{"uin":"HDHHLIP21379V022021","name":"Optima Senior","url":"https://indiainsurances.com/policy/hdfc-ergo-general-insurance/optima-senior-hdhhlip21379v022021","insurer":{"slug":"hdfc-ergo-general-insurance","name":"HDFC ERGO General Insurance Company Limited","url":"https://indiainsurances.com/insurer/hdfc-ergo-general-insurance"},"line":"health","category":"health-senior","category_name":"Senior citizen health","irdai_type":"Revision","kind":"product","status":"unknown","approved_on":"2020-09-22","withdrawn_on":null,"summary":"Optima Senior from HDFC ERGO is an individual hospitalisation indemnity policy for people aged 61 and above, paying in-patient, day care, domiciliary and pre and post hospitalisation costs in India, with a sum insured of Rs. 2, 3 or 5 lakh per person and a policy period of 1, 2 or 3 years. Every claim carries a co-payment of 15% in a shared room or 30% in a single room, with 30% instead on listed surgeries, and a pre-policy check-up is required.","analysis":{"state":"extracted","analysed_at":"2026-10-16 07:11:55.306787+00","note":"Every stated fact carries a verbatim quote found in the cited clause."},"facts":[{"key":"plan_variants","label":"Plans and variants","section":"Overview","meaning":"The named plans inside this product (not cover types or payout options). Facts can differ between them.","status":"not-stated","value":null,"display":null,"note":"The documents describe one cover with no named plans; the choices are the sum insured (Rs. 2, 3 or 5 lakh) and a policy period of 1, 2 or 3 years.","quote":null,"sources":[],"law":[]},{"key":"policy_term","label":"Policy term","section":"Eligibility","meaning":"How long one policy runs before it ends or must be renewed.","status":"cross-checked","value":"The policy is issued for a period of 1, 2 or 3 years.","display":"1, 2 or 3 years","note":"A discount of 7.5% (two years) or 10% (three years) applies when the premium for the whole period is paid in advance as a single premium.","quote":"c) The policy will be issued for a period 1/2/3 years. ... A discount of 7.5% / 10% will be provided if insured person is paying two year/ three year premium respectively in advance as a single premium","sources":[{"clause":null,"heading":"Optima Senior - Prospectus","page":1,"url":"https://indiainsurances.com/policy/hdfc-ergo-general-insurance/optima-senior-hdhhlip21379v022021/document/157#c-optima-senior-prospectus"},{"clause":null,"heading":"2/3 Year Premium","page":12,"url":"https://indiainsurances.com/policy/hdfc-ergo-general-insurance/optima-senior-hdhhlip21379v022021/document/157#c-2-3-year-premium"}],"law":[]},{"key":"claim_intimation","label":"Claim intimation deadline","section":"Claims","meaning":"How soon you must tell the insurer about a claim or hospitalisation.","status":"cross-checked","value":"For planned hospitalisation the insurer or TPA must be told immediately and at least 48 hours before admission; for emergency hospitalisation within 24 hours of admission.","display":"At least 48 hours before planned admission; within 24 hours of an emergency admission","note":"Claim documents are due within 15 days of the insurer's request or of discharge or completion of treatment (Section D(II)(f)).","quote":"Any treatment for which a claim may be made requires Hospitalisation: | Immediately and in any event at least 48 hours prior to the start of the Insured Person’s Hospitalisation. ... Any treatment for which a claim may be made requires Hospitalisation in an Emergency: | Within 24 hours of the start of the Insured Person’s Hospitalisation. ... within 15 days of the either of Our request or the Insured Person’s discharge from Hospitalisation or completion of treatment","sources":[{"clause":"Section D(II)(d)","heading":null,"page":23,"url":"https://indiainsurances.com/policy/hdfc-ergo-general-insurance/optima-senior-hdhhlip21379v022021/document/156#c-section-d-ii-d"},{"clause":"Section D(II)(f)","heading":null,"page":24,"url":"https://indiainsurances.com/policy/hdfc-ergo-general-insurance/optima-senior-hdhhlip21379v022021/document/156#c-section-d-ii-f"}],"law":[{"title":"Master Circular on Protection of Policyholders' Interests, 2024","section":"Sec 1, Part A, V.1","url":"https://indiainsurances.com/law/irdai-ppi-mc-2024"},{"title":"Master Circular on Protection of Policyholders' Interests, 2024","section":"Sec 1, Part B, V.1","url":"https://indiainsurances.com/law/irdai-ppi-mc-2024"},{"title":"Master Circular on Protection of Policyholders' Interests, 2024","section":"Sec 1, Part C, V.1","url":"https://indiainsurances.com/law/irdai-ppi-mc-2024"},{"title":"Master Circular on Protection of Policyholders' Interests, 2024","section":"Para 20, 21","url":"https://indiainsurances.com/law/irdai-ppi-mc-2024"}]},{"key":"claim_documents","label":"Claim documents","section":"Claims","meaning":"Documents the insurer asks for when you claim.","status":"cross-checked","value":["Claim form, duly completed and signed","Original bills with detailed breakup of charges","Original payment receipts","All reports, including medical reports, case histories, investigation reports, treatment papers, discharge summaries","Discharge Summary","Invoice/Sticker of the Implants","A precise diagnosis of the treatment","A detailed list of the individual medical services and treatments provided and a unit price for each","Prescriptions that name the Insured Person, with the drugs prescribed, their price and a receipt for payment"],"display":"Claim form, original bills and receipts, medical reports, discharge summary, implant invoice, diagnosis, itemised list of services, prescriptions","note":"Documents are due within 15 days of the insurer's request or of discharge or completion of treatment; the list is not exhaustive and the insurer may ask for a medical examination at its own cost.","quote":"i) Our claim form, duly completed and signed for on behalf of the Insured Person. ii) Original bills with detailed breakup of charges ... iii) Original payment receipts iv) All reports, including but not limited to all medical reports, case histories, investigation reports, treatment papers, discharge summaries. v) Discharge Summary, with Date of admission and discharge, clinical history, past history, procedure details and details of treatment taken vi) Invoice/Sticker of the Implants. vii) A precise diagnosis of the treatment for which a claim is made. viii) A detailed list of the individual medical services and treatments provided and a unit price for each. ix) Prescriptions that name the Insured Person and in the case of drugs: the drugs prescribed, their price and a receipt for payment.","sources":[{"clause":"Section D(II)(f)","heading":null,"page":24,"url":"https://indiainsurances.com/policy/hdfc-ergo-general-insurance/optima-senior-hdhhlip21379v022021/document/156#c-section-d-ii-f"}],"law":[{"title":"Master Circular on Health Insurance Business, 2024","section":"Ch I Para 17","url":"https://indiainsurances.com/law/irdai-health-mc-2024"},{"title":"Insurance Regulatory and Development Authority of India (Protection of Policyholders’ Interests, Operations and Allied Matters of Insurers) Regulations, 2024","section":"Reg 22","url":"https://indiainsurances.com/law/irdai-ppi-2024"},{"title":"Insurance Regulatory and Development Authority of India (Protection of Policyholders’ Interests, Operations and Allied Matters of Insurers) Regulations, 2024","section":"Reg 23","url":"https://indiainsurances.com/law/irdai-ppi-2024"},{"title":"Master Circular on Protection of Policyholders' Interests, 2024","section":"Sec 1, Part A, V.2","url":"https://indiainsurances.com/law/irdai-ppi-mc-2024"},{"title":"Master Circular on Protection of Policyholders' Interests, 2024","section":"Sec 1, Part B, V.3(iii)","url":"https://indiainsurances.com/law/irdai-ppi-mc-2024"},{"title":"Master Circular on Protection of Policyholders' Interests, 2024","section":"Sec 1, Part C, V.2","url":"https://indiainsurances.com/law/irdai-ppi-mc-2024"}]},{"key":"claim_settlement_time","label":"Claim settlement time promised","section":"Claims","meaning":"How quickly the policy says a claim is decided or paid, and from when that is counted (intimation or last document).","status":"cross-checked","value":"The company settles or rejects a claim within 15 days from the date of receipt of intimation; for delay it pays interest at 2% above the Bank Rate.","display":"Within 15 days from receipt of intimation","note":"Interest at 2% above the Bank Rate for delay. CIS: cashless authorisation decision within 1 hour of request; cashless final bill authorisation within 3 hours of the discharge request.","quote":"a) The Company shall settle or reject a claim, as the case may be, within 15 days from the date of receipt of intimation. ... b) In the case of delay in the payment of a claim, the Company shall be liable to pay interest to the Policyholder from the date of receipt of intimation to the date of payment of claim at a rate 2% above the Bank Rate. ... Decision on cashless authorization to be provided within 1 hour from the time of receipt of request ... Within 3 hours of the receipt of discharge authorization request from the hospital.","sources":[{"clause":"Section D(I)(a)","heading":null,"page":18,"url":"https://indiainsurances.com/policy/hdfc-ergo-general-insurance/optima-senior-hdhhlip21379v022021/document/156#c-section-d-i-a-2"},{"clause":"Section