Insured Person participates or competes for
the credit gained for pre-existing conditions and entertainment or as part of his Profession whether
time-bound exclusions if he/she chooses to switch he / she is trained or not.
from one insurer to another Def. 2. Age or Aged means completed years as at the
Def. 17. Pre-existing Condition means any condition, Commencement Date.
ailment, injury, or disease: Def. 3. Alternative treatments means forms of treatments
i) That is/are diagnosed by a physician within 48 other than treatment “Allopathy” or “modern
months prior to the effective date of the policy medicine” and includes Ayurveda, Unani, Sidha and
issued by the insurer or its reinstatement or Homeopathy in the Indian context
ii) For which Medical advice or treatment was Def. 4. Bank Rate shall mean the rate fixed by the Reserve
recommended by, or received from, a physician Bank of India (RBI) at the beginning of the financial
within 48 months prior to the effective date of year in which claim has fallen due
the policy or its reinstatement. Def. 5. Commencement Date means the commencement
Def. 18. Pre- Hospitalisation Medical Expenses means the date of this Policy as specified in the Schedule.
medical expenses incurred during predefined Def. 6. Material facts for the purpose of this policy shall
number of days preceding the hospitalization of the mean all relevant information sought by the company
Insured Person, provided that: in the proposal form and other connected documents
i. Such Medical Expenses are incurred for the to enable it to take informed decision in the context
same condition for which the Insured Person’s of underwriting the risk
Hospitalisation was required, and Def. 7. Policy means Your statements in the proposal
ii. The In-patient Hospitalization claim for such form (which are the basis of this Policy), this policy
Hospitalization is admissible by the Insurance wording (including endorsements, if any) and the
Company Schedule (as the same may be amended from time
Def. 19. Post-Hospitalisation Medical Expenses means to time).
medical expenses incurred during predefined Def. 8. Policy Period means the period between the
number of days immediately after the insured person Commencement Date and the Expiry Date specified
in the Schedule.
d. Day Care Procedures 5. Out-Patient Treatment
Def. 9. P o l i c y Ye a r m e a n s a y e a r f o l l o w i n g t h e
Medical treatment, and/ 6. Treatment at a
Commencement Date and its subsequent annual
or surgical procedure healthcare facility NOT
anniversary.
which is undertaken conforming to Hospital
Def. 10. TPA means the third party administrator that We under General or definition
appoint from time to time as specified in the Local Anaesthesia in a
Schedule. Hospital/day care centre
Def. 11. We/Our/Us means the HDFC ERGO General for less than 24 hours
Insurance company Ltd. because of technological
advancement,
Def. 12. You/Your/Policyholder means the person named in
which would have
the Schedule who has concluded this Policy with
otherwise required a
Us.
hospitalisation of more
than 24 hours.
Section B. Benefits
e. Domiciliary Treatment 1. Treatment of less
than 3 days
I. Coverages
f. Organ Donor: 1. Claims which have
The following benefits are available to all Insured Persons
Medical treatment of NOT been admitted
who suffer an Illness or Accident during the Policy
the organ donor for under 1a).
Period which requires Hospitalisation on an Inpatient
basis or treatment defined as a Day Care Procedure. Any harvesting the organ. 2. Claims not
claims made under these benefits will impact eligibility covered under the
for a “No claim discount”. Transplantation of
Human Organs Act,
We will cover the We will not cover 1994 (as amended).
Medical Expenses for: treatment, costs or 3. The organ
expenses for*: donor’s Pre and
*The following Post-Hospitalisation
exclusions apply in expenses.
addition to the waiting
g. Emergency 1. Claims which have
periods and general
Ambulance: NOT been admitted
exclusions specified in
Expenses incurred on under 1a).
section C-I,II,III
an ambulance in an 2. A non- Emergencies.
1 a. In-Patient Treatment 1. Prosthetics NOT emergency, subject 3. NON registered
implanted by surgery to Rs. 2000 per healthcare or ambulance
2. Hospitalisation for Hospitalisation. service provider
evaluation, Investigation ambulances.
only
Additional Benefit: The following benefit is available to all
3. Treatment availed
Insured Persons during the Policy Period. Claims made
outside India
under this benefit will not impact eligibility for a “No claim
4. Treatment at a discount”
healthcare facility NOT
conforming to Hospital
definition.
b. Pre-Hospitalization 1. Claims which have
Medical expenses NOT been admitted
for consultations, under 1a), 1d), and 1 e)
investigations and 2. Any conditions which
medicines incurred are NOT the same as
upto 30 days before the condition for which
Hospitalisation. Hospitalisation was
c. Post-Hospitalization required.
Medical expenses
for consultations,
investigations and
medicines incurred upto
60 days after discharge
from Hospitalisation.
2 a. E-Opinion 1. More than one claim injury which in the normal course would require care
We shall arrange and for this benefit in a and treatment at a Hospital but is actually taken
pay for a second opinion Policy Year. while confined at home under any of the following
from Our panel of 2. More than one claim circumstances:
Medical Practitioners, if: for the same Critical 1. The condition of the Insured Person is such that he is
Illness. not in a condition to be removed to a Hospital or,
• The Insured Person 2. The Insured Person takes treatment at home on
suffers a Critical Illness 3. Any other liability due account of non availability of room in a Hospital.
during the Policy Period; to any errors or omission
and or representation or Important terms You should know.
• He requests an consequences of
E-opinion; and any action taken in Medical Practitioner means a person who holds a
reliance of the E-opinion valid registration from the medical council of any state
The Insured Person can provided by the Medical
choose one of Our panel of India and is thereby entitled to practice medicine
Practitioner. within its jurisdiction, and is acting within the scope and
Medical Practitioners.
The opinion will be jurisdiction of his license.
directly sent to the
Insured Person by the Shared or any lower accommodation type means a
Medical Practitioner. Hospital room with two or more patient beds.
“Critical Illness” includes
Single occupancy or any higher accommodation n type
Cancer, Open Chest
means a Hospital room with only one patient bed.
CABG, First Heart
Attack, Kidney Failure,
Major Organ/Bone II. Renewal Benefits:
Marrow Transplant,
No Claim Discount - A 5% non-cumulative discount
Multiple Sclerosis,
will be offered on the renewal premium payable under
Permanent Paralysis of
the Policy after every CLAIM FREE Policy Year,
Limbs and Stroke.
provided that the Policy is renewed with Us and
without a break.
Important terms You should know.
III. Special terms and conditions
Sum Insured means the sum shown in the Schedule which
represents Our maximum liability for each Insured Person Co-Payment
for any and all benefits claimed for during the Policy Period. ‘Co-Payment’ means a cost-sharing requirement
applicable under this Policy in which the Insured Person
In-patient Treatment means treatment arising from Accident will bear the percentage of the admissible claim amount
or Illness where Insured Person has to stay in a Hospital which is specified in the table below. A Co-Payment does
for more than 24 hours and includes Hospital room rent or not reduce or otherwise affect the Sum Insured.
boarding expenses, nursing, Intensive Care Unit charges,
Medical Practitioner’s charges, anesthesia, blood, oxygen,
operation theatre charges, surgical appliances, medicines, A. Co-Payment applicable on accommodation Type
drugs, consumables, diagnostic procedures.
Accommodation Type Co-Payment (Percentage
to be borne by the Insured
Day Care Procedures means those medical treatment, and/
Person as a percentage
or surgical procedure which is undertaken under General
of the admissible claim
or Local Anaesthesia in a Hospital/day care centre in less
amount)
than 24 hours because of technological advancement, and
which would have otherwise required a Hospitalisation Shared Accommodation or 15%
of more than 24 hours, but treatment normally taken on any lower accommodation
an Out-patient basis is not included in the scope of this type
definition.
Single occupancy or any 30%
Out-patient Treatment means consultation, diagnosis higher accommodation type
or medical treatment taken by an Insured Person at an
out-patient department of a Hospital, clinic or associated
facility, provided that he is not Hospitalised. Note –
If any urgent medical and/or surgical treatment is taken for
Domiciliary treatment means medical treatment for a acute cardiac Illness or Accident to avoid serious impairment
period exceeding 3 days, for an Illness/disease/injury of health in a single occupancy accommodation due to
unavailability of Shared or any lower accommodation then
only a 15% Co-Payment would be applicable. c) The within referred waiting period is made
applicable to the enhanced sum insured in the
event of granting higher sum insured
A Co-payment of 15% shall be applicable to all Day Care subsequently.
Procedures; no additional copay’s shall apply.
ii) Specified disease/procedure waiting period: Code
– Excl02
B. Co-Payment applicable on specified Illnesses/
surgeries a) Expenses related to the treatment of the
listed Conditions, surgeries/treatments as
If a claim has been admitted under Section B.I in mentioned in the table below shall be excluded
respect of any of the following Illnesses/Surgeries then, the until the expiry of 24 months of continuous
insured person shall bear 30% of the claim amount coverage after the date of inception of the
payable under the Policy and Our liability, if any, shall first Policy with us. This exclusion shall not be
only be in excess of that sum and would be subject to applicable for claims arising due to an
the Sum Insured. Accident.
S.no Illnesses/Surgeries b) In case of enhancement of sum insured the
exclusion shall apply afresh to the extent of
i. Cataract (each eye) Sum Insured increase.
ii. Hysterectomy c) If any of the specified disease/procedure falls
under the waiting period specified for Pre-
iii. Cholecystectomy
existing diseases, then the longer of the two
iv. Transurethral resection of the prostate (TURP)/ waiting periods shall apply.
Benign prostate surgery d) The waiting period for listed conditions shall
v. Surgery of Hemia apply even if contracted after the Policy or
declared and accepted without a specific
vi. Angiography (CT Angiogram excluded) exclusion.
vii. Arthroscopy e) If the Insured Person is continuously covered
without any break as defined under the
viii. PID-Discectomy applicable norms on portability stipulated by
ix. Mastectomy IRDAI, then waiting period for the same would
be reduced to the extent of prior coverage.
x. Joint Replacement
f) List of specific diseases/procedure:
xi. PTCA (Angioplasty)
xii. Hydrocele SI Organ / Organ Illness Treatment
xiii. Major Organ Transplant No System
a ENT • Any benign ear, • Any ear,
xiv. CABG
nose and throat nose and
(ENT) disorder throat (ENT)
Note – If We admit a claim under Section B.III B then, no Example: surgery
Co-Payment shall be applicable under Section B.III A for Sinusitis, Rhinitis Example:
the same claim. adenoidectomy,
mastoidectomy,
tonsillectomy,
Section C. Exclusions & Waiting Period tympanoplasty
• surgery for
I. Standard Waiting Period nasal septum
deviation
All claims payable will be subject to the waiting periods
b Gynaecological • Internal tumors, • Dilatation
specified below:
cysts, nodules, and curettage
polyps including (D&C)
i) 30-day Waiting period: Code – Excl03 breast lumps • Hysterectomy
• Polycystic for
a) Expenses related to the treatment of any
ovarian diseases menorrhagia
illness within 30 days from the first policy
or fibromyoma
commencement date shall be excluded except
or prolapse of
claims arising due to an accident, provided
uterus
the same are covered.
• Myomectomy
b) This exclusion shall not, however, apply if the for fibroids
insured person has continuous coverage for
more than twelve months.
c Orthopaedic • Non infective • Surgery for Important terms You should know.
arthritis prolapsed inter
• Gout and vertebral disk Pre-existing Condition means any condition, ailment,
Rheumatism • Joint injury or disease:
• Age related replacement i) That is/are diagnosed by a physician within 48 months
Osteoarthritis and prior to the effective date of the policy issued by the insurer
Osteoporosis or its reinstatement or
d Gastrointestinal • Calculus • surgery of ii) For which Medical advice or treatment was recommended
diseases of gall gallbladder and by, or received from, a physician within 48 months prior to
bladder including bile duct the effective date of the policy or its reinstatement.
Cholecystitis • surgery of
II. Standard General exclusions
• Pancreatitis hernia
• Fissure/ We will not pay for any claim in respect of any
fistula in anus, Insured Person arising from:
hemorrhoids,
pilonidal sinus Non-Medical i) Breach of law: Code – Excl10
• Gastric and Exclusions Expenses for treatment directly arising
duodenal ulcers from or consequent upon any Insured
• All forms of Person committing or attempting to
cirrhosis commit a breach of law with criminal
intent.
e Urogenital • Calculus • Any surgery ii) Hazardous or Adventure Sports:
diseases of of Urogenital Code – Excl09
Urogenital system system Expenses related to any treatment
Example: Kidney • Surgery on necessitated due to participation as a
stone, Urinary prostate professional in hazardous or adventure
bladder stone. • Surgery for sports, including but not limited to, para-
• Benign Hydrocele jumping, rock climbing, mountaineering,
Hyperplasia of rafting, motor racing, horse racing or
prostate scuba diving, hand gliding, sky diving,
deep-sea diving.
f Eye • Cataract • Nil
Medical iii) Investigation & Evaluation: Code
• Glaucoma
Exclusions Excl04
g Others • Internal tumors, • Surgery of a. Expenses related to any admission
cysts, nodules, varicose veins primarily for diagnostic and evaluation
polyps, skin and varicose purposes only are excluded.
tumors ulcers b. Any diagnostic expenses which are
not related or not incidental to the current
diagnosis and treatment are excluded.
iii) Pre-Existing Diseases: Code – Excl01 vi) Rest Cure, rehabilitation and respite
a) Expenses related to the treatment of a care–Code – Excl05: Expenses related
pre-existing disease (PED) and its direct to any admission primarily for enforced
complications shall be excluded until the expiry bed rest and not for receiving treatment.
of 36 months of continuous coverage after the This also includes:
date of inception of the first policy with insurer. a. Custodial care either at home or in a
nursing facility for personal care such
b) In case of enhancement of Sum Insured the
as help with activities of daily living such
exclusion shall apply afresh to the extent of
as bathing, dressing, moving around
sum of Sum Insured increase.
either by skilled nurses or assistant or
c) If the Insured Person is continuously covered non-skilled persons.
without any break as defined under the b. Any services for people who are
portability norms of the extant IRDAI (Health terminally ill to address physical, social,
Insurance) Regulations, then waiting period for emotional and spiritual needs.
the same would be reduced to the extent of v) Obesity/ Weight Control: Code –
prior coverage. Excl06
d) Coverage under the Policy after the expiry of Expenses related to the surgical
36 months for any pre-existing disease is treatment of obesity that does not fulfil
subject to the same being declared at the time all the below conditions:
of application and accepted by Insurer.
a. Surgery to be conducted is upon x. Dietary supplements and
the advice of the Doctor substances that can be purchased
b. The surgery/Procedure conducted without prescription, including but
should be supported by clinical not limited to Vitamins, minerals and
protocols organic substances unless prescribed
c. The member has to be 18 years of by a Medical Practitioner as part of
age or older and Hospitalization claim or day care
