Health Insurance 394 views January 16, 2021

HDFC ERGO Optima Vital Health Insurance Plan will pay the insured a lump sum amount for identified critical illnesses, medical events or surgical procedures. This policy can be purchased either on an individual or family floater basis as per your requirements. HDFC ERGO Optima Vital Health Insurance Plan covers adults within the age group of 18-65 years and children from 18-25 years, provided both parents are covered in the policy. There is no cover ceasing age under this policy as stated in the HDFC ERGO policy document. The sum insured for HDFC ERGO Optima Vital Health Insurance Plan would range from INR 1,00,000 to INR 50,00,000 in multiples of INR 1,00,000. And the maximum sum insured available above the age of 55 years for a new policy will be restricted up to INR 20 lakh. And it will be issued for a 1 or 2 years. To know the applicable benefits of the policy year, read this page further.

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Critical Illness Coverage Under HDFC ERGO Optima Vital Health Insurance Plan

Under the HDFC ERGO Optima Vital Health Insurance Plan, several critical illnesses will be covered. But the condition for the payment of claims is that you need to survive the following period. The survival period starts from the date of confirmed diagnosis. So have a look at them below and know more.

30-Day Survival period

The survival period for the following critical illnesses will start from the date of confirmed diagnosis with severity.

  1. Cancer of Specified Severity
  2. Kidney failure requiring regular dialysis
  3. Multiple sclerosis with persisting symptoms
  4. End-stage liver disease of specified severity
  5. First heart attack of specified severity
  6. Coma of specified severity
  7. Major burns
  8. Goodpasture’s Syndrome
  9. Apallic Syndrome
  10. Aplastic Anaemia
  11. Systemic Lupus Erythematosus
  12. Bacterial Meningitis
  13. Multiple System Atrophy
  14. Progressive Scleroderma

90-Day Survival Period

The survival period for the following critical illnesses will start from the date of confirmed diagnosis with defined severity.

  1. Primary Parkinson’s Disease
  2. Alzheimer’s Disease
  3. Motor Neuron Disease with Permanent Symptoms
  4. Stroke resulting in Permanent Symptoms
  5. Permanent paralysis of limbs
  6. Primary Pulmonary Arterial Hypertension
  7. Benign Brain Tumor
  8. Cardiomyopathy
  9. End-stage lung disease
  10. Brain Surgery
  11. Progressive Supranuclear palsy
  12. Creutzfeldt-Jakob Disease ( CJD)
  13. Major head Trauma
  14. Encephalitis

30-Day Survival Period

The survival period for the following critical illnesses will be started from the date of actual undergoing of the procedure

  1. Open chest Coronary Artery Bypass Graft surgery
  2. Major Organ/ Bone Marrow Transplant
  3. Aorta Graft Surgery
  4. Open Heart Replacement or Repair of Heart Valves
  5. Pneumonectomy
  6. Pulmonary Artery Graft Surgery

6 Months Survival Period

Any of the following permanent impairment from the date of confirmed diagnosis.

  1. Blindness
  2. Deafness
  3. Total Loss of speech

Note – The policy will terminate upon the occurrence of the first critical illness and you will receive the sum insured and the policy ceases with no subsequent renewals for the insured person. However, the other insured members will continue to be covered under HDFC ERGO Optima Vital Health Insurance Plan.

E-opinion for Critical Illness

When you suffer from a critical illness during the policy period and you request a second opinion, HDFC ERGO will arrange a second opinion from a medical practitioner chosen by its panel. The second opinion will be based only on the information and documentation provided to the medical practitioner by you or on your behalf. And the second opinion will be sent directly to you by the medical practitioner.

Note – You can claim this benefit only once in a policy year

Free Look

The free look period for the shall be applicable on new individual HDFC ERGO Optima Vital Health Insurance Plan only. During the free look period of fifteen days which starts from the date of receipt of the policy document, you can review the terms and conditions of the policy and return the policy if they are not acceptable to you.

And if you haven’t made any claim, you will be entitled to a refund of the paid premium less the medical examination and stamp duty charges, if any. Or if the risk has already commenced and the policy is returned, a deduction towards the proportionate risk premium for a period of cover will be provided to you. In case only a part of the insurance coverage has commenced, such proportionate premium commensurate with the current insurance coverage.

Exclusions from HDFC ERGO Optima Vital Health Insurance Plan

  1. War or similar situations
  2. Breach of law
  3. Participation or involvement in naval, military or air force operation
  4. Involvement in Adventure Sports
  5. Abuse and de-addiction programs of intoxicants or hallucinogenic substances like narcotic drugs and alcohol
  6. Congenital external diseases, defects or anomalies.
  7. Any treatment arising from pregnancy
  8. Any specific illness or injury that comes under the waiting period will come under exclusion until the waiting period expiry.

Claim Process

For Critical Illness:- You should intimate HDFC ERGO in case of occurrence of any of the covered critical illnesses within 14 days of the diagnosis of its first occurrence. After that, submit a duly filled claim form along with specified documents within 45 days or completion of the survival period. If the insurer requires any additional information, you must submit it within 15 days from the date of its request.

Once all the claim documents are submitted, the company will send the admissible amount, along with a settlement statement within 30 days. The claim will be made in the name of the proposer.

For E-Opinion:- First, submit a duly filled claim form along with a copy of all your medical reports including investigation reports and discharge summary. After that, select a doctor from the HDFC ERGO Panel to take the second opinion. You can also visit the HDFC ERGO official website or call at 24X7 Toll-Free line to obtain the list of Panel Doctors. On receipt of the complete set of documents, the company will forward the same to the concerned doctor.

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