D(I)(b)","heading":null,"page":18,"url":"https://indiainsurances.com/policy/hdfc-ergo-general-insurance/optima-senior-hdhhlip21379v022021/document/156#c-section-d-i-b-2"},{"clause":"Excl08(iv)","heading":null,"page":5,"url":"https://indiainsurances.com/policy/hdfc-ergo-general-insurance/optima-senior-hdhhlip21379v022021/document/158#c-excl08-iv"}],"law":[{"title":"The Insurance Act, 1938","section":"Section 64UM(4) to (6)","url":"https://indiainsurances.com/law/insurance-act-1938"},{"title":"Master Circular on General Insurance Business, 2024","section":"Ch I, Para 10","url":"https://indiainsurances.com/law/irdai-general-mc-2024"},{"title":"Master Circular on Health Insurance Business, 2024","section":"Ch I Para 15","url":"https://indiainsurances.com/law/irdai-health-mc-2024"},{"title":"Master Circular on Health Insurance Business, 2024","section":"Ch I Para 16","url":"https://indiainsurances.com/law/irdai-health-mc-2024"},{"title":"Insurance Regulatory and Development Authority of India (Protection of Policyholders’ Interests, Operations and Allied Matters of Insurers) Regulations, 2024","section":"Reg 22","url":"https://indiainsurances.com/law/irdai-ppi-2024"},{"title":"Master Circular on Protection of Policyholders' Interests, 2024","section":"Sec 1, Part A, V.2","url":"https://indiainsurances.com/law/irdai-ppi-mc-2024"},{"title":"Master Circular on Protection of Policyholders' Interests, 2024","section":"Sec 1, Part B, V.2","url":"https://indiainsurances.com/law/irdai-ppi-mc-2024"},{"title":"Master Circular on Protection of Policyholders' Interests, 2024","section":"Sec 1, Part B, V.3(i), V.3(ii)","url":"https://indiainsurances.com/law/irdai-ppi-mc-2024"},{"title":"Master Circular on Protection of Policyholders' Interests, 2024","section":"Sec 1, Part B, V.3(iii)","url":"https://indiainsurances.com/law/irdai-ppi-mc-2024"},{"title":"Master Circular on Protection of Policyholders' Interests, 2024","section":"Sec 1, Part C, V.3","url":"https://indiainsurances.com/law/irdai-ppi-mc-2024"},{"title":"Master Circular on Protection of Policyholders' Interests, 2024","section":"Sec 1, Part C, V.4","url":"https://indiainsurances.com/law/irdai-ppi-mc-2024"},{"title":"Master Circular on Protection of Policyholders' Interests, 2024","section":"Para 23","url":"https://indiainsurances.com/law/irdai-ppi-mc-2024"},{"title":"The Motor Vehicles Act, 1988: Chapter XI, insurance of motor vehicles against third party risks","section":"Section 149","url":"https://indiainsurances.com/law/motor-vehicles-act-1988"}]},{"key":"exclusions_main","label":"Main exclusions","section":"Exclusions","meaning":"What the policy does not pay for, in the policy's own words.","status":"cross-checked","value":["Excl03: any illness within 30 days from the first policy commencement date, except accidents","Excl02: listed conditions, surgeries and treatments until 24 months of continuous coverage","Excl01: pre-existing disease and its direct complications until 36 months of continuous coverage","Excl04: admission primarily for diagnostic and evaluation purposes","Excl09: participation as a professional in hazardous or adventure sports","Excl10: breach of law with criminal intent","Excl12: alcoholism, drug or substance abuse or any addictive condition","Excl08: cosmetic or plastic surgery","Excl18: maternity","War or similar situations","Intentional self-injury or attempted suicide","Treatment availed outside India","Out-patient treatment","Non-Medical expenses such as food, laundry and attendant charges","Claims arising due to non-disclosure of pre-existing illness or material fact"],"display":"Waiting periods (Excl01 to Excl03), investigation, adventure sports, breach of law, addiction, cosmetic surgery, maternity, war, self-injury, treatment outside India, out-patient treatment, non-medical expenses, non-disclosure","note":"The policy endorsements can delete the 30-day waiting period, delete or reduce the 24-month waiting period to 12 months, and delete or reduce the 36-month pre-existing disease waiting period to 24 or 12 months. Cosmetic surgery is covered for reconstruction following an Accident, Burn(s) or Cancer or when medically necessary.","quote":"i) 30-day Waiting period: Code – Excl03 ... a) Expenses related to the treatment of any illness within 30 days from the first policy commencement date shall be excluded except claims arising due to an accident ... ii) Specified disease/procedure waiting period: Code – Excl02 ... shall be excluded until the expiry of 24 months of continuous coverage ... iii) Pre-Existing Diseases: Code – Excl01 ... a) Expenses related to the treatment of a pre-existing disease (PED) and its direct complications shall be excluded until the expiry of 36 months of continuous coverage ... iii)Investigation & Evaluation: Code Excl04 a. Expenses related to any admission primarily for diagnostic and evaluation purposes only are excluded. ... ii)Hazardous or Adventure Sports: Code – Excl09 Expenses related to any treatment necessitated due to participation as a professional in hazardous or adventure sports ... i) Breach of law: Code – Excl10 Expenses for treatment directly arising from or consequent upon any Insured Person committing or attempting to commit a breach of law with criminal intent. ... vi) Treatment for Alcoholism, drug or substance abuse or any addictive condition and consequences thereof.Code – Excl12 ... iv) Cosmetic or plastic surgery:Code – Excl08:Expenses for cosmetic or plastic surgery ... xii) Maternity:Code – Excl18 ... i) War or similar situations ... ii) Intentional self-injury or attempted suicide while sane or insane ... 3. Treatment availed outside India ... xxiv) Treatment taken on Outpatient basis ... xxiii) Non-Medical expenses such as Food charges (other than ... laundry charges, attendant charges ... xxix) Any Claim arising due to Non-disclosure of Pre-existing Illness or Material fact as sought to be declared on the Proposal form.","sources":[{"clause":"Section B(I)","heading":null,"page":7,"url":"https://indiainsurances.com/policy/hdfc-ergo-general-insurance/optima-senior-hdhhlip21379v022021/document/156#c-section-b-i"},{"clause":"Section C","heading":"EXCLUSIONS & WAITING PERIOD","page":11,"url":"https://indiainsurances.com/policy/hdfc-ergo-general-insurance/optima-senior-hdhhlip21379v022021/document/156#c-section-c"},{"clause":"Section C(I)(a)","heading":null,"page":11,"url":"https://indiainsurances.com/policy/hdfc-ergo-general-insurance/optima-senior-hdhhlip21379v022021/document/156#c-section-c-i-a"},{"clause":"Section C(I)(c)","heading":null,"page":11,"url":"https://indiainsurances.com/policy/hdfc-ergo-general-insurance/optima-senior-hdhhlip21379v022021/document/156#c-section-c-i-c"},{"clause":"Section C(I)(a)","heading":null,"page":11,"url":"https://indiainsurances.com/policy/hdfc-ergo-general-insurance/optima-senior-hdhhlip21379v022021/document/156#c-section-c-i-a-2"},{"clause":"2","heading":"For which Medical advice or treatment was recommended by, or received from, a","page":12,"url":"https://indiainsurances.com/policy/hdfc-ergo-general-insurance/optima-senior-hdhhlip21379v022021/document/156#c-2-2"},{"clause":null,"heading":"II. Standard General exclusions","page":13,"url":"https://indiainsurances.com/policy/hdfc-ergo-general-insurance/optima-senior-hdhhlip21379v022021/document/156#c-ii-standard-general-exclusions"},{"clause":"2(d)(iv)","heading":null,"page":14,"url":"https://indiainsurances.com/policy/hdfc-ergo-general-insurance/optima-senior-hdhhlip21379v022021/document/156#c-2-d-iv"},{"clause":"2(d)(vi)","heading":null,"page":15,"url":"https://indiainsurances.com/policy/hdfc-ergo-general-insurance/optima-senior-hdhhlip21379v022021/document/156#c-2-d-vi"},{"clause":"Excl12","heading":null,"page":15,"url":"https://indiainsurances.com/policy/hdfc-ergo-general-insurance/optima-senior-hdhhlip21379v022021/document/156#c-excl12"},{"clause":"Excl16","heading":null,"page":15,"url":"https://indiainsurances.com/policy/hdfc-ergo-general-insurance/optima-senior-hdhhlip21379v022021/document/156#c-excl16"},{"clause":null,"heading":"III. Specific Exclusions","page":16,"url":"https://indiainsurances.com/policy/hdfc-ergo-general-insurance/optima-senior-hdhhlip21379v022021/document/156#c-iii-specific-exclusions"}],"law":[{"title":"Insurance Regulatory and Development Authority of India (Protection of Policyholders’ Interests, Operations and Allied Matters of Insurers) Regulations, 2024","section":"Reg 11","url":"https://indiainsurances.com/law/irdai-ppi-2024"},{"title":"Master Circular on Protection of Policyholders' Interests, 2024","section":"Para 16","url":"https://indiainsurances.com/law/irdai-ppi-mc-2024"}]},{"key":"grievance","label":"Grievance route","section":"Claims","meaning":"Who to complain to first, as stated in the policy, before going to the Insurance Ombudsman.","status":"cross-checked","value":"First call 022 6158 2020 / 022 6234 6234 or use www.hdfcergo.com; then write to the Complaints & Grievance Cell (grievance@hdfcergo.com); then to the Chief Grievance Officer (cgo@hdfcergo.com).","display":"Customer service first, then the Complaints & Grievance Cell (grievance@hdfcergo.com), then the Chief Grievance Officer (cgo@hdfcergo.com)","note":"Level 1 phone 18002677444 (Monday to Saturday 9AM to 6PM). Senior citizen helpline seniorcitizen@hdfcergo.com, 022 6158 2026 in the wording; the prospectus and CIS give 022 6242 6226. Escalate to Level 2 if no response within 15 days.","quote":"First Point of Contact | Call us at 022 6158 2020 / 022 6234 6234/www.hdfcergo.com ... 