Optima Restore Prospectus

HDFC ERGO General Insurance Company Limited
Prospectus
Optima Restore
Suitability: Salient Features & Benefits:

We will cover the Medical In addition to the waiting
a) This policy covers persons in the age group 91 days to 65 years. Expenses for: periods (Section 5a) and
The maximum entry age is restricted to 65 years. The Minimum general exclusions (Section
entry age for adult dependent: is 18 years and maximum entry age 5c), We will also not cover
is 65 years. expenses:
b) Children between 91 days and 5 years can be insured provided a. In-patient Treatment. If as per any or all of the
either parent is getting insured under this policy. This includes Medical references herein
• Hospital room rent or below containing guidelines
c) There is no maximum cover ceasing age on renewals.
boarding; and protocols for Evidence
d) The policy will be issued for a period of 1/2/3 year(s) period, the • Nursing; Based Medicines, the
sum insured & benefits will applicable on policy year basis. • Intensive Care Unit Hospitalisation for treatment
e) This policy can be issued to an individual and/or family. A maximum • Medical Practitioners under claim is not necessary
of 6 members can be added in a single policy, whether on an (Fees) or the stay at the hospital is
individual or family floater basis. • Anaesthesia found unduly long:
f) The policy offers option of covering on individual sum insured basis • Blood • Medical text books,
and on family floater basis. • Oxygen • Standard treatment
• Operation theatre guidelines as stated in
g) The family includes following relationships spouse, dependent • Surgical appliances; clinical establishment
children and dependent parents and dependent in laws. • Medicines, drugs & act of Government of
h) In a family floater policy, a maximum of 2 adults and a maximum of consumables; India,
5 children can be included in a single policy. The 2 adults can be a • Diagnostic procedures. • World Health
combination of self, spouse, father, father in law, mother or mother Note pertaining specifically to Organisation (WHO)
in law. AYUSH Treatments only: protocols,
i) In a family floater the age of the eldest member will be considered Medical expenses pertaining • Published guidelines by
while computing premium for the family. only to In-patient care AYUSH healthcare providers,
treatment are also covered • Guidelines set by
j) In an individual policy, a maximum of 4 adults and a maximum of
under ‘In-patient treatment’ medical societies like
5 children can be included in a single policy. The 4 adults can be a
cover if undertaken in an cardiological society of
combination of self, spouse, father, father in law, mother or mother
AYUSH Hospital. Any medical India, neurological
in law.
expense other than In-patient society of India etc.
k) The Sum Insured of the dependent insured members should be c a r e AY U S H t r e a t m e n t
equal to or less than the sum insured of the primary insured member. expenses are not covered
In case where two or more children are covered, the sum insured for under this policy.
all the children must be same. Sum insured of dependent parents b. Pre-Hospitalisation i) Claims which have NOT
must be the same. expenses for been admitted under
Note: consultations, Inpatient treatment
I. Dependents means only the family members listed below: investigations and benefit and day care
medicines incurred procedure benefit.
i. Your legally married spouse as long as she continues to be
upto 60 days before ii) Expenses not related
married to you;
the date of admission to the admission and
ii. Your children aged between 91 days and 25 years if they are to the hospital (In-patient not incidental to the
unmarried OR Day Care OR treatment for which the
iii. Your natural parents or parents that have legally adopted you, Domiciliary treatment). admission has taken
provided that the parent was below 65 years at his initial place.
participation in the Optima Restore policy. c. Post-Hospitalisation i. Claims which have NOT
iv. You’re Parent -in-law as long as your spouse continues to be expenses for been admitted under
married to you and were below 65 years at his initial participation consultations, Inpatient treatment
in the Optima Restore policy. investigations and benefit and day care
medicines incurred upto procedure benefit.
v. All dependent parents must be financially dependent on you.
180 days after discharge ii. Expenses not related
Dependent Child means a child (natural or legally adopted), who from the Hospital (In- to the admission and
is unmarried, aged between 91 days and 25 years, financially patient OR Day Care not incidental to the
dependent on the primary Insured or Proposer and does not have OR Domiciliary treatment for which the
his / her independent sources of income. treatment). admission has taken
place
d. Day Care Procedures i) Treatment that can
Medical treatment or be and is usually taken
surgical procedure on an out-patient basis
which is undertaken is not covered.
under general or local ii) Treatment NOT taken at
anaesthesia, which a Hospital or daycare
require admission in centre.
a Hospital/Day Care
Centre for stay less than
24 hours. 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. For more details on the risk factors, terms and conditions, please read the policy document carefully before concluding a sale. UIN - Optima Restore -
HDFHLIP25012V082425 | Protector Rider - HDHHLIP21335V022021 | Individual Personal Accident Rider - APOPAIP19004V011920 | Hospital Daily Cash Rider - HDHHLIP21344V022021 | Critical Advantage 1
Rider HDHHLIP21342V022021 | my:health Critical Illness - HDFHLIA22141V032122 | Optima Wellbeing (Add-on) - HDFHLIA24099V012324
Prospectus
Optima Restore
normally taken on out- h. Daily Cash for choosing 1. Daily Cash Benefit for
patient basis is not shared Accommodation time spent by the
included in the scope of Daily cash amount Insured Person in an
this definition. will be payable per day intensive care unit
e. Domiciliary Treatment 1. Treatment of less as mentioned in 2. Claims which have NOT
Medical treatment for an than 3 days (Coverage schedule of benefits been admitted under
Illness/disease/injury will be provided for if the Insured Person Inpatient Treatment
which in the normal expenses incurred is hospitalised in Shared benefit
course would require in first three days only Accommodation in a
care and treatment if treatment period is Network Hospital
at a Hospital but is greater than three days). for each continuous and
actually taken while completed period of 24
confined at home hours if the
under any of the Hospitalisation exceeds
following circumstances: 48 hours.
i. The condition of the i. E-Opinion in respect of a 1. More than one claim for
patient is such that he/ Critical Illness this benefit in a Policy
she is not in a condition We shall arrange and Year.
to be removed to a pay for a second opinion 2. Any other liability due
Hospital or, from Our panel of to any errors or
ii. The patient takes medical Practitioners, if: omission or
treatment at home on - The Insured Person representation or
account of non- suffers a Critical Illness consequences of any
availability of room in a during the Policy Period; action taken in reliance
Hospital. and of the E-opinion
iii. Pre and Post - He requests an provided by the Medical
Hospitalisation E-opinion; and Practitioner
expenses for
consultations, The Insured Person
investigations and can choose one of Our
medicines incurred upto panel Medical
60 days before Practitioners. The
hospitalisation and opinion will be directly
180 days after sent to the Insured
hospitalization Person by the Medical
respectively will be Practitioner.
covered in case of Critical Illness” includes
domiciliary treatment. Cancer, Open Chest
f. Organ Donor: 1. Claims which have NOT CABG, First Heart
Medical and surgical been admitted under Attack, Kidney Failure,
Expenses of the organ Inpatient treatment Major Organ/Bone
donor for harvesting benefit for insured Marrow Transplant,
the organ where member. Multiple Sclerosis,
an Insured Person is the 2. Admission not compliant Permanent Paralysis of
recipient. under the Limbs and Stroke.
IMPORTANT: Expenses Transplantation of j. Emergency Air 1. Claims which have NOT
incurred by an insured Human Organs Act, Ambulance Cover been admitted under 1
person while donating 1994 (as amended). We will pay for a) and 1d).
an organ is NOT 3. The organ donors Pre ambulance 2. Expenses incurred
covered. and Post-Hospitalisation transportation in an in return transportation
expenses. airplane or helicopter to the insured’s home by
g Ambulance Cover 1. Claims which have NOT subject to maximum air ambulance is
Expenses incurred been admitted under limit prescribed in j (1) , excluded.
on transportation of Inpatient Treatment for emergency life
Insured Person to a Benefit and Daycare threatening health
Hospital for treatment procedure benefit conditions which
in case of an 2. Healthcare or require immediate
Emergency, subject to ambulance service and rapid ambulance
Rs. 2000 per provider not registered transportation to the
Hospitalisation. with road traffic hospital/medical centre
authority. that ground
transportation cannot
provide subject to:
2 HDFHLIP25012V082425 | Protector Rider - HDHHLIP21335V022021 | Individual Personal Accident Rider - APOPAIP19004V011920 | Hospital Daily Cash Rider - HDHHLIP21344V022021 | Critical Advantage
Prospectus
Optima Restore
• Necessary medical In case of a Family

treatment not being Floater Policy, Restore
available at the Sum Insured will be
location where the available on floater
Insured Person basis for all Insured
is situated at the time Persons in the Policy.
of Emergency; b. Unlimited Restore
• The Medical Evacuation Benefit (Optional
been prescribed by a benefit)
Medical Practitioner and This optional cover will
is Medically Necessary; be provide instant
• The insured person addition of 100%
is in India and the Basic Sum Insured on
treatment is required in complete or partial
India only and not utilization of Your
overseas in any Restore benefit or
condition whatsoever; Unlimited Restore
and benefit (as applicable)
• The air ambulance during the Policy Year.
provider being This optional cover will
registered in India. trigger unlimited times
j(i) The amount payable in and is available for all
case of Air ambulance subsequent claims in a
facility shall be either Policy Year.
the actual expenses
or Rs. 2.5 Lacs per Conditions for Unlimited
hospitalisation, Restore benefit:
whichever is lower; upto i. The Sum Insured will be
basic sum insured limit restored under this optional
for a year. cover for the subsequent claim
in the Policy Year.
Section II. ii. A single claim in a Policy
a. Restore Benefit Year cannot exceed the sum
Instant addition of of Basic Sum Insured and the
100% Basic Sum Multiplier Benefit (if applicable).
Insured on complete In case of a Family
or partial utilization of Floater Policy, Unlimited
Your existing Policy Restore Sum Insured will be
Sum Insured and available on floater basis for all
Multiplier Benefit (if Insured Persons in the Policy.
applicable) during c. Aggregate Deductible
the Policy Year. The The Insured Person shall
Total amount (Basic bear an amount equal
sum insured, Multiplier to the Aggregate
benefit and Restore Deductible specified on
sum insured) will be Policy Schedule for all
available to all Insured admissible claims made
Persons for all claims by the Insured Person
under In-patient Benefit and assessed by the
during the current Company in a Policy Year.
Policy Year and subject The liability of the
to the condition that Company to pay the
single claim in a Policy admissible claim under
Year cannot exceed the that Policy Year will
sum of Basic Sum commence only once
Insured and the the specified Aggregate
Multiplier Benefit (if Deductible has been
applicable). exhausted. This Cover
Conditions for Restore benefit: shall be subject to the
i. The Sum Insured will be following conditions:
restored only once in a
Policy Year.
ii. If the Restored Sum
Insured is not utilized in
a Policy Year, it will
expire.
Prospectus
Optima Restore
conditions d. Co-Payment
i. This Cover is applicable on
annual aggregate basis and i. If opted and mentioned
can be opted only at inception on the Policy Schedule that
of the Policy or at subsequent a Co-payment is effective,
Renewals. and an admissible claim
ii. Once the Aggregate has been admitted, then the
Deductible option is opted by insured person shall bear
the Insured Person, it cannot the percentage (%) of Co-
be opted out or reduced at payment mentioned in the
any time during the Policy Year policy schedule on all eligible
or at subsequent Renewals. claims payable under the
Deductible however can Policy and Our liability, if any,
be increased at the time of shall only be in excess of that
Renewal. amount and would be subject
iii. In case of Individual Policy, to the Sum Insured.
the entire amount of Aggregate ii. Co-payment is not applicable
Deductible must first be to Section 3 (Preventive Health
exhausted on per Insured checkup), Section 1.h (Daily
Person basis, once in a Policy Cash for choosing shared
Year, before the Company Accommodation) and Section
pays for claims of that Insured 1.i (E-Opinion in respect of a
Person in that Policy Year. Critical Illness).
iv. In case of family floater iii. This benefit once opted,
Policy, the entire amount of cannot be opted out at any
Aggregate Deductible must time during the Policy Year or
first be exhausted by any one at subsequent Renewals.
or more of the Insured Persons
v. once in a Policy Year before Illustration of Sum Insured utilization in a Policy Year
the Company pays for claims
Basic Sum Insured : 5 Lacs
of any Family Member covered
under the Policy in that Policy Multiplier Benefit: 2.5 Lacs
Year.
v. The Aggregate Deductible
is not applicable to section 3
(Preventive Health checkup),
Section 1.i (E-Opinion in
respect of a Critical Illness).
Number Claim Available Benefit Limit Admissible Utilization of Sum Insured

