ManipalCigna Health

There is no upper limit on the number of claims during the policy period. However, the total cumulative claim amount cannot exceed the Policy Sum Insured, unless the chosen plan has a Sum Insured Refill benefit, which provides additional coverage even after filing a claim.

In case of an Individual policy, each Insured person under the policy will have a separate sum insured for them. Individual plan can be bought for self, lawfully wedded spouse, children, parents, siblings, parent in laws, grandparents and grandchildren, son in-law and daughter in-law, uncle, aunty, nephew & niece.

In case of a floater cover, one family will share a single sum insured as opted. A floater plan can cover self, lawfully wedded spouse, children upto the age of 23 years or parents. A floater cover can cover a maximum of 2 adults and 3 children under a single policy.

You can buy the policy for one, two or three continuous years at the option of the Insured. One Policy Year shall mean a period of one year from the inception date of the policy.

• any insured member covered is greater than 55 years
• Or sum insured >50 lakh.
• Insured member >45 years and upto 55 years will undergo an underwriting call and medicals (if required) will be scheduled.

Medical check-up depends upon the disease declared, age of insured person and Sum Insured. Pre-policy medical check-up typically has Medical Examination Report by the Physician, few blood & Urine tests & ECG. Additional test like TMT, 2D echo, Sonography etc can also be part of the PPC check up list depending on the health status, Sum insured and age of the customer.

Pre-existing waiting period for ManipalCigna ProHealth Insurance Plan is 48/36/24 months (as per plan). That means, your pre-existing diseases declared at the time of policy purchase will be covered after 4/3/2 years subject to continuous renewals.

• Portability Form
• Proposal Form
• Previous insurance policy copies of last 4 years

A compulsory co-payment of 20% is applicable on all claims for Insured Persons aged 65 years and above irrespective of the age of entry in to the Policy. Co-pay will be applied on the admissible claim amount. For persons who have opted for a Waiver of Mandatory Co-pay the same will not apply. In case the Insured has selected the Voluntary co-pay under Optional Cover and/or chooses to avail treatment outside his Zone of Cover, then the co-pay percentages will apply in conjunction

A pre-existing disease is any condition, ailment or injury or related condition(s), for which the insured person had signs or symptoms, and /or were diagnosed, and / or received medical advice / treatment within 36 months prior to 1st health insurance policy issued by Us under which the insured person was covered.

Under cashless hospitalization, the insured person does not settle the hospitalization expenses at the time of discharge from hospital. The settlement is done directly by us for treatment that the insured person is eligible to receive under the terms of his/her policy. This is for your convenience. However, it is important to note here that prior approval is required from us before admission into the hospital. In some cases, you may have to pay for all or part of the treatment if it is not fully covered under the terms of the policy. However, in case of emergency hospitalization, you can obtain approval post-admission. Please note that the cashless facility is available only at our Network Hospitals.

The premium paid on a health insurance policy is eligible for deduction under Section 80D of the Income Tax Act. So save with your policy now!

A waiting period is the length of time you, the insured, will have to wait before the benefits under the health policy can be utilised.

• If claim amount is below 1 lakh- Photo Id proof & address proof
• If claim amount is above 1 lakh- Photo Id proof, address proof and a recent photograph

A deductible is a cost-sharing requirement. It states that the insurer will not be liable for a specified amount in case of indemnity policies. This is applicable for a specified number of days/hours in case of hospital cash policies which apply before any benefits are payable by the insurer. Remember that a deductible does not reduce your sum insured.

We cover reasonable and customary charges for medical expenses incurred during the insured person’s medically necessary and medically advised in-patient hospitalisation during the policy period for treatments like Ayurveda, Unani, Sidha and Homeopathy (AYUSH). However, treatment must take place in a government hospital or in any institute recognised by the government and/or accredited by the Quality Council of India/the National Accreditation Board of Health.

You can avail of our cashless facility arrangement with over 6500+ network hospitals across india. Decision of the cashless claim will be given to you/hospital within 90 mins of receipt of last necessary document( i.e last document necessary for us to decide admissibility of cashless). At the time of discharge, we will confirm the final approved amount. The deductions on account of non payable expenses if any will have to paid by you at the time of discharge. Post discharge of patient from hospital, hospital sends us the original claim documents for us to reimburse the expenses to the extent of the approved amount.
Alternatively, you can pay all hospitalization bills directly and submit the original claims documents post discharge for reimbursement to nearest ManipalCigna branch. Once we approve the claim, a cheque will be sent to you for the benefit amount payable under your policy.

• Policy number
• Name of the policyholder
• Name of the insured person in whose relation the claim is being lodged
• Nature of illness / injury
• Name and address of the attending medical practitioner and hospital
• Date of admission
• Any other information as requested by us

In planned hospitalization the treatment is planned well in advance. The intimation of such hospitalization and authorization from us has to be taken minimum 3 days prior to the date of hospitalization. E.g. Cataract, pace maker implantation, total knee replacement etc are examples for which the hospitalisation can be planned.The insured person should at least 3 days prior to admission to the hospital approach the network provider for hospitalization for medical treatment.

In emergency hospitalization the patient is admitted to the hospital in an emergency situation, for e.g. Severe abdominal pain, accident, heart attack etc. In such event, we should be intimated within 48 hours of admission to the hospital.

You should submit your claim within 15 days from date of discharge from the hospital.

We will not be liable to pay for any claim arising out of an injury/ accident/ condition that occurred during the grace period.

If two of more policies are taken by you during the same period from one or more insurers to indemnify treatment costs and the amount of claim is within the sum insured limit of any of the policies, you will have the right to opt for a full settlement of your claim in terms of any of your policies.
Where the amount to be claimed exceeds the sum insured under a single policy after considering deductibles, co-pays (if applicable), you can choose the insurer with which you would like to settle the claim. Wherever we receive such claims we have the right to apply the contribution clause while settling the claim.