1. Write to The Complaints & Grievance Cell (C&G Cell) HDFC ERGO General Insurance Company Limited ... 2. You can also write an email to grievance@hdfcergo.com ... Level 2 | If you're not satisfied with the resolution or if no response was received within 15 days, you can: 1. Write to the Chief Grievance Officer ... 2. You can also write an email to cgo@hdfcergo.com","sources":[{"clause":"Section D(I)(d)(v)","heading":null,"page":20,"url":"https://indiainsurances.com/policy/hdfc-ergo-general-insurance/optima-senior-hdhhlip21379v022021/document/156#c-section-d-i-d-v"}],"law":[{"title":"Consumer Protection (Jurisdiction of the District Commission, the State Commission and the National Commission) Rules, 2021","section":"Rule 3","url":"https://indiainsurances.com/law/consumer-jurisdiction-rules-2021"},{"title":"Consumer Protection (Jurisdiction of the District Commission, the State Commission and the National Commission) Rules, 2021","section":"Rule 4","url":"https://indiainsurances.com/law/consumer-jurisdiction-rules-2021"},{"title":"Consumer Protection (Jurisdiction of the District Commission, the State Commission and the National Commission) Rules, 2021","section":"Rule 5","url":"https://indiainsurances.com/law/consumer-jurisdiction-rules-2021"},{"title":"The Consumer Protection Act, 2019","section":"Section 2(11)","url":"https://indiainsurances.com/law/consumer-protection-act-2019"},{"title":"The Consumer Protection Act, 2019","section":"Section 2(42)","url":"https://indiainsurances.com/law/consumer-protection-act-2019"},{"title":"The Consumer Protection Act, 2019","section":"Section 34","url":"https://indiainsurances.com/law/consumer-protection-act-2019"},{"title":"The Consumer Protection Act, 2019","section":"Section 69","url":"https://indiainsurances.com/law/consumer-protection-act-2019"},{"title":"The Insurance Act, 1938","section":"Section 38","url":"https://indiainsurances.com/law/insurance-act-1938"},{"title":"Master Circular on General Insurance Business, 2024","section":"Ch I, Para 12","url":"https://indiainsurances.com/law/irdai-general-mc-2024"},{"title":"Master Circular on Health Insurance Business, 2024","section":"Ch I Para 19","url":"https://indiainsurances.com/law/irdai-health-mc-2024"},{"title":"Master Circular on Health Insurance Business, 2024","section":"Ch I Para 20","url":"https://indiainsurances.com/law/irdai-health-mc-2024"},{"title":"Master Circular on Life Insurance Products, 2024","section":"Chapter 1, Para 13","url":"https://indiainsurances.com/law/irdai-life-products-2024"},{"title":"Master Circular on Life Insurance Products, 2024","section":"Chapter 1, Para 2","url":"https://indiainsurances.com/law/irdai-life-products-2024"},{"title":"Insurance Regulatory and Development Authority of India (Protection of Policyholders’ Interests, Operations and Allied Matters of Insurers) Regulations, 2024","section":"Reg 5(5), 5(6)","url":"https://indiainsurances.com/law/irdai-ppi-2024"},{"title":"Insurance Regulatory and Development Authority of India (Protection of Policyholders’ Interests, Operations and Allied Matters of Insurers) Regulations, 2024","section":"Reg 5(9)","url":"https://indiainsurances.com/law/irdai-ppi-2024"},{"title":"Insurance Regulatory and Development Authority of India (Protection of Policyholders’ Interests, Operations and Allied Matters of Insurers) Regulations, 2024","section":"Reg 25","url":"https://indiainsurances.com/law/irdai-ppi-2024"},{"title":"Master Circular on Protection of Policyholders' Interests, 2024","section":"Sec 1, Part A, VI.1","url":"https://indiainsurances.com/law/irdai-ppi-mc-2024"},{"title":"Master Circular on Protection of Policyholders' Interests, 2024","section":"Sec 1, Part A, VI.2","url":"https://indiainsurances.com/law/irdai-ppi-mc-2024"},{"title":"Master Circular on Protection of Policyholders' Interests, 2024","section":"Sec 1, Part A, VI.3","url":"https://indiainsurances.com/law/irdai-ppi-mc-2024"},{"title":"Master Circular on Protection of Policyholders' Interests, 2024","section":"Para 26","url":"https://indiainsurances.com/law/irdai-ppi-mc-2024"},{"title":"IRDAI (Insurance Products) Regulations, 2024","section":"Schedule III, Para 11","url":"https://indiainsurances.com/law/irdai-products-regs-2024"},{"title":"Review of revision in premium rates under health insurance policies for senior citizens, 2025","section":"Para 3","url":"https://indiainsurances.com/law/irdai-senior-premium-2025"},{"title":"Insurance Ombudsman Rules, 2017","section":"Rule 13","url":"https://indiainsurances.com/law/ombudsman-rules-2017"},{"title":"Insurance Ombudsman Rules, 2017","section":"Rule 14","url":"https://indiainsurances.com/law/ombudsman-rules-2017"}]},{"key":"sum_insured_options","label":"Sum insured options","section":"Cover","meaning":"The cover amounts you can choose from.","status":"cross-checked","value":"Rs. 2,00,000, Rs. 3,00,000 or Rs. 5,00,000 per insured person per policy year, on an individual basis.","display":"Rs. 2 lakh, 3 lakh or 5 lakh per insured person","note":"Schedule of Benefits: 'Sum Insured per Insured Person per Policy Year (Rs. in Lakh) | 2.00, 3.00, 5.00'.","quote":"Sum Insured: Rs. 200,000; 300,000; 500,000 on individual basis.","sources":[{"clause":null,"heading":"Co-Payment applicable on specified Illnesses/surgeries","page":3,"url":"https://indiainsurances.com/policy/hdfc-ergo-general-insurance/optima-senior-hdhhlip21379v022021/document/157#c-co-payment-applicable-on-specified-illnesses-sur"}],"law":[]},{"key":"initial_waiting","label":"Initial waiting period","section":"Waiting periods","meaning":"Days from the start of the first policy during which illness claims are not paid (accidents usually are).","status":"cross-checked","value":{"unit":"days","amount":30},"display":"30 days (accidents excepted)","note":"Does not apply if the insured person has had continuous coverage for more than twelve months; applies afresh to an enhanced sum insured. A policy endorsement can delete this waiting period for all insured persons.","quote":"a) Expenses related to the treatment of any illness within 30 days from the first policy commencement date shall be excluded except claims arising due to an accident, provided the same are covered.","sources":[{"clause":"Section C(I)(a)","heading":null,"page":11,"url":"https://indiainsurances.com/policy/hdfc-ergo-general-insurance/optima-senior-hdhhlip21379v022021/document/156#c-section-c-i-a"}],"law":[]},{"key":"ped_waiting","label":"Pre-existing disease waiting period","section":"Waiting periods","meaning":"How long you wait before conditions you already had when you bought the policy are covered. The law caps it at 36 months.","status":"cross-checked","value":{"unit":"months","amount":36},"display":"36 months","note":"Applies afresh to any increase in sum insured; reduced by prior continuous coverage under portability. A policy endorsement can delete it or reduce it to 24 or 12 months. Cover after 36 months is subject to the disease being declared and accepted.","quote":"a) Expenses related to the treatment of a pre-existing disease (PED) and its direct complications shall be excluded until the expiry of 36 months of continuous coverage after the date of inception of the first policy with insurer.","sources":[{"clause":"2","heading":"For which Medical advice or treatment was recommended by, or received from, a","page":12,"url":"https://indiainsurances.com/policy/hdfc-ergo-general-insurance/optima-senior-hdhhlip21379v022021/document/156#c-2-2"}],"law":[{"title":"Master Circular on Health Insurance Business, 2024","section":"Ch I Para 8","url":"https://indiainsurances.com/law/irdai-health-mc-2024"},{"title":"Master Circular on Health Insurance Business, 2024","section":"Ch I Para 12","url":"https://indiainsurances.com/law/irdai-health-mc-2024"},{"title":"IRDAI (Insurance Products) Regulations, 2024","section":"Schedule III, Para 1.6","url":"https://indiainsurances.com/law/irdai-products-regs-2024"},{"title":"IRDAI (Insurance Products) Regulations, 2024","section":"Schedule III, Para 7","url":"https://indiainsurances.com/law/irdai-products-regs-2024"}]},{"key":"specific_waiting","label":"Specific illness waiting period","section":"Waiting periods","meaning":"Waiting period for a list of named illnesses and procedures (cataract, hernia, joint replacement...). With several tiers (24 and 36 months), the shortest in the answer, the others in the note.","status":"cross-checked","value":{"unit":"months","amount":24},"display":"24 months","note":"Not for accidents. If a listed condition is also pre-existing, the longer waiting period applies. A policy endorsement can delete it or reduce it to 12 months.","quote":"a) Expenses related to the treatment of the listed Conditions, surgeries/treatments as mentioned in the table below shall be excluded until the expiry of 24 months of continuous coverage after the date of inception of the first Policy with us. This exclusion shall not be applicable for claims arising due to an Accident.","sources":[{"clause":"Section C(I)(a)","heading":null,"page":11,"url":"https://indiainsurances.com/policy/hdfc-ergo-general-insurance/optima-senior-hdhhlip21379v022021/document/156#c-section-c-i-a-2"}],"law":[{"title":"Master Circular on Health Insurance Business, 2024","section":"Ch I Para 12","url":"https://indiainsurances.com/law/irdai-health-mc-2024"},{"title":"IRDAI (Insurance Products) Regulations, 2024","section":"Schedule III, Para 1.7","url":"https://indiainsurances.com/law/irdai-products-regs-2024"}]},{"key":"specific_waiting_list","label":"Illnesses with a specific waiting period","section":"Waiting periods","meaning":"The named illnesses and procedures that carry the specific waiting period.","status":"cross-checked","value":["Any benign ear, nose and throat (ENT) disorder; any ENT surgery; surgery for nasal septum deviation","Internal tumors, cysts, nodules, polyps including breast lumps","Polycystic ovarian diseases","Dilatation and curettage (D&C)","Hysterectomy for menorrhagia or fibromyoma or prolapse of uterus","Myomectomy for fibroids","Non infective arthritis","Gout and Rheumatism","Age related Osteoarthritis and Osteoporosis","Surgery for prolapsed inter vertebral disk","Joint replacement","Calculus diseases of gall bladder including Cholecystitis","Pancreatitis","Fissure/fistula in anus, hemorrhoids, pilonidal sinus","Gastric and duodenal ulcers","All forms of cirrhosis","Surgery of gallbladder and bile duct","Surgery of hernia","Calculus diseases of Urogenital system","Benign Hyperplasia of prostate","Any surgery of Urogenital system; surgery on prostate; surgery for Hydrocele","Cataract","Glaucoma","Skin tumors","Surgery of varicose veins and varicose ulcers"],"display":"ENT disorders and surgery, gynaecological conditions, arthritis and joint replacement, gall bladder, hernia, piles and fistula, ulcers, cirrhosis, kidney stones, prostate, hydrocele, cataract, glaucoma, varicose veins and others","note":null,"quote":"a. | ENT | • Any benign ear, nose and throat (ENT) disorder Example: Sinusitis, Rhinitis | • Any ear, nose and throat (ENT) surgery Example: adenoidectomy, mastoidectomy, tonsillectomy, tympanoplasty • surgery for nasal septum deviation ... • Internal tumors, cysts, nodules, ... polyps including breast lumps • Polycystic ovarian diseases | • Hysterectomy for menorrhagia or fibromyoma or prolapse of uterus • Myomectomy for fibroids ... • Dilatation and curettage (D&C) ... c. | Orthopaedic | • Non infective arthritis • Gout and Rheumatism • Age related Osteoarthritis and Osteoporosis | • Surgery for prolapsed inter vertebral disk • Joint replacement ... d. | Gastrointestinal | • Calculus diseases of gall bladder including Cholecystitis • Pancreatitis • Fissure/fistula in anus, hemorrhoids, pilonidal sinus • Gastric and duodenal ulcers • All forms of cirrhosis | • surgery of gallbladder and bile duct • surgery of hernia ... e. | Urogenital | • Calculus diseases of Urogenital system Example: Kidney stone, Urinary bladder stone. • Benign Hyperplasia of prostate | • Any surgery of Urogenital system • Surgery on prostate • Surgery for Hydrocele ... f. | Eye | • Cataract • Glaucoma ... g. | Others | • Internal tumors, cysts, nodules, polyps, skin tumors | • Surgery of varicose veins and varicose ulcers","sources":[{"clause":"Section C(I)(f)","heading":null,"page":11,"url":"https://indiainsurances.com/policy/hdfc-ergo-general-insurance/optima-senior-hdhhlip21379v022021/document/156#c-section-c-i-f"}],"law":[]},{"key":"moratorium","label":"Moratorium period","section":"Renewal and rights","meaning":"After this many months of continuous cover, the insurer cannot reject a claim for non-disclosure, except for proven fraud or permanent exclusions. The law sets 60 months.","status":"cross-checked","value":{"unit":"months","amount":60},"display":"60 months (sixty continuous months)","note":"Applies to the first policy's sum insured; for an enhanced sum insured the sixty months run from the date of enhancement. The CIS words it as 5 continuous years.","quote":"e) Moratorium Period After completion of sixty continuous months of coverage (including portability and migration) in health insurance policy, no policy and claim shall be contestable by the insurer on grounds of non-disclosure, misrepresentation, except on grounds of established fraud.","sources":[{"clause":"Section D(I)(b)","heading":null,"page":18,"url":"https://indiainsurances.com/policy/hdfc-ergo-general-insurance/optima-senior-hdhhlip21379v022021/document/156#c-section-d-i-b-2"}],"law":[{"title":"Master Circular on Health Insurance Business, 2024","section":"Ch I Para 13","url":"https://indiainsurances.com/law/irdai-health-mc-2024"},{"title":"Master Circular on Protection of Policyholders' Interests, 2024","section":"Sec 1, Part B, IV.8","url":"https://indiainsurances.com/law/irdai-ppi-mc-2024"},{"title":"IRDAI (Insurance Products) Regulations, 2024","section":"Schedule III, Para 8","url":"https://indiainsurances.com/law/irdai-products-regs-2024"}]},{"key":"portability","label":"Portability","section":"Renewal and rights","meaning":"Whether you can move this policy to another insurer and keep waiting-period credit.","status":"cross-checked","value":"Yes. The policy can be ported to another insurer by applying at least 30 days but not earlier than 60 days before the renewal date, with accrued continuity benefits in waiting periods.","display":"Yes, apply 30 to 60 days before renewal; waiting-period credit carried over","note":"Porting in: the prospectus says if the sum insured is enhanced on porting in, portability benefits apply only to the previous sum insured.","quote":"k) Portability The insured person will have the option to port the policy to other insurers by applying to such insurer to port the entire policy along with all the members of the family, if any, at least 30 days before, but not earlier than 60 days from the policy renewal date as per IRDAI guidelines related to portability. If such person is presently covered and has been continuously covered without any lapses under any health insurance policy with an Indian General/Health insurer, the proposed insured person will get the accrued continuity benefits in waiting periods as per IRDAI guidelines on portability. ... If the Insured person transfers from any other insurer and enhances the sum insured, then the portability benefits will be offered only in respect to the previous sum insured.","sources":[{"clause":"Section D(I)(d)(v)","heading":null,"page":20,"url":"https://indiainsurances.com/policy/hdfc-ergo-general-insurance/optima-senior-hdhhlip21379v022021/document/156#c-section-d-i-d-v"},{"clause":null,"heading":"Co-Payment applicable on specified Illnesses/surgeries","page":3,"url":"https://indiainsurances.com/policy/hdfc-ergo-general-insurance/optima-senior-hdhhlip21379v022021/document/157#c-co-payment-applicable-on-specified-illnesses-sur"}],"law":[{"title":"Master Circular on Health Insurance Business, 2024","section":"Ch I Para 11","url":"https://indiainsurances.com/law/irdai-health-mc-2024"},{"title":"Master Circular on Health Insurance Business, 2024","section":"Ch I Para 12","url":"https://indiainsurances.com/law/irdai-health-mc-2024"},{"title":"Master Circular on Protection of Policyholders' Interests, 2024","section":"Sec 1, Part B, IV.6","url":"https://indiainsurances.com/law/irdai-ppi-mc-2024"},{"title":"Master Circular on Protection of Policyholders' Interests, 2024","section":"Sec 1, Part B, VII.3","url":"https://indiainsurances.com/law/irdai-ppi-mc-2024"},{"title":"Master Circular on Protection of Policyholders' Interests, 2024","section":"Para 24","url":"https://indiainsurances.com/law/irdai-ppi-mc-2024"},{"title":"IRDAI (Insurance Products) Regulations, 2024","section":"Schedule III, Para 1.4 and 1.5","url":"https://indiainsurances.com/law/irdai-products-regs-2024"},{"title":"IRDAI (Insurance Products) Regulations, 2024","section":"Schedule III, Para 10","url":"https://indiainsurances.com/law/irdai-products-regs-2024"}]},{"key":"lifelong_renewal","label":"Lifelong renewal","section":"Renewal and rights","meaning":"Whether the policy can be renewed for life without a maximum age.","status":"cross-checked","value":true,"display":"Yes, no maximum cover ceasing age","note":"Renewal can be refused on grounds of established fraud, non-disclosure or misrepresentation, or if the product is withdrawn.","quote":"b) There is no maximum cover ceasing age in this policy. ... 