d. Body Mass Index (BMI); procedure.Code – Excl14
i. greater than or equal to 40 or xi. Expenses related to the treatment
ii. greater than or equal to 35 in for correction of eye sight due to
conjunction with any of the refractive error less than 7.5 dioptres.
following severe co-morbidities Code – Excl15
following failure of less invasive xii. Unproven Treatments– Expenses
methods of weight loss: related to any unproven treatment,
1. Obesity-related services and supplies for or in
cardiomyopathy connection with any treatment.
2. Coronary heart disease Unproven treatments are treatments,
3. Severe Sleep Apnoea procedures or supplies that lack
4. Uncontrolled Type2 Diabetes significant medical documentation to
vi. Change-of-Gender treatments: support their effectiveness.Code –
Code – Excl07 Excl16
Expenses related to any treatment, xiii. Sterility and Infertility –Code –
including surgical management, to Excl17 -Expenses related to sterility
change characteristics of the body to and infertility. This includes:
those of the opposite sex. a. Any type of contraception,
vii. Cosmetic or plastic Surgery: Code sterilization
– Excl08 b. Assisted Reproduction services
Expenses for cosmetic or plastic including artificial insemination and
surgery or any treatment to change advanced reproductive technologies
appearance unless for reconstruction such as IVF, ZIFT, GIFT, ICSI
following an Accident, Burn(s) or c. Gestational Surrogacy
Cancer or as part of medically d. Reversal of sterilization
necessary treatment to remove a xiv. Maternity:Code – Excl18
direct and immediate health risk to the a. Medical treatment expenses
insured. For this to be considered a traceable to childbirth (including
medical necessity, it must be certified complicated deliveries and
by the attending Medical Practitioner. caesarean sections incurred during
vii. Excluded Providers- Code – hospitalization) except ectopic
Excl11 Expenses incurred towards pregnancy;
treatment in any hospital or by any b. Expenses towards miscarriage
Medical Practitioner or any other (unless due to an accident) and lawful
provider specifically excluded by the medical termination of pregnancy
Insurer and disclosed in its website/ during the Policy period.
notified to the policyholders are not
admissible. However, in case of life
threatening situations or following an III. Specific Exclusions
Accident, expenses up to the stage of
Non-Medical iv) War or similar situations:
stabilization are payable but not the
Exclusion War or any act of war, invasion, act
complete claim.
of foreign enemy, (whether war be
viii. Treatment for Alcoholism, drug
declared or not or caused during
or substance abuse or any addictive
service in the armed forces of any
condition and consequences thereof.
country), civil war, public defence,
Code – Excl12
rebellion, revolution, insurrection,
ix. Treatments received in health
military or usurped acts, Nuclear,
hydros, nature cure clinics, spas or
Chemical or Biological attack or
similar establishments or private beds
weapons, radiation of any kind.
registered as a nursing home attached
v) Intentional self-injury or attempted
to such establishments or where
suicide while sane or insane
admission is arranged wholly or partly
for domestic reasons.Code – Excl13
Medical i. Any Insured Person committing or xv. Any treatment or part of a
Exclusions attempting to commit intentional self- treatment that is not of a Reasonable
injury or attempted suicide or suicide and Customary charge, not Medically
while mentally sound or unsound. Necessary; treatments or drugs not
ii. Any Insured Person’s participation supported by a prescription.
or involvement in naval, military or air xvi. Expenses for Artificial limbs
force operation. and/or device used for diagnosis or
iii. Investigative treatment for Sleep- treatment (except when used intra-
apnoea, General debility or exhaustion operatively).prosthesis, corrective
(“run-down condition”). devices external durable medical
iv. Congenital external diseases, equipment of any kind, wheelchairs,
defects or anomalies, crutches, and oxygen concentrator for
v. Stem cell harvesting bronchial asthma/ COPD conditions,
vi. Investigative treatments for cost of cochlear implant(s) unless
analysis and adjustments of spinal necessitated by an Accident.
subluxation,diagnosis and treatment Exhaustive list of Non-Medical
by manipulation of the skeletal expenses attached and also available
structure or for muscle stimulation on www.hdfcergo.com
by any means except treatment of xvii. Any Claim arising due to Non-
fractures (excluding hairline fractures) disclosure of Pre-existing Illness or
and dislocations of the mandible and Material fact as sought to be declared
extremities). on the Proposal form.
vii. Circumcisions (unless necessitated xviii. Non-allopathic treatments
by Illness or Injury and forming part of xix. Treatment rendered by a Medical
treatment). Practitioner which is outside his
viii. Any Convalescence, ,sanatorium discipline or the discipline for which he
treatment, private duty nursing or is licensed.
long-term nursing care. xx. Treatments rendered by a Medical
ix. Preventive care, and other Practitioner who is a member of the
nutritional and electrolyte Insured Person’s family or stays with
supplements, unless certified to be him, however proven material costs
required by the attending Medical are eligible for reimbursement in
Practitioner as a direct consequence accordance with the applicable cover
of an otherwise covered claim. xxi. Any specific timebound or
x. Vaccination including inoculation lifetime exclusion(s) applied by Us
and immunisations (Except post and specified in the Schedule and
Animal bite treatment), accepted by the insured, as per Our
xi. Non-Medical expenses such as underwriting guidelines
Food charges (other than patient’s
diet provided by hospital), laundry
charges, attendant charges, Section D. General Terms & Clauses
ambulance collar, ambulance
equipment, baby food, baby utility I Standard General Terms & Clauses
charges and other such items. Full list a) Conditions Precedent to Admission of Liability
of Non-Medical expenses is attached The terms and conditions of the policy must be
and also available at fulfilled by the insured person for the Company to
www.hdfcergo.com. make any payment for claim(s) arising under the
xii. Treatment taken on Outpatient policy.
basis b) Disclosure of Information
xiii. The provision or fitting of hearing The policy shall be void and all premium paid
aids, spectacles or contact lenses. thereon shall be forfeited to the Company in the
xiv. Any treatment and associated event of misrepresentation, mis description or
expenses for alopecia, baldness non-disclosure of any material fact by the
including corticosteroids and topical policyholder.
immunotherapy wigs, toupees, c) Claim Settlement (Provision for Penal Interest)
hair pieces, any non-surgical hair a. The Company shall settle or reject a claim, as
replacement methods, Optometric the case may be, within 30 days from the date
therapy. of receipt of last necessary document.
b. In the case of delay in the payment of a claim,
the Company shall be liable to pay interest to
the policyholder from the date of receipt of last
necessary document to the date of payment of a) the suggestion, as a fact of that which is not
claim at a rate 2% above the bank rate. true and which the insured person does not
c. However, where the circumstances of a claim believe to be true;
warrant an investigation in the opinion of the b) the active concealment of a fact by the insured
Company, it shall initiate and complete such person having knowledge or belief of the fact;
investigation at the earliest, in any case not c) any other act fitted to deceive; and
later than 30 days from the date of receipt of last d) any such act or omission as the law specially
necessary document. In such cases, the declares to be fraudulent
Company shall settle or reject the claim within The Company shall not repudiate the claim and / or
45 days from the date of receipt of last necessary forfeit the policy benefits on the ground of Fraud,
document. if the insured person / beneficiary can prove that the
d. In case of delay beyond stipulated 45 days, the misstatement was true to the best of his knowledge
Company shall be liable to pay interest to the and there was no deliberate intention to suppress
policyholder at a rate 2% above the bank rate the fact or that such misstatement of or suppression
from the date of receipt of last necessary of material fact are within the knowledge of the
document to the date of payment of claim. insurer.
d) Complete Discharge g) Multiple Policies
Any payment to the policyholder, insured person or (i) In case of multiple policies taken by an insured
his/ her nominees or his/ her legal representative or person during a period from one or more
assignee or to the Hospital, as the case may be, for insurers to indemnify treatment costs, the
any benefit under the policy shall be a valid insured person shall have the right to require a
discharge towards payment of claim by the settlement of his/her claim in terms of any of
Company to the extent of that amount for the his/her policies. In all such cases the insurer
particular claim. chosen by the insured person shall be obliged
e) Moratorium Period: to settle the claim as long as the claim is within
After completion of eight continuous years under the limits of and according to the terms of the
this Policy no look back would be applied. This chosen policy.
period of eight years is called as Moratorium (ii) Insured person having multiple policies shall
Period. The moratorium would be applicable for the also have the right to prefer claims under this
Sums Insured of the first Policy and subsequently policy for the amounts disallowed under any
completion of eight continuous years would be other policy / policies even if the sum insured
applicable from date of enhancement of Sums is not exhausted. Then the insurer shall
Insured only on the enhanced limits. After the expiry independently settle the claim subject to the
of Moratorium Period no claim under this Policy terms and conditions of this policy.
shall be contestable except for proven fraud & (iii) If the amount to be claimed exceeds the sum
permanent exclusions specified in the policy insured under a single policy, the insured
contract. person shall have the right to choose insurer
The Policy would however be subject to all from whom he/she wants to claim the balance
limits, sub limits, co-payments, Deductibles as per amount.
the policy contract. (iv) Where an insured person has policies from
more than one insurer to cover the same
f) Fraud risk on indemnity basis, the insured person
If any claim made by the insured person, is in any shall only be indemnified the treatment costs
respect fraudulent, or if any false statement, or in accordance with the terms and conditions of
declaration is made or used in support thereof, or the chosen policy.
if any fraudulent means or devices are used by the h) Renewal of Policy
insured person or anyone acting on his/her behalf The policy shall ordinarily be renewable except on
to obtain any benefit under this policy, all benefits grounds of fraud, misrepresentation by the insured
under this policy and the premium paid shall be person.
forfeited. i. The Company shall endeavor to give notice
Any amount already paid against claims made for renewal. However, the Company is not under
under this policy but which are found fraudulent later obligation to give any notice for renewal.
shall be repaid by all recipient(s)/policyholder(s), ii. Renewal shall not be denied on the ground
who has made that particular claim, who shall be that the insured person had made a claim or
jointly and severally liable for such repayment to claims in the preceding policy years.
the insurer. iii. Request for renewal along with requisite
For the purpose of this clause, the expression “fraud” premium shall be received by the Company
means any of the following acts committed by the before the end of the policy period.
insured person or by his agent or the iv. At the end of the policy period, the policy shall
hospital/doctor/any other party acting on behalf terminate and can be renewed within the Grace
of the insured person, with intent to deceive the Period of 30 days to maintain continuity of
insurer or to induce the insurer to issue an insurance benefits without break in policy. Coverage is
policy:.
not available during the grace period. continuity benefits in waiting periods as per IRDAI
v. No loading shall apply on renewals based on guidelines on migration.
individual claims experience.
i) Withdrawal of Policy For Detailed Guidelines on Migration, kindly refer
i. In the likelihood of this product being withdrawn the link
in future, the Company will intimate the insured
person about the same 90 days prior to expiry h t t p s : / / w w w. i r d a i . g o v. i n / A D M I N C M S / c m s /
of the policy. frmGuidelines_Layout.aspx?page=PageNo3987
ii. Insured Person will have the option to migrate m) Change of Policyholder
to similar health insurance product available The Policyholder may be changed only at the time
with the Company at the time of renewal with of renewal. The new policyholder must be a member
all the accrued continuity benefits such as of the Insured Person’s immediate family. Such
cumulative bonus, waiver of waiting period. as change would be subject to Our acceptance and
per IRDAI guidelines, provided the policy has payment of premium (if any). The renewed Policy
been maintained without a break. shall be treated as having been renewed without
j) Possibility of Revision of Terms of the Policy break.
Including the Premium Rates
The Company, with prior approval of IRDAI, may The Policyholder may be changed in case of his
revise or modify the terms of the policy including demise or him moving out of India during the Policy
the premium rates. The insured person shall be Period.
notified three months before the changes are n) Free Look Period
effected. The Free Look Period shall be applicable on new
k) Portability individual health insurance policies and not on
The insured person will have the option to port renewals or at the time of porting/migrating the
the policy to other insurers by applying to such policy.
insurer to port the entire policy along with all the
members of the family, if any, at least 45 days before, The insured person shall be allowed free look period
but not earlier than 60 days from the policy renewal of fifteen days from date of receipt of the policy
date as per IRDAI guidelines related to portability. If document to review the terms and conditions of the
such person is presently covered and has been policy, and to return the same if not acceptable.
continuously covered without any lapses under
any health insurance policy with an Indian General/ If the insured has not made any claim during the
Health insurer, the proposed insured person will Free Look Period, the insured shall be entitled to
get the accrued continuity benefits in waiting periods i. a refund of the premium paid less any expenses
as per IRDAI guidelines on portability. incurred by the Company on medical
examination of the insured person and the
For Detailed Guidelines on Portability, kindly refer stamp duty charges or
the link ii. where the risk has already commenced and
the option of return of the policy is exercised
h t t p s : / / w w w. i r d a i . g o v. i n / A D M I N C M S / c m s / by the insured person, a deduction towards the
frmGuidelines_Layout.aspx?page=PageNo3987 proportionate risk premium for period of
l) Migration cover
The insured person will have the option to migrate iii. Where only a part of the insurance coverage
the policy to other health insurance products/plans has commenced, such proportionate premium
offered by the company by applying for migration commensurate with the insurance coverage
of the policyatleast30 days before the policy renewal during such period;
date as per IRDAI guidelines on Migration. If such o) Cancellation
person is presently covered and has been The policyholder may cancel this policy by giving
continuously covered without any lapses under 15days’ written notice and in such an event, the
any health insurance product/plan offered by the Company shall refund premium for the unexpired
company, the insured person will get the accrued policy period as detailed below
1 Year Policy Period 2 Year Policy Period