of Claim amount Basic Sum Multiplier Restore Unlimited claim
Insured Benefit Benefit Restore Benefit amount
1st claim 7,00,000 5,00,000 2,50,000 0 0 7,00,000 Basic + Multiplier (Partial)

2nd claim 3,50,000 - 50,000 5,00,000 0 3,50,000 Multiplier (balance) + Restore (partial)
3rd claim 3,00,000 - - 2,00,000 5,00,000 3,00,000 Restore (balance) + Unlimited Restore
4th claim 7,00,000 - - - 5,00,000 5,00,000 Unlimited Restore
5th claim 5,00,000 - - - 5,00,000 5,00,000 Unlimited Restore
Prospectus
Optima Restore
Basic Sum Insured: Rs. 3Lacs; 5 Lacs; 10 Lacs; 15 Lacs; 20 Lacs; 25 same rate at which it is accrued. However this reduction will
Lacs; 50 Lacs; 100 Lacs on individual as well as on family floater basis. not reduce the Sum Insured below the basic Sum Insured of
the policy, and only the accrued multiplier bonus will be
Policy Period decreased.
• The policy will be issued for 1/2/3 year period, the sum insured & iv. If the Insured Persons in the expiring policy are covered on
benefits will be applicable on Policy Year basis. individual basis and thus have accumulated the multiplier
bonus for each member in the expiring policy, and such expiring
Payment Facility:
policy is renewed with Us on a Family Floater basis, then the
• Online multiplier bonus to be carried forward for credit in the Policy
• Cheque/ Credit Card Payment would be the least multiplier bonus amongst all the Insured
Persons.
• Electronic Clearing System
v. Portability/Migration benefit will be offered to the extent of sum of
Renewal Incentives:
previous sum insured and accrued multiplier bonus, portability/
• Multiplier Benefit: migration benefit shall not apply to any other additional
i.
If no claim has been made in respect of inpatient benefits under increased Sum Insured.
this policy and the policy is renewed with us without any break, vi. In policies with a 2/3 year Policy Period, the application of above
we will apply a bonus to the next policy year by automatically guidelines of Multiplier Benefit shall be post completion of each
increasing the Sum Insured for the next Policy Year by 50% of policy year.
the Basic Sum Insured for this Policy Year. The maximum bonus
• Preventive Health checkup
will not exceed 100% of the Basic Sum Insured in any Policy
Year. This benefit is effective only if mentioned in the Schedule of Benefits.
If You have maintained an Optima Restore Policy with Us for the
ii. In Family Floater policy,
period of time mentioned in the schedule of benefits without any
a) The multiplier benefit shall be available on floater basis and break, then at the end of each block of continuous years (as
accrue only if no claims have been made in respect of any mentioned in the schedule of benefits) We will pay upto the amount
Insured Person during the expiring Policy Year. mentioned in the Schedule of Benefits towards the cost of a
b) Accrued Multiplier benefit is available to all insured persons preventive health check-up for those Insured Persons who were
under the policy insured for the number of previous Policy Years mentioned in the
iii. If a Multiplier benefit has been applied and a claim is made in Schedule.
any Policy Year, then in the subsequent Policy Year We will
automatically decrease the accrued multiplier benefit at the
Plan/SI 3 Lacs 5 Lacs 10 Lacs 15 Lacs 20/25/50/100 Lacs

Individual Not Upto a maximum of Rs.1,500 Upto a maximum of Upto a maximum of Upto a maximum of
(Per Applicable per insured person, only once Rs.2,000 per insured Rs.4,000 per insured Rs. 5000 per Insured
Person) at the end of a block of every person at the end of each person, at the end of each Person, at the end of
continuous two policy years. year at renewal. year at renewal each year at renewal
Floater Not Upto a maximum of Rs.2,500 Upto a maximum of Upto a maximum of Upto a maximum of Rs.
(Per Applicable per policy, only once at Rs.5,000 per policy at the Rs.8,000 per policy, at the 10,000 per policy, at
Policy) the end of a block of every end of each year at renewal end of each year at renewal. the end of each year at
continuous two Policy Years. renewal.
on any medical check-up, stamp duty charges and proportionate risk

Note: Preventive Health Check-up means a package of medical test(s) premium. You can cancel your Policy only if you have not made any claims
undertaken for general assessment of health status, it does not include under the Policy. All Your rights under this Policy shall immediately stand
any diagnostic or investigative medical tests for evaluation of illness or extinguished on the free look cancellation of the Policy. Free look provision
a disease. is not applicable and available at the time of renewal of the Policy.
Portability: Exclusions:
If you are insured continuously and without interruption under a health A. Waiting Period
insurance plan issued by an Indian non-life insurer and you want to shift
All Illnesses and treatments shall be covered subject to the waiting
to us on renewal, Optima Restore policy offers you transfer of accrued
periods specified below:
benefits and make due allowances for waiting periods etc. If the Insured
person transfers from any other insurer and enhances coverage, then i. 30-day waiting period – Code – Excl03
the portability benefits will be offered only in respect to the previous sum a) Expenses related to the treatment of any illness within 30
insured. days from the first policy commencement date shall be
The application for portability should be received by us at least 45 days excluded except claims arising due to an accident, provided
before the policy renewal date of the existing policy. the same are covered.
b) This exclusion shall not, however, apply if the insured
person has continuous coverage for more than twelve
Free Look Period:
months.
You have a period of 15 days from the date of receipt of the Policy
c) The within referred waiting period is made applicable to
document to review the terms and conditions of this Policy. If you have
the enhanced sum insured in the event of granting higher
any objections to any of the terms and conditions, you have the option
sum insured subsequently.
of canceling the Policy stating the reasons for cancellation and you shall
be refunded the premium paid by you after adjusting the amounts spent
Prospectus
Optima Restore
ii. Specified disease/procedure waiting period – Code – Excl02

Gastrointestinal • Cholelithiasis • Cholecystectomy
a) Expenses related to the treatment of the listed Conditions,
• Cholecystitis • Surgery of hernia
surgeries/treatments shall be excluded until the expiry of
• Pancreatitis
24 months of continuous coverage after the date of
• Fissure/ fistula in
inception of the first policy with us. This exclusion shall not
anus, Hemorrhoids,
be applicable for claims arising due to an accident or
Pilonidal sinus
underlying cause is cancer(s).
• Gastro
b) In case of enhancement of sum insured the exclusion shall Esophageal
apply afresh to the extent of sum insured increase. Reflux Disorder
c) If any of the specified disease/procedure falls under the (GERD), Ulcer
waiting period specified for pre-existing diseases, then the and erosion
longer of the two waiting periods shall apply. of stomach and
d) The waiting period for listed conditions shall apply even if duodenum
contracted after the policy or declared and accepted without • Cirrhosis
a specific exclusion. (However
Alcoholic
e) If the Insured Person is continuously covered without any
break as defined under the applicable norms on portability/ cirrhosis is
migration stipulated by IRDAI, then waiting period for the permanently
same would be reduced to the extent of prior coverage. excluded)
• Perineal and
f) List of specific diseases/procedures: -
Perianal Abscess
• Rectal Prolapse
Organ / Organ Illness / diagnoses Surgeries / Urogenital • Calculus • Surgery on

System (irrespective of procedure diseases of prostate
treatments medical or (irrespective of any Urogenital • Surgery for
surgical) illness / diagnosis system including Hydrocele/
other than cancers) Kidney, ureter, Rectocele
bladder stones
Ear, Nose & • Sinusitis • Adenoidectomy
• Benign
Throat (ENT) • Rhinitis • Mastoidectomy
Hyperplasia of
• Tonsillitis • Tonsillectomy
prostate
• Tympanoplasty
• Varicocele
• Surgery for Nasal
septum deviation Eye • Cataract • Nil
• Surgery for • Retinal
Turbinate detachment
hypertrophy • Glaucoma
• Nasal concha Others • NIL • Surgery of varicose
resection veins and varicose
• Nasal ulcers
polypectomy
General • Benign tumors • NIL
Gynaecological • Cysts, polyps • Hysterectomy (Applicable to all of Non-infectious
including breast organ systems/ etiologye.eg.
lumps organs whether cysts, nodules,
• Polycystic ovarian or not described polyps, lump,
diseases above) growth, etc.
• Fibromyoma
• Adenomyosis iii. Pre-Existing Diseases – Code – Excl01
• Endometriosis
a) Expenses related to the treatment of a pre-existing disease
• Prolapsed Uterus
(PED) and its direct complications shall be excluded until the
Orthopaedic • Non infective • Joint replacement expiry of 36 months of continuous coverage after the date of
arthritis surgeries inception of the first policy with insurer.
• Gout and b) In case of enhancement of sum insured the exclusion shall
Rheumatism apply afresh to the extent of sum insured increase.
Osteoporosis
• Ligament, c) If the insured person is continuously covered without any
Tendon and break as defined under the portability/migration norms of the
Meniscal tear extant IRDAI (Health Insurance) Regulations, then waiting
• Prolapsed inter period for the same would be reduced to the extent of prior
vertebral disk coverage.
d) Coverage under the policy after the expiry of 36 months for
any pre-existing disease is subject to the same being
declared at the time of application and accepted by insurer.
Prospectus
Optima Restore
B. General exclusions
Medical 6. Treatment for Alcoholism, drug or
We will not pay for any claim in respect of any Insured Person for, Exclusions substance abuse or any addictive
caused by, arising from or attributable to: condition and consequences thereof. Code
– Excl12
7. Prosthetic and other devices which are self-
Non-Medical 1. War or similar situations:
detachable /removable without surgery
Exclusions Treatment arising from or consequent involving anaesthesia.
upon war or any act of war, invasion, act
8. Treatment availed outside India
of foreign enemy, (whether war be
declared or not or caused during 9. Treatment at a healthcare facility which is
service in the armed forces of any NOT a Hospital.
country), civil war, public defence, 10. Obesity/ Weight Control: Code – Excl06
rebellion, revolution, insurrection, military Expenses related to the surgical treatment
or usurped acts, nuclear weapons/ of obesity that does not fulfil all the below
materials, chemical and biological conditions:
weapons, radiation of any kind.
i. Surgery to be conducted is upon the advice
2. Intentional self-injury or attempted suicide. of the Doctor
3. Breach of law: Code – Excl10 ii. The surgery/Procedure conducted should
Expenses for treatment directly arising be supported by clinical protocols
from or consequent upon any Insured iii. The member has to be 18 years of age or
Person committing or attempting to commit older and
a breach of law with criminal intent.
iv. Body Mass Index (BMI);
4. Hazardous or Adventure sports: Code –
Excl09 a. greater than or equal to 40 or
Expenses related to any treatment b. greater than or equal to 35 in conjunction