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","sources":[{"clause":null,"heading":"Optima Senior - Prospectus","page":1,"url":"https://indiainsurances.com/policy/hdfc-ergo-general-insurance/optima-senior-hdhhlip21379v022021/document/157#c-optima-senior-prospectus"},{"clause":"Section D(I)(d)(iv)","heading":null,"page":19,"url":"https://indiainsurances.com/policy/hdfc-ergo-general-insurance/optima-senior-hdhhlip21379v022021/document/156#c-section-d-i-d-iv"}],"law":[{"title":"Master Circular on Health Insurance Business, 2024","section":"Ch I Para 10","url":"https://indiainsurances.com/law/irdai-health-mc-2024"},{"title":"Master Circular on Health Insurance Business, 2024","section":"Ch II D.II","url":"https://indiainsurances.com/law/irdai-health-mc-2024"},{"title":"Master Circular on Protection of Policyholders' Interests, 2024","section":"Sec 1, Part B, IV.5","url":"https://indiainsurances.com/law/irdai-ppi-mc-2024"},{"title":"IRDAI (Insurance Products) Regulations, 2024","section":"Schedule III, Para 9","url":"https://indiainsurances.com/law/irdai-products-regs-2024"},{"title":"Review of revision in premium rates under health insurance policies for senior citizens, 2025","section":"Para 7","url":"https://indiainsurances.com/law/irdai-senior-premium-2025"}]},{"key":"claim_loading","label":"Premium loading after claims","section":"Renewal and rights","meaning":"Whether the premium can go up at renewal because you made a claim.","status":"cross-checked","value":"No. No loading applies on renewals based on individual claims experience, and renewal is not denied because of claims.","display":"No loading for claims at renewal","note":"A risk loading based on health status (up to 100% per condition and 150% overall per individual) can apply at the start, on renewal or on an increase in sum insured. A claim also removes the 5% no claim discount for that year.","quote":"i. Renewal of a health insurance policy shall not be denied on the ground that the insured had made a claim or claims in the preceding policy years ... iii. No loading shall apply on renewals based on individual claims experience ... The maximum risk loading applicable for an individual will not exceed 100% per diagnosis / medical condition and an overall risk loading of 150% per individual.","sources":[{"clause":"Section D(I)(d)(iv)","heading":null,"page":19,"url":"https://indiainsurances.com/policy/hdfc-ergo-general-insurance/optima-senior-hdhhlip21379v022021/document/156#c-section-d-i-d-iv"},{"clause":"Section D(II)(c)","heading":null,"page":23,"url":"https://indiainsurances.com/policy/hdfc-ergo-general-insurance/optima-senior-hdhhlip21379v022021/document/156#c-section-d-ii-c"}],"law":[{"title":"Master Circular on Health Insurance Business, 2024","section":"Ch I Para 10","url":"https://indiainsurances.com/law/irdai-health-mc-2024"},{"title":"Master Circular on Protection of Policyholders' Interests, 2024","section":"Sec 1, Part B, IV.5","url":"https://indiainsurances.com/law/irdai-ppi-mc-2024"},{"title":"IRDAI (Insurance Products) Regulations, 2024","section":"Schedule III, Para 9","url":"https://indiainsurances.com/law/irdai-products-regs-2024"},{"title":"IRDAI (Insurance Products) Regulations, 2024","section":"Schedule III, Para 4","url":"https://indiainsurances.com/law/irdai-products-regs-2024"},{"title":"Review of revision in premium rates under health insurance policies for senior citizens, 2025","section":"Para 7","url":"https://indiainsurances.com/law/irdai-senior-premium-2025"}]},{"key":"permanent_exclusions","label":"Permanent exclusions","section":"Exclusions","meaning":"Conditions or treatments that are never covered: the standard IRDAI exclusion codes Excl04 to Excl18 and the product's own permanent exclusions. Excl01 to Excl03 are waiting periods, not permanent exclusions.","status":"cross-checked","value":["Investigation and evaluation (Excl04)","Rest cure, rehabilitation and respite care (Excl05)","Obesity/weight control surgery not meeting the conditions (Excl06)","Change-of-gender treatments (Excl07)","Cosmetic or plastic surgery (Excl08)","Hazardous or adventure sports (Excl09)","Breach of law (Excl10)","Excluded providers (Excl11)","Alcoholism, drug or substance abuse or any addictive condition (Excl12)","Treatments in health hydros, nature cure clinics, spas or similar establishments (Excl13)","Dietary supplements and substances purchased without prescription (Excl14)","Correction of eye sight due to refractive error (Excl15)","Unproven treatments (Excl16)","Sterility and infertility (Excl17)","Maternity (Excl18)","War or similar situations","Intentional self-injury or attempted suicide","Participation in naval, military or air force operation","Investigative treatment for sleep-apnoea, general debility or exhaustion","Congenital external diseases, defects or anomalies","Stem cell harvesting","Spinal subluxation adjustments and manipulation of the skeletal structure","Circumcisions unless necessitated by illness or injury","Convalescence, sanatorium treatment, private duty nursing or long-term nursing care","Preventive care and nutritional and electrolyte supplements","Vaccination (except post animal bite treatment)","Non-Medical expenses","Treatment taken on outpatient basis","Hearing aids, spectacles or contact lenses","Alopecia and baldness treatment","Treatment not reasonable and customary or not medically necessary","Artificial limbs, external devices and durable medical equipment","Claims arising from non-disclosure of pre-existing illness or material fact","Non-allopathic treatment except in-patient AYUSH cover","Treatment by a practitioner outside his discipline","Treatment by a practitioner who is a family member","Specific timebound or lifetime exclusions in the Schedule","Treatment availed outside India"],"display":"Standard exclusions Excl04 to Excl18, plus war, self-injury, military operations, external congenital defects, OPD, non-medical expenses, hearing aids and spectacles, non-allopathic treatment beyond in-patient AYUSH, treatment outside India and others","note":"Excl06 and Excl08 carry conditions (obesity surgery is covered when the listed BMI and medical conditions are met; cosmetic surgery is covered for reconstruction after an Accident, Burn(s) or Cancer or when medically necessary). Excluded providers are paid up to stabilisation in life threatening situations or after an Accident.","quote":"iii)Investigation & Evaluation: Code Excl04 ... Rest Cure, rehabilitation and respite care–Code – Excl05 ... ii) Obesity/Weight control:Code – Excl06 ... iii) Change-of-Gender treatments - Code – Excl07 ... iv) Cosmetic or plastic surgery:Code – Excl08 ... ii)Hazardous or Adventure Sports: Code – Excl09 ... i) Breach of law: Code – Excl10 ... v) Excluded Providers- Code – Excl11 ... vi) Treatment for Alcoholism, drug or substance abuse or any addictive condition and consequences thereof.Code – Excl12 ... vii)Treatments received in health hydros, nature cure clinics, spas or similar establishments ... Code – Excl13 ... viii) Dietary supplements and substances that can be purchased without prescription ... Code – Excl14 ... ix) Expenses related to the treatment for correction of eye sight due to refractive error less than 7.5 dioptres.Code – Excl15 ... x) Unproven Treatments– Expenses related to any unproven treatment ... Code – Excl16 ... xi) Sterility and Infertility –Code – Excl17 ... xii) Maternity:Code – Excl18 ... i) War or similar situations ... ii) Intentional self-injury or attempted suicide while sane or insane ... xiv) Any Insured Person’s participation or involvement in naval, military or air force operation. xv)Investigative treatment for Sleep-apnoea, General debility or exhaustion (“run-down condition”). xvi)Congenital external diseases, defects or anomalies, xvii) Stem cell harvesting xviii) Investigative treatments for analysis and adjustments of spinal subluxation,diagnosis and treatment by manipulation of the skeletal structure ... xix) Circumcisions (unless necessitated by Illness or Injury and forming part of treatment). xx) Any Convalescence, ,sanatorium treatment, private duty nursing or long-term nursing care. xxi) Preventive care, and other nutritional and electrolyte supplements ... xxii) Vaccination including inoculation and immunisations (Except post Animal bite treatment), xxiii) Non-Medical expenses ... xxiv) Treatment taken on Outpatient basis ... xxv) The provision or fitting of hearing aids, spectacles or contact lenses. ... xxvi) Any treatment and associated expenses for alopecia, baldness ... xxvii) Any treatment or part of a treatment that is not of a Reasonable and Customary charge, not Medically Necessary ... xxviii) Expenses for Artificial limbs and/or device used for diagnosis or treatment (except when used intra-operatively).prosthesis, corrective devices external durable medical equipment of any kind ... xxix) Any Claim arising due to Non-disclosure of Pre-existing Illness or Material fact as sought to be declared on the Proposal form. ... xxx) Any non-allopathic treatment except to the extent of coverage provided for under 'In-patient treatment' cover. ... xxxi) Treatment rendered by a Medical Practitioner which is outside his discipline or the discipline for which he is licensed. ... xxxii) Treatments rendered by a Medical Practitioner who is a member of the Insured Person’s family or stays with him ... xxxiii) Any specific timebound or lifetime exclusion(s) applied by Us and specified in the Schedule ... 