Length of time Policy in % of premium refunded Length of time Policy in % of premium refunded
force force
Upto 1 Month 75.00% Upto 1 Month 87.50%
Upto 3 Months 50.00% Upto 3 Months 75.00%
Upto 6 Months 25.00% Upto 6 Months 62.50%
Exceeding 6 Months Nil Upto 12 Months 50.00%
Upto 15 Months 37.50%
Upto 18 Months 25.00%
Exceeding 18 Months Nil
Notwithstanding anything contained herein or otherwise, no and in case there is no subsisting nominee, to the
refunds of premium shall be made in respect of Cancellation legal heirs or legal representatives of the
where, any claim has been admitted or has been lodged or Policyholder whose discharge shall be treated as
any benefit has been availed by the insured person under full and final discharge of its liability under the Policy.
the policy. q. Grievance Redressal Procedure
In case of any grievance the insured person may contact
The Company may cancel the policy at any time on grounds the company through:
of misrepresentation non-disclosure of material facts, fraud • Website: www.hdfcergo.com
by the insured person by giving 15 days’ written notice. There • Toll free: 022 6234 6234 / 0120 6234 6234
would be no refund of premium on cancellation on grounds of • Contact Details for Senior Citizen: 022 - 6242 - 6226
misrepresentation, non-disclosure of material facts or fraud. | [email protected]
• E-mail: [email protected]
p) Nomination: Insured person may also approach the grievance
The Policyholder is required at the inception cell at any of the company’s branches with the details of
of the Policy to make a nomination for the purpose grievance.
of payment of claims under the Policy in the event If Insured person is not satisfied with the redressal of
of death of the Policyholder. Any change of grievance through one of the above methods, Insured
nomination shall be communicated to the Company Person may contact the grievance officer at
in writing and such change shall be effective only [email protected]
when an endorsement on the Policy is made. In the For updated details of grievance officer, kindly refer
event of death of the Policyholder, the Company the link: https://www.hdfcergo.com/customer-voice/
will pay the nominee {as named in the Policy grievances
Schedule/Policy Certificate/Endorsement (if any)}
Contact
First Contact Point Escalation level 1 Escalation level 2
Points
Contacts https://www.hdfcergo.com/customer- https://www.hdfcergo.com/customer- https://www.hdfcergo.com/customer-
us at care/grievances care/grievances/escalation level 1 care/grievances/escalation level 2
Call: 022 6234 6234 / 0120 6234 6234
Call: 022 6234 6234 / 0120 6234 6234 Call: 022 6234 6234 / 0120 6234 6234
Contact https://www.hdfcergo.com/customer- https://www.hdfcergo.com/customer-care/ https://www.hdfcergo.com/customer-
Point for care/grievances grievances/escalation level 1 care/grievances/escalation level 2
Senior
Citizen Call: 022 6242 6226 Call: 022 6242 6226 Call: 022 6242 6226
Email id: [email protected] Email id: [email protected] Email id: [email protected]

