Health Insurance Claims FAQ's | ManipalCigna Health Insurance

Frequently Asked Questions

Content with PRODUCTS ProHealth Insurance .

Insurance coverage that pays for medical and surgical expenses that are incurred by the insured person during the treatment of a disease or injury. Health insurance can either reimburse the insured for expenses incurred from illness or injury or pay the care provider directly.

ManipalCigna offers comprehensive coverage of medical expenses for Inpatient hospitalization including Daycare, Pre and Post hospitalization expenses. It offers AYUSH in-hospital cover, Restoration benefit and Smart non- reducing guaranteed Cumulative bonus as inbuilt features.

Policy also offers Optional Cumulative Bonus Booster which works on non-reducing basis and adds more to the policy every  year irrespective of claims. It also covers Worldwide Emergency, Domiciliary treatment and Donor expenses upto Sum Insured

Outpatient treatment, AYUSH, Doctor consultation, diagnostics and pharmacy bills are covered under Health Maintenance benefit. We offer Healthy Rewards as value added benefit associated with our ProActiv Living Program.

All above features are also offered for policies where Optional Deductible or Voluntary co-pay has been opted**

Basic Covers

Value Added Covers

Optional Covers

Add on Cover

a. In patient   Hospitalization cover

a. Health Check-up

a. Hospital Daily Cash Benefit

a. Critical Illness Add-on

b. Pre/Post Hospitalization cover

b. Expert Opinion on Critical Illness

b. Deductible*

c. Day  Care Treatment

c. Cumulative Bonus

c. Waiver of Deductible

d. Domiciliary treatment

d. Healthy Rewards

c. Reduction in Maternity Waiting   

e. Ambulance Cover 

d. Voluntary Co-pay*

f.  Donor expenses

e. Waiver of Mandatory Co-pay  

g. Worldwide Emergency Cover

f. Cumulative Bonus Booster

h. Restoration of Sum Insured

 

i. AYUSH Cover

j. Health Maintenance Benefit

k. Cumulative Bonus on Health Maintenance Benefit

I.  Maternity Expenses

m.  New Born Baby Expenses

n. First Year Vaccinations

  

*Voluntary Co-pay and Deductible cannot be taken under a single plan.

 Note - Above is the list of covers under the product and are applicable as per availability in the plan chosen.

You can buy ProHealth Online by visiting our website www.manipalcigna.com

Under this policy, coverages are divided into Basic, Value added, Optional and Add-on. The Basic, Value Added covers as detailed in (Q2) and will be available as per the plan and Sum Insured chosen.

The optional covers and Critical illness add-on can be opted by paying additional premium.

Alterations like increase or decrease in Sum Insured, change in plan will be allowed at the time of Renewal of Policy. However, any such change request will be subject to underwriting decision or requirement of medical tests on a case to case basis.

You can choose from 5 plan types (Protect/ Plus/ Preferred/ Premier / Accumulate).

Plan

Protect

Plus

  Preferred

  Premier

Accumulate

Sum

Insured

2.5 , 3.5 , 4.5, 5.5, 7.5, 10, 15, 20, 25, 30, 50 Lacs

4.5 , 5.5 , 7.5, 10, 15, 20, 25, 30, 50 Lacs

15, 30, 50 Lacs

  1 Cr

5.5 , 7.5,10, 15, 20, 25, 30, 50 Lacs

All figures in rupees.

The age of eligibility of the insured for taking the policy is the Entry Age. Age will mean completed age as on last birthday.

No, there is no exit age in this policy.

Yes. Premium paid under the Policy shall be eligible for income tax benefit under Sec 80 D of the Income Tax Act and any amendments thereon. If Policy Term is more than 1 year then tax benefit can be taken for all the years separately as applicable.

When an insured is hospitalized and stays in hospital for more than 24 hours solely for receiving treatment it is termed as in-patient treatment.

Out-patient treatment is when insured visits a clinic/hospital or a consultation room for diagnosis and treatment based on the advice of medical practitioner. In out-patient hospitalization patient is not admitted in the hospital.

For in-patient hospitalization we will pay for the below medical expenses:

•     Charges for Room Rent for accommodation in Hospital room,

•     Intensive Care Unit charges for accommodation in ICU,

•     Operation theatre charges,

•     Fees of Medical Practitioner,

•     Anaesthetist,

•     Qualified Nurses,

•     Specialists,

•     Cost of diagnostic tests,

•     Medicines,

•     Drugs and consumables, blood, oxygen, surgical appliances and prosthetic devices recommended by the attending Medical Practitioner and that are used intra operatively during a Surgical Procedure.