3. Treatment availed outside India","sources":[{"clause":"Section B(I)","heading":null,"page":7,"url":"https://indiainsurances.com/policy/hdfc-ergo-general-insurance/optima-senior-hdhhlip21379v022021/document/156#c-section-b-i"},{"clause":null,"heading":"II. Standard General exclusions","page":13,"url":"https://indiainsurances.com/policy/hdfc-ergo-general-insurance/optima-senior-hdhhlip21379v022021/document/156#c-ii-standard-general-exclusions"},{"clause":"2(d)(iii)","heading":null,"page":14,"url":"https://indiainsurances.com/policy/hdfc-ergo-general-insurance/optima-senior-hdhhlip21379v022021/document/156#c-2-d-iii"},{"clause":"2(d)(iv)","heading":null,"page":14,"url":"https://indiainsurances.com/policy/hdfc-ergo-general-insurance/optima-senior-hdhhlip21379v022021/document/156#c-2-d-iv"},{"clause":"2(d)(v)","heading":null,"page":14,"url":"https://indiainsurances.com/policy/hdfc-ergo-general-insurance/optima-senior-hdhhlip21379v022021/document/156#c-2-d-v"},{"clause":"2(d)(vi)","heading":null,"page":15,"url":"https://indiainsurances.com/policy/hdfc-ergo-general-insurance/optima-senior-hdhhlip21379v022021/document/156#c-2-d-vi"},{"clause":"Excl12","heading":null,"page":15,"url":"https://indiainsurances.com/policy/hdfc-ergo-general-insurance/optima-senior-hdhhlip21379v022021/document/156#c-excl12"},{"clause":"Excl14","heading":null,"page":15,"url":"https://indiainsurances.com/policy/hdfc-ergo-general-insurance/optima-senior-hdhhlip21379v022021/document/156#c-excl14"},{"clause":"Excl15","heading":null,"page":15,"url":"https://indiainsurances.com/policy/hdfc-ergo-general-insurance/optima-senior-hdhhlip21379v022021/document/156#c-excl15"},{"clause":"Excl16","heading":null,"page":15,"url":"https://indiainsurances.com/policy/hdfc-ergo-general-insurance/optima-senior-hdhhlip21379v022021/document/156#c-excl16"},{"clause":null,"heading":"III. Specific Exclusions","page":16,"url":"https://indiainsurances.com/policy/hdfc-ergo-general-insurance/optima-senior-hdhhlip21379v022021/document/156#c-iii-specific-exclusions"}],"law":[{"title":"Master Circular on Protection of Policyholders' Interests, 2024","section":"Para 16","url":"https://indiainsurances.com/law/irdai-ppi-mc-2024"}]},{"key":"cancellation_refund","label":"Cancellation by you","section":"Renewal and rights","meaning":"What you get back if you cancel during the year.","status":"cross-checked","value":"You may cancel with 7 days' written notice and get a pro-rata premium refund for the unexpired policy period; no refund if any claim has been admitted or any benefit availed.","display":"Pro-rata refund for the unexpired period; nothing if a claim was admitted","note":"7 days' written notice. For instalment premiums, after an admissible claim future instalments for the year are adjusted in the claim and no premium is refunded that year. Premium for a deceased insured person is refunded proportionately for the unexpired period.","quote":"o) Cancellation The Policyholder may cancel this policy by giving 7 days’ written notice and in such an event, the Company shall refund to the Insured a pro-rata premium for the unexpired Policy Period. ... iii. Notwithstanding anything contained herein or otherwise, no refunds of premium shall be made in respect of Cancellation where any claim has been admitted or any benefit has been availed by the Insured Person under the Policy.","sources":[{"clause":"Section D(I)(d)(v)","heading":null,"page":20,"url":"https://indiainsurances.com/policy/hdfc-ergo-general-insurance/optima-senior-hdhhlip21379v022021/document/156#c-section-d-i-d-v"}],"law":[{"title":"The Insurance Act, 1938","section":"Section 64VB","url":"https://indiainsurances.com/law/insurance-act-1938"},{"title":"Master Circular on General Insurance Business, 2024","section":"Ch I, Para 8","url":"https://indiainsurances.com/law/irdai-general-mc-2024"},{"title":"Master Circular on Health Insurance Business, 2024","section":"Ch I Para 6","url":"https://indiainsurances.com/law/irdai-health-mc-2024"},{"title":"Master Circular on Life Insurance Products, 2024","section":"Chapter 1, Para 5","url":"https://indiainsurances.com/law/irdai-life-products-2024"},{"title":"Insurance Regulatory and Development Authority of India (Protection of Policyholders’ Interests, Operations and Allied Matters of Insurers) Regulations, 2024","section":"Reg 17","url":"https://indiainsurances.com/law/irdai-ppi-2024"},{"title":"Insurance Regulatory and Development Authority of India (Protection of Policyholders’ Interests, Operations and Allied Matters of Insurers) Regulations, 2024","section":"Reg 20(3) to 20(5)","url":"https://indiainsurances.com/law/irdai-ppi-2024"},{"title":"Master Circular on Protection of Policyholders' Interests, 2024","section":"Sec 1, Part A, III.2","url":"https://indiainsurances.com/law/irdai-ppi-mc-2024"},{"title":"Master Circular on Protection of Policyholders' Interests, 2024","section":"Sec 1, Part B, IV.4","url":"https://indiainsurances.com/law/irdai-ppi-mc-2024"},{"title":"Master Circular on Protection of Policyholders' Interests, 2024","section":"Sec 1, Part C, IV.3","url":"https://indiainsurances.com/law/irdai-ppi-mc-2024"}]},{"key":"territory","label":"Where it covers","section":"Overview","meaning":"Geographic area of cover: India only, worldwide, or listed countries. 'As stated in the schedule' is not an answer.","status":"cross-checked","value":"India only.","display":"India only","note":"The CIS and the wording's claim contacts also print outside-India claim contacts, but the policy covers treatment in India only.","quote":"a) Geography This Policy only covers medical treatment taken within India. All payments under this Policy will only be made in Indian Rupees within India.","sources":[{"clause":"Section D(II)(a)","heading":null,"page":23,"url":"https://indiainsurances.com/policy/hdfc-ergo-general-insurance/optima-senior-hdhhlip21379v022021/document/156#c-section-d-ii-a"}],"law":[]},{"key":"free_look","label":"Free-look period","section":"Renewal and rights","meaning":"Days after you receive the policy in which you can return it for a refund if you do not agree with its terms.","status":"cross-checked","value":{"unit":"days","amount":30},"display":"30 days","note":"New individual policies only, not renewals or porting/migration. Refund is the premium less medical examination expenses and stamp duty, with a proportionate risk premium deducted if cover has started. The CIS also says 'within 30 days from the beginning of the policy'.","quote":"The insured person shall be allowed free look period of 30 days from date of receipt of the policy document to review the terms and conditions of the policy, and to return the same if not acceptable.","sources":[{"clause":"Section D(I)(d)(v)","heading":null,"page":20,"url":"https://indiainsurances.com/policy/hdfc-ergo-general-insurance/optima-senior-hdhhlip21379v022021/document/156#c-section-d-i-d-v"}],"law":[{"title":"Master Circular on Health Insurance Business, 2024","section":"Ch I Para 5","url":"https://indiainsurances.com/law/irdai-health-mc-2024"},{"title":"Master Circular on Life Insurance Products, 2024","section":"Chapter 1, Para 5","url":"https://indiainsurances.com/law/irdai-life-products-2024"},{"title":"Insurance Regulatory and Development Authority of India (Protection of Policyholders’ Interests, Operations and Allied Matters of Insurers) Regulations, 2024","section":"Reg 20(1), 20(2)","url":"https://indiainsurances.com/law/irdai-ppi-2024"},{"title":"Insurance Regulatory and Development Authority of India (Protection of Policyholders’ Interests, Operations and Allied Matters of Insurers) Regulations, 2024","section":"Reg 20(3) to 20(5)","url":"https://indiainsurances.com/law/irdai-ppi-2024"},{"title":"Insurance Regulatory and Development Authority of India (Protection of Policyholders’ Interests, Operations and Allied Matters of Insurers) Regulations, 2024","section":"Reg 20(6)","url":"https://indiainsurances.com/law/irdai-ppi-2024"},{"title":"Master Circular on Protection of Policyholders' Interests, 2024","section":"Sec 1, Part A, II.8","url":"https://indiainsurances.com/law/irdai-ppi-mc-2024"},{"title":"Master Circular on Protection of Policyholders' Interests, 2024","section":"Sec 1, Part A, III.2","url":"https://indiainsurances.com/law/irdai-ppi-mc-2024"},{"title":"Master Circular on Protection of Policyholders' Interests, 2024","section":"Sec 1, Part B, III.2","url":"https://indiainsurances.com/law/irdai-ppi-mc-2024"}]},{"key":"grace_period","label":"Grace period","section":"Renewal and rights","meaning":"Days you get after the due date to pay without losing cover or continuity.","status":"cross-checked","value":{"unit":"days","amount":30},"display":"30 days (15 days if paid monthly)","note":"Fifteen days where the premium is paid monthly.","quote":"The grace period for payment of the premium for all types of insurance policies shall be: fifteen days where premium payment mode is monthly and thirty days in all other cases.","sources":[{"clause":null,"heading":"Def. 5.","page":3,"url":"https://indiainsurances.com/policy/hdfc-ergo-general-insurance/optima-senior-hdhhlip21379v022021/document/156#c-def-5-2"}],"law":[{"title":"The Insurance Act, 1938","section":"Section 50","url":"https://indiainsurances.com/law/insurance-act-1938"},{"title":"Master Circular on Health Insurance Business, 2024","section":"Ch I Para 8","url":"https://indiainsurances.com/law/irdai-health-mc-2024"},{"title":"Master Circular on Health Insurance Business, 2024","section":"Ch I Para 9","url":"https://indiainsurances.com/law/irdai-health-mc-2024"},{"title":"Master Circular on Life Insurance Products, 2024","section":"Chapter 1, Para 8","url":"https://indiainsurances.com/law/irdai-life-products-2024"},{"title":"Master Circular on Protection of Policyholders' Interests, 2024","section":"Sec 1, Part A, IV.2","url":"https://indiainsurances.com/law/irdai-ppi-mc-2024"},{"title":"Master Circular on Protection of Policyholders' Interests, 2024","section":"Sec 1, Part B, IV.2","url":"https://indiainsurances.com/law/irdai-ppi-mc-2024"},{"title":"Master Circular on Protection of Policyholders' Interests, 2024","section":"Para 3","url":"https://indiainsurances.com/law/irdai-ppi-mc-2024"},{"title":"IRDAI (Insurance Products) Regulations, 2024","section":"Schedule I, Para 1.2","url":"https://indiainsurances.com/law/irdai-products-regs-2024"},{"title":"IRDAI (Insurance Products) Regulations, 2024","section":"Schedule III, Para 1.3","url":"https://indiainsurances.com/law/irdai-products-regs-2024"}]},{"key":"eligibility_entry_age","label":"Entry age","section":"Eligibility","meaning":"The youngest and oldest age at which you can buy this