Write to [email protected] [email protected] [email protected]
us at
Visit us Grievance cell of any of our Branch The Grievance Cell, Chief Grievance Officer,
office HDFC ERGO General Insurance HDFC ERGO General Insurance
Company Ltd., D-301, 3rd Floor, Eastern Company Ltd., D-301, 3rd Floor, Eastern
Business District (Magnet Mall), LBS Business District (Magnet Mall), LBS
Marg, Bhandup (West) Mumbai - 400 078. Marg, Bhandup (West) Mumbai - 400 078.
i. If Insured person is not satisfied with the redressal of II. Specific General Terms & Clauses
grievance through above methods, the insured person a. Geography
may also approach the office of Insurance Ombudsman
This Policy only covers medical treatment taken within
of the respective area/region for redressal of grievance India. All payments under this Policy will only be made
as per Insurance Ombudsman Rules 2017. in Indian Rupees within India.
ii. Grievance may also be lodged at IRDAI Integrated b. Insured Person
Grievance Management System - https://bimabharosa.irdai.
Only those persons named as Insured Persons in the
gov.in/. Schedule shall be covered under this Policy. Any eligible
person may be added during the Policy Period after his
application has been accepted by Us and additional
premium has been received. Insurance cover for this
person shall only commence once We have issued an You shall give Us Your consent and the additional
endorsement confirming the addition of such person as premium (if any), within 15 days of the issuance of Our
an Insured Person. letter. If You neither accept Our letter nor revert to Us
If an Insured Person dies, he will cease to be an Insured within 15 days, We will cancel Your application and refund
Person upon Us receiving all relevant particulars in this the premium paid within the next 7 days.
regard. We will return a rateable part of the premium d. Notification of Claim
received for such person IF AND ONLY IF there are no
claims in respect of that Insured Person under the Policy. Treatment, We or Our TPA must be
c. Loadings Consultation or notified:
Procedure:
We may apply a risk loading on the premium payable
(based on the declarations made in the proposal form i) Any treatment for Immediately and in any
and the health status of the persons proposed for which a claim may event at least 48 hours prior
insurance) at the Commencement Date or on any be made requires to the start of the Insured
renewal of the Policy with Us or on the receipt of a Hospitalisation: Person’s Hospitalisation.
request for enhancing the Sum Insured. The maximum ii) Any treatment for which Within 24 hours of the start
risk loading applicable for an individual will not exceed a claim may be made of the Insured Person’s
100% per diagnosis / medical condition and an overall requires Hospitalisation Hospitalisation.
risk loading of 150% per individual in an Emergency:
We will send You the applicable risk loading in writing.
e. Cashless Service:
Treatment, Consultation or Treatment, Cashless Service is Available: Notice period for the Insured
Procedure: Consultation Person to take advantage of
or Procedure the cashless service*:
Taken at: *Written notice must be
accompanied by full particulars.
i) Any planned treatment, Network We will provide cashless service Immediately and in any event
consultation or procedure for Hospital by making payment to the extent at least 48 hours prior to the
which a claim may be made: of Our liability directly to the start of the Insured Person’s
Network Hospital. Hospitalisation.
ii) Any treatment, consultation Network We will provide cashless service Within 24 hours of the start
or procedure for which a Hospital by making payment to the extent of the Insured Person’s
claim may be made taken in of Our liability directly to the Hospitalisation.
an Emergency: Network Hospital.
f. Supporting Documentation & Examination iii) Original payment receipts