necessitated due to participation as a with any of the following severe co-
professional in hazardous or adventure morbidities following failure of less invasive
sports, including but not limited to, para- methods of weight loss:
jumping, rock climbing, mountaineering, i. Obesity-related cardiomyopathy
rafting, motor racing, horse racing or scuba ii. Coronary heart disease
diving, hand gliding, sky diving, deep-sea
iii. Severe Sleep Apnoea
diving.
iv. Uncontrolled Type2 Diabetes
5. Any Insured Person’s participation or
involvement in naval, military or air force 11. Expenses related to the treatment for
operation. correction of eye sight due to refractive
error less than 7.5 dioptres. Code – Excl15
12. Cosmetic or plastic Surgery: Code – Excl08
Expenses for cosmetic or plastic surgery
or any treatment to change appearance
unless for reconstruction following an
Accident, Burn(s) or Cancer or as part of
medically necessary treatment to remove a
direct and immediate health risk to the
insured. For this to be considered a
medical necessity, it must be certified by
the attending Medical Practitioner.
13. Circumcisions (unless necessitated by
Illness or injury and forming part of
treatment)
14. Change-of-Gender treatments: Code –
Excl07
Expenses related to any treatment,
including surgical management, to change
characteristics of the body to those of the
opposite sex.
Prospectus
Optima Restore
15. Any non-allopathic treatment except to the prescribed by a medical practitioner as part
extent of coverage provided for under of hospitalization claim or day care
‘In-patient Hospitalization treatment’ cover. procedure. Code – Excl14
16. Conditions for which treatment could have 24. Sleep-apnoea.
been done on an outpatient basis without
25. Congenital external diseases, defects or
any Hospitalisation.
anomalies
17. Unproven Treatments:
26. Maternity: Code – Excl18
Expenses related to any unproven
a. Medical treatment expenses traceable
treatment, services and supplies for or
to childbirth (including complicated
in connection with any treatment. Unproven
deliveries and caesarean sections
treatments are treatments, procedures
incurred during hospitalization) except
or supplies that lack significant medical
documentation to support their ectopic pregnancy;
effectiveness. Code – Excl16 b. Expenses towards miscarriage (unless due
18. Investigation & Evaluation: Code – Excl04 to an accident) and lawful medical
termination of pregnancy during the policy
a. Expenses related to any admission
period.
primarily for diagnostics and evaluation
purposes only are excluded. 27. Sterility and Infertility: Code – Excl17
Expenses related to sterility and infertility.
b. Any diagnostic expenses which are not
related or not incidental to the current This includes:
diagnosis and treatment are excluded. a. Any type of contraception, sterilization
19. Rest Cure, rehabilitation and respite care: b. Assisted Reproduction services including
Code – Excl05 artificial insemination and advanced
a. Expenses related to any admission reproductive technologies such as IVF,
primarily for enforced bed rest and not for ZIFT, GIFT, ICSI
receiving treatment. This also includes: c. Gestational Surrogacy
i. Custodial care either at home or in a d. Reversal of sterilization
nursing facility for personal care such as
help with activities of daily living such 28. The expense incurred by the insured on
as bathing, dressing, moving around either organ donation.
by skilled nurses or assistant or non-skilled 29. Treatment and supplies for analysis and
persons. adjustments of spinal subluxation,
ii. Any services for people who are terminally diagnosis and treatment by manipulation
ill to address physical, social, emotional of the skeletal structure; muscle stimulation
and spiritual needs. by any means except treatment of fractures
(excluding hairline fractures) and
20. Preventive care, vaccination including
inoculation and immunisations (except in dislocations of the mandible and
case of post-bite treatment); extremities.
21. Provision or fitting of hearing aids, 30. Any non-medical expenses mentioned in
spectacles or contact lenses including Annexure I.
optometric therapy, any treatment and 31. Excluded Providers: Code – Excl11
associated expenses for alopecia, Expenses incurred towards treatment in
baldness, wigs, or toupees, medical any hospital or by any Medical Practitioner
supplies including elastic stockings, or any other provider specifically excluded
diabetic test strips, and similar products. by the Insurer and disclosed in its website /
22. Treatments received in heath hydros, notified to the policyholders are not
nature cure clinics, spas or similar admissible. However, in case of life
establishments or private beds registered as threatening situations or following
a nursing home attached to such an accident, expenses up to the stage of
establishments or where admission is stabilization are payable but not the
arranged wholly or partly for domestic complete claim.
reasons. Code – Excl13 32. Treatment rendered by a Medical
23. Dietary supplements and substances that Practitioner which is outside his discipline
can be purchased without prescription, or the discipline for which he is licensed.
including but not limited to Vitamins,
minerals and organic substances unless
Prospectus
Optima Restore
Limited at least 48 hours prior to the hospitalization.

33. Treatments rendered by a Medical
Practitioner who is a member of the • HDFC ERGO General Insurance Company Limited will check
Insured Person’s family or stays with him, your coverage as per the eligibility and send an authorization
however proven material costs are eligible letter to the provider. In case there is any deficiency in the
for reimbursement in accordance with the documents sent, the same shall be communicated to the
applicable cover. hospital within 1 hours of receipt of documents.
34. Any treatment or part of a treatment that is • Please pay the non-medical and expenses not covered to the
not of a reasonable charge and not hospital prior to the discharge.
Medically Necessary. • In case the ailment /treatment is not covered under the policy a
35. Drugs or treatments which are not rejection letter would be sent to the provider within 1 hours.
supported by a prescription. Note:
36. Any specific time bound or lifetime • Insured person is entitled for cashless coverage only in our
exclusion(s) applied by us and specified in empanelled hospitals.
the Schedule and accepted by the insured.
• Please refer to the list of empanelled hospitals on our website or
37. Admission for administration of the list provided along with Policy kit or call us on our customer
Intra-articular or Intra-lesional injections, care number at 0226234 6234 / 0120 6234 6234.
Supplementary medications like
• Rejection of cashless facility in no way indicates rejection of the
Zolendronic acid (Trade name Zometa,
claim.
Reclast, etc) or IV immunoglobulin infusion
Renewal of Policy:
38. Dental treatment and surgery of any kind,
unless requiring Hospitalisatio A health insurance policy shall be renewable except on grounds of
established fraud or non-disclosure or misrepresentation by the insured,
provided the policy is not withdrawn and also subject to conditions stated
Claim Procedure: under Moratorium clause.
i. The Company shall endeavour to give notice for Renewal.
HDFC ERGO General Insurance Company Limited will process all ii. Renewal of a health insurance policy shall not be denied on the
claims under this policy. ground that the insured had made a claim or claims in the preceding
policy years, except for benefit based policies where the policy
terminates following payment of the benefit covered under the
Intimation & Assistance - Please contact HDFC ERGO General policy like critical illness policies.
Insurance Company at least 7 days prior to an event which might give
iii. The company shall condone a delay in renewal up to the grace
rise to a claim. For any emergency situations, kindly contact HDFC
period from the due date of renewal without considering such
ERGO General Insurance Company Limited within 24 hours of the
condonation as a break in policy.
event.
iv. No loading shall apply on renewals based on individual claims
Procedure for Reimbursement of Medical Expenses –
experience
• HDFC ERGO General Insurance Company Limited must
v. The Company shall not resort to fresh underwriting unless there is
be informed no later than 7 days of completion of such
an increase in sum insured. In case increase in sum insured is
treatment, consultation or procedure using the Claim Intimation
requested by the Policyholder, the Insurer may underwrite only to
Form.
the extent of increased sum insured.
• Please send the duly signed claim form and all the information/
vi. Renewal premium due can be paid prior to the due date as per
documents mentioned therein to HDFC ERGO General
norms set out by the Company..
Insurance Company Limited 15 days of the occurrence of the
Incident. The Company may accept claims where documents • Basic Sum Insured Enhancement – Basic sum insured can be
have been provided after a delayed interval only in special enhanced only at the time of renewal subject to the underwriting
circumstances and for the reasons beyond the control of the norms and acceptability criteria of the policy. If the insured
insured. enhances the basic sum insured one grid up, no fresh medicals
shall be required. In cases where the basic sum insured
* Please refer to claim form for complete documentation.
enhanced is more than one grid up, the case may be subject to
• If there is any deficiency in the documents/information submitted medicals. In case of enhancement in the basic sum insured
by you, HDFC ERGO General Insurance Company Limited waiting period will apply afresh in relation to the amount by which
will send the deficiency letter within 7 days of receipt of the claim the basic sum insured has been enhanced. However the quantum
documents. of increase shall be at the discretion of the company.
• On receipt of the complete set of claim documents, HDFC Tax Benefit:
ERGO General Insurance Company Limited will send admissible
The premium amount paid under this policy qualifies for deduction
amount, along with a settlement statement within 30 days.
under Section 80D of the Income Tax Act.
• The payment will be made in the name of the Policyholder.
Requirement:
Note: Payment will only be made for items covered under your
policy and upto the limits therein. Completed proposal form
Procedure to avail Cashless facility - Pre- Policy Check-up:
• For any emergency Hospitalization, HDFC ERGO General Pre-Policy Check-up at our network may be required based upon
Insurance Company Limited must be informed no later than 24 the age and basic sum insured.
hours after hospitalization. • We will reimburse 100% of the expenses incurred per Insured
• For any planned hospitalization, kindly seek cashless Person on the acceptance of the proposal.
authorization from HDFC ERGO General Insurance Company
Prospectus
Optima Restore
• If Proposal is declined post PPC, 100% of Medical test charges • Aggregate Deductible Discount: If Aggregate Deductible is opted
will be borne by the customer for Rs. 3,00,000 & 500,000 sum for all Insured Person, following discount will be applicable on the
insured, 50% for Rs. 10,00,000 Sum Insured and NIL for other Sum Policy premium
Insureds.
• In case of any adverse medical declaration on the proposal form,
Deductible Discount % by Aggregate Deductible for All Ages
we may request for additional medical tests
(INR) For Base Sum For Base Sum Insured >
Discounts:
Insured < = 20,00,000
• Online Discount: The Insured Person is eligible for 5% discount on 20,00,000
premium in case he / she purchase the Policy online from the
25,000 25% 15%
Company’s website or the Company’s mobile app. The subsequent
Renewal of the same Policy will continue to enjoy the 5% discount, 50,000 40% 30%
provided the Policy remains without the involvement of any other 1,00,000 50% 40%
insurance agent or insurance intermediary.
• Co-payment Discount: A premium discount of 10% or 20% shall
• Employee Discount: A discount of 5 % on the Premium is applicable apply, if you choose to opt for a co-payment of 10% or 20%
if any Insured Person is a HDFC Group employee (full time respectively.
employee) / Munich Re Group employee (full time employee) at
• Stay Active
the time of enrolment, or subsequent renewal; provided that such
Policy is purchased through the Company’s website or the We will offer a discount at each renewal if the insured member
Company’s mobile app and without the involvement of any achieves the average step count target on the mobile application
insurance agent or insurance intermediary. provided by Us in the specified time interval ( calculated from the
policy risk start date) as per the grid below. In an individual policy,
• Loyalty Discount: If any Insured Person has an active retail
the average step count would be calculated per adult member and
insurance Policy with premium above Rs. 2,000 with the Company,
in a floater policy it would be an average of all adult members
a discount of 2.5% on the Policy premium will be applicable at the
covered. Dependent children covered either in individual or floater
time of enrolment as well as subsequent renewals.
plan will not be considered for calculation of average steps.
• Family Discount: The Insured Person will be entitled to receive
This discount will be accrued at defined time intervals as given in
10% discount on the premium if two or more family members are
table below. The discount will be cumulated and offered as discount
covered under the same Policy under the individual Policy option.
on the renewal premium.
The above mentioned discounts are cumulative in nature and the
In individual policies the discount percentage (%) would be applied
total discount offered under Employee discount, Online discount,
on premium applicable per insured member (Dependent Children
Loyalty discount and Family discount shall not exceed 20%.
are not eligible for this stay active discount in an individual policy)
• Long Term Policy Discount: If the Policy Period is more than one and in a floater policy it would be applied on premium applicable
year, the Insured Person will be entitled to receive a discount of on policy.
7.5% and 10% will be offered in case a Policy is purchased for
2-year and 3-year tenure respectively, provided he has paid the
premium in advance as a single premium.
The discount grid would be as per the table below:

1 Year Policy
Time Interval (calculated from policy risk start date)
Average Step Target Risk start date or date 91-180 days 181-270 days 271-300 days Maximum
of download of mobile Discount at the
application -90 days end of the year
5000 or below 0% 0% 0% 0% 0%
5001 to 8000 0.5% 0.5% 0.5% 0.5% 2%
8001 to 10000 1.25% 1.25% 1.25% 1.25% 5%
Above 10000 2% 2% 2% 2% 8%
2 Year Policy
Average Step Risk start date or date 91-180 181-270 271-300 361-450 451-540 541-630 631-660 Maximum Discount
target of download of mobile days days days days days days days at the end of the
application -90 days year
5000 or below 0% 0% 0% 0% 0% 0% 0% 0% 0%
5001 to 8000 0.25% 0.25% 0.25% 0.25% 0.25% 0.25% 0.25% 0.25% 2%
8001 to 10000 .625% .625% .625% .625% .625% .625% .625% .625% 5%
Above 10000 1% 1% 1% 1% 1% 1% 1% 1% 8%
Prospectus
Optima Restore
3 Year Policy
Average Step Risk start date or date 91-180 181-270 days 271-300 361-450 451-540 days
target of download of mobile days days days
application -90 days
5000 or below 0% 0% 0% 0% 0% 0%
5001 to 8000 0.1667% 0.1667% 0.1667% 0.1667% 0.1667% 0.1667%
8001 to 10000 0.41667% 0.41667% 0.41667% 0.41667% 0.41667% 0.41667%
Above 10000 0.6667% 0.6667% 0.6667% 0.6667% 0.6667% 0.6667%
541-630 days 631-720 days 721-810 811-900 days 901-990 991-1020 Maximum Discount at the
days days days end of 3 years
0% 0% 0% 0% 0% 0% 0%
0.1667% 0.1667% 0.1667% 0.1667% 0.1667% 0.1667% 2%
0.41667% 0.41667% 0.41667% 0.41667% 0.41667% 0.41667% 5%
0.6667% 0.6667% 0.6667% 0.6667% 0.6667% 0.6667% 8%
The mobile app must be downloaded within 30 days of the policy risk start date to avail this benefit. The average step count completed by an Insured
member would be tracked on this mobile application.
We reserve the right to remove or reduce any count of steps if found to be achieved in unfair manner by manipulation.
Illustration
Policy start date 1st Jan 2016

Policy Tenure 1 year
Time Interval
Risk start date or date 91 days - 180 days 181 days - 270 days 271 - 300 days
of download of mobile
application -90 days
Average steps taken in the 8500 10000 5001 7500
defined time period
Discount %applicable 1.25% 1.25% 0.5% 0.5%
Please note that this example is for enumerative purposes only, the
Total discount applicable on renewal premium = 3.5% decisions may vary based on age, co morbidities etc.
Loadings • We will inform you about the applicable risk loading or exclusion or
• We may apply a risk loading on the premium payable (based both as the case may be through a counter offer letter. You need
upon the declarations made in the proposal form and the health to revert to us with consent and additional premium (if any), within
status of the persons proposed for insurance). The maximum 7 days of the receipt of such counter offer letter. In case, you neither
risk loading applicable for an individual shall not exceed accept the counter offer nor revert to us within 7 days, we shall
above 100% per diagnosis / medical condition and an overall cancel your application and refund the premium paid within next 7
risk loading of over 150% per person. These loadings are days.
applied from Commencement Date of the policy including • The application of loading does not mean that the illness/ condition,
subsequent renewal(s) with us or on the receipt of the request of for which loading has been applied, would be covered from
enhancement in sum insured (for the enhanced Sum Insured). inception. Any waiting period as mentioned in Section 5 A i), ii) & iii)
For Example: Consider a male aged 35 who is undergoing treatment of the policy wordings or specifically mentioned on the Policy
for hypertension. Schedule shall be applied on illness/condition, as applicable.
• Please note that we will issue Policy only after getting your consent
Age Hypertension Treatment Systolic Diastolic Loading and additional premium, if any.
35 Yes Yes 110-145 70-95 10% • We will not apply any additional loading on your policy premium at
35 Yes Yes 146-160 70-95 20% renewal based on claim experience.
35 Yes Yes 110-140 96-105 20% • Please visit our nearest branch to refer our underwriting guidelines,
if required.
35 Yes Yes >160 Any Reject
35 Yes Yes Any >105 Reject
Prospectus
Optima Restore
Cancellation of sixty continuous months would be applicable from the date of

i. The Policyholder may cancel this policy by giving 15days’ written enhancement of sums insured only on the enhanced limits
notice and in such an event, the Company shall refund to the Portability
Insured a pro-rata premium for the unexpired Policy Period. The Insured Person will have the option to port the Policy to other
ii. Note : For Policies where premium is paid by instalment : In case of insurers by applying to such Insurer to port the entire policy along
admissible claim under the Policy, future instalment for the current with all the members of the family, if any, at least 45 days before,
Policy Year will be adjusted in the claim amount and no refund of but not earlier than 60 days from the policy renewal date as per
any premium will be applicable during the Policy Year.. IRDAI guidelines related to Portability. If such person is presently
iii. The Company may cancel the policy at any time on grounds of covered and has been continuously covered without any lapses
misrepresentation non-disclosure of material facts, fraud by the under any health insurance policy with an Indian General/Health
insured person by giving 15 days’ written notice. There would be insurer, the proposed Insured Person will get the accrued continuity
no refund of premium on cancellation on grounds of benefits in waiting periods as per IRDAI guidelines on portability.
misrepresentation, non-disclosure of material facts or fraud. For Detailed Guidelines on Portability, kindly refer the link
Renewability https://www.irdai.gov.in/ADMINCMS/cms/frmGuidelines_Layout.
• There shall be no cover ceasing age on renewal. aspx?page=PageNo3987
Free Look Period Migration
The Free Look Period shall be applicable on new individual health The Insured Person will have the option to migrate the Policy to
insurance policies and not on renewals or at the time of porting/ other health insurance products/plans offered by the Company by
migrating the Policy. applying for Migration of the policyatleast30 days before the policy
renewal date as per IRDAI guidelines on Migration. If such person is
The Insured Person shall be allowed free look period of Thirty
presently covered and has been continuously covered without any
days from date of receipt of the policy document to review the terms
lapses under any health insurance product/plan offered by the
and conditions of the policy, and to return the same if not acceptable.
Company, the Insured Person will get the accrued continuity
If the Insured has not made any claim during the Free Look Period, benefits in waiting periods as per IRDAI guidelines on Migration.
the insured shall be entitled to
For Detailed Guidelines on Migration, kindly refer the link
i. a refund of the premium paid less any expenses incurred by the
https://www.irdai.gov.in/ADMINCMS/cms/frmGuidelines_Layout.
Company on medical examination of the Insured Person and
aspx?page=PageNo3987
the stamp duty charges or
Possibility of Revision of terms of the Policy including the Premium Rates
ii. where the risk has already commenced and the option of return
of the Policy is exercised by the Insured Person, a deduction The Company, with prior approval of IRDAI, may revise or modify
towards the proportionate risk premium for period of cover or the terms of the Policy including the premium rates. The Insured
Person shall be notified three months before the changes are
iii. Where only a part of the insurance coverage has commenced,
effected
such proportionate premium commensurate with the insurance
coverage during such period. Withdrawal of Policy
Disclosure of Information i. In the likelihood of this product being withdrawn in future, the
Company will intimate the Insured Person about the same 90 days
The policy shall be void and all premium paid thereon shall be
prior to expiry of the policy.
forfeited to the Company in the event of misrepresentation, mis
description or non-disclosure of any material fact by the policyholder. ii. Insured Person will have the option to migrate to similar health
insurance product available with the Company at the time of renewal
Utilization of Sum Insured
with all the accrued continuity benefits such as Cumulative Bonus,
The sequence of utilization of the Sum Insured in this Policy, subject waiver of waiting period as per IRDAI guidelines, provided the
to the optional covers in force under the Policy, will be as follows; policy has been maintained without a break.
i. Aggregate deductible (if applicable) Nomination:
ii. Co-payment (if applicable) The Policyholder is required at the inception of the Policy to make
iii. Basic Sum Insured / Benefit sub-limit a nomination for the purpose of payment of claims under the Policy
in the event of death of the Policyholder. Any change of nomination
iv. Multiplier Benefit (if applicable and available)
shall be communicated to the Company in writing and such change
v. Restore Benefit shall be effective only when an endorsement on the Policy is
vi. Unlimited Restore (if applicable) made. In the event of death of the Policyholder, the Company will
Complete Discharge pay the nominee {as named in the Policy Schedule/Policy
Certificate/Endorsement (if any)} and in case
Any payment to the Policyholder, Insured Person or his/ her
nominees or his/ her legal representative or assignee or to the Condition Precedent to admission of Liability
Hospital, as the case may be, for any benefit under the Policy shall The terms and conditions of the Policy must be fulfilled by the
be a valid discharge towards payment of claim by the Company to Insured Person for the Company to make any payment for claim(s)
the extent of that amount for the particular claim. arising under the Policy.
Moratorium Period Fraud
After completion of sixty continuous months of coverage (including If any claim made by the Insured Person, is in any respect
portability and migration) in health insurance policy, no policy and fraudulent, or if any false statement, or declaration is made or used
claim shall be contestable by the insurer on grounds of non- in support thereof, or if any fraudulent means or devices are used
disclosure, misrepresentation, except on grounds of established by the Insured Person or anyone acting on his/her behalf to obtain
fraud. This period of sixty continuous months is called as moratorium any benefit under this Policy, all benefits under this policy and the
period. The moratorium would be applicable for the sums insured of premium paid shall be forfeited.
the first policy. Wherever, the sum insured is enhanced, completion
Prospectus
Optima Restore
Any amount already paid against claims made under this Policy /coverages/revision in premium.
but which are found fraudulent later shall be repaid by all d. The Company should be informed at least 15 days prior to the due
recipient(s)/policyholder(s), who have made that particular claim, date of instalment premium if the Insured Person wishes to
who shall be jointly and severally liable for such repayment to the discontinue the ECS facility.
Insurer.
Non-payment of premium on due date as opted by the Insured
For the purpose of this clause, the expression “fraud” means any Person in the mandate form subject to an additional 15 days of
of the following acts committed by the Insured Person or by his relaxation period will lead to termination of the Policy.
agent or the hospital/doctor/any other party acting on behalf of the
Multiple Policies
Insured Person, with intent to deceive the insurer or to induce the
insurer to issue an insurance policy: i. In case of multiple policies taken by an Insured Person during a
period from one or more insurers to indemnify treatment costs, the
a) the suggestion, as a fact of that which is not true and which the
Insured Person shall have the right to require a settlement of his/
Insured Person does not believe to be true;
her claim in terms of any of his/her policies. In all such cases the
b) the active concealment of a fact by the Insured Person having Insurer chosen by the Insured Person shall be obliged to settle
knowledge or belief of the fact; the claim as long as the claim is within the limits of and according
c) any other act fitted to deceive; and to the terms of the chosen Policy.
d) any such act or omission as the law specially declares to be ii. Insured Person having multiple policies shall also have the right
fraudulent to prefer claims under this Policy for the amounts disallowed under
The Company shall not repudiate the claim and / or forfeit the any other policy / policies even if the Sum Insured is not exhausted.
Policy benefits on the ground of Fraud, if the Insured Person / Then the insurer shall independently settle the claim subject to the
beneficiary can prove that the misstatement was true to the best of terms and conditions of thisPolicy.
his knowledge and there was no deliberate intention to suppress iii. If the amount to be claimed exceeds the Sum Insured under a
the fact or that such misstatement of or suppression of material single Policy, the Insured Person shall have the right to choose
fact are within the knowledge of the Insurer. Insurer from whom he/she wants to claim the balance amount.
Premium Payment in Instalments iv. Where an Insured Person has policies from more than one Insurer
If the Insured Person has opted for payment of Premium on an to cover the same risk on indemnity basis, the Insured Person shall
installment basis i.e. Half Yearly, Quarterly or Monthly, as only be indemnified the treatment costs in accordance with the
mentioned in the Policy Schedule, the following Conditions shall terms and conditions of the chosen Policy.
apply (notwithstanding any terms contrary elsewhere in the Policy): Redressal of Grievance
a. Grace Period as mentioned in the table below would be given to In case of any grievance the insured person may contact the
pay the installment premium due for the Policy Company through:
Options Instalment Premium Grace Period • Website: www.hdfcergo.com