policy.","status":"cross-checked","value":"Minimum entry age 61 years; no maximum entry age is given (premium rates run to above 85 years).","display":"61 years and above","note":"No maximum entry age is printed; the prospectus premium table has a '> 85 Yrs' band and there is no maximum cover ceasing age.","quote":"a) The minimum entry age under this policy is 61 years and above. ... > 85 Yrs","sources":[{"clause":null,"heading":"Optima Senior - Prospectus","page":1,"url":"https://indiainsurances.com/policy/hdfc-ergo-general-insurance/optima-senior-hdhhlip21379v022021/document/157#c-optima-senior-prospectus"},{"clause":null,"heading":"Possibility of Revision of Terms of the Policy Including the Premium Rates","page":11,"url":"https://indiainsurances.com/policy/hdfc-ergo-general-insurance/optima-senior-hdhhlip21379v022021/document/157#c-possibility-of-revision-of-terms-of-the-policy-i"}],"law":[]},{"key":"premium_modes","label":"Premium payment options","section":"Premium","meaning":"How often you can pay: yearly, half-yearly, quarterly, monthly.","status":"cross-checked","value":["Single premium paid in advance for the policy period of 1, 2 or 3 years"],"display":"Single premium in advance for the 1, 2 or 3 year policy period","note":"Discount of 7.5% for a two year and 10% for a three year premium paid in advance. The wording mentions instalment premiums in its grace period and cancellation clauses, but no instalment frequency (monthly, quarterly, half-yearly) is listed for this product.","quote":"c) The policy will be issued for a period 1/2/3 years. ... A discount of 7.5% / 10% will be provided if insured person is paying two year/ three year premium respectively in advance as a single premium","sources":[{"clause":null,"heading":"Optima Senior - Prospectus","page":1,"url":"https://indiainsurances.com/policy/hdfc-ergo-general-insurance/optima-senior-hdhhlip21379v022021/document/157#c-optima-senior-prospectus"},{"clause":null,"heading":"2/3 Year Premium","page":12,"url":"https://indiainsurances.com/policy/hdfc-ergo-general-insurance/optima-senior-hdhhlip21379v022021/document/157#c-2-3-year-premium"}],"law":[]},{"key":"optional_covers","label":"Optional covers","section":"Cover","meaning":"Covers you can add for an extra premium. They change the answers above only if you buy them.","status":"cross-checked","value":["Endorsement deleting the 30 days waiting period","Endorsement deleting or reducing to 12 months the 24 months waiting period for specified illnesses/surgeries","Endorsement deleting or reducing to 24 or 12 months the 36 months waiting period for pre-existing conditions"],"display":"Endorsements that delete or shorten the waiting periods (price not stated)","note":"The endorsements are printed in the policy wording; the documents do not say what they cost or how they are chosen.","quote":"a) 30 days waiting period The 30 days waiting period under Section C-I- i) stands deleted for all the Insured Persons. ... i) The 24 months waiting period for the specified Illnesses/ Surgeries specified under Section C- I-ii) stands deleted for all the Insured Persons. ii) The 24 months waiting period for the specified Illnesses/ Surgeries specified under Section C- I-ii) stands reduced to 12 months for all the Insured Persons. ... i) The 36 months waiting period for the Pre-existing Conditions under Section C-I-iii) stands deleted for all the Insured Persons. ii) The 36 months waiting period for the Pre-existing Conditions under Section C-I-iii) stands reduced to 24 months for all the Insured Persons. iii) The 36 months waiting period for the Pre-existing Conditions under Section C-I-iii) stands reduced to 12 months for all the Insured Persons. ... Note: Waiting Periods in force for Insured Persons shall be as per the plan opted or option selected","sources":[{"clause":null,"heading":"Endorsements – Optima Senior","page":31,"url":"https://indiainsurances.com/policy/hdfc-ergo-general-insurance/optima-senior-hdhhlip21379v022021/document/156#c-endorsements-optima-senior"},{"clause":"Excl08(iv)","heading":null,"page":5,"url":"https://indiainsurances.com/policy/hdfc-ergo-general-insurance/optima-senior-hdhhlip21379v022021/document/158#c-excl08-iv"}],"law":[]},{"key":"grace_cover","label":"Cover during the grace period","section":"Renewal and rights","meaning":"Whether a claim during the grace period is paid.","status":"cross-checked","value":"Cover is given during the grace period only if the premium is paid in instalments; for non-instalment premium payment there is no cover for the period for which no premium is received.","display":"No cover for the unpaid period, unless premium is paid in instalments","note":"The renewal is treated as continuous if paid within the grace period.","quote":"Coverage need not be available during the period for which no premium is received. ... Provided the insurers shall offer coverage during the grace period, if the premium is paid in instalments during the policy period (Note: In case of non-instalment premium payment, coverage shall not be available for the period for which no premium is received).","sources":[{"clause":null,"heading":"Def. 5.","page":3,"url":"https://indiainsurances.com/policy/hdfc-ergo-general-insurance/optima-senior-hdhhlip21379v022021/document/156#c-def-5-2"}],"law":[]},{"key":"room_rent","label":"Room rent limit","section":"Limits and co-pay","meaning":"The most the policy pays per day for the hospital room, or the room category allowed.","status":"cross-checked","value":"In-patient treatment, including room rent, is covered in shared accommodation with a 15% co-payment; in a single occupancy or higher room the co-payment is 30%.","display":"Shared room; a single room is allowed but raises the co-payment from 15% to 30%","note":"No rupee or per-day room rent limit is printed. Only a 15% co-payment applies if a single room is used for urgent treatment of acute cardiac illness or accident because no shared room was available.","quote":"includes Hospital room rent or boarding expenses ... 1a) In-patient Treatment (in Shared Accommodation) | Covered ... Shared Accommodation or any lower accommodation type | 15% ... Single occupancy or any higher accommodation type | 30%","sources":[{"clause":"Section B(I)","heading":null,"page":7,"url":"https://indiainsurances.com/policy/hdfc-ergo-general-insurance/optima-senior-hdhhlip21379v022021/document/156#c-section-b-i"},{"clause":null,"heading":"Schedule of Benefits","page":1,"url":"https://indiainsurances.com/policy/hdfc-ergo-general-insurance/optima-senior-hdhhlip21379v022021/document/157#c-schedule-of-benefits"},{"clause":null,"heading":"A. Co-Payment applicable on accommodation Type","page":10,"url":"https://indiainsurances.com/policy/hdfc-ergo-general-insurance/optima-senior-hdhhlip21379v022021/document/156#c-a-co-payment-applicable-on-accommodation-type"}],"law":[]},{"key":"copay","label":"Co-payment","section":"Limits and co-pay","meaning":"The share of every admissible claim you pay yourself.","status":"cross-checked","value":"15% of every admissible claim in shared accommodation and for all day care procedures; 30% in single occupancy or higher; 30% for listed illnesses and surgeries instead of the accommodation co-payment.","display":"15% (shared room or day care); 30% (single room or listed surgeries)","note":"The 30% listed-illness co-payment covers cataract, hysterectomy, cholecystectomy, prostate surgery, hernia, angiography, arthroscopy, PID-discectomy, mastectomy, joint replacement, PTCA, hydrocele, major organ transplant and CABG. Single room for urgent acute cardiac illness or accident when no shared room was available: 15%.","quote":"Shared Accommodation or any lower accommodation type | 15% ... Single occupancy or any higher accommodation type | 30% ... A Co-payment of 15% shall be applicable to all Day Care Procedures; no additional copay’s shall apply. ... the insured person shall bear 30% of the claim amount payable under the Policy ... Note – If We admit a claim under Section B.III B then, no Co-Payment shall be applicable under Section B.III A for the same claim.","sources":[{"clause":null,"heading":"A. Co-Payment applicable on accommodation Type","page":10,"url":"https://indiainsurances.com/policy/hdfc-ergo-general-insurance/optima-senior-hdhhlip21379v022021/document/156#c-a-co-payment-applicable-on-accommodation-type"},{"clause":null,"heading":"B. Co-Payment applicable on specified Illnesses/surgeries","page":10,"url":"https://indiainsurances.com/policy/hdfc-ergo-general-insurance/optima-senior-hdhhlip21379v022021/document/156#c-b-co-payment-applicable-on-specified-illnesses-s"}],"law":[]},{"key":"disease_sublimits","label":"Disease or procedure sub-limits","section":"Limits and co-pay","meaning":"Caps on what is paid for named treatments even if the sum insured is higher.","status":"cross-checked","value":["Emergency ambulance: up to Rs. 2,000 per hospitalisation","E-opinion: one opinion per Policy Year"],"display":"Ambulance up to Rs. 2,000 per hospitalisation; one e-opinion per year","note":"No rupee caps on named diseases; instead a 30% co-payment applies to listed illnesses and surgeries (see co-payment). Domiciliary treatment of less than 3 days is not covered.","quote":"1g) Emergency Ambulance | Upto Rs.2,000 per Hospitalisation ... 