Optima Restore
Coverage
Inpatient treatment up to sum insured
Domiciliary treatment up to sum insured
Day care procedures up to sum insured
No Coverage
Ayush
OPD
Maternity
Special Features:
No room rent capping
No sub limits
No copayment
Restore benefit*
Multiplier benefit** (Cumulative Bonus)
Stay Alive - walking up to10000 steps will entitle you to discount in premium of up to 8%
Preventive health checkups - 1.5k to 5k for individuals; 2k to 10 k for floaters
Air Ambulance- for sum insured of Rs.10 lakhs and above;return expenses are not allowed
*Restore Benefit Example
Sum insured = 5 lakhs; Multiplier benefit = 2.5 lakhs
Insured(A) undergoes angioplasty
Claims 1 lakh
Claim paid 1 lakh
After 3 months,
Insured A undergoes CABG procedure
Claims = 2.5 lakhs
Claims paid = 2.5 lakhs
Insured A (same policy year)
Hospitalized due to accident
Claims=8 lakhs
Claim paid=7.5 lakhs(single claim cannot exceed total of sum insured+multiplier benefit)
** Multiplier benefit example:(claim in 2nd year)
Year1 Year2 Year3
Base sum insured 1000000 1000000 1000000
Multiplier Benefit Nil 500000 (-)500000
Total amount 1000000 1500000 1000000
(at the start of year)
Waiting periods:
Initial 30 days (hospitalization due to accident is covered)
Specified Diseases 24 months (hospitalization due to accident or cancer is covered)
Pre existing diseases 36 months#
# covered only if declared and accepted by the insurer at the time of prosal
List of specified diseases:
Sinusitis
Rhinitis
Tonsillitis
Cysts, Polyps including breast lumps
Polycystic ovarian diseases
Fibromyoma
Adenomyosis
Endometriosis
Prolapsed uterus
Non infective arthritis
Gout and rheumatism
Exclusions:
Non medical exclusions:
War or similar situations
Intentional self injury or attempted suicide
Breach of law
Hazardous or adventure sports
Medical exclusions:
Treatment for alcoholism, drug or substance use
Prosthetic devices which are self detachable without surgery involving anaesthesia
Treatment availed outside India
Treatment at a healthcare facility which is not a hospital
obesity/weight control
Expenses related to the treatment for correction of eyesight due to refractive error less than 7.5 diopters
Cosmetic or plastic surgery (except accident)
Circumcision (except required for treatment)
Change of gender treatments
Non allopathic treatment
Treatment which could have done on OPD basis
Unproven treatments
Investigation & evaluation
Rest cure rehabilitation and respite care
Nursing facility for activities of daily living like bathing etc. are not covered
Any services for terminally ill people to address physical,social,emotional and spiritual needs
Vaccination except post bite treatment
Hearing aids, spectacles etc.
Treatment in spas
Dietary supplements
Sleep apnoea
External congenital diseases, defects or anomalies
Maternity
Sterility & infertility
Expenses incurred on organ donation by the insured
Treatment for adjustment of spinal subluxation
Non medical expenses mentioned in Annexure 1
Excluded providers (hospitals, medical practitioners excluded by the insurer)
Treatment by a medical practitioner for which he is not licensed
Treatments by doctors who are close relatives
Unreasonable charges or medically unnecessary treatments
Drugs or treatments not supported by a prescription
Specific exclusions imposed by the insurer
Admission for administration of Intra - articular or Intra-lesion injections, supplementary medications like Zolendronic acid or !V immunoglobulin infusion.
When buying a health policy, study the exclusions and waiting periods. These are more important than restore benefits or cumulative bonuses. It is true that the policy is really good. But that does not mean that you should not be well informed about what is not covered in the policy.
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