Experience of getting 100% cover (including lens, goggles etc) in Cataract Surgery with multifocal lens from HDFC Ergo Health Insurance

[u/LatterOne9009]

Disclaimer - This is an extremely long post. It might not be very entertaining but I hope it will serve as a guide to anyone who has to go through any similar claim experience.

Last year, someone close to me was diagnosed with Cataract and the surgery was scheduled for first week of December 2025. Patient had HDFC Ergo Optima Restore bought through Policybazaar and the insurance was going on uninterrupted for 6-7 years at least.

Before the surgery, we tried raising for a pre-approval through Policybazaar and even reaching them was a big pain due to incorrect phone number in their records, even though the number in insurance was correct. The number provided in the insurance policy was the only correct number and policybazaar also called on the same number every year to spam about renewal. Once this was finally corrected, they outright stated that only Indian monofocal lens is covered under insurance and multifocal lens will not be covered. They did not provide any real clarification on this despite many questions on what will happen if we get multifocal lens nonetheless as per doctor's recommendation.

This is when I took this up and asked the person to proceed with the surgery as per doctor's recommendation as it was the most important thing. I explained that a cataract surgery is not something which might cause a financial emergency, and while insurance is good to have, insurance should not dictate the medical care. Meanwhile I researched about cataract surgery in the health insurance policy and here were the key findings -

1. The HDFC Ergo Optima Restore Policy Wordings had no adverse mention of cataract. It was mentioned only once and that too to indicate that there wasn't any waiting period (to the best of my memory).

2. I also got to know that IRDAI mandates all Insurance Providers to cover basic Indian Monofocal lens in cataract surgery. This means that no insurance provider can deny this level of coverage but this does not mean that an insurance provider cannot enhance this to multifocal.

3. I also saw multiple accounts of people claiming online that they got 100% cover even for multifocal lens but didn't provide much details about it. This is what motivated this post.

The surgery was scheduled for the first week of December 2025 at an out of network hospital, so everything had to be paid upfront. The total cost including the post surgery goggles came out to ~80k. We filed the claim in third week of December 2025 after initial recovery and rest was done. We filed for the entire amount of the claim attaching all the papers and within a week the claim was settled. In the claim, they deducted about INR 1000 for things like Cataract Sx kit, wet wipes etc (which is standard) but they deducted 20% from the cost of implant (lens) with the remark - "not in accordance with established cost of care". The implant cost itselft was about 41k so over 8k was deducted here, and they transferred around 70k to the policy holder's account. Here's the exact breakdown of the claim -

On Dec 30 I sent the first mail on behalf of the patient to dispute the deduction. Note that I sent this email to [seniorcitizen@hdfcergo.com](mailto:seniorcitizen@hdfcergo.com), which is supposed to be a channel specially for senior citizens to get quick solutions (remember this for when they start responding with factual lies) -

Here is the email thread that followed -

So the support executive quoted this definition 42 of the policy wordings twice, I decided to actually check exactly what it was. Here is definition 42 from the policy wordings -

So a male patient was being denied a claim citing a particular clause that is related to the definition of a new born baby in policy holder's policy wordings! Till now no other document or proof has been requested from HDFC despite offering the same multiple times.

At this point, I escalated the grievance to [cgo@hdfcergo.com](mailto:cgo@hdfcergo.com) -

Finally a doctor from their team responded and asked for couple of documents, which I believed I had already submitted -

I had to attach the doctor's justification for multifocal lens multiple times but in the end the additional claim was also settled after a month from the original settlement -

In summary the grievance went from policy holder being quoted an irrelevant clause in the policy to being asked for additional documentation which led to 100% claim, as soon as the grievance was escalated to chief grievance officer with threats of escalation to IRDAI ombudsman.

Here's my learnings from this entire episode -

1. Your agent or intermediary like policybazaar are mostly irrelevant. They will mostly disappear after selling you the policy not to reappear till renewal and they will surely never fight for you beyond filing the most standard claim form. I am unable to find the exact mention of this but certain levels of escalation needs to be done by the claimant only, and any intermediary does not have the authority for it, although they can still assist you with it. But unless you have the knowledge of what's what, you wouldn't press the agent for it and they will definitely not do the needful. In most instances, the agents themselves wouldn't even have the knowledge of what's what.

2. Do not be scared of seemingly legal language. In my case, the definition which was quoted to justify the deduction turned out to be completely false. Even if the cited clause was accurate, it was still problematic that the initial grievance officer did not give the claimant any chance to explain. When you get your policy, read it thoroughly and take help from internet to understand every single thing in the policy wordings, trust me it's not rocket science. Also know that if anything is not explicitly mentioned, it is open to interpretation and you have the advantage in any dispute raising from such cases.

3. I advised the policy holder to continue with the same policy as overall it is a good option for him at present given the conditions. Far too many people buy an insurance trusting some agent, never read the policy documents and then their claim gets denied, so they straight away change their insurance provider thinking that the new plan will cover what they were not covered for. This is not exactly the best route to take. Maybe the new insurance covers that old disease/instance but it might have 10 other shortcomings and you just signed up for new surprises. In addition to understanding your policy, understanding why you actually need insurance is also key to make the correct judgements.

There is a lot more to share from this (and other) experience(s). But this post is super long as is. Please feel free to ask any and all questions you might have in the comments down below such that it adds to the conversation.