The Insured Person or someone claiming on the Insured iv) All reports, including but not limited to all medical
Person’s behalf will provide Us with any documentation, reports, case histories, investigation reports,
medical records and information We or Our TPA may treatment papers, discharge summaries.
request to establish the circumstances of the claim, its v) Discharge Summary, with Date of admission and
quantum or Our liability for the claim within 15 days of discharge, clinical history, past history, procedure
the either of Our request or the Insured Person’s details and details of treatment taken
discharge from Hospitalisation or completion of treatment.
The Company may accept claims where documents vi) Invoice/Sticker of the Implants.
have been provided after a delayed interval only in special vii) A precise diagnosis of the treatment for which a
circumstances and for the reasons beyond the control of claim is made.
the insured. Such documentation will include but is not viii) A detailed list of the individual medical services and
limited to the following: treatments provided and a unit price for each.
i) Our claim form, duly completed and signed for on ix) Prescriptions that name the Insured Person and
behalf of the Insured Person. in the case of drugs: the drugs prescribed, their price
ii) Original bills with detailed breakup of charges and a receipt for payment. Prescriptions must be
(including but not limited to pharmacy purchase bill, submitted with the corresponding Medical
consultation bill, diagnostic bill) and any attachments Practitioner’s invoice.
thereto like receipts or prescriptions in support of The Insured Person will have to undergo medical
any amount claimed which will then become Our examination by Our authorised Medical Practitioner,
property. as and when We may reasonably require, to obtain
an independent opinion for the purpose of processing any • the claim under such Policy if any, shall be
claim. We will bear the cost towards performing such prejudiced.
medical examination (at the specified location) of the ii. We may also exercise any of the below listed options
Insured Person. for the purpose of continuing the health insurance
g. Claims Payment coverage in case of Non-Disclosure/
ii) We will be under no obligation to make any payment Misrepresentation of Pre-existing diseases subject
under this Policy unless We have received all to your prior consent;
premium payments in full in time and all payments a. Permanently exclude the disease/condition and
have been realised and We have been provided continue with the Policy
with the documentation and information We or Our b. Incorporate additional waiting period of not
TPA has requested to establish the circumstances exceeding 4 years for the said undisclosed
of the claim, its quantum or Our liability for it, and disease or condition from the date the non-
unless the Insured Person has complied with his disclosed condition was detected and continue
obligations under this Policy. with the Policy.
iii) We will only make payment to or at Your direction. If c. Levy underwriting loading from the first year of
an Insured Person submits the requisite claim issuance of policy or renewal, whichever is later.
documents and information along with a declaration
in a format acceptable to Us of having incurred the The above options will not prejudice the rights of the
expenses, this person will be deemed to be Company to invoke cancellation under clause j i)
authorised by You to receive the concerned above.
payment. In the event of Your death, We will make i. Endorsements
payment to the Nominee (as named in the This Policy constitutes the complete contract of
Schedule). The assignment of benefits of the policy insurance. This Policy cannot be changed by
shall be subject to applicable law. anyone (including an insurance agent or broker)
iv) We are not obliged to make payment for any claim except Us. Any change that We make will be
or that part of any claim that could have been evidenced by a written endorsement signed and
avoided or reduced if the Insured Person had taken stamped by Us.
reasonable care, or that is brought about or j. Notices
contributed to by the Insured Person failing to follow
Any notice, direction or instruction under this Policy
the directions, advice or guidance provided by a
shall be in writing and if it is to:
Medical Practitioner.
i) Any Insured Person, it would be sent to You at
h. Non- Disclosure or Misrepresentation
the address specified in Schedule / endorsement
i. If at the time of issuance of Policy or during ii) Us, shall be delivered to Our address specified
continuation of the Policy, the information provided in the Schedule.
to Us in the proposal form or otherwise, by You or the
iii) No insurance agents, brokers, other person or
Insured Person or anyone acting on behalf of You
entity is authorised to receive any notice on Our
or an Insured Person is found to be incorrect,
behalf unless explicitly stated in writing by Us.
incomplete, suppressed or not disclosed, wilfully or
otherwise, the Policy shall be: k) Dispute Resolution Clause
• cancelled ab initio from the inception date or the Any and all disputes or differences under or in
renewal date (as the case may be), or the Policy relation to this Policy shall be determined by the
may be modified by Us, at our sole discretion, upon Indian Courts and subject to Indian law.
15 day notice by sending an endorsement to Your Section E. Others
address shown in the Schedule ; and
Section E. Others
I. Claim Related Information

