PAST Shravak Arogyam Policies
Information about past policies launched by JIO in Collaboration with Various Insurance Companies.
Information about past policies launched by JIO Phase-1, Phase-2, Phase-3, Phase-4, Phase-5, Phase-6, Phase-7
Information about past policies launched by JIO
- HNI Policy
BELOW GIVEN ARE FEW FAQ’s For your ready Reference
1. FAQ’S ABOUT.... MISUNDERSTANDINGS AND MYTHS OF JIO HEALTH PLAN
JIO is not an insurance company and does not give any type of insurance policy. JIO has ONLY played the role of a negotiator for benefits of its Shravak / Shravika members.
The Policy is serviced by the following three entities:
- Insurance Brokers (Like Prudent, Alliance, Almonds etc.) Insurance brokers are the mediators and communicator between JIO and Insurance Company to receive best terms.
- The responsibility of compiling the enrolment data, getting the policy endorsed, overview on claims process and resolving the queries of members is to be executed by the Insurance brokers. The Insurance brokers are the working hand of JIO for overall assistance for Group Policies.
- Insurance Company (Like Govt. companies – National Insurance, Oriental Insurance & Pvt. Companies – ICICI Lombard, Star Health etc.)
The Mediclaim policy is issued by the government approved Insurance Companies under the regulation of IRDA. Means, the premium collected from members is transferred to the Insurance Company. The Insurance company bears the risks of the policy and pays claims to the members as per terms of the policy.
- Third Party Administrators – TPA (Like Paramount, Vipul TPA, IL Health Care, Health India etc)
The TPA’s are appointed by the Insurance Companies for issuing members Medi-claim card, communicate terms to policy holders, prepare panel of hospitals for cashless, receiving claim documents, evaluating the documents and sanctioning the claim amount.
JIO is NOT a profit making organization and is formed with a noble objective of serving its Shravak / Shravika members as well as society at large. Under the medical insurance scheme, the premiums are collected individually from the members and then full amount is transferred as a group premium to the insurance company.
In-fact, Gurudev has inspired several Jain Shravaks to donate partly towards the premiums for members of their respective Samaj / Gnyati, who are financially troubled. Hence the health security could be availed by members of their Samaj at further discounted premiums. This will immensely help such families to face the additional financial burden of medical expenses, if any.
The enrolment process requires registering accurate details of the member and their family so that they do not face any trouble during the full year or at time of claim. The forms have been designed in a way to get the important details only and no un-necessary details are to filled.
105. Whether any person are available for help during enrollment or at the time of claim like Insurance Agents ?
JIO has not appointed/authorized any retail agents for selling / marketing its policies. When the enrolment for policy is started, JIO chapters and volunteers across India assist in the policy and enrolment process and spreading information of policy.
Because of the dedicated service of its volunteers, JIO has been able to reach huge number of Shravaks across India easily, without additional cost of hiring huge number of professionals.
And at the time of claim, members can take help / advice from helpline number of the insurance company. Alternatively, the members can also take help from any insurance agent because the process of claim is same as retail insurance policies.
JIO has pioneered in adopting to the latest technologies and online tool for your convenience and better service. The online enrolment process has the following major advantages:
- – The data entry and processing time is saved.
- – Accuracy of the data entered. This will also help in hassle free claims to the members.
- – Enroll anytime from anywhere
- – Immediate confirmation of enrolment completion.
JIO JAC is required not only for group Mediclaim but also for other JIO schemes. JIO introduced the Jain Advantage Card (JAC) as a comprehensive scheme for benefit of its members through bulk buying.
JIO JAC is a unique and permanent identification for availing benefits of various schemes launched by JIO. Members can easily participate in the programs of JIO without having to provide various details every time.
JAC members can also connect with fellow Shravaks and take full advantage of the JIO Global network.
JIO Group Policy is negotiated with Insurance Company for the Best TERMS and Lowest PREMIUM based on a commitment of certain Minimum NUMBERS of enrollment.
For enrolling the members, messages are sent to Shravaks residing all over India. An enrolment window period is kept open for members to fill forms and make premium payment.
In case the numbers fall short of the minimum target, then the enrolment period is extended for few days.
After the closure of enrolment period, a list is compiled for all the forms received and payments are reconciled. Any errors found at the stage of validation and verification are corrected by contacting the members.
JIO pays the insurance premium to the Insurance Company through a single payment for all the members together for commencing policy. Upon payment, the Insurance cover period starts on common date for all the members. A single group policy document is issued in the name of JIO with the list of enrolled members and their families. On the basis of this TPA’s issue Health Cards to all members with unique enrolment number for taking benefits of the policy.