2a) E-opinion | One opinion per Policy Year","sources":[{"clause":null,"heading":"Schedule of Benefits","page":1,"url":"https://indiainsurances.com/policy/hdfc-ergo-general-insurance/optima-senior-hdhhlip21379v022021/document/157#c-schedule-of-benefits"}],"law":[]},{"key":"pre_policy_checkup","label":"Medical tests before buying","section":"Eligibility","meaning":"Whether you need medical tests before the policy is issued.","status":"cross-checked","value":"Yes. A pre-policy check-up at the insurer's network is required; 50% of the cost per insured person is reimbursed if the proposal is accepted.","display":"Yes, required; 50% of cost reimbursed on acceptance","note":"Tests vary by age (61-65, 66 onwards) and sum insured and include medical examination, blood and urine tests, TMT and ultrasound; reports are valid for 30 days.","quote":"Pre-Policy Check-up at our network will be required. We will reimburse 50% of the expenses incurred per insured person on the acceptance of the proposal. The medical reports are valid for a period of 30 days from the date of Pre-Policy Check-up.","sources":[{"clause":null,"heading":"Possibility of Revision of Terms of the Policy Including the Premium Rates","page":11,"url":"https://indiainsurances.com/policy/hdfc-ergo-general-insurance/optima-senior-hdhhlip21379v022021/document/157#c-possibility-of-revision-of-terms-of-the-policy-i"}],"law":[]},{"key":"pre_hospitalisation","label":"Pre-hospitalisation cover","section":"Cover","meaning":"Medical costs before admission that are paid.","status":"cross-checked","value":{"unit":"days","amount":30},"display":"30 days","note":"Only if the in-patient, day care or domiciliary claim is admitted and for the same condition.","quote":"b. Pre-Hospitalization Medical expenses for consultations, investigations and medicines incurred upto 30 days before Hospitalisation.","sources":[{"clause":"Section B(I)","heading":null,"page":7,"url":"https://indiainsurances.com/policy/hdfc-ergo-general-insurance/optima-senior-hdhhlip21379v022021/document/156#c-section-b-i"}],"law":[]},{"key":"post_hospitalisation","label":"Post-hospitalisation cover","section":"Cover","meaning":"Medical costs after discharge that are paid.","status":"cross-checked","value":{"unit":"days","amount":60},"display":"60 days","note":"Only if the in-patient, day care or domiciliary claim is admitted and for the same condition.","quote":"c. Post-Hospitalization Medical expenses for consultations, investigations and medicines incurred upto 60 days after discharge from Hospitalisation.","sources":[{"clause":"Section B(I)","heading":null,"page":7,"url":"https://indiainsurances.com/policy/hdfc-ergo-general-insurance/optima-senior-hdhhlip21379v022021/document/156#c-section-b-i"}],"law":[]},{"key":"day_care","label":"Day-care treatments","section":"Cover","meaning":"Treatments needing less than 24 hours in hospital.","status":"cross-checked","value":"All day care procedures are covered, with a 15% co-payment.","display":"All day care procedures covered (15% co-payment)","note":"Treatment normally taken on an out-patient basis is not a day care procedure.","quote":"1d) Day Care Procedures | Covered, All Day Care Procedures ... A Co-payment of 15% shall be applicable to all Day Care Procedures; no additional copay’s shall apply.","sources":[{"clause":null,"heading":"Schedule of Benefits","page":1,"url":"https://indiainsurances.com/policy/hdfc-ergo-general-insurance/optima-senior-hdhhlip21379v022021/document/157#c-schedule-of-benefits"},{"clause":null,"heading":"A. Co-Payment applicable on accommodation Type","page":10,"url":"https://indiainsurances.com/policy/hdfc-ergo-general-insurance/optima-senior-hdhhlip21379v022021/document/156#c-a-co-payment-applicable-on-accommodation-type"}],"law":[]},{"key":"restoration","label":"Restoration of sum insured","section":"Cover","meaning":"Whether the sum insured is refilled after it is used up.","status":"not-stated","value":null,"display":null,"note":"The documents do not mention restoration or refill of the sum insured.","quote":null,"sources":[],"law":[]},{"key":"no_claim_bonus","label":"No-claim or cumulative bonus","section":"Cover","meaning":"How much the cover grows each year, the maximum, whether it depends on not claiming, and what happens after a claim.","status":"cross-checked","value":"No bonus on the sum insured is described; a 5% non-cumulative discount on the renewal premium is given after every claim-free policy year if renewed without a break.","display":"5% renewal premium discount after each claim-free year (non-cumulative)","note":"Claims under the main coverages remove the discount; an E-opinion claim does not. The table of contents lists a 'Cumulative Bonus (CB)' section but the section itself gives only this discount.","quote":"No Claim Discount - A 5% non-cumulative discount will be offered on the renewal premium payable under the Policy after every CLAIM FREE Policy Year, provided that the Policy is renewed with Us and without a break.","sources":[{"clause":null,"heading":"II. Renewal Benefits","page":9,"url":"https://indiainsurances.com/policy/hdfc-ergo-general-insurance/optima-senior-hdhhlip21379v022021/document/156#c-ii-renewal-benefits"}],"law":[]},{"key":"cashless","label":"Cashless treatment","section":"Claims","meaning":"Whether and where the insurer pays the hospital directly instead of you paying and claiming back.","status":"cross-checked","value":"Yes, at network hospitals: the insurer pays the network hospital directly, with notice at least 48 hours before planned treatment or within 24 hours of an emergency admission.","display":"Yes, at network hospitals","note":"CIS: cashless authorisation decision within 1 hour of request; final bill authorisation within 3 hours of the discharge request.","quote":"Network Hospital | We will provide cashless service by making payment to the extent of Our liability directly to the Network Hospital. | Immediately and in any event at least 48 hours prior to the start of the Insured Person’s Hospitalisation. ... Within 24 hours of the start of the Insured Person’s Hospitalisation.","sources":[{"clause":"Section D(II)(e)","heading":null,"page":23,"url":"https://indiainsurances.com/policy/hdfc-ergo-general-insurance/optima-senior-hdhhlip21379v022021/document/156#c-section-d-ii-e"}],"law":[]},{"key":"claims_handled_by","label":"Claims handled by","section":"Claims","meaning":"The insurer itself or a third-party administrator (TPA).","status":"cross-checked","value":"A specified Third Party Administrator (TPA) processes and settles claims on behalf of HDFC ERGO; the final decision rests with HDFC ERGO.","display":"TPA, on behalf of HDFC ERGO","note":"The wording refers to 'We or Our TPA' throughout.","quote":"Specified Third Party Administrator (TPA) licensed by IRDA will process and settle all claims under this policy on behalf of HDFC ERGO General Insurance Company Limited. The final decision on any claim solely rests with HDFC ERGO General Insurance Company Limited .","sources":[{"clause":"1(b)(ii)","heading":null,"page":9,"url":"https://indiainsurances.com/policy/hdfc-ergo-general-insurance/optima-senior-hdhhlip21379v022021/document/157#c-1-b-ii"}],"law":[]},{"key":"family_floater","label":"Family floater available","section":"Cover","meaning":"Whether one sum insured can be shared by the whole family.","status":"cross-checked","value":false,"display":"No, each person has an individual sum insured","note":"Self and spouse can be covered in one policy, each with a separate sum insured; 5% family discount if 2 family members are covered.","quote":"d) Policy can be issued to an individual and/or family on individual sum insured basis. e) The family includes self and spouse only.","sources":[{"clause":null,"heading":"Optima Senior - Prospectus","page":1,"url":"https://indiainsurances.com/policy/hdfc-ergo-general-insurance/optima-senior-hdhhlip21379v022021/document/157#c-optima-senior-prospectus"}],"law":[]}],"documents":[{"kind":"wording","label":"Optima Senior","pages":32,"fetched_at":"2026-10-16 07:11:40.003884+00","source_url":"https://customer-portal-assets.hdfcergo.com/documents/optima-senior-combined-pw-cis-hegi-757265377962.pdf","url":"https://indiainsurances.com/policy/hdfc-ergo-general-insurance/optima-senior-hdhhlip21379v022021/document/156"},{"kind":"prospectus","label":"Optima Senior","pages":16,"fetched_at":"2026-10-16 07:11:40.003884+00","source_url":"https://customer-portal-assets.hdfcergo.com/assets/v2/docs/default-source/downloads/prospectus/health/optima-senior-prospectus-614793389221.pdf","url":"https://indiainsurances.com/policy/hdfc-ergo-general-insurance/optima-senior-hdhhlip21379v022021/document/157"},{"kind":"cis","label":"Optima Senior","pages":13,"fetched_at":"2026-10-16 07:11:40.003884+00","source_url":"https://customer-portal-assets.hdfcergo.com/assets/v2/docs/default-source/downloads/cis/cis---optimasenior/PDF190-188459275217.pdf","url":"https://indiainsurances.com/policy/hdfc-ergo-general-insurance/optima-senior-hdhhlip21379v022021/document/158"}],"versions":[],"where_to_buy":[],"claims_and_complaints":[],"notice":"Information, not advice. IndiaInsurances is not an insurer or an insurance intermediary, does not sell insurance and earns no commission. Policy terms change and your own policy schedule can differ: always confirm with the policy document and the insurer before you buy or claim.","cite_as":"Optima Senior (UIN HDHHLIP21379V022021), IndiaInsurances, https://indiainsurances.com/policy/hdfc-ergo-general-insurance/optima-senior-hdhhlip21379v022021"}