Within India Outside India
Claim Intimation: Customer Service No. 022-62346234 / 0120- 62346234 Toll Free No: 800 08250825
Email: [email protected] Global Toll Free No : +800 08250825
(accessible from locations outside India only)
Landline no (Chargeable) : 0120-4507250
Claim document HDFC ERGO General Insurance Co. Ltd. HDFC ERGO General Insurance Co. Ltd.
submission at Stellar IT Park, Tower-1, 5th Floor, C - 25, Stellar IT Park, Tower-1, 5th Floor, C - 25,
address Noida, Sector 62, 201301, Uttar Pradesh Noida, Sector 62, 201301,Uttar Pradesh
II. List of Ombudsman
NAMES OF OMBUDSMAN AND ADDRESSES OF OMBUDSMAN CENTRES

Office Details Jurisdiction of Office Union Territory, District
AHMEDABAD - Shri Kuldip Singh
Office of the Insurance Ombudsman,
Gujarat,
Jeevan Prakash Building, 6th floor, Tilak Marg, Relief Road,
Dadra & Nagar Haveli,
Ahmedabad – 380 001.
Daman and Diu.
Tel.: 079 - 25501201/02/05/06
BENGALURU - Smt. Neerja Shah
Jeevan Soudha Building,PID No. 57-27-N-19, Ground Floor, 19/19,
Karnataka.
24th Main Road, JP Nagar, Ist Phase, Bengaluru – 560 078.
Tel.: 080 - 26652048 / 26652049
BHOPAL
Janak Vihar Complex, 2nd Floor, 6, Malviya Nagar, Opp. Airtel
Office, Near New Market, Bhopal – 462 003. Madhya Pradesh Chattisgarh.
Tel.: 0755 - 2769201 / 2769202
Fax: 0755 - 2769203
BHUBANESHWAR - Shri Suresh Chandra Panda
62, Forest park, Bhubneshwar – 751 009.
Orissa.
Tel.: 0674 - 2596461 /2596455
Fax: 0674 - 2596429
CHANDIGARH
S.C.O. No. 101, 102 & 103, 2nd Floor, Batra Building, Sector 17 – States of Punjab, Haryana (excluding 4 districts viz Gurugram,
D, Chandigarh – 160 017. Faridabad, Sonepat and Bahadurgarh), Himachal Pradesh, Union
Tel.: 0172 - 2706196 / 2706468 Territories of Jammu & Kashmir, Ladakh and Chandigarh.
Fax: 0172 - 2708274
CHENNAI
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 / 24335284
Fax: 044 - 24333664
DELHI - Shri Sudhir Krishna
2/2 A, Universal Insurance Building, Asaf Ali Road, Delhi, 4 Districts of Haryana viz. Gurugram, Faridabad, Sonepat
New Delhi – 110 002. and Bahudurgarh
Tel.: 011 - 23232481/23213504
GUWAHATI Assam,
Office of the Insurance Ombudsman, Meghalaya,
Jeevan Nivesh, 5th Floor, Nr. Panbazar over bridge, S.S. Road, Manipur,
Guwahati – 781001(ASSAM). Mizoram,
Tel.: 0361 - 2632204 / 2602205 Arunachal Pradesh,
Email: [email protected] Nagaland and Tripura.
HYDERABAD
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, Hyderabad - 500 004.
Territory of Puducherry.
Tel.: 040 - 23312122
Fax: 040 - 23376599
JAIPUR
2nd Floor, Pulinat Bldg., Opp. Cochin Shipyard, M. G. Road,
Ernakulam - 682 015. Rajasthan.
Tel.: 0484 - 2358759 / 2359338
Fax: 0484 - 2359336
ERNAKULAM - Ms. Poonam Bodra
2nd Floor, Pulinat Bldg., Opp. Cochin Shipyard, M. G. Road,
Kerala, Lakshadweep, Mahe-a part of Union Territory of
Ernakulam - 682 015.
Puducherry
Tel.: 0484 - 2358759 / 2359338
Fax: 0484 - 2359336
KOLKATA - Shri P. K. Rath
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 / 22124340
Fax : 033 - 22124341
LUCKNOW - Shri Justice Anil Kumar Srivastava Districts of Uttar Pradesh :

Office of the Insurance Ombudsman, Laitpur, Jhansi, Mahoba, Hamirpur, Banda, Chitrakoot, Allahabad,
6th Floor, Jeevan Bhawan, Phase-II, Mirzapur, Sonbhabdra, Fatehpur, Pratapgarh, Jaunpur,Varanasi,
Nawal Kishore Road, Hazratganj, Gazipur, Jalaun, Kanpur, Lucknow, Unnao, Sitapur, Lakhimpur,
Lucknow - 226 001. Bahraich, Barabanki, Raebareli, Sravasti, Gonda, Faizabad,
Tel.: 0522 - 2231330 / 2231331 Amethi, Kaushambi, Balrampur, Basti, Ambedkarnagar, Sultanpur,
Fax: 0522 - 2231310 Maharajgang, Santkabirnagar, Azamgarh, Kushinagar, Gorkhpur,
Email: [email protected] Deoria, Mau, Ghazipur, Chandauli, Ballia, Sidharathnagar
MUMBAI
3rd Floor, Jeevan Seva Annexe, S. V. Road, Santacruz (W),
Goa, Mumbai Metropolitan Region excluding Navi Mumbai &
Mumbai - 400 054.
Thane
Tel.: 69038821/23/24/25/26/27/28/28/29/30/31
Fax: 022 - 26106052
IRDA REGULATION NO 12: This Policy is subject to regulation 12 of IRDA (Protection of Policyholder’s Interests) Regulation 2017.
Endorsements – Optima Senior Surgeries specified under Section C-I-ii) stands reduced to 12
months for all the Insured Persons.
a) 30 days waiting period c) 36 months waiting period for Pre-existing Conditions
The 30 days waiting period under Section C-I- i) stands i) The 36 months waiting period for the Pre-existing
deleted for all the Insured Persons. Conditions under Section C-I-iii) stands deleted for all the Insured
Persons.
b) 24 months waiting period for specified Illnesses/ ii) The 36 months waiting period for the Pre-existing
surgeries Conditions under Section C-I-iii) stands reduced to 24 months for
i) The 24 months waiting period for the specified Illnesses/ all the Insured Persons.
Surgeries specified under Section C-I-ii) stands deleted for all the iii) The 36 months waiting period for the Pre-existing
Insured Persons. Conditions under Section C-I-iii) stands reduced to 12 months for
ii) The 24 months waiting period for the specified Illnesses/ all the Insured Persons.
Annexure I – List of Non-Medical Expenses
Sr. No. Item Sr. No. Item

