ManipalCigna Prohealth Plan

ManipalCigna Prohealth Plan

  • 100% restoration of sum insured
  • Worldwide medical facility
  • Free Health Check-ups
  • 546 daycare treatments
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ManipalCigna Prohealth Insurance Plan

ManipalCigna Prohealth insurance motive is to provide medical coverage to the individuals and family when they face any unanticipated medical contingencies. The Prohealth insurance plan formulated by ManipalCigna is the chief of all the product of the company. The Prohealth insurance plan offers comprehensive coverage from 2.5 lakhs to 1 crore where individuals are free to choose the sum insured according to their income, age, and the number of members they want to include.

ManipalCigna is a result of a partnership between two companies, US-originated health services Acer, Cigna Corporation and Indian composite organization, TTK groups.

Features of the Policy

Eligibility: Anyone who is more than 91 days can easily enter the policy. Children between 91 to 18 years will get coverage only if one of the parents is included in the policy.

Children up to 23 can be named dependent under a floater policy plan and above dependent child is covered under the individual policy.

Tenure: The insured have the option to buy either one or two-year policy according to their choice. You can apply for renewals if you want to continue the existing policy.

Sum Insured Options: The insured has a variety of option in choosing their coverage amount. The sum insured offered under this policy is between 2.5 lakhs to 100 lakhs.

Premiums: The amount of premium will be the result of factors such as sum insured, age, policy life, gender, add-on benefits, number of the members included, zone of cover, health status of the insured etc

Benefits: Over a period of time, the insured is bound to receive benefits accumulated during the policy. The benefits are in the state of cumulative bonus, expert opinion on critical illness, health rewards etc.

Types of Coverage: There are two coverages offered by the plan, Individual cover, and Family floater cover. The former plan is only for individually purchased for self or spouse, or a parent or children. While in family floater, each family member involved will share one amount of sum insured. In a floater plan, a maximum of 2 adult and 3 children dependent on parents can be chosen.

Free-Look Period: The insured will get 15 days time to make confirm that they are in agreement with terms an conditions of the policy. There is an option of canceling the policy within the specified limits.

Waiting Period: The policy also have waiting of 24 months to 48 months for the treatment of pre-existing diseases, critical illness and for using maternity benefit.

Different Variants of the Plan

ManipalCigna Prohealth Plans Sum Insured In-patient Hospitalization Pre-existing Diseases Coverage Health Maintenance Cumulative Bonus Maternity Expenses Ambulance Cover Post Hospitalisation
Prohealth Protect 2.5L, 3.5L, 4.5L , 5.5L, 7.5L, 10L Covered up to single room facility After 48 months Covered up to Rs 500 10% rise in the sum insured Not covered Coverage up to 2000 per hospitalisation Upto 90 days
Prohealth Plus 4.5L, 5.5L, 7.5L, 10L Covered up to single room facility After 36 months Covered up to Rs 2000 5% rise in the sum insured Up to 15000 for normal delivery and Rs 1 lakh for C-section delivery after 48 months Coverage up to 3000 per hospitalisation Upto 180 days after hospitalization
Prohealth Accumulate 5.5L, 7.5L, 10L, 15L, 20L, 25L Covered up to single room facility After 48 months Covered upto Rs 5000, 10000, 15000, 20000 10% rise in the sum insured Not covered Coverage up to 2000 per hospitalisation -
Prohealth Preferred 15L, 30L, 50L Any room is covered except suite After 24 months Covered up to Rs 15000 5% rise in the sum insured Up to 50,000 for normal delivery and Rs 1 lakh for c-section delivery after 48 months Actual expenses incurred during hospitalization Upto 180 days after hospitalization
Prohealth Premier 100L Any room is covered except suite After 24 months Covered up to Rs 15000 Not available Up to 50,000 for normal delivery and Rs 1 lakh for c-section delivery after 48 months Actual expenses incurred during hospitalization Upto 180 days after hospitalization

Basic Coverage

In-patient Hospitalization - The insurer will provide compensation for all the expenses related to hospitalisation that was incurred by the insured at the time of illness, accident, or any injuries. All the expenses related to ICU charges, pharmaceuticals, diagnostic process, fees of medical practitioner fee, nursing fee, operation theatre expense etc will be given due coverage.

Pre-hospitalisation - The insured will get a reimbursed amount of expenses incurred 60 days before hospitalization which mainly include charges of medicines, drugs, medical test, doctor consultation, physician etc.

Post-hospitalisation - Al the expenses incurred within the 90 days after getting discharged or relief from the hospital will be reimbursed by the insurer on submitting a claim.

Road Ambulance - When insured is medically unfit to and need immediate transfer to the hospital then this emergency ambulance service can be availed up to Rs 3000 per hospitalization.