The above process takes lot of time and efforts, hence the commencement of policy is after necessary period from the date of payment.
The process of filing claims for Cashless or Reimbursement with the Insurance Company is the same for JIO policy like any other retail mediclaim policies and in accordance with IRDA guidelines. In-fact, the norms for intimation of claim and the period for submitting claim documents after discharge are more beneficial in JIO Policy.
The deductions from claims are as per the terms of the policy and no ad-hoc deductions are made by the TPA or Insurance Company. The TPA and insurance company are bound by the guidelines of Insurance Regulatory & Development Authority.
However, in case any claims are wrongly deducted or disallowed, then the members can approach grievance department of Insurance company or Ombudsman department of IRDA. These actions are within the rights of every policy holder.
As clarified above, JIO is neither the Insurance Broker / Agent to the policy nor the company undertaking the insurance. JIO has played a role of Group Leader to the policy issuance.
All the queries regarding the claims process, status of claims, reasons of deductions from claim etc, are handled by the concerned Third Party Administrator (TPA).
In cases, where the grievances of the policy members remain unresolved by the TPA, the members can escalate such urgent / important issues with the JIO officials. JIO in turn will take up these issues with the concerned authorities through brokers.
However the claims will be decided on merits of the case and within the terms of the policy.
112. Why has JIO not kept its word at the time of renewal by Increasing Insurance premiums and altering certain terms like amount cappings on specific treatments and Co-pays on pre-existing diseases?
The 1st phase of policy saw an overwhelming response due to unbelievably low premiums and attractive benefits which are not available in any other policies. The biggest benefit of the policy was to cover elder members and members who were already ill. Due to such extra ordinary benefits, our Shravak families received a claim of almost 350% over the premiums paid. As a result of the heavy claim ratio, the renewal premiums were bound to be increased extensively by the Insurance Companies.
However it was necessary for JIO to keep the premium low and also provide suitable terms to members who have not lodged any claim. It is also necessary that group policy has a good share of healthy families to keep the claim ratio balanced along-with affordable premiums year after year. This will help to serve more number of needy and sick people with stable premium year after year.
Accordingly JIO had renegotiated the terms of policy with insurance company and achieved a group policy with balanced terms and appropriate premiums which were still better then the market rates.
The JIO mediclaim policy still continues to be hugely beneficial to the middle class families and the senior citizens who otherwise were not able to take benefit out of medical insurance.
Each phase of policy had been negotiated with different insurance companies and the Best offer with maximum benefits and lowest premiums has been selected. The brokers and TPA change accordingly.
JIO is a group policy and enrolment for each phase is open only for a limited period. The coverage for all members of one phase commences on same date. Due to heavy demand for enrolments even after the closure of one phase, JIO had negotiated for further policy and launched subsequent phases as per the demand. It is important to note that based on previous experiences, each new phases has always added new features.
The introduction of new phases is not as per a planned schedule. JIO receives proposals from different insurance companies and if JIO is convinced about the suitability of the terms, the new phase will be announced through SMS, e-mails and website to all JIO JAC members.
Why No one answers the call or proper answers are not received from helpline?
The responsibility for coordination of enrolment and claims has been assigned to the brokers by JIO. The brokers are required to maintain appropriate number of contact points in the form of helpline numbers and email id for helping members and resolving their queries.
For any help or assistance at the time of enrolment the members can contact the brokers helpline numbers.
For any assistance at the time of claim, the members can contact the TPA helpline. The details of contact numbers and emails for every phase of policies are available on JIO’s website.
The JIO group policy is NOT a temporary affair and will continue in future like all other insurance policies.
However, as discussed earlier, the terms of the policies and the premiums are subject to change at the time of each renewal based on previous year experience & analysis.
JIO group Mediclaim policy was started with a noble vision of giving financial security in medical emergency to all the Shravak / Shravika families. Therefore JIO will never think about discontinuing the scheme.
2. FAQ’S ABOUT ….. DELAY & STATUS OF Renewal
As everyone is aware that before any group policy is incepted or renewed, there are few steps to be executed which are as follows
- – Various levels of negotiations with the Insurance Companies through insurance brokers
- – Drafting of MOU for terms with the insurance company
- – Intimation of the policy terms to the members
- – Collection of premium by JIO from members
- – Sending detailed list of members with amounts of coverage by JIO to Insurance Company
- – Issue of payment for Premium by JIO to Insurance Company
- – Commencement of Group Insurance Policy.