1 BABY FOOD 26 BIRTH CERTIFICATE
2 BABY UTILITIES CHARGES 27 CERTIFICATE CHARGES
3 BEAUTY SERVICES 28 COURIER CHARGES
4 BELTS/ BRACES 29 CONVEYANCE CHARGES
5 BUDS 30 MEDICAL CERTIFICATE
6 COLD PACK/HOT PACK 31 MEDICAL RECORDS
7 CARRY BAGS 32 PHOTOCOPIES CHARGES
8 EMAIL / INTERNET CHARGES 33 MORTUARY CHARGES
9 FOOD CHARGES (OTHER THAN PATIENT'S 34 WALKING AIDS CHARGES
DIET PROVIDED BY HOSPITAL)
10 LEGGINGS 35 OXYGEN CYLINDER (FOR USAGE OUTSIDE THE
HOSPITAL)
11 LAUNDRY CHARGES 36 SPACER
12 MINERAL WATER 37 SPIROMETRE
13 SANITARY PAD 38 NEBULIZER KIT
14 TELEPHONE CHARGES 39 STEAM INHALER
15 GUEST SERVICES 40 ARMSLING
16 CREPE BANDAGE 41 THERMOMETER
17 DIAPER OF ANY TYPE 42 CERVICAL COLLAR
18 EYELET COLLAR 43 SPLINT
19 SLINGS 44 DIABETIC FOOT WEAR
20 BLOOD GROUPING AND CROSS MATCHING OF 45 KNEE BRACES (LONG/ SHORT/ HINGED)
DONORS SAMPLES
21 S E RV IC E C H A R GE S W HE RE NURS I NG 46 KNEE IMMOBILIZER/SHOULDER IMMOBILIZER
CHARGE ALSO CHARGED
22 TELEVISION CHARGES 47 LUMBO SACRAL BELT
23 SURCHARGES 48 NIMBUS BED OR WATER OR AIR BED CHARGES
24 ATTENDANT CHARGES 49 AMBULANCE COLLAR
25 EXTRA DIET OF PATIENT (OTHER THAN THAT 50 AMBULANCE EQUIPMENT
WHICH FORMS PART OF BED CHARGE)
51 ABDOMINAL BINDER 60 MASK
52 PRIVATE NURSES CHARGES- SPECIAL 61 OUNCE GLASS
NURSING CHARGES
53 SUGAR FREE TABLETS 62 OXYGEN MASK
54 CREAMS POWDERS LOTIONS (TOILETRIES 63 PELVIC TRACTION BELT
ARE NOT PAYABLE, ONLY PRESCRIBED
MEDICAL PHARMACEUTICALS PAYABLE)
55 ECG ELECTRODES 64 PAN CAN
56 GLOVES 65 TROLLY COVER
57 NEBULISATION KIT 66 UROMETER, URINE JUG
58 ANY KIT WITH NO DETAILS MENTIONED 67 AMBULANCE
[DELIVERY KIT, ORTHOKIT, RECOVERY KIT,
ETC]
59 KIDNEY TRAY 68 VASOFIX SAFETY

Optima Senior Combined PW Cis Hegi

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HDFC ERGO General Insurance Company Limited

TITLE DESCRIPTION REFER TO POLICY

• Expenses related to any treatment necessitated due to participation as a

• However, –If we accept a claim for above mentioned specified illnesses/

Notwithstanding anything contained herein or otherwise, no refunds

The Company may cancel the policy at any time on grounds of

Section Description Page No.

1 Year Policy Period 2 Year Policy Period

Email id: [email protected] Email id: [email protected] Email id: [email protected]

f. Supporting Documentation & Examination iii) Original payment receipts

I. Claim Related Information

NAMES OF OMBUDSMAN AND ADDRESSES OF OMBUDSMAN CENTRES

LUCKNOW - Shri Justice Anil Kumar Srivastava Districts of Uttar Pradesh :

Annexure I – List of Non-Medical Expenses

Sr. No. Item Sr. No. Item

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