Health Insurance Claims FAQ's | ManipalCigna Health Insurance

Frequently Asked Questions

Content with PRODUCTS ProHealth Group Insurance Policy .

ProHealth Group Insurance Policy covers a defined group of people, for example employees of an organization, members of a society or professional association or an affinity group. The plan has been designed to provide medical coverage to members of the group in the event of hospitalization due to illness or injury. This plan offers a comprehensive protection with base covers and a range of multiple options to choose as per the need of the group.

Coverage is available to Group Member/ Employee of the Policyholder or Non-Employer Group enrolled member as nominated by the policy holder. Dependent Children can be covered from day 1 of birth up to 25 years of age.

We offer a wide range of Sum Insured options from ₹ 5, 000 up to ₹ 100 Lacs.

It is available to any homogeneous group/association/ institution/corporate body provided it has a Central administration and subject to minimum group size of 7 persons.

Product offers a set of benefits including:

• Easy and flexible plan management
• Efficient, accurate implementation
• Expert guidance on healthcare issues
• Extensive network coverage
• Innovative Health risk & Wellness management programs
• Dedicated customer support

Plan offers an all-round coverage including 7 inbuilt benefits under Base cover and 42 benefits under Optional covers.

Base coverage includes:

i.  In-patient Hospitalisation Expenses Cover
ii.  Day Care Treatment Cover
iii.  Pre-Hospitalisation Medical Expenses Cover
iv.  Post-Hospitalisation Medical Expenses Cover
v.  Road Ambulance Cover
vi.  Domiciliary Hospitalisation Cover
vii.  Donor Expenses Cover

It covers Medical Expenses towards room charges, operation theatre, doctor fees, specialist fees, surgeon fees, anesthetist’s fees, radiologist, pathologist fees, nursing charges, medicines, diagnostic tests, medical and/or surgical appliances.

No, Domiciliary treatment covers treatment taken at home due to lack of accommodation in the hospital/nursing home or the patient’s condition being such that he/she cannot be shifted to the hospital.

In Home Nursing a qualified nurse is arranged by the hospital to give nursing services to insured person at home because he/she is significantly facing problem to cope up with the activities of daily living i.e. washing, dressing, toileting, feeding etc. Home Nursing is an optional cover under the Policy.

Under base cover per day room rent allowance is restricted up to 1% of Sum Insured opted and 2% of Sum Insured for ICU. However, this capping can be modified as per below options:
•     Select percentage limit of Sum Insured for per day Room Rent
•     Select an amount limit on per day Room Rent
•     Select limit on room type (Category) 

^For ICU hospitalization, the limit will be two times room rent 

We will reimburse medical expenses of an insured person which are incurred pre and/or post hospitalization. Base cover provides 30 days pre-hospitalization and 60 days post-hospitalization benefit. However, you have option to choose this coverage from 0 days to 180 days.
Please note Pre & Post medical expenses claims should be related to the same illness/condition for which insured was admitted in the hospital.
 

Day care procedures cover medically necessary treatment or surgery undertaken for illness / conditions which require less than 24 hours of hospitalization. We cover all Day care procedures up to full sum insured opted.

Yes, we will reimburse expenses incurred toward transportation of the insured person by a registered ambulance provider to a hospital for treatment of illness or injury.

Disease category sub-limit covers medical expenses towards distinct illness/injury up to the limit selected for that particular disease category. There is no restriction on the number of claims made in the current policy year provided it does not exceed the specified limit.

Yes, they are available as optional covers. Maternity expenses cover expense towards delivery or termination up to 2 events up to the limits selected under the plan as an optional benefit.   
•    It covers normal delivery, routine or elective caesarean or complicated pregnancy or Pre and
      Post Natal expenses.
•    New born baby coverage is available with sub- limit option. It can form a part of maternity 
      sub-limit or in addition to maternity expenses cover.
•   Option to choose the cover for Surrogacy pregnancy
 

Medical expenses incurred towards treatment on an out-patient basis are covered up to the Sum Insured selected. Any one or combination of the following can be opted under the cover:

1) Consultation

2) Diagnostics

3) Pharmacy

4) Medical Aids

5) AYUSH

6) Dental

7) Vision

8) Physiotherapy

9) Over The Counter (OTC) Medicine

Outpatient treatment and Accumulate benefit covers expenses towards consultation, diagnostics, pharmacy, medical aid,  AYUSH, Dental, Vision, Physiotherapy and Over the counter (OTC) Medicine (any one or in combination as opted)

In addition to this, accumulate cover can be utilized towards payment of Deductible/Co-Payment/non- payable of an In-patient Hospitalisation Expenses claim or day care treatment claim. Also on renewal, unutilized Accumulate sum insured will get carried forward next year.

Option to choose cumulative bonus percentage per annum.

No waiting period or exclusion will apply on OPD and Accumulate benefits. Also claim under OPD/Accumulate benefit will not affect cumulative bonus, if opted.

Deductible is the amount beyond which all admissible claims will be settled by the insurer.

Deductible option can be selected on annual aggregate or per claim basis.

Voluntary Co-pay is a fixed percentage of the admissible claim amount that insured person will pay each time a claim is made during the policy year.

Specified treatment/illness/surgical procedure will be covered up to sub-limit opted.

Sub Limit (Amount in )

S. No.

Illnesses/ Surgeries / Medical Procedures

Option 1

Option 2

Option 3

1

Cataract (Per eye)

20,000

25,000

30,000

2

Surgeries for non-malignant Tumors/Cysts/Nodule/Polyp/ Abscess

15,000

30,000

45,000

3

Stone in Urinary(Kidney) /Biliary System

20,000

40,000

60,000

4

Hernia (unilateral/ Bilateral) Excluding cost of mesh

20,000

30,000

40,000

5

Appendicitis

20,000

30,000

40,000

6

Hysterectomy/ Benign Prostate Hypertrophy/Fibroid Uterus

15,000

30,000

45,000

7

Any Joint Replacement

80,000

90,000

1,00,000

8

Piles/Fissures/Fistula

20,000

30,000

40,000

9

Ligament Tear

40,000

50,000

60,000

 

This is an indicative list, customized options with customized sub-limits can be offered as per the specific requirements of the group.

 

Corporate deductible is available as an option. It becomes payable once the aggregate of all admissible claims exceed corporate deductible limit.
If insured level deductible is opted along with corporate deductible, claim will be payable once insured level and corporate level limits are over.

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