ManipalCigna ProHealth Group Insurance Policy
Group Scheme for the customers of Ola Financial Services (Part of ANI Technologies)
Frequently Asked Questions (FAQ’s) – Phase 1
1. What is ManipalCigna ProHealth Group Insurance Policy?
A: ManipalCigna ProHealth Group Insurance Policy 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 full suite of benefits.
2. What are the relationship covered under this policy?
A: Relationship covered under this policy is: Self.
3. What is the entry age limit for ManipalCigna ProHealth Group Insurance Policy?
A: Coverage is available to Group Member/ Employee of the Policyholder or Non-Employer Group enrolled member as nominated by the policy holder.
Eldest Member Entry age should be between the Age bands:
- Min. Entry Age – 18 Years
- Max. Entry Age – 65 Years
4. What Sum Insured can be opted under ManipalCigna ProHealth Group Insurance Policy?
A: We offer a Sum Insured options of Rs. 20 Lacs with Deductible option of Rs. 3 Lacs.
5. Why to choose ManipalCigna ProHealth Group Insurance Policy?
A: Product offers a set of benefits including:
- Easy and flexible plan management
- Expert guidance on healthcare issues
- Extensive network coverage
- Dedicated customer support
6. What benefits are available under ManipalCigna ProHealth Group Insurance Policy?
A: Plan offers an all-round coverage including 7 inbuilt benefits under Base Cover with In-patient hospitalisation Cover for AYUSH Treatment and Enhanced Hospitalisation Cover – Accidental Hospitalisation.
7. What benefits are included in Base cover?
A: Base coverage includes:
- In-patient Hospitalization Expenses Cover
- Day Care Treatment Cover
- Pre-Hospitalization Medical Expenses Cover
- Post-Hospitalization Medical Expenses Cover
- Road Ambulance Cover
- Domiciliary Hospitalization Cover
- Donor Expenses Cover
8. What expenses are covered under In-patient hospitalization?
A: 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.
9. Is Home Nursing and Domiciliary treatment similar?
A: 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.
Domiciliary cover is available; however, Home Nursing cover is not available under this policy.
10. Is there a capping on the room rent allowance?
A: Under base cover per day room rent allowance is available up to Single Private Room.
11. Will medical expenses before and after hospitalization be covered?
A: We will reimburse medical expenses of an insured person which are incurred pre and/or post-hospitalization. Base cover provides 60 day’s pre-hospitalization and 90 days post-hospitalization benefit.
Please note Pre & Post medical expenses claims should be related to the same illness / condition for which insured was admitted in the hospital.
12. What happens when I undergo a treatment/ surgery under Day Care facility and get discharged the same day?
A: 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.
13. Will Ambulance cost get covered under this plan?
A: 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 up to Rs. 2,500 per hospitalization.
14. Is Deductible and Voluntary co-payment similar?
A: Deductible is the amount beyond which all admissible claims will be settled by the insurer. Deductible option can be selected on annual aggregate 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. Voluntary co-pay is not available under this policy.
15. What is covered under In-patient Hospitalisation Cover for AYUSH Treatment?
A: We will pay the Medical Expenses incurred during the Policy Year, up to the limits specified in the Policy Schedule/ Certificate of Insurance of an Insured Person in case of Medically Necessary Treatment taken during In-patient Hospitalisation for AYUSH Treatment for an Illness or Injury that occurs during the Policy Year.
16. What is covered under In-patient Enhanced Hospitalisation Cover – Accidental Hospitalisation?
A: We will pay the Sum Insured specified in the Policy Schedule/ Certificate of Insurance for Hospitalisation of the Insured Person during the Policy Year due to an Accident upto 100%.
17. How Deductible amount will work?
A: Deductible means a cost sharing requirement under a health insurance policy that provides that the insurer will not be liable for a specified rupee amount in case of indemnity policies which will apply before any benefits are payable by the insurer. A deductible does not reduce the Sum Insured.
Deductible amount is paid either out of pocket or from any existing health Insurance.
18. What is the premium payment mode?
A: The premium payment mode under this scheme is monthly.
19. Does this scheme covers pre- existing diseases?
A: No. the scheme does not covers any pre-existing disease.
20. Is Air Ambulance covered?
A: No, air ambulance is not covered.
21. Is Bariatric surgery covered?
A: No, Bariatric surgery cover is not covered in this plan.
22. If there is any adventure sports injury, will the claim get settled?
A: Adventure Sports is a part of Permanent Exclusions.
23. What are the applicable waiting periods?
A: Applicable waiting period are listed below:
- 2 years’ specific illness waiting period
- 30 days initial waiting period for Hospitalization
24. Does this scheme provides coverages for Pre- existing Diseases?
A: No, Pre Existing Diseases are not covered in this scheme.
25. What is covered under specific illness?
A: Medical or surgical for all Medical Expenses along with their complications on Treatment towards:
b) Hysterectomy for Menorrhagia or Fibromyoma or prolapse of Uterus unless necessitated by malignancy myomectomy for fibroids,
c) Knee Replacement Surgery (other than caused by an Accident) Non-infectious Arthritis, Gout,
Rheumatism, Oestoarthritis and Osteoposrosis, Joint Replacement Surgery (other than caused by Accident), Prolapse of Intervertibral discs(other than caused by Accident), all Vertibrae Disorders,including but not limited to Spondylitis, Spondylosis, Spondylolisthesis, Congenital Internal,
d) Varicose Veins and Varicose Ulcers,
e) Stones in the urinary uro-genital and biliary systems including calculus diseases,
f) Benign Prostate Hypertrophy, all types of Hydrocele,
g) Fissure, Fistula in anus, Piles, all types of Hernia, Pilonidal sinus, Hemorrhoids and any abscess related to the anal region.
h) Chronic Suppurative Otitis Media (CSOM), Deviated Nasal Septum, Sinusitis and related disorders, Surgery on tonsils/Adenoids, Tympanoplasty and any other benign ear, nose and throat disorder or surgery.
i) Gastric and duodenal ulcer, any type of Cysts/Nodules/Polyps/internal tumors/skin tumors, and any type of Breast lumps(unless malignant), Polycystic Ovarian Diseases,
j) Any Surgery of the genito-urinary system unless necessitated by malignancy.
If these diseases are Pre-Existing Diseases at the time of proposal or subsequently found to be Pre-Existing Diseases, the claim will not qualify for the settlement.
26. Will Health card be issued?
A. 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).
27. What do you mean by cashless hospitalization?
A. 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 by ManipalCigna Health Insurance Company.
28. If any of the insured person died during the policy year, then policy type or premium will change. Or any refund will occur?
A. No refund would be processed, but during renewal policy type will change to Individual & premium as per terms will be charged.
29. How much time does the claim process of Health Insurance require?
A. Cashless Claims – TAT is 90 minutes from last document received from the hospital till our communication to the hospital for Claim decision or Query.
Reimbursement Claims – TAT is 7 working days from the last document received from the customer till pay-outs. TAT – Turn around time.
30. What is the maximum number of claims allowed in a policy year?
A: There is no limit on the number of claims made in a policy year provided it is within the limit of sum insured opted.
31. I am working in Mumbai and covered under ManipalCigna Pro Health Group Insurance Policy including my family (Spouse). But my family members reside in Bangalore. Can all of us claim under the policy?
A: 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.
32. How does one get reimbursement in case of treatment in non- network hospital?
A: 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 (download section).
33. When do ManipalCigna be intimated, if there is a cashless treatment undertaken in network hospital?
A: 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.
34. What is the claim settlement procedure, when the claimed amount is more than the balance premium amount?
A: When claims amount is more than balance premium amount, then balance premium amount will be deducted from the claim payable amount and claim will be settled. Future instalment for current policy year will not be deducted.
35. What is the claim settlement procedure, when the claim amount is less than balance premium amount?
A: When claim amount is less than balance premium amount, then balance premium will be asked from Insured and then claim will be processed.
36. What is the claim settlement procedure, when the claim is received in grace period for Instalment premium?
A: Any claim where date of injury or illness is arising in grace period such claims will not be payable. Even for monthly, quarterly, half-yearly mode of premium payment frequency.
37. Who to contact in case of any query or information required related to the policy?
A: You can reach us at:
Toll Free: 1800-102-4462
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 email@example.com.
38. What are the claim related touch points?
A: please contact to any mode of communication to details below,
Address for correspondence:-
Medi Assist Insurance TPA Pvt. Ltd.
Tower D, 4th Floor, IBC Knowledge Park, 4/1, Bannerghatta Road,
Bengaluru, Bengaluru, Karnataka – 560020
HealthLine No.: Call (Toll Free): 18004259449
Fax Number : 1800-425-9559
E-mail ID: firstname.lastname@example.org
You may also write to us at email@example.com and for claims related queries, you may
write to us at firstname.lastname@example.org. or call us at Health Line No. (Toll Free): 1800-102-4462.
39. How will the monthly premium paying option impact my claim?
It is a yearly policy and valid as long as the monthly premiums are paid in continuity. In case of claim, the complete year premium amount will be deducted and the rest will be settled.
Example: The policy premium amount for a month is 55 INR, yearly amount will be 55*12 = 660 INR. Let’s assume the policy is purchased in Jan 2022. The customer raises the claim on August 18 2022 of eligible claim amount 8 lac. If the customer has paid all premiums till August (which should be 8*55 =440 INR ), then the customer is eligible to claim and during claim settlement balance the premium amount (eligible premium amount – already paid premium amount) i.e = 660-440 = 220 INR will be deducted from claim and rest (800000- 220) = 799780 INR will be settled.
40. What if I am not between age 18-40 and have opted for the insurance?
The product is open for 18-65 years old customers. In case you have opted for an incorrect age bracket, customers can still file the claim. The balance premium amount will be deducted from the claim and rest will be settled.Example: The policy premium amount for a month is 55 INR for 18-40 years age bracket, yearly amount will be 55*12 = 660 INR. But if you fall in the age bracket of 61-65, the monthly premium would be 642, yearly amount would be 642*12= 7704 INR. Let’s assume the policy is purchased in Jan 2022. The customer raises the claim on August 18 2022 of eligible claim amount 8 lac. If the customer has paid all premiums till August (which should be 8*55 =440 INR ), then the customer is eligible to claim and during claim settlement balance the premium amount (eligible premium amount – already paid premium amount) i.e 7704 – 440 = 7264 INR will be deducted from claim and rest (800000- 7264) = 792736 INR will be settled.