Initial discussions with the National Insurance Co had started in May 2016 and MOU was signed in July 2016. Under the MOU, Phase 7 – Part 1 policy (including Gold, Silver and Women Plan) was issued in 23rd Sept. 2016, which is still continuing. It was further decided that the same terms and same amount of premium will be applicable for renewal of Phase 1.
Based on the MOU and promise of National Insurance Co to continue the same terms for other renewals also, JIO had intimated all the members that the Phase 1 policy expiring in Oct 2016 will be renewed with National Insurance Co. The premium amounts for Rs 5 Lakhs family floater policy which was Rs. 16,985/- in 2015 with ICICI Lombard shall now be Rs. 13,107/- by National Insurance. Similarly premiums for other sums insured shall also be reduced.
JIO collected the premiums from members and made payment to National Insurance co alongwith details of members in last week of Oct. 2016.
Before the policy could be issued the Senior Officer who had signed the MOU and had promised the renewal, got retired. The new senior officer reviewed the performance of the earlier years of Phase 1 and observed that the claim ratio was 180 % (i.e. the insurance company had paid claims of Rs 180 against premium receipt of Rs. 100). Further the reduced premium made the claims ratio to almost 200%. He was of the view that the company does not have a capacity to bear such a big loss and hence he denied to renew the policy.
If we talk about National Insurance Co, then it is important to note that the very first phase of JIO Mediclaim was issued by National Insurance Co and they have contributed much in the welfare of members by issuing claims to the tune of 300% of the premium amount.
However, due to various legal obligations and considering the loss in this group policy, the National Insurance Co denied to renew the JIO Mediclaim policy.
After further negotiations, the insurance co offered revised terms for renewal with 52% Co-pay (i.e. the insurance co will pay only 48% of the claim and the balance 52% is to be paid by the member). All the JIO directors were of the view that policy with 52% Co-pay is completely unacceptable. After deliberations of almost 45 days, further negotiations were stopped with National Insurance and the advance premium paid was received back by JIO.
JIO then started negotiations with other insurance companies for renewal. However, it was difficult to convince the companies for taking policy with very high past claim ratio. Further, the fact that the premium amounts have already been collected from the members posed additional problems.
However, because to Aashirwad and Guidance of GURUJI, JIO has been able to strike a deal with Star Health and Allied Insurance Co Ltd. The terms of the policy have been modified to some extent and the new premium amount have been negotiated.
This is the main reason why other Renewals also got delayed.
If a group policy is issued for the first time then the general claim ratio of individual policies is considered. Further the fact that the company receives huge number of policy holders at one time, the reduced advertisement costs can be passed on by way of discount on premium.
For renewal of group policy, the premiums are decided on the basis of past claim ratio, age composition of the policy holders, types of claims made earlier and assumptions made for future claims.
Against the premium amount of Rs. 13,107/- for 5 Lakhs floater policy, the Star Health Insurance group offered certain terms of policy which were not acceptable to JIO and the ultimate claim benefits to the members would have been very less. Hence JIO offered to accept increase in premium with relaxation in policy terms that are beneficial to the members at large. Accordingly the premium of Rs 17,950/- for 5 lakhs floater policy was fixed.
It is important to note here that ideally there has been negligible increase in premium as compare to the premium paid for renewal with ICICI Lombard in 2015. An offer for reduced premium was received from National Insurance which could not materialise and JIO is now offering renewal at premiums similar to earlier year.
Every insurance policy with an Insurance Company commences after the payment of premium and punching of policy and in the software.
Since the premium to Star Health and Allied Insurance Co Ltd will be paid now, the policy coverage will commence from new date after completion of enrolment process and the policy period will be for 12 months from the commencement date.
204. Whether the premium paid earlier in Oct 2016 will be adjusted against the premium payable to Star Health ?
The Policy coverage could not commence in October 2016 due to reasons already discussed above and no claims were paid during the intervening period. Hence the full premium paid in Oct 2016 is now available for adjustment against the premium now payable to Star Health.
At the time of online application, the details of premium paid earlier in Oct 2016 will be reflected which will be adjusted against the new premium and ONLY the balance amount will have to be paid.
