The Definitive Guide to Paripoorna Mediclaim Ayush Bima (PMAB)
A Comprehensive Manual for Central Government Employees and Retirees
Launched on January 14, 2026, by The New India Assurance Company Limited (NIACL), the Paripoorna Mediclaim Ayush Bima (PMAB) is an exclusive retail health insurance product specifically for CGHS beneficiaries. It is a voluntary "ground-up" policy designed to provide a secondary layer of financial protection and expanded access to private healthcare.
I. Eligibility and Enrollment
This policy is tailored for those already under the CGHS umbrella:
- Primary Beneficiaries: All serving and retired Central Government Health Scheme members.
- Family Scope: Up to 6 family members per floater policy.
- Eligible Relationships: Proposer, spouse, children, parents, and parents-in-law. Serving employees can also include financially dependent brothers and sisters.
- Mandatory Documents: A valid CGHS Card is mandatory for all members, especially for retirees.
- Mid-term Entry: Newlyweds and newborns can be added by paying a pro-rata premium once they are enrolled in CGHS.
II. Core Coverage and Financial Limits
The policy offers robust indemnity-based coverage for in-patient hospitalization within India:
| Feature | Detailed Benefit |
|---|---|
| Sum Insured Options | Choose between ₹10 Lakh or ₹20 Lakh. |
| GST Benefits | NIL GST applies to ensure maximum affordability. |
| Room Rent Cap | Capped at 1% of Sum Insured per day. |
| ICU/ICCU Cap | Capped at 2% of Sum Insured per day. |
| AYUSH Coverage | 100% of Sum Insured for in-patient treatments under Ayurveda, Yoga, Homeopathy, etc. |
| Cataract Cover | Up to ₹1 Lakh (10L SI) or ₹1.5 Lakh (20L SI) per eye. |
| Pre/Post Hospitalization | Covers 30 days before admission and 60 days after discharge. |
III. The Co-Payment System
Subscribers must share a portion of every claim. At the time of purchase, you must choose one of two options:
- Option A (70:30): The insurance company pays 70% of the admissible claim; you pay 30%.
- Option B (50:50): The insurance company pays 50% of the admissible claim; you pay 50%.
IV. Waiting Periods and Critical Waivers
To prevent immediate high-risk claims, standard waiting periods apply:
- General Wait: Initial 30 days from the policy start date (not applicable to accidents).
- Specific Conditions: 90 days for Diabetes and Hypertension.
- Disease Specific: 24 months for hernia, stones, cataracts, and joint replacements.
- Pre-Existing Disease (PED): Standard 24-month waiting period.
- The PED Waiver: This is a unique feature. The 24-month wait may be waived if you provide a Good Health Certificate from CGHS/Employer showing no hospitalization in the past 24 months.
V. Modern Treatment and Riders
The policy includes inbuilt coverage for advanced procedures (robotic surgeries, immunotherapy, etc.) up to 25% of the Sum Insured. Subscribing to the Modern Treatment Rider (costs 15% extra premium) enhances this coverage to 100% of the Sum Insured.
VI. Bonuses and Claims Procedure
- Cumulative Bonus: Sum Insured increases by 10% for every claim-free year, up to a maximum of 100%.
- Cashless Hospitalization: Available at network hospitals through the TPA. Prior intimation (48 hours) is required for planned surgeries; emergency admission must be intimated within **24 hours**.
- Network: Access to ~20,800 TPA hospitals and ~5,050 insurer network hospitals.
Primary Policy Exclusions
Liability is limited for the following:
- Diagnostic/Evaluation-only admissions.
- Cosmetic/Plastic surgery (unless due to accident/burns).
- Breach of law with criminal intent.
- Maternity expenses (except ectopic pregnancy).
- Alcohol/Drug abuse and related treatments.
Enrollment Strategy
ENROLL IF: You live in a city where CGHS-empanelled hospitals are often crowded, and you want the freedom to go to any top-tier private hospital without bill-rejection stress. The **PED Waiver** is highly valuable if you have a clean 2-year history.
RECONSIDER IF: You are on a fixed salary/pension and cannot bear the 30% or 50% co-payment for major surgeries. While the premium is low, the out-of-pocket share during a claim is substantial.
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