Option applicable • Toll free: 022 6234 6234 / 0120 6234 6234
Option 1 Multi-Year / Yearly 30 days • E-mail: [email protected]
Option 2 Half Yearly 30 days • Contact Details for Senior Citizen: 022 – 6242 – 6226
Option 3 Quarterly 30 days • E-mail specific for Senior citizens : [email protected]
Option 4 Monthly 15 Days

Insured Person may also approach the grievance cell at any of the
Company’s branches with the details of grievance.
b. If premium is paid in instalments then coverage will be available
during the grace period also. (Note: In case of non-instalment
premium payment, coverage shall not be available for the period If Insured Person is not satisfied with the redressal of grievance through
for which no premium is received). one of the above methods, Insured Person may contact the grievance
officer at [email protected]
c. The Insured Person will get the accrued continuity benefit in respect
of the “Waiting Periods”, “Specific Waiting Periods” in the event of
payment of premium within the stipulated Grace Period The Insurer is required to comply with the award of the Insurance
d. No interest will be charged If the installment premium is not paid Ombudsman within 30 days of receipt of award by the Insurer. In case
on due date the Insurer does not honour the ombudsman award, a penalty of Rs.
5000/- per day shall be payable to the complainant. Such penalty is in
e. In case of installment premium due not received within the Grace
addition to the penal interest liable to be paid by the Insurer under The
Period, the Policy will get cancelled
Insurance Ombudsman Rules, 2017.
f. In the event of a claim, all subsequent premium installments shall
For updated details of grievance officer, kindly refer the link: https://www.
immediately become due and payable
hdfcergo.com/customer-voice/grievances
g. The Company has the right to recover and deduct all the pending
installments from the claim amount due under the Policy.
Instalment premium payment through Auto Debit/ECS Facility
a. If Option of Premium payment by instalment is opted through auto
Debit/ECS facility, Electronic Clearing Service (ECS) Mandate form
needs to be completely filled & signed by the Insured Person.
b. The Premium amount which would be auto debited & frequency of
instalment should be duly filled in the ECS Mandate form.
c. New ECS Mandate Form is required to be filled in case of any
change in the Premium due to change of Sum Insured / age / plan
Prospectus
Optima Restore
Schedule of Benefits
Optima Restore Individual
Basic Sum Insured per 3.00 5.00 10.00 15.00 20.00, 25.00,
Insured Person per 50.00, 100.00
Policy Year (Rs. in Lakh)
1a) In-patient Treatment Covered upto sum Covered upto sum Covered upto sum Covered upto sum Covered upto sum
insured insured insured insured insured
1b) Pre-Hospitalization Covered, upto 60 Covered, upto 60 Covered, upto 60 Covered, upto 60 Covered, upto 60
Days Days Days Days Days
1c) Post-Hospitalization Covered, upto 180 Covered, upto 180 Covered, upto 180 Covered, upto 180 Covered, upto 180
1d) Day Care Procedures Covered upto sum Covered upto sum Covered upto sum Covered upto sum Covered upto sum
1e) Domiciliary Treatment Covered upto sum Covered upto sum Covered upto sum Covered upto sum Covered upto sum
1f) Organ Donor Covered upto sum Covered upto sum Covered upto sum Covered upto sum Covered upto sum
1g) Emergency Upto Rs.2,000 per Upto Rs.2,000 per Upto Rs.2,000 per Upto Rs.2,000 per Upto Rs.2,000 per
Ambulance Hospitalization Hospitalization Hospitalization Hospitalization Hospitalization
1h) Daily Cash for Rs.800 per day, Rs.800 per day, Rs.800 per day, Rs.800 per day, Rs.1000 per day,
choosing Shared Maximum Rs.4,800 Maximum Rs.4,800 Maximum Rs.4,800 Maximum Rs.4,800 Maximum Rs.6,000
Accommodation
1i) E-Opinion in respect Covered Covered Covered Covered Covered
of a Critical Illness
1j) Emergency Air Not Covered Not Covered Covered upto Covered upto Covered upto
Ambulance Cover rs. 2.5 Lacs per rs. 2.5 Lacs per rs. 2.5 Lacs per
hospitalization and hospitalization and hospitalization and
maximum upto sum maximum upto sum maximum upto sum
insured in an year insured in an year insured in an year
2) Restore Benefit Equal to 100% of Equal to 100% of Equal to 100% of Equal to 100% of Equal to 100% of
Basic Sum Insured Basic Sum Insured Basic Sum Insured Basic Sum Insured Basic Sum Insured
2 b. Unlimited Restore Applicable if opted Applicable if opted Applicable if opted Applicable if opted Applicable if opted
Benefit (Optional Benefit)
2c) Aggregate Deductible 25K/50K/1L 25K/50K/1L 25K/50K/1L 25K/50K/1L 25K/50K/1L
(Optional Benefit)
2d) Co-Payment (Optional 10% / 20% 10% / 20% 10% / 20% 10% / 20% 10% / 20%
Benefit)
3) Preventive Health Not Applicable Upto Rs. 1500 Upto Rs. 2000 Upto Rs. 4000 Upto Rs. 5000
Checkup (per person)
4) Multiplier Benefit Bonus of 50% of the Bonus of 50% of the Bonus of 50% of the Bonus of 50% of the Bonus of 50% of the
Basic Sum Insured Basic Sum Insured Basic Sum Insured for Basic Sum Insured for Basic Sum Insured
for every claim free for every claim free every claim free year, every claim free year, for every claim free
year, maximum upto year, maximum upto maximum upto 100%. maximum upto 100%. year, maximum upto
100%. In case of 100%. In case of In case of claim, In case of claim, 100%. In case of
claim, bonus will claim, bonus will bonus will be reduced bonus will be reduced claim, bonus will
be reduced by 50% be reduced by 50% by 50% of the Basic by 50% of the Basic be reduced by 50%
of the Basic Sum of the Basic Sum Sum Insured at the Sum Insured at the of the Basic Sum
Insured at the time Insured at the time time of renewal time of renewal Insured at the time of
of renewal of renewal renewal
Prospectus
Optima Restore
Optima Restore Family
Basic Sum Insured per 3.00 5.00 10.00 15.00 20.00, 25.00,
Insured Person per Policy 50.00, 100.00
Year (Rs. in Lakh)
1a) In-patient Treatment Covered upto sum Covered upto sum Covered upto sum Covered upto sum Covered upto sum
1b) Pre-Hospitalization Covered, upto 60 Covered, upto 60 Covered, upto 60 Covered, upto 60 Covered, upto 60
1c) Post-Hospitalization Covered, upto 180 Covered, upto 180 Covered, upto 180 Covered, upto 180 Covered, upto 180
1d) Day Care Procedures Covered upto sum Covered upto sum Covered upto sum Coveredupto sum Covered upto sum
1e) Domiciliary Treatment Covered upto sum Covered upto sum Covered upto sum Covered upto sum Covered upto sum
1f) Organ Donor Covered upto sum Covered upto sum Covered upto sum Covered upto sum Covered upto sum
1g) Emergency Ambulance Upto Rs.2,000 per Upto Rs.2,000 per Upto Rs.2,000 per Upto Rs.2,000 per Upto Rs.2,000 per
Hospitalization Hospitalization Hospitalization Hospitalization Hospitalization
1h) Daily Cash for choosing Rs.800 per day, Rs.800 per day, Rs.800 per day, Rs.800 per day, Rs.1000 per day,
Shared Accommodation Maximum Rs.4,800 Maximum Rs.4,800 Maximum Rs.4,800 Maximum Rs.4,800 Maximum Rs.6,000
1i) E-Opinion in respect of Covered Covered Covered Covered Covered
a Critical Illness
1j) Emergency Air Not Covered Not Covered Covered upto Covered upto Covered upto
Ambulance Cover rs. 2.5 Lacs per rs. 2.5 Lacs per rs. 2.5 Lacs per
hospitalization and hospitalization and hospitalization and
maximum upto sum maximum upto sum maximum upto sum
insured in an year insured in an year insured in an year
2a) Restore Benefit Equal to 100% of Equal to 100% of Equal to 100% of Equal to 100% of Equal to 100% of
Basic Sum Insured Basic Sum Insured Basic Sum Insured Basic Sum Insured Basic Sum Insured
2b) Unlimited Restore Applicable if opted Applicable if opted Applicable if opted Applicable if opted Applicable if opted
Benefit (Optional Benefit)
2c) Aggregate Deductible 25K/50K/1L 25K/50K/1L 25K/50K/1L 25K/50K/1L 25K/50K/1L
(Optional Benefit)
2d) Co-Payment (Optional 10% / 20% 10% / 20% 10% / 20% 10% / 20% 10% / 20%
Benefit)
3) Preventive Health Not Applicable Upto Rs 2500 Upto Rs.5000 Upto Rs. 8000 Upto Rs. 10,000
Checkup (per policy)
4) Multiplier Benefit Bonus of 50% of the Bonus of 50% of the Bonus of 50% of the Bonus of 50% of the Bonus of 50% of the
Basic Sum Insured Basic Sum Insured for Basic Sum Insured Basic Sum Insured Basic Sum Insured
for every claim free every claim free year, for every claim free for every claim free for every claim free
year, maximum upto maximum upto 100%. year, maximum upto year, maximum upto year, maximum upto
100%. In case of In case of claim, 100%. In case of 100%. In case of 100%. In case of
claim, bonus will bonus will be reduced claim, bonus will claim, bonus will claim, bonus will
be reduced by 50% by 50% of the Basic be reduced by 50% be reduced by 50% be reduced by 50%
of the Basic Sum Sum Insured at the of the Basic Sum of the Basic Sum of the Basic Sum
Insured at the time time of renewal Insured at the time of Insured at the time Insured at the time of
of renewal renewal of renewal renewal
Premium rates:
• The premium under individual coverage will be charged on the completed age of the individual insured member.
• In case of Family Floater policies Floater discount of 55% will be applied on all the members except the oldest member.
• The premium for the policy will remain the same for the Policy Period mentioned in the policy schedule.
• Please note that your premium at renewal may change due to a change in your age or changes in the applicable tax rate.
• Premium rates are subject to change with prior approval from IRDA.
• The Sum Insured of the dependent insured members should be equal to or less than the Sum Insured of the Primary Insured member. In case
where two or more children are covered, the Sum Insured for all the children must be same. Sum insured of all Dependent Parents and
Dependent Parent in law must be same.
• The premium will be computed basis the city of residence provided by the insured person in the application form. The premium that would be
Prospectus
Optima Restore
applicable zone wise and the cities defined in each zone are as under:
o Tier 1 : Delhi, NCR, Mumbai, Thane, Mumbai Suburban and Navi Mumbai, Surat, Ahmedabad & Vadodara
o Tier 2 : Rest of India- All other cities
Pl Note. Premium rates and policy terms and conditions are for standard healthy individuals. These may change post underwriting of proposal based
on medical tests (where applicable) and information provided on the proposal form.
Add – On Covers:
‘Optima Restore’ offers following Add on Covers:
• Optima Wellbeing (Add on) : Covers expenses for various outpatient benefits
• 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
• Protector Rider: Covers expenses which are not payable under the Base Plan as per the List of Excluded items released by IRDA along with
benefits such as Multiplier benefit protector & Sum Insured protector
• Hospital daily cash rider: Daily cash benefit upto 1K/2K/3K
• Critical Advantage rider: covers planned treatment abroad for listed 8 major illness
• my:health Critical Illness: Comprehensive policy with coverage for 50 Critical Illnesses
(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).
Gross Premium Tables (Exclusive of Taxes)
Optima Restore - Gross Premium (Excl. GST) - Tier 1 (Delhi, NCR, Mumbai, Thane, Mumbai Suburban and Navi Mumbai,
Surat, Ahmedabad & Vadodara)
Sum Insured
Age Band
3,00,000 5,00,000 10,00,000 15,00,000 20,00,000 25,00,000 50,00,000 1,00,00,000
0 6,300 7,350 7,950 8,900 9,700 10,350 12,550 15,550
1 6,400 7,450 8,050 9,000 9,800 10,500 12,700 15,800
2 6,500 7,550 8,150 9,100 9,900 10,650 12,850 16,050
3 6,600 7,650 8,250 9,200 10,000 10,800 13,000 16,300
4 6,700 7,750 8,350 9,300 10,100 10,950 13,150 16,550
5 6,800 7,850 8,450 9,400 10,200 11,100 13,300 16,800
6 6,900 7,950 8,550 9,500 10,300 11,250 13,450 17,050
7 7,000 8,050 8,650 9,600 10,400 11,400 13,600 17,300
8 7,100 8,150 8,750 9,700 10,500 11,550 13,750 17,550
9 7,200 8,250 8,850 9,800 10,600 11,700 13,900 17,800
10 7,300 8,350 8,950 9,900 10,700 11,850 14,050 18,050
11 7,400 8,450 9,050 10,000 10,800 12,000 14,200 18,300
12 7,500 8,550 9,150 10,100 10,900 12,150 14,350 18,550
13 7,600 8,650 9,250 10,200 11,000 12,300 14,500 18,800
14 7,700 8,750 9,350 10,300 11,100 12,450 14,650 19,050
15 7,800 8,850 9,450 10,400 11,200 12,600 14,800 19,300
16 7,900 8,950 9,550 10,500 11,300 12,750 14,950 19,550
17 8,000 9,050 9,650 10,600 11,400 12,900 15,100 19,800
18 9,550 10,850 11,900 12,300 13,100 14,050 16,250 20,900
19 9,650 10,950 12,050 12,500 13,300 14,250 16,500 21,200
20 9,750 11,050 12,200 12,700 13,500 14,450 16,750 21,500
21 9,850 11,150 12,350 12,900 13,700 14,650 17,000 21,800
22 9,950 11,250 12,500 13,100 13,900 14,850 17,250 22,100
23 10,050 11,350 12,650 13,300 14,100 15,050 17,500 22,400
24 10,150 11,450 12,800 13,500 14,300 15,250 17,750 22,700
25 10,250 11,550 12,950 13,700 14,500 15,450 18,000 23,000
26 10,350 11,650 13,100 13,900 14,700 15,650 18,250 23,300
27 10,450 11,750 13,250 14,100 14,900 15,850 18,500 23,600
28 10,550 11,850 13,400 14,300 15,100 16,050 18,750 23,900
29 10,650 11,950 13,550 14,500 15,300 16,250 19,000 24,200
30 10,750 12,050 13,700 14,700 15,500 16,450 19,250 24,500
Prospectus
Optima Restore
31 10,850 12,150 13,850 14,900 15,700 16,650 19,500 24,800

32 10,950 12,250 14,000 15,100 15,900 16,850 19,750 25,100
33 11,050 12,350 14,150 15,300 16,100 17,050 20,000 25,400
34 11,150 12,450 14,300 15,500 16,300 17,250 20,250 25,700
35 11,250 12,550 14,450 15,700 16,500 17,450 20,500 26,000
36 11,450 13,150 14,850 16,000 16,800 17,950 20,900 26,450
37 11,650 13,350 15,100 16,250 17,100 18,250 21,250 26,850
38 11,850 13,550 15,350 16,500 17,400 18,550 21,600 27,250
39 12,050 13,750 15,600 16,750 17,700 18,850 21,950 27,650
40 12,250 13,950 15,850 17,000 18,000 19,150 22,300 28,050
41 12,450 14,150 16,100 17,250 18,300 19,450 22,650 28,450
42 12,650 14,350 16,350 17,500 18,600 19,750 23,000 28,850
43 12,850 14,550 16,600 17,750 18,900 20,050 23,350 29,250
44 13,050 14,750 16,850 18,000 19,200 20,350 23,700 29,650
45 13,250 14,950 17,100 18,250 19,500 20,650 24,050 30,050
46 16,250 17,400 20,700 22,350 23,500 24,900 29,400 36,050
47 17,100 18,300 21,800 23,550 24,950 26,250 31,200 38,450
48 17,950 19,200 22,900 24,750 26,400 27,600 33,000 40,850
49 18,800 20,100 24,000 25,950 27,850 28,950 34,800 43,250
50 19,650 21,000 25,100 27,150 29,300 30,300 36,600 45,650
51 20,600 22,250 26,300 29,950 30,950 31,950 38,500 48,300
52 21,250 23,300 27,500 31,400 32,400 33,500 40,400 50,350
53 21,900 24,350 28,700 32,850 33,850 35,050 42,300 52,400
54 22,550 25,400 29,900 34,300 35,300 36,600 44,200 54,450
55 23,200 26,450 31,100 35,750 36,750 38,150 46,100 56,500
56 26,300 28,850 34,850 38,300 39,350 40,950 49,400 61,250
57 27,250 30,100 36,250 40,500 41,900 43,450 52,400 65,000
58 28,200 31,350 37,650 42,700 44,450 45,950 55,400 68,750
59 29,150 32,600 39,050 44,900 47,000 48,450 58,400 72,500
60 30,100 33,850 40,450 47,100 49,550 50,950 61,400 76,250
61 31,100 35,200 46,400 49,600 53,600 56,050 67,300 83,450
62 31,950 36,550 47,850 52,100 57,400 60,750 72,750 90,200
63 32,800 37,900 49,300 54,600 61,200 65,450 78,200 96,950
64 33,650 39,250 50,750 57,100 65,000 70,150 83,650 1,03,700
65 34,500 40,600 52,200 59,600 68,800 74,850 89,100 1,10,450
66 41,950 47,700 64,500 69,900 78,300 81,650 1,01,150 1,22,750
67 43,150 49,450 66,500 72,900 81,650 85,650 1,04,950 1,28,800
68 44,350 51,200 68,500 75,900 85,000 89,650 1,08,750 1,34,850
69 45,550 52,950 70,500 78,900 88,350 93,650 1,12,550 1,40,900
70 46,750 54,700 72,500 81,900 91,700 97,650 1,16,350 1,46,950
71 49,150 56,500 74,950 85,200 95,650 1,01,900 1,22,100 1,53,050
72 50,150 57,800 77,350 88,450 98,700 1,05,100 1,27,350 1,58,750
73 51,150 59,100 79,750 91,700 1,01,750 1,08,300 1,32,600 1,64,450
74 52,150 60,400 82,150 94,950 1,04,800 1,11,500 1,37,850 1,70,150
75 53,150 61,700 84,550 98,200 1,07,850 1,14,700 1,43,100 1,75,850
76 56,300 64,750 88,450 1,03,350 1,13,600 1,20,300 1,49,750 1,84,700
77 58,250 67,250 92,350 1,07,300 1,18,500 1,25,850 1,55,350 1,92,150
78 60,200 69,750 96,250 1,11,250 1,23,400 1,31,400 1,60,950 1,99,600
79 62,150 72,250 1,00,150 1,15,200 1,28,300 1,36,950 1,66,550 2,07,050
80 64,100 74,750 1,04,050 1,19,150 1,33,200 1,42,500 1,72,150 2,14,500
81 68,574 79,256 1,10,832 1,29,379 1,44,879 1,54,292 1,88,931 2,34,274
82 68,574 79,256 1,10,832 1,29,379 1,44,879 1,54,292 1,88,931 2,34,274
Prospectus
Optima Restore
83 68,574 79,256 1,10,832 1,29,379 1,44,879 1,54,292 1,88,931 2,34,274