Most of the policy benefits of earlier JIO Mediclaim policy have been retained. The following are changes in the terms of policy:
- In House TPA of Star Health Insurance Co
- Co-pay (Contribution of policy holder) of 10 % on all claims / 15 % on all claims for existing HNI Policy holders
- Co-pay of 50% in case of Pre-existing Diseases
- No Co-pay In case of Cataract and maternity claims
- Only Cashless Claim Facility
- More than 8000 network hospitals
- Additional Co-Pay of 30% in case of Reimbursement claims.
- Total Knee Joint Replacement waiting period of 1 year.
A member is required to visit the designated website for renewal and login with JIO JAC ID. The details of proposer, family members and payment made earlier in Oct 2016 will be reflected. The member is required to confirm the complete details before proceeding. The member can also read the detailed terms and conditions of the new policy. On acceptance of the terms of the policy the member can make payment of balance premium and complete the process.
Physical forms will not be accepted at all for the renewal of policy. All the information has to be provided online as mentioned in point 6.
The members can choose to make payment of balance premium amount from following options
- Online payment through credit / debit card or netbanking
- Send Demand Draft alongwith print out of online application
In case a member does not want to renew his mediclaim policy with the new terms, then the member can claim full refund of the premium paid by them earlier in Oct 2016.
For claiming refund of premium amount paid earlier, a member has to follow the following steps:
- Login to the designated website with JIO JAC id.
- Confirm the proposer details and the payment details of premium paid earlier.
- Confirm for refund of premium
- Provide NEFT details for bank account of proposer
The refund amount will be credited directly to the proposer bank account provided above within 10-15 days.
211. If a member is not aware about the online process or the working on internet and computers, how will they be able to renew?
In this age of digitization, internet and computer facility is easily available. The members who are not very conversant with use of computers are advised to approach young members in their family for help in completing the online process.
3. FAQ’S ABOUT ….. TERMS, CONDITIONS & PROCEDURE for this New Plan
This is an Insurance scheme, where an Individual can opt for an Insurance Plan for Rs.2 Lacs against Mediclaim for Self only. Individuals above the age of 40 can’t opt for Individual Policy; he/she would compulsory need to buy a 5 lac /10 lac cover.
This is an insurance scheme where a family can opt for an insurance plan for Rs.5 Lac & 10 Lac against Mediclaim for Self + Spouse + 4 Dependent Children up to 25 years of Age and Parents or parents in-laws this policy includes personal accident cover for a sum of Rs.5 Lac and Rs. 10 Lac respectively for Proposer.
Under the family floater policy you can cover your wife as long as the proposer is Jain and because now she is a part of the Jain family.
Family Floater Policy is available for family size ranging between 2 to 8 members i.e. Proposer + Spouse + 4 Dependent Children up to 25 years of Age + Parents/or Parents or Laws.
Yes you can but any person can’t be covered more than once under whole group in JIO Policy. If declared more than once, benefit would be payable under one Sum Insured only
306. We are two brothers & we have two different policies, Can we enroll our Parents in both policies?
No. One person can be covered only once in a JIO policy.
As per policy T&C she is not considered part of your family. Regardless of this she can avail a separate policy for her family members.
No. Individuals above the Age of 40 would compulsory need to buy a 5 lacs /10 lacs cover
This policy is for Pan India Jain population only.
310. What if I am or my family member is already suffering from a disease? Can I yet get myself or my family members covered?
Pre-Existing Diseases are covered from day 1, however Co-pay of 50% will be applicable for PRE-EXISTING Ailments and Sub Limits will be applicable as mentioned in Point No. 343.
311. In my family few are having Jain certificate but my parents don’t have any proof? Then what I can do?
Please get a confirmation from your Sangh / Gyati that you are a Jain.
- Copay of 50% will be applicable for Pre-existing Ailments / Diseases
- Copay of 10% will be applicable for Non-Pre-Existing Ailments / Diseases for Sum Insured of 2Lacs and 5Lacs and 10 Lacs
- Copay of 15% will be applicable for Non-Pre-Existing Ailments / Diseases for Sum Insured of 5 Lacs and 10 Lacs for HNI Customer
- Revised Sub Limits will be applicable with the above mentioned Copay
Star Health and Allied Insurance Company Limited
Please follow the below mentioned steps
- Please go on www.jiojac.com
- Select “PHASE 1 Renewal” Scheme
- Read revise Terms & Conditions carefully
- Enter JIOJAC ID
- Fill your enrolment details
- Make payment ONLINE Or by DD
You can only Renew your PHASE 1 Policy Online as per the Procedure mentioned in Point No.314. You CANNOT submit Physical Form
You need to Enrol Online only, however payment can be done via Online through Pay U Money or by submitting Demand Draