Overview
HDFC ERGO’s Optima Senior is a specialized health insurance plan designed for senior citizens aged 61 and above. It includes benefits like organ donor expenses, domiciliary hospitalization, pre-post hospitalization [30-60 days respectively], daycare procedures, emergency ambulance [ subject to Rs. 2000 per hospitalization], and a second medical opinion for critical illnesses. The plan also provides lifelong renewability and a no-claim discount of 5% on renewal premiums after every claim-free policy year.
Experts' Review
Written by Nikhil Nair
Senior Writer
The HDFC ERGO Optima Senior plan is a tailored health insurance solution for senior citizens, offering coverage with lifelong renewability and no claim-based loading. However, it includes a 15% co-payment clause [shared accommodation or any lower accommodation type] on all claims and a 30% co-payment if opting for a higher room category [Single occupancy or any higher accommodation type] and a 30% co-payment on specified illnesses, which may increase out-of-pocket expenses. The plan excludes OPD treatments, dental treatments, and expenses related to drug or alcohol abuse.
The premium for this plan is generally 5-10% higher than comparable senior citizen plans like Care Senior due to its benefits. Additionally, it includes sub-limits for certain procedures like cataract surgery and benign prostatic hyperplasia. Fortunately, HDFC ERGO's high claim settlement ratio (98% avg. of 2021-24) supports its operational efficiency and overshadows the price point.
Pros
Insurer has a solid track record with great claim and service metrics.
Cons
Not very feature-rich.
No Restoration Benefit, which is a notable gap.
No Bonus for being healthy and not claiming insurance, which could be a drawback for some.
Your insurer doesn’t provide free health check-ups, which is a key feature.
HDFC Ergo
Key Insights
Founded
2002
HDFC Ergo was established 23 years ago and has built strong credibility over time, backed by its long-standing presence in the market.
Claims Experience
97% claims settled in 30 Days
HDFC Ergo settles 97% of all claims it receives demonstrating strong credibility.
Network Hospitals
13,000+
HDFC Ergo has a strong network with over 13,000 hospitals, ensuring wide accessibility and convenience for policyholders.
Complaints
9 complaints per 10,000 claims registered
HDFC Ergo maintains a low volume of complaints, reflecting strong customer satisfaction and effective service.
Features
All
Great
Good
Bad
Co-payment
The policy will only cover 100% of the final bill. The rest is on you. They call this a co-payment.
Room Rent
Tough luck if you are thinking about opting for a single private room. Because the policy only lets you stay in a shared room. If you still want to pick a better room, then be ready to pay a lot more when the final bill shows up.
Disease sub-limit
Your insurer won’t bear the full costs if you are treated for Joint Replacement, Surgery of Hernia, Angiography, Cataract and a few other complications. In fact, you will have to bear 30% of the cost in the event you are hospitalized for these illnesses.
Pre existing diseases waiting
If you’re already dealing with diabetes, cardiovascular problems or any such illnesses, the insurer will cover all costs arising out of these pre-existing problems after you wait for 3 years.
Pre/Post hospitalization
No worries if the doctor had to run a host of diagnostic tests before or after hospitalizing you. The insurer has your back. They will cover this amount in full for a pretty reasonable duration - 30 days before you are hospitalized and 60 days after discharge. This includes the cost of medication by the way.
Permanent Exclusions
Conditions or treatments that the policy clearly says it will not cover.
Any Convalescence, ,sanatorium treatment, private duty nursing or long-term nursing care.
Expenses related to any admission primarily for diagnostics and evaluation purposes are excluded.
Diagnostic expenses not related or incidental to current diagnosis and treatment are excluded.
Expenses for admission primarily for bed rest and not for treatment are excluded.
Custodial care at home or in a facility for help with daily activities is excluded.
Disclaimer: For illustration purposes only - exact terms are in the policy wording.
Specific Illness
The following illnesses are not covered under the policy for 2 years.
Internal congenital diseases
Non‑infective arthritis
Pilonidal sinus
Diseases of gall bladder (including cholecystitis)
Calculus diseases of urogenital system (e.g., kidney stones, urinary bladder stones)
Waiting Period
30 days Initial waiting period
2 years Specific illness waiting period
3 years Pre-existing disease waiting period
Ditto's Take
◦ Standard ◦
After a close look at the waiting periods, it’s safe to say they are fairly standard.
What's missing in the policy
No Restoration Benefit.
No Bonus for being healthy and not claiming insurance.
Your insurer doesn’t provide free health check-ups.
Maternity benefits not offered.
Doctor consultations are not covered.
Customer Reviews
P
Prakash
Tailored for seniors, which is exactly what I needed.
R
Ritu
Good benefits for older age group.
S
Sanjay
The plan seems to understand senior health needs.
C
Chandni
Premium is quite high for seniors.
A
Aarti
Co-payment is a concern for senior plans.
V
Vani
A reliable option for senior citizens.
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Frequently Asked Questions
Does Optima Senior have waiting periods?
- 30-Day Waiting Period: Hospitalizations won’t be covered for the first 30 days of the policy unless it’s an accident.
- Specific Illness Waiting Period: There’s a 2-year waiting period for a list of diseases which is a mandate before you can start claiming.
- Pre-Existing Disease Waiting Period: There's a 3-year waiting period for any pre-existing disease you may have while buying the policy.
Does Optima Senior have room rent restrictions?
Does Optima Senior offer a restoration benefit?
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