84 68,574 79,256 1,10,832 1,29,379 1,44,879 1,54,292 1,88,931 2,34,274
85 68,574 79,256 1,10,832 1,29,379 1,44,879 1,54,292 1,88,931 2,34,274
86 68,574 79,256 1,10,832 1,29,379 1,44,879 1,54,292 1,88,931 2,34,274
87 68,574 79,256 1,10,832 1,29,379 1,44,879 1,54,292 1,88,931 2,34,274
88 68,574 79,256 1,10,832 1,29,379 1,44,879 1,54,292 1,88,931 2,34,274
89 68,574 79,256 1,10,832 1,29,379 1,44,879 1,54,292 1,88,931 2,34,274
90 68,574 79,256 1,10,832 1,29,379 1,44,879 1,54,292 1,88,931 2,34,274
*Only for Renewal Purposes
Optima Restore Gross Premium (Excl. GST) - Tier 2 (Rest of India)

Sum Insured
Age Band
3,00,000 5,00,000 10,00,000 15,00,000 20,00,000 25,00,000 50,00,000 1,00,00,000
0 5,300 6,400 7,100 8,450 9,500 10,100 12,300 15,150
1 5,400 6,500 7,200 8,550 9,600 10,250 12,450 15,350
2 5,500 6,600 7,300 8,650 9,700 10,400 12,600 15,550
3 5,600 6,700 7,400 8,750 9,800 10,550 12,750 15,750
4 5,700 6,800 7,500 8,850 9,900 10,700 12,900 15,950
5 5,800 6,900 7,600 8,950 10,000 10,850 13,050 16,150
6 5,900 7,000 7,700 9,050 10,100 11,000 13,200 16,350
7 6,000 7,100 7,800 9,150 10,200 11,150 13,350 16,550
8 6,100 7,200 7,900 9,250 10,300 11,300 13,500 16,750
9 6,200 7,300 8,000 9,350 10,400 11,450 13,650 16,950
10 6,300 7,400 8,100 9,450 10,500 11,600 13,800 17,150
11 6,400 7,500 8,200 9,550 10,600 11,750 13,950 17,350
12 6,500 7,600 8,300 9,650 10,700 11,900 14,100 17,550
13 6,600 7,700 8,400 9,750 10,800 12,050 14,250 17,750
14 6,700 7,800 8,500 9,850 10,900 12,200 14,400 17,950
15 6,800 7,900 8,600 9,950 11,000 12,350 14,550 18,150
16 6,900 8,000 8,700 10,050 11,100 12,500 14,700 18,350
17 7,000 8,100 8,800 10,150 11,200 12,650 14,850 18,550
18 7,150 8,250 9,500 10,800 11,800 13,100 15,900 20,400
19 7,250 8,350 9,650 11,000 12,000 13,300 16,100 20,600
20 7,350 8,450 9,800 11,200 12,200 13,500 16,300 20,800
21 7,450 8,550 9,950 11,400 12,400 13,700 16,500 21,000
22 7,550 8,650 10,100 11,600 12,600 13,900 16,700 21,200
23 7,650 8,750 10,250 11,800 12,800 14,100 16,900 21,400
24 7,750 8,850 10,400 12,000 13,000 14,300 17,100 21,600
25 7,850 8,950 10,550 12,200 13,200 14,500 17,300 21,800
26 7,950 9,050 10,700 12,400 13,400 14,700 17,500 22,000
27 8,050 9,150 10,850 12,600 13,600 14,900 17,700 22,200
28 8,150 9,250 11,000 12,800 13,800 15,100 17,900 22,400
29 8,250 9,350 11,150 13,000 14,000 15,300 18,100 22,600
30 8,350 9,450 11,300 13,200 14,200 15,500 18,300 22,800
31 8,450 9,550 11,450 13,400 14,400 15,700 18,500 23,000
32 8,550 9,650 11,600 13,600 14,600 15,900 18,700 23,200
33 8,650 9,750 11,750 13,800 14,800 16,100 18,900 23,400
34 8,750 9,850 11,900 14,000 15,000 16,300 19,100 23,600
35 8,850 9,950 12,050 14,200 15,200 16,500 19,300 23,800
36 9,000 10,100 12,450 14,500 15,500 16,950 19,850 24,750
37 9,150 10,250 12,650 14,700 15,800 17,250 20,150 25,050
38 9,300 10,400 12,850 14,900 16,100 17,550 20,450 25,350
Prospectus
Optima Restore
39 9,450 10,550 13,050 15,100 16,400 17,850 20,750 25,650

40 9,600 10,700 13,250 15,300 16,700 18,150 21,050 25,950
41 9,750 10,850 13,450 15,500 17,000 18,450 21,350 26,250
42 9,900 11,000 13,650 15,700 17,300 18,750 21,650 26,550
43 10,050 11,150 13,850 15,900 17,600 19,050 21,950 26,850
44 10,200 11,300 14,050 16,100 17,900 19,350 22,250 27,150
45 10,350 11,450 14,250 16,300 18,200 19,650 22,550 27,450
46 13,500 13,900 18,000 20,250 22,650 23,900 28,250 34,250
47 14,100 14,650 18,950 21,350 23,850 25,200 29,800 36,550
48 14,700 15,400 19,900 22,450 25,050 26,500 31,350 38,850
49 15,300 16,150 20,850 23,550 26,250 27,800 32,900 41,150
50 15,900 16,900 21,800 24,650 27,450 29,100 34,450 43,450
51 16,600 18,000 23,250 26,400 29,050 30,750 36,400 45,850
52 17,250 18,750 24,100 28,000 30,550 32,400 38,250 47,800
53 17,900 19,500 24,950 29,600 32,050 34,050 40,100 49,750
54 18,550 20,250 25,800 31,200 33,550 35,700 41,950 51,700
55 19,200 21,000 26,650 32,800 35,050 37,350 43,800 53,650
56 21,950 23,400 30,150 35,300 37,700 39,850 46,950 57,550
57 22,600 24,400 31,450 37,450 40,350 42,300 49,800 61,450
58 23,250 25,400 32,750 39,600 43,000 44,750 52,650 65,350
59 23,900 26,400 34,050 41,750 45,650 47,200 55,500 69,250
60 24,550 27,400 35,350 43,900 48,300 49,650 58,350 73,150
61 25,200 28,650 38,000 46,700 51,950 54,050 63,950 80,200
62 25,700 29,350 40,300 48,700 55,450 58,400 69,100 86,150
63 26,200 30,050 42,600 50,700 58,950 62,750 74,250 92,100
64 26,700 30,750 44,900 52,700 62,450 67,100 79,400 98,050
65 27,200 31,450 47,200 54,700 65,950 71,450 84,550 1,04,000
66 33,650 37,900 55,200 64,900 75,450 79,650 95,050 1,16,600
67 34,900 39,700 57,250 67,500 78,700 82,600 99,150 1,22,350
68 36,150 41,500 59,300 70,100 81,950 85,550 1,03,250 1,28,100
69 37,400 43,300 61,350 72,700 85,200 88,500 1,07,350 1,33,850
70 38,650 45,100 63,400 75,300 88,450 91,450 1,11,450 1,39,600
71 40,100 47,500 65,700 78,900 91,750 95,750 1,16,350 1,45,400
72 41,350 48,350 68,000 81,400 94,900 99,300 1,21,200 1,50,850
73 42,600 49,200 70,300 83,900 98,050 1,02,850 1,26,050 1,56,300
74 43,850 50,050 72,600 86,400 1,01,200 1,06,400 1,30,900 1,61,750
75 45,100 50,900 74,900 88,900 1,04,350 1,09,950 1,35,750 1,67,200
76 47,150 53,900 77,950 92,800 1,08,750 1,14,950 1,41,650 1,75,450
77 49,000 56,200 81,000 96,550 1,13,000 1,19,900 1,47,250 1,82,500
78 50,850 58,500 84,050 1,00,300 1,17,250 1,24,850 1,52,850 1,89,550
79 52,700 60,800 87,100 1,04,050 1,21,500 1,29,800 1,58,450 1,96,600
80 54,550 63,100 90,150 1,07,800 1,25,750 1,34,750 1,64,050 2,03,650
81 58,573 67,368 98,641 1,17,735 1,37,635 1,46,578 1,79,484 2,22,561
82 58,573 67,368 98,641 1,17,735 1,37,635 1,46,578 1,79,484 2,22,561
83 58,573 67,368 98,641 1,17,735 1,37,635 1,46,578 1,79,484 2,22,561
84 58,573 67,368 98,641 1,17,735 1,37,635 1,46,578 1,79,484 2,22,561
85 58,573 67,368 98,641 1,17,735 1,37,635 1,46,578 1,79,484 2,22,561
86 58,573 67,368 98,641 1,17,735 1,37,635 1,46,578 1,79,484 2,22,561
87 58,573 67,368 98,641 1,17,735 1,37,635 1,46,578 1,79,484 2,22,561
88 58,573 67,368 98,641 1,17,735 1,37,635 1,46,578 1,79,484 2,22,561
89 58,573 67,368 98,641 1,17,735 1,37,635 1,46,578 1,79,484 2,22,561
90 58,573 67,368 98,641 1,17,735 1,37,635 1,46,578 1,79,484 2,22,561
Prospectus
Optima Restore
*Only for Renewal Purposes