Domiciliary Hospitalisation - The insurer will also pay for the expenses when the treatment of the illness or any disease is taken at home due to the critical condition of the insured or non-availability of the accommodation. The diseases treated should last for 3 days and the treatment is taken under the advice of an expert doctor.

Day Care Treatments - Some of the illness get treated within the 24 hours of a day on the advice of doctor and expenses are paid by the insurer. The Prohealth insurance includes 171 daycare procedures as listed in the policy.

Organ Donor Expense - This will cover the in-patient hospitalization expenses towards the organ transplantation. The donor treatment for extraction of the organ will be covered up to a percentage of the sum insured.

Vaccination for the First Year - The vaccinations took for the newly born baby during the first year of childbirth. Vaccines for Hepatitis-B, Measles, chicken pox, diphtheria, tetanus are essential for a baby to lead a healthy life.

Maternity Expenses - The expenses of deliveries took upon by the insured are covered by the insurer after a waiting period of 48 months. Insured can avail this coverage up to a maximum of 2 deliveries.

Worldwide Emergency Cover - In-patient treatment of any illness that happened on a foreign land away from Indian boundaries also get coverage.

Reload of Sum Insured - When the insured confronts total exhaustion of the um insured in previous claims, then he is left with an option to refill the sum insured. The refill option is applicable for one time during the tenure of the policy.

Health Maintenance Benefit - Under this, all necessary medical expenses can be covered which become inevitable by the insured. It will cover medical tests, preventative tests, drugs, prosthetics, dental treatments, medicines etc.

NewBorn Baby Expense - It covers the reasonable expenses devoted to the treatment of newborn baby up to 90 days after the delivery.

Health Checkups - The insured will be given ease of medical check-ups for certain illnesses. The health check-up is applicable on every renewal of the policy, in case of Prohealth Plus, Preferred and Premier plan. While in Protect plan, the health check-ups are available once in every 3rd year of the policy.

Benefits

  1. Cumulative Bonus : To avail cumulative benefits, renewal has to be applied within the grace period. The bonus should be more than 50% of the sum insured. The bonus is not for maternity, newborn baby, first-year vaccination and worldwide emergency.
  2. Health Rewards : ManipalCigna has launched its online wellness programs to facilitate the insured in evaluating his/her health conditions and assist in improving degraded health. Insured can secure reward points equal to 1% of the premium deposited for years by seeking interest in online programs
  3. Types of Wellness Programs Points Earned on the Percentage of Premium Paid the Previous Year
    Health Risk Assessment (HRA) 0.50%
    Targeted Risk Assessment (TRA) 0.50%
    Online Lifestyle Management Program (LMP) 1%
    Chronic Condition Management Programs 1%
    ManipalCigna Sponsored Programs and Worksite or Online/Offline Health Initiatives Up to 2%
    Health Check Up 0.5%

    The points earned under the policy are redeemed through-

    • Getting a discount on renewing for the first time.
    • The equivalent worth of Health Maintenance Benefit in the third year of the policy
  4. Expert Opinion on Critical illness : The insured can avail the facility of procuring the second opinion from a chain of network medical practitioner if the insured is detected with a critical illness.

Add-on Covers

Reduction in the Maternity Waiting Period : The time limit of waiting can be minimized from 48 months to 24 months if insured has chosen this add-on cover.

Deductible : The option of deductibles is only available under Protect and Plus plans of Prohealth. The insured can select the number of deductibles (can be 1L, 2L or 3L) on the sum insured. The deductible sum will be used for the aggregate claims made in each policy year.

Voluntary Co-Pay : The insurer will pay 90% or 80% of the amount to settle admissible claims, irrespective of the age and number of claims applied by an insured person. The rest of the amount has to be paid out by insured.

Cumulative Bonus Booster : The insured can receive a 25% increase in the amount of sum insured for every claim free year and if the renewal of policy is done without any delay. The maximum limit of increase is 100%.

Case Study 1

Rahul, who is 36 years of age and have taken a sum insured of Rs 10 lakhs under the Prohealth Protect plan. The premium decided by the insurer to be paid by Rahul on purchasing the individual policy is Rs 10,162.

Rahul made a claim in the fourth year for the in-patient treatment of urinary stones. He waited for two years to get coverage for the illness as it was under the waiting period of the policy. The total expense came out Rs 1,00,000 where Rahul paid Rs 20,000 (20% of 1 lakh) as a voluntary co-pay and rest amount was settled by the insurer.

Case Study 2

Akash (45 years) and Rupal(42) are married with two children, one daughter (17 years) and one son (15 years). Akash took the family floater under the Prohealth Plus plan and purchased the policy of Rs 10 lakhs. Both Akash and Rupal have to undergo a pre-medical checkup as their age is above 41 years* whereas children are exempted under Plus plan. The family also got a discount of 10% and 7.5% on including more than 2 members buying a two-year policy, where the premium determined is 46,906 (after discount).