Medical Expenses related to any admission (under In-patient Hospitalization, Day Care Treatment or Domiciliary Hospitalization) primarily for enteral feedings will be covered maximum up to 15 days in a Policy Year

HIV or AIDS related expenses will be covered up to Sum Insured.

Listed modern and advanced treatments (eg. Robotic surgery) will be covered up to Sum Insured.

[Refer Policy Terms and Conditions available on our website (download section for more details.]

It refers to any medical treatment and/or surgical procedure which are:

i. Undertaken under general/local anesthesia in a hospital/day care center with less than 24 hours stay due to technological advancement, and

ii. Which would have otherwise required hospitalization of more than 24 hours.

*Treatment normally taken on an out-patient basis is not included in the scope of this definition.

ProHealth Insurance covers 500 plus listed Day Care treatments or surgery that requires less than 24 hours hospitalization due to advancement in technology and which is undertaken in a hospital / nursing home/day care centre on the recommendation of a medical practitioner. Coverage is available upto the Sum Insured opted under the plan.

Pre-hospitalization expenses are medical expenses incurred immediately before the insured is hospitalized provided that:
i.  Such hospitalization expenses are incurred for the same condition for which the Insured
    Person’s hospitalization was required
ii. And an in-patient hospitalization claim is admissible for that hospitalization by ManipalCigna Health Insurance.

Post-hospitalization medical expenses include expenses incurred immediately after the insured is discharged from the hospital provided that:
i.  Such medical expenses are incurred for the same condition for which the insured’s
    Hospitalization was required
ii. An in-patient hospitalization claim is admissible for that hospitalization by ManipalCigna Health Insurance.

Yes, prescribed Allopathic and Non-allopathic treatments including Ayurveda, Yoga, Naturopathy, Unani, Siddha and Homeopathy are covered under this insurance. However facilities and services availed for pleasure or rejuvenation or as a preventive aid like beauty treatments, Panchakarma, purification, detoxification and rejuvenation, Hydrotherapy, Acupuncture, Reflexology, Chiropractic treatment or any other form of indigenous system of medicine are permanently excluded under this policy. 
You are also covered for AYUSH treatments on out-patient basis under Health Maintenance Benefit provided it is prescribed by a Certified Medical Practitioner

It means medical treatment for an illness/disease/injury which normally would require care and treatment at a hospital but is actually taken while confined at home because:

- The condition of the patient is such that he/she cannot be move to a hospital, or

- The patient takes treatment at home under the care of a medical practitioner on account of non- availability of room in a hospital.

Claims for pre-hospitalization and post-hospitalization expenses will be payable upto 30 days each.

AYUSH covers in-patient treatment under Ayurveda, Yoga, Naturopathy, Unani, Siddha and Homeopathy for an illness or injury that occurs during the policy year. Coverage is available upto the sum insured.

For calculating premium the country has been divided into 3 zones. Zone will be identified based on the location city of the insured person and premium will be calculated accordingly.
Zone I: Mumbai, Thane, Navi Mumbai, Gujarat, Delhi and NCR    

Zone II: Bangalore, Hyderabad, Chennai, Chandigarh, Ludhiana, Kolkata and Pune

Zone III: Rest of India excluding the locations mentioned under Zone I & Zone II

(a) Persons paying Zone I premium can avail treatment all over India without any sub limits.

(b) Persons paying Zone II premium
i) Can avail treatment in Zone II and Zone III without any sub limits.
ii) Availing treatment in Zone I will have to bear Co-pay of 10% of each and every claim.

(c) Person paying Zone III premium
i) Can avail treatment in Zone III, without any sub limits.
ii) Availing treatment in Zone II will have to bear Co-pay of 10% on each and every claim.
iii) Availing treatment in Zone I will have to bear Co-pay of 20% on each and every claim.

Domiciliary Hospitalization benefits cover the expenses on employment of qualified nurses, who are employed on the recommendation of the attending Medical Practitioner and who holds a certificate of a recognized Nursing Council. However the treatment has to be under a qualified Medical Practitioner only.

In this scenario, the medical treatment and expenses will be covered under Day Care Procedure.

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