Premium for Unlimited Restore Benefit (Optional benefit) : 0.50% will be applied on the Final Policy Premium in respect of all the base/in-built
coverages under this product
• Premium Computation Illustration
Illustration 1
• Plan Name – Optima Restore
• Tenure – 1 Year
• Location – Delhi - Tier 1
Age of the Coverage opted on individual basis covering Coverage opted on individual basis covering multiple
members insured each member of the family separately (at a single members of the family under a single policy (Sum Insured is
(in Years) point in time) available for each member of the family)
Premium (INR) Sum Insured in Lakhs Premium Family Premium Sum Insured
(INR) (INR) Discount of after discount in Lakhs (INR)
10% (if any) (INR)
5 8,450 10 8,450 845 7,605 10
25 12,950 10 12,950 1295 11,655 10
37 15,100 10 15,100 1510 13,590 10
47 21,800 10 21,800 2180 19,620 10
57 36,250 10 36,250 3625 32,625 10
63 49,300 10 49,300 4930 44,370 10
1,43,850 Total Premium (exclusive of 1,29,465
taxes)
Total premium (exclusive of taxes) for all members Total premium (exclusive of taxes) for all members of the family is
of the family is INR 1,43,850, when each member is INR 1,29,465, when they are covered under a single policy (Sum
covered separately (at a single point in time). Insured is available for each member of the family).
Sum Insured available for each individual is INR 10 Sum Insured available for each individual is INR 10 Lakhs.
Lakhs.
Illustration 2
• Plan Name – Optima Restore
• Tenure – 1 Year
• Location – Lucknow - Tier 2
Age of the members Coverage opted on family floater basis with overall Sum Insured (only one Sum Insured is available for the
insured (in Years) entire family)
Premium or consolidated premium for all Floater discount of 55% Premium Sum Insured
family members of the family (Rs.) applied on all the members after discount in Lakhs (INR)
except the oldest member (INR)
8 7,900 4,345 3,555 10
19 9,650 5,307 4,343 10
37 12,650 6,958 5692 10
42 13,650 0 13,650 10
Total Premium (exclusive of 27,240
taxes)
Total premium (exclusive of taxes) when policy is opted on floater basis is INR 27,240.
Sum Insured of Rs. 10 Lakhs is available for the entire family.
Prospectus
Optima Restore
• 2 year & 3year Premium Calculation Annexure B - List I – Items for which coverage is not available in
7.5% Discount on premium if Insured Person is paying premium the policy (Non-Medical Expenses)
of 2 years in advance & 10% Discount on premium if Sl No Item
Insured Person is paying premium of 3 years in advance 1 BABY FOOD
Example 2 BABY UTILITIES CHARGES
1) Proposed Insured Age 32 years from Delhi opting for Optima 3 BEAUTY SERVICES
Restore Individual 2 year policy with Sum Insured of 5 Lac 4 BELTS/ BRACES
Calculation – 9753 x 2 x 92.5% = Rs. 18043.05/- plus taxes.
5 BUDS
2) Proposed Insured Age 45 years from Lucknow opting for Optima
6 COLD PACK/HOT PACK
Restore Individual 3 year policy with Sum Insured of 15 Lac
7 CARRY BAGS
Calculation – (14818+21496+21496) x 90% = Rs. 52029/- plus
taxes 8 EMAIL / INTERNET CHARGES
Section 41 of Insurance Act 1938 as amended by Insurance Laws 9 FOOD CHARGES (OTHER THAN PATIENT's DIET PROVIDED
BY HOSPITAL)
Amendment Act, 2015 (Prohibition of Rebates):
10 LEGGINGS
1. No person shall allow or offer to allow, either directly or indirectly,
as an inducement to any person to take out or renew or continue 11 LAUNDRY CHARGES
an insurance in respect of any kind of risk relating to lives or 12 MINERAL WATER
property in India, any rebate of the whole or part of the 13 SANITARY PAD
commission payable or any rebate of the premium shown on the 14 TELEPHONE CHARGES
policy, nor shall any person taking out or renewing or continuing 15 GUEST SERVICES
a Policy accept any rebate, except such rebate as may be
16 CREPE BANDAGE
allowed in accordance with the published prospectuses or
tables of the insurers. 17 DIAPER OF ANY TYPE
18 EYELET COLLAR
2. Any person making default in complying with the provision of
this section shall be liable for a penalty which may extend to 19 SLINGS
ten lakh rupees. 20 BLOOD GROUPING AND CROSS MATCHING OF DONORS
SAMPLES
21 SERVICE CHARGES WHERE NURSING CHARGE ALSO
Note: Policy Term and Conditions & Premium rates are subject to CHARGED
change with prior approval from IRDA.
22 TELEVISION CHARGES
23 SURCHARGES
Disclaimer 24 ATTENDANT CHARGES
This is only a summary of the product features. The actual benefits 25 EXTRA DIET OF PATIENT (OTHER THAN THAT WHICH
available are as described in the policy, and will be subject to the FORMS PART OF BED CHARGE)
policy terms, conditions and exclusions. Please seek the advice 26 BIRTH CERTIFICATE
of your insurance advisor if you require any further information or
27 CERTIFICATE CHARGES
clarification.
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 The Hospital)
36 Spacer
37 Spirometre
38 Nebulizer Kit
39 Steam Inhaler
40 Armsling
41 Thermometer
42 Cervical Collar
43 Splint
44 Diabetic Foot Wear
45 Knee Braces (Long/ Short/ Hinged)
46 Knee Immobilizer/Shoulder Immobilizer
47 Lumbo Sacral Belt
48 Nimbus Bed Or Water Or Air Bed Charges
49 Ambulance Collar
50 Ambulance Equipment
Prospectus
Optima Restore
Sl No Item Sl No Item
51 Abdominal Binder 34 FILE OPENING CHARGES
52 Private Nurses Charges- Special Nursing Charges 35 INCIDENTAL EXPENSES / MISC. CHARGES (NOT
53 Sugar Free Tablets EXPLAINED)
54 Creams Powders Lotions (Toiletries Are Not Payable, Only 36 PATIENT IDENTIFICATION BAND / NAME TAG
Prescribed Medical Pharmaceuticals Payable) 37 PULSEOXYMETER CHARGES
55 ECG Electrodes
56 Gloves
57 Nebulisation Kit
List III – Items that are to be subsumed into Procedure Charges
58 Any Kit With No Details Mentioned [Delivery Kit, Orthokit,
Recovery Kit, etc.] Sl No Item
59 Kidney Tray 1 HAIR REMOVAL CREAM
60 Mask 2 DISPOSABLES RAZORS CHARGES (for site
preparations)
61 Ounce Glass
3 EYE PAD
62 Oxygen Mask
4 EYE SHEILD
63 Pelvic Traction Belt
5 CAMERA COVER
64 Pan Can
6 DVD, CD CHARGES
65 Trolly Cover
7 GAUSE SOFT
66 Urometer, Urine Jug
8 GAUZE
67 Ambulance
9 WARD AND THEATRE BOOKING CHARGES
68 Vasofix Safety
10 ARTHROSCOPY AND ENDOSCOPY INSTRUMENTS
List II – Items that are to be subsumed into Room Charges 11 MICROSCOPE COVER
Sl No Item 12 SURGICAL BLADES, HARMONICSCALPEL,SHAVER
13 SURGICAL DRILL
1 BABY CHARGES (UNLESS SPECIFIED/INDICATED)
14 EYE KIT
2 HAND WASH
15 EYE DRAPE
3 SHOE COVER
16 X-RAY FILM
4 CAPS
17 BOYLES APPARATUS CHARGES
5 CRADLE CHARGES
18 COTTON
6 COMB
19 COTTON BANDAGE
7 EAU-DE-COLOGNE / ROOM FRESHNERS
20 SURGICAL TAPE
8 FOOT COVER
21 APRON
9 GOWN
22 TORNIQUET
10 SLIPPERS
23 ORTHOBUNDLE, GYNAEC BUNDLE
11 TISSUE PAPER
12 TOOTH PASTE
List IV – Items that are to be subsumed into costs of treatment
13 TOOTH BRUSH
Sl No Item
14 BED PAN
1 ADMISSION/REGISTRATION CHARGES
15 FACE MASK
2 HOSPITALISATION FOR EVALUATION/ DIAGNOSTIC
16 FLEXI MASK
PURPOSE
17 HAND HOLDER
3 URINE CONTAINER
18 SPUTUM CUP
4 BLOOD RESERVATION CHARGES AND ANTE NATAL
19 DISINFECTANT LOTIONS BOOKING CHARGES
20 LUXURY TAX 5 BIPAP MACHINE
21 HVAC 6 CPAP/ CAPD EQUIPMENTS
22 HOUSE KEEPING CHARGES 7 INFUSION PUMP– COST
23 AIR CONDITIONER CHARGES 8 HYDROGEN PEROXIDE\SPIRIT\ DISINFECTANTS ETC
24 IM IV INJECTION CHARGES 9 NUTRITION PLANNING CHARGES - DIETICIAN
25 CLEAN SHEET CHARGES- DIET CHARGES
26 BLANKET/WARMER BLANKET 10 HIV KIT
27 ADMISSION KIT 11 ANTISEPTIC MOUTHWASH
28 DIABETIC CHART CHARGES 12 LOZENGES
29 DOCUMENTATION CHARGES / ADMINISTRATIVE 13 MOUTH PAINT
EXPENSES 14 VACCINATION CHARGES
30 DISCHARGE PROCEDURE CHARGES 15 ALCOHOL SWABES
31 DAILY CHART CHARGES 16 SCRUB SOLUTION/STERILLIUM
32 ENTRANCE PASS / VISITORS PASS CHARGES 17 Glucometer& Strips
33 EXPENSES RELATED TO PRESCRIPTION ON 18 URINE BAG
DISCHARGE

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Optima Restore Prospectus

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HDFC ERGO General Insurance Company Limited

Suitability: Salient Features & Benefits:

• Necessary medical In case of a Family

Number Claim Available Benefit Limit Admissible Utilization of Sum Insured

1st claim 7,00,000 5,00,000 2,50,000 0 0 7,00,000 Basic + Multiplier (Partial)

Plan/SI 3 Lacs 5 Lacs 10 Lacs 15 Lacs 20/25/50/100 Lacs

on any medical check-up, stamp duty charges and proportionate risk

ii. Specified disease/procedure waiting period – Code – Excl02

Organ / Organ Illness / diagnoses Surgeries / Urogenital • Calculus • Surgery on

Expenses related to any treatment b. greater than or equal to 35 in conjunction

Limited at least 48 hours prior to the hospitalization.

The discount grid would be as per the table below:

Time Interval (calculated from policy risk start date)

Time Interval (calculated from policy risk start date)

Time Interval (calculated from policy risk start date)

Policy start date 1st Jan 2016

Cancellation of sixty continuous months would be applicable from the date of

Options Instalment Premium Grace Period • Website: www.hdfcergo.com

Option 3 Quarterly 30 days • E-mail specific for Senior citizens : [email protected]

Option 4 Monthly 15 Days

Optima Restore Family

Gross Premium Tables (Exclusive of Taxes)

31 10,850 12,150 13,850 14,900 15,700 16,650 19,500 24,800

83 68,574 79,256 1,10,832 1,29,379 1,44,879 1,54,292 1,88,931 2,34,274

*Only for Renewal Purposes

Optima Restore Gross Premium (Excl. GST) - Tier 2 (Rest of India)

39 9,450 10,550 13,050 15,100 16,400 17,850 20,750 25,650

*Only for Renewal Purposes

Sum Insured of Rs. 10 Lakhs is available for the entire family.

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