ManipalCigna ProHealth Group Insurance Policy

What is 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.

What is the entry age limit for ProHealth Group Insurance Policy?

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.

What Sum Insured can be opted under ProHealth Group Insurance Policy?

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

Who can buy ProHealth Group Insurance Policy?

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.

Why to choose ProHealth Group Insurance Policy?

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

What benefits are available under ProHealth Group Insurance Policy?

Plan offers an all-round coverage including 7 inbuilt benefits under Base cover and 41 benefits under Optional covers.

What benefits are included in Base cover?

Base coverage includes:

I. In-patient Hospitalisation Expenses Cover IV. Post-Hospitalisation Medical Expenses Cover
II. Day Care Treatment Cover V. Road Ambulance Cover
III. Pre-Hospitalisation Medical Expenses Cover VI. Domiciliary Hospitalisation Cover
VII. Donor Expenses Cover

What expenses are covered under In-patient hospitalization?

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.

Is Home Nursing and Domiciliary treatment similar?

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.

Is there a capping on the room rent allowance?

Under base cover per day room rent allowance is restricted up to 1% of Sum Insured opted. However this coverage can further be modified as per below options:
• Select percentage limit for per day Room Rent of Sum Insured
• Select a per day room rent limit
• Choose room type

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

Will medical expenses before and after hospitalization be covered?

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 extend this coverage as:
• 60 days before hospitalization and 90 days post hospitalization
• 90 days before hospitalization and 180 days post hospitalization.
Please note Pre & Post medical expenses claims should be related to the same illness / condition for which insured was admitted in the hospital.

What happens when I undergo a treatment/ surgery under Day Care facility and get discharged the same day?

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.

Will Ambulance cost get covered under this plan?

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.

What is Disease category Sub-Limit?

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.

Are Maternity / New born baby expenses covered in this plan?

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.
• If Maternity Expenses cover is opted, Pre & Post Natal Expenses will be covered up to 20% of Maternity Sub-limit
• 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.

Is Out-patient treatment covered?

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

What is difference between Outpatient treatment and Accumulate benefit?

Outpatient treatment and Accumulate benefit covers expenses towards consultation, diagnostics, pharmacy, medical aid and AYUSH (any one or in combination as opted)

In addition to this, accumulate benefit amount can be utilized towards payment of deductibles, co-payment and non-payable component of an in-patient claim. Also on renewal, unutilized Accumulate sum insured will get carried forward next year with a cumulative bonus on the unutilized amount.

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.

Is Deductible and Voluntary co-payment similar?

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. Deductible and co-pay can never be opted together.

What is sub-limit on Illness/Surgery/Medical Procedure?

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

Sub Limit (Amount in ₹)
Sr. 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 mess. 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

What is a Corporate Deductible at group level?

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.

How do maximum limit on out-of-pocket works?

Maximum limit on out-of-pocket means the over-all amount an insured will bear out of his pocket during the policy year against all admissible claims.

What is a direct plan option?

Direct plan provides a specified network of Healthcare providers for availing healthcare services under the policy

Any one or a combination of Direct Plan Options can be selected:
1) 10/20% co-pay on admissible claim amount within network
2) 10/20/50% co pay on admissible claim amount outside network
3) 10/20% co pay on admissible claim amount for non – Personal accident/Critical Illness and no co-pay for Personal accident/Critical Illness within network
4) 10/20/50% co pay on admissible claim amount for non - Personal accident/Critical Illness and no co-pay of Personal accident/Critical Illness out of network
5) Only directed network

What is Hospital Daily Cash Benefit?

This policy provides Daily Hospital Cash option to take care of the incidental expenses during hospitalization period.
Hospital daily cash benefit offers protection for you, your spouse as well as children (as covered). The benefit will be paid for each completed 24 hours of hospitalization depending upon the plan range from ₹ 200 to ₹10,000 for 30 to 90 days per policy year.
One can opt for a deductible of 1 or 2 days, post which benefit will trigger.
Also there is a cover eligibility option whereby benefit will trigger after first 24 hours/ 48 hours/ 72 hours of hospitalization.

In addition to hospital daily cash, one can choose from below:
• Accident Hospital Daily Cash Benefit (AHDCB) Cover: Daily cash amount equivalent to 2 times of HDCB benefit if insured is hospitalized due to accident.
• Worldwide Hospital Daily Cash Benefit (WWHDCB) Cover: Daily cash amount equivalent to 3 times of HDCB benefit if insured is hospitalized outside India due to illness/injury.
• Convalescence Benefit Cover: Lump sum amount equivalent to 10 times of HDCB benefit if insured is hospitalized for at least 10 consecutive days.
• Companion Benefit: Daily cash amount equivalent to HDCB benefit to cover cost towards accompany person taking care of the insured hospitalized.

Note: For ICU hospitalization, benefit will be 2 times the HDCB or AHDCB or WWHDCB as applicable.
Convalescence benefit is payable only once in a policy year for an insured

What is Critical Illness Benefit?

Critical illness benefit provides specified amount on first diagnosis of listed illness or undergoing covered surgical procedure for the first time.
Critical illness includes:
1. Cancer of specified severity
2. Myocardial infarction
3. Open chest CABG
4. Open heart replacement or repair of heart valves
5. Coma of specified severity
6. Kidney failure requiring regular dialysis
7. Stroke resulting in permanent symptoms
8. Major organ /bone marrow transplant
9. Permanent paralysis of limbs
10. Motor neuron disease with permanent symptoms
11. Multiple sclerosis with persisting symptoms

What is loss of pay cover?

The benefit provides fixed amount on happening of any one or combination of below events:
• Critical Illness of the specified nature
• Injury due to an accident leading to disablement
• Any Illness where hospitalisation is more than 15 days
The benefit will be paid subject to a maximum of 50 weeks per Policy Year.

Is there an Accidental Death or Disability cover?

Policy provides option to select Accidental Death, Permanent Total Disablement or Permanent Partial Disablement (any one or in combination). On selection insured person will be covered for death due to accidental injury, total or partial permanent disability due to accidental injury within policy period.
The type and nature of disability forms a part of policy terms and conditions.

Will Group ProHealth Insurance Policy cover dental expenses?

Dental expenses cover is available as an option.
Any one or combination of the following can be opted under this cover:

• Class 1 (covers Investigative & Preventative Treatment)
• Class 2 (covers Basic Restorative, Periodontal Treatment)
• Class 3 (covers Major Restorative & Orthodontic Treatment)

What is Vision expenses cover?

Vision expenses cover is available as an option. Under this benefit we will cover
• Eye examination by an optometrist or ophthalmologist
• Cost of lenses to correct refractory errors

What is Refractive Error Correction beyond +/-5 Expenses Cover?

It is an optional benefit covering medical expenses towards Laser-Assisted In Situ Keratomileusis (LASIK) surgery or any other advanced surgical procedures conducted to correct the refractive errors beyond +/- 5.

Is Physiotherapy charges covered if taken on OPD basis?

Medically necessary physiotherapy treatment taken on OPD basis in a hospital is covered if this benefit is opted. The coverage is available over and above the base sum insured.

Is there a Health Check-up benefit available?

Health check-up benefit is available as an optional cover. On selection, a comprehensive health check-up can be availed from our Network Providers for members aged 18 years and above.

What is Compassionate Cover for family member in case of Emergency or Accident?

This optional benefit reimburses cost of one way air travel (economy class) or railway travel (first class) in India by immediate family member to take care of the insured hospitalized due to emergency or accidental injury at a hospital situated at a distance of 100 kms or more from place of residence.

What is Air Ambulance Cover?

This optional benefit reimburses cost of transportation by a medically equipped air ambulance service to any hospital facility during a health related emergency within India

What is Emergency Evacuation Cover?

Emergency evacuation cover provides reimbursement of expenses towards medical evacuation of the insured to a nearest facility capable of providing adequate care not available locally. To avail the benefit pre-authorization is required. Transportation can be through medically equipped aircraft, commercial airline, train or Ambulance depending upon the medical needs and available transportation service.

Is Bariatric surgery covered?

Yes, if Bariatric surgery cover is opted, we will pay hospitalization expenses for Bariatric surgical procedure.For cashless benefit prior approval is required.

If there is any adventure sports injury will the claim get settled?

Adventure sports cover is available as an optional cover. It will cover medical expenses towards an injury sustained while engaged in any adventure sports, specified in the policy.

What is Birth control procedure cover?

This benefit is available as an optional cover to pay for the medical expenses on implanted/ injected contraceptives post appropriate counseling, surgical therapies including but not limited to Tubal Ligation, Vasectomies.

Is Infertility treatment covered?

Optional benefit is available to cover medical expenses for diagnostic infertility services, treatment and procedures taken as in-patient, day care or OPD once in a policy year. Coverage will form part of base sum insured.

What all are covered under AYUSH Treatment – Inpatient Hospitalisation Cover?

AYUSH includes Ayurveda, Yoga, Unani, Siddha and also Homeopathy. It will cover medically necessary treatment taken during In-patient Hospitalisation for an illness or injury within policy period.Sub limit options also available.

What is Worldwide Emergency Cover?

This extension covers in-patient medical expenses up to base sum insured for emergency treatments of the insured for an illness or injury sustained or contracted outside of India which cannot be postponed until return to India.

How does Restoration of sum insured works?

Restoration benefit provides 100% additional sum insured once or as per the number of times in a Policy Year as opted once the base sum insured and cumulative bonus (if any) is insufficient to settle a present claim. The benefit is available towards unrelated illness or injury including complications.

How cumulative bonus works in this policy?

Cumulative benefit is available as an optional cover. On selection, the base sum insured will be increased at the end of the policy year on renewal basis the sub-option selected:

The option can be further limited by selecting:
1. Non Reducing CB:
Increase Sum Insured by X% at the end of policy year up to a maximum of 100% provided that there are
no claims paid/outstanding in respect of any or all of the Insured Persons in the expiring Policy Year. Any
earned Cumulative Bonus will not be reduced for claims made in the future

2. Reducing CB:
Increase Your Sum Insured by X% at the end of policy year, upto a maximum of 100%, provided that there
are no claims paid/outstanding in respect of any or all of the Insured Persons in the expiring Policy Year.
In case of a claim being paid or remaining outstanding at the end of a Policy Year or at the time of
Renewal of such Policy, the earned cumulative bonus will reduce by X% in the subsequent year. However
this does not impact the opted Sum Insured.

3. Non Reducing CB irrespective of claims:
Increase Your Sum Insured by X% at the end of policy year, up to a maximum of 100%.

What is Corporate Buffer?

This optional benefit will provide additional cover to insured who have already exhausted their sum insured limit subject to per insured person/ family limit (as applicable). This benefit is payable over and above the base sum insured.

Note - Corporate Buffer for Critical Illness only can also be selected as a separate cover at group level.

What is a Healthy Living Program?

Healthy living program provides an all-round health and fitness solution which helps to assess health status, and engage in activities to improve well-being.

Any one or a combination of following program can be opted under this plan:
• Enrollment into Wellness Program
• Health Risk Assessment (HRA)
• Targeted Risk Assessment (TRA)
• Online Lifestyle Management Program (LMP)
• Chronic Condition Management Programs
• Participating in ManipalCigna Sponsored Programs and Worksite or Online/Offline Health Initiatives
• Health Check Up
Healthy reward points will be awarded on successful completion of the programs and these reward points can be redeemed in multiple ways (details of which will form part of the policy).

What is covered under Condition Management Reward Program?

ManipalCigna offers specific Condition Management Program to help insured person assess their health status and aid in improving health condition related to an illness and overall well-being. Wellness Points may be awarded on adherence to Health check schedule, maintenance of health i.e. if test results are in limits specified by us, and competition of health activities defined under this program. Earned reward points can be utilized towards renewal premium discount.

What is Wellness Services program?

This benefit provides various Wellness Services ranging from:
1) Track your Health
2) Medical Concierge services
3) Health check up
4) Medical Practitioner’s consultations
5) Health tips or newsletters
The programs may change from time to time as per need.

Will Health card be issued?

Yes, a health card will be issued to all group members who are covered under the policy. It is similar to an identity card. This card would entitle you to avail cashless hospitalization facility at our network hospital. A health card mentions the contact details of the TPA. In case of medical emergency, you can call on these numbers for queries and clarification. This card need to be displayed at the time of admission in the hospital along with a valid pass post size photo, identification and address proof (as applicable).

What do you mean by cashless hospitalization?

Under cashless hospitalization the insured patient does not have to settle the hospitalization expenses at the time of discharge from the hospital apart from the non-admissible expenses. Cashless facility is only available at our network hospital wherein bills will get settled down by ManipalCigna.

What is the maximum number of claims allowed in a policy year?

There is no limit on the number of claims made in a policy year provided it is within the limit of sum insured opted.

I am working in Mumbai and covered under ProHealth Group Insurance Policy including my family. But my family members reside in Bangalore. Can all of us claim under the policy?

Yes, you and your family members are eligible to claim under the policy for all covered benefits across India. Cashless facility will be available at our network hospitals. In case of any emergency or if network facility is not available, you can directly pay the hospital and claim for reimbursement of admissible expenses.

How does one get reimbursement in case of treatment in non- network hospital?

While it’s recommended that you choose a network hospital, you are at liberty to choose non-network hospital also. Wherever you have opted for a reimbursement of expenses you may submit the document specified in the policy to our branch or head office at your own expenses not later than 15 days from the date of discharge from the hospital. Claim form will be available at ManipalCigna branch office or you can download a copy from our website www.manipalcigna.com.

Can Non-residential Indians or Foreign Nationals living in India be covered under this policy?

Yes, non-residential Indians or foreign nationals living in India can be covered under ProHealth Group Insurance Policy provided coverage would be restricted to India unless worldwide emergency is opted.

When do ManipalCigna be intimated if there cashless treatment undertaken within network hospital?

In case of planned hospitalization the insured person should intimate ManipalCigna at least 3 days prior to admission to the hospital and in case of emergency hospitalization it should be intimated within 48 hours of admission.

Who to contact in case of any query or information required related to the policy?

You can reach us at:
Toll Free: 1800-102-4462
Email: servicesupport@manipalcigna.com
You may contact Our Head of Customer Service at ManipalCigna Health Insurance Company Limited,
401/402, Raheja Titanium, Western Express Highway, Goregaon (East), Mumbai – 400063 or email at
headcustomercare@manipalcigna.com.