*If you are taking 10 lakh of sum insured in Plus plan, then you have to appear for the test if you are above 41. However, if you are taking sum insured of less than 10 lakh, then the medical checkup is exempted up to the age 45 years.

FAQs

1. What are the permanent exclusions of the plan?

Exclusions are sexually transmitted diseases like HIV/AIDS, illness due to intake of alcohol or other to hallucinogenic substance, genetic disorder, preventive medicines, non-allopathic treatments, injuries due to war/foreign enemy attack/ military attack/revolution, cosmetic surgeries etc.

2. What is the procedure to apply for a cashless claim?

If the hospitalization is planned by the insured, then the insurance company must be informed within 7 days before the planned hospitalization.

In case of emergency hospitalization, the insured must notify the insurance company within the 48 hours of admission to the hospital.

IThe insured should supply compulsory documents to register a cashless claim with the insurer. The cashless facility can only be availed at network hospitals by showing your health card with an ID card at the time of admitting the patient.

3. What is the process for Reimbursement of claim?

Below is the list of documents which should be laid down before claiming the reimbursement-

  • Fully completed Claim form
  • Original pre-authorization request
  • Copy of pre-authorization approval letter
  • Original discharge summary, hospital bill, pharmacy bill, investigation reports, X-Ray, CT Films etc
  • Operation theatre notes and doctor reference slips for Investigations/pharmacy.

The insurance company may ask you to provide additional documents if required.

4. How to file the claim in case of illness or injury?

The first step is to notify the insurer on a call or writing about the incident took place and then submit the details of policy number, name of the policyholder, name of the insured person, nature of the illness, name, and address of the hospital or the attending doctor, date of admission.

5. Is there any need for a pre-policy medical check-up?

In most of the plans under ManipalCigna Prohealth insurance, there is no compulsion for individuals below 45 to take medical check-up before buying Prohealth policy. However, a person above the age of 45 is required to appear for a medical test for the protect plan.

Moreover, if you are taking 10 lakh of sum insured under Plus plan, then individuals up to 40 years are exempted from test whereas above 41 years will require.

The scenario is different in case of Preferred and Premier plan, as everybody had to undergo for the medical test regardless of age.

6. How many pre-existing illnesses are covered in the plan?

There are 24 ailments that are given the status of pre-existing illness and will get coverage after two years of waiting period. Some of them are asthma, cataract, biliary stones, Fissure in Ano, Diabetes, hypertension, urinary tract infection, tuberculosis, ovarian cysts, vertigo, renal stones etc.

7. What kind of discounts are available under the policy?

  1. Long Term Discount- If the policy is taken for two consecutive years, the discount received will be 7.5%
  2. Family Discount- For choosing more than two family member in the policy, a discount of 10% will be given.
  3. Social Media Discount- If the insured tells his/her friends about the online purchase of the policy through various social media channels, then 2.5% of discount will be credited to him/her.
  4. Copay Discount- Choosing a 10% Copay can give you a 7.5% discount and 20% Co-pay can offer you a 15% discount.

8. How deductibles are applicable for different Prohealth plans?

Sum Insured Options for Deductibles Co-Payments
Protect 2.5 lakhs NA 10% to 20% on each and every claim made during the term of the policy
3.5 lakhs to 4.5 lakhs 1 lakh 10% to 20% on each and every claim made during the term of the policy
Plus 4.5 lakhs, 5.5 lakhs, 7.5 lakhs, 10 lakhs 1 lakh or 2 lakhs, 3 lakhs, 4 lakhs, 5 lakhs, 7.5 lakhs, 10 lakhs 10% to 20% on each and every claim made during the term of the policy
Preferred
Premier
Accumulated 5.5 lakhs to 25 Lakhs 50K, 1 lakhs, 2 lakhs, 3 lakhs, 5 lakhs, 7.5 lakhs, 10 lakhs 10% to 20% on each and every claim made during the term of the policy

9. What are voluntary co-pay?

The co-payment option gives insured the flexibility to share the amount of admissible claim each and every year whose percentage is decided at the time of policy purchase.

10. What to do, if the cashless facility is not authorized to the insured?

The insured can go reimbursement settlement option in case cashless treatment does not work.

11. Are Allopathic and Non-allopathic treatments are covered in the Prohealth plan?

Yes, you definitely get coverage for Allopathic and Non-Allopathic treatment that covers Ayush treatments. Any treatment related to Yoga, Ayurveda, Unani, Siddha, Naturopathy, and Homeopathy is given coverage on an outpatient basis under Health Maintenance Benefit. The treatment must be prescribed by a renowned medical expert.

Make sure the treatment is not for obtaining pleasure, rejuvenation, detoxification, and relaxation of the body. This is an exclusion to the policy.

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