For cashless claims, the payment shall be made to the network hospital whose discharge would be complete and final. For reimbursement claims, the payment will be made to you. In the unfortunate event of death of policy holder, we will pay the nominee (as named in the policy schedule) and in case of no nominee to the legal heir who holds a succession certificate or indemnity bond to that effect, whichever is available and whose discharge shall be treated as full and final discharge of its liability under the policy.

You may submit the claim form along with the documents for reimbursement of the claim to the nearest ManipalCigna branch or head office at your own expense not later than 15 days from the date of discharge from the hospital.

• Claim form duly signed
• Copy of photo id of patient
• Hospital discharge summary
• Operation theatre notes
• Hospital main bill
• Hospital break up bill
• Investigation reports
• Original investigation reports, X ray, MRI, CT films, HPE, ECG
• Doctors reference slip for investigation
• Pharmacy bills
• MLC/ FIR report, post mortem report if applicable and conducted

You will receive an update on status of your claim through sms and emails on the registered contact details with us. Hence, it is important that your contact details are updated with us at all times. You can also reach out to your health advisor or connect with our health relationship managers to get an update or clarification on the claim. In case of cashless claims, we will issue the authorisation letter to the hospital through fax or email.

You should carry the health card provided by the company with this policy, along with a valid photo identification proof (voter id card / driving license / passport / pan card / any other identity proof as approved by the company).

We shall scrutinize the claim and accompanying documents. Any deficiency of documents, shall be intimated to you and the network provider, as the case may be within 5 days of their receipt. If the deficiency in the necessary claim documents is not met or are partially met in 10 working days of the first intimation, we shall remind you of the same and every 10 (ten) days thereafter. We will send a maximum of 3 (three) reminders following which we will send a closure letter.

We may investigate claims at our own discretion to examine validity of claim. Such investigation shall be concluded within 15 days from the date of assigning the claim for investigation and not later than 6 months from the date of receipt of claim intimation. Verification carried out, if any, will be done by individuals or entities authorised by us to carry out such verification / investigation(s) and the costs for such verification / investigation shall be borne by the us.

We shall settle claims, including its rejection, within 5 (five) working days of the receipt of the last ‘necessary’ document but not later than 30 days.

You should submit the post-hospitalization claim documents at your own expense within 15 days of completion of post-hospitalization treatment or period, whichever is earlier. We shall receive pre and post- hospitalization claim documents either along with the inpatient hospitalization papers or separately and process the same based on merit of the claim derived on the basis of documents received.

The sum insured opted under the plan shall be reduced by the amount payable / paid under the benefit(s) and the balance shall be available as the sum insured for the unexpired policy period. We are not obliged to make payment for any claim or that part of any claim that could have been avoided or reduced you/ insured person could reasonably have minimized the costs incurred, or that is brought about or contributed to by you/insured person failing to follow the directions, advice or guidance provided by a medical practitioner. If you/ insured person suffers a relapse within 45 days of the date of discharge from the hospital for which a claim has been made, then such relapse shall be deemed to be part of the same claim and all the limits for “instance of same illness” under this policy shall be applied as if they were under a single claim.

Where a rejection is communicated by us, you may if so desired within 15 days represent to us for reconsideration of the decision.

Completed claim forms and documents must be furnished to us within the stipulated timelines. Failure to furnish such evidence within the time required shall not invalidate nor reduce any claim if you can satisfy us that it was not reasonably possible for you to submit / give proof within such time. The due intimation, submission of documents and compliance with requirements by you as mentioned above shall be essential failing which we shall not be bound to entertain a claim.

This benefit covers reimbursement of outpatient expenses incurred by insured person upto the limits specified under the plan. It can be used to cover diagnostic tests, medical aids, drugs, prosthetics, dental treatments and alternative forms of medicines.

You can submit your request for a expert opinion by calling our call centre or register request through email. We will schedule an appointment or facilitate delivery of medical records of the insured person to a medical practitioner. The expert opinion is available only in the event of the insured person being diagnosed with covered critical illness.

• For protect plan – available once every 3rd policy year
• For plus, preferred and premier plan – available at each renewal

• The treatment is medically necessary and has been certified as an emergency by a medical practitioner, where such treatment cannot be postponed until the insured person has returned to India and is payable under section ii.1 of the policy.
• The medical expenses payable shall be limited to inpatient hospitalization only.
• Any payment under this benefit will only be made in India, in Indian rupees on a re-imbursement basis and subject to sum insured.
• The payment of any claim under this benefit will be based on the rate of exchange as on the date of payment to the hospital published by reserve bank of India (RBI) and shall be used for conversion of foreign currency into Indian rupees for payment of claim. You further understand and agree that where on the date of discharge, if RBI rates are not published, the exchange rate next published by RBI shall be considered for conversion.

In an unlikely event of you/insured person requiring emergency medical treatment outside India, the same shall be availed at his/her own cost. You/insured person, must notify us either at the call center or in writing within 48 hours of such admission. You shall file a claim for reimbursement in accordance with claim process of the policy.

In the event that the cost of hospitalization exceeds the authorized limit as mentioned in the authorization letter, the network provider shall request us for an enhancement of authorisation limit including details of the specific circumstances which have led to the need for increase in the previously authorized limit. We will verify the eligibility and in our sole discretion evaluate the request for enhancement on the availability of further limits.

In the event of a change in the treatment during hospitalization to the insured person, the network provider shall obtain a fresh authorization letter from us in accordance with the process.