Frequently Asked Questions

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.

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.

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.

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.
    
    Option to choose other daily cash benefits as:
•    Accident Hospital Daily Cash Benefit (AHDCB) Cover: Daily cash amount from 
      ₹ 200 to ₹20,000 if insured is hospitalized due to accident.
•    Worldwide Hospital Daily Cash Benefit (WWHDCB) Cover: Daily cash amount from 
      ₹ 200 to ₹30,000 if insured is hospitalized outside India due to illness/injury.
•    Convalescence Benefit Cover: Lump sum amount from 
      ₹ 2000 to ₹1,00,000 if insured is hospitalized for at least 10 consecutive days.
•    Companion Benefit: Daily cash amount from 
      ₹ 200 to ₹10,000 to cover cost towards accompany person taking care of the insured hospitalized.
•    ICU Daily Cash Benefit: Daily cash Amount from 
      ₹ 200 to ₹10,000 to cover the cost towards an ICU expenses.
•    Chemotherapy and Radiotherapy Benefit: Daily cash Amount from 
      ₹ 100 to ₹50,000 per sitting to cover the cost towards Chemotherapy and Radiotherapy.
 

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 

Yes. under an in-Patient hospitalization we will cover medical expenses towards a 
Medically Necessary Modern and Advanced Treatment of the Insured Person subject to illness/injury.

Yes, under in-Patient hospitalization we will cover medical expenses towards  artificial life maintenance, including life support machine used as certified by the  treating medical practitioner.

Yes, We will cover the medical expenses towards the enteral feeding during
in- patient hospitalization, day care or domiciliary hospitalization maximum up to 15 days in a policy year.

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.

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
6)    Well-baby care
7)    Well-Mother care

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.

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 hospitalization is above selected option from 5 days - 15 Days
The benefit will be paid subject to a maximum of 50 weeks per Policy Year.

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
12.    Primary pulmonary hypertension
13.    Aorta graft surgery
14.    Deafness (loss of hearing)
15.    Blindness (loss of sight)
16.    Aplastic anaemia
17.    Coronary artery disease
18.    End stage lung disease
19.    End stage liver failure
20.    Third degree burns (major burns
21.    Fulminant hepatitis
22.    Alzheimer’s disease
23.    Bacterial meningitis
24.    Benign brain tumour
25.    Apallic syndrome 
26.    Parkinson’s disease
27.    Medullary cystic disease
28.    Muscular dystrophy
29.    Loss of speech
30.    Systemic lupus erythematous
31.    Loss of limbs
32.    Major head trauma
33.    Brain surgery
34.    Cardiomyopathy
35.    Creutzfeldt-jacob disease (cjd)
36.    Terminal illness

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)    x% co-pay on admissible claim amount within network 
2)    x% co pay on admissible claim amount outside network 
3)    x% co pay on admissible claim amount for non – Personal accident/Critical Illness and no 
      co-pay for Personal accident/Critical Illness within network
4)    x% 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

(Where ‘x’ is any number from 5 to 50)

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. (Available only with the Voluntary Co-pay option)

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

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

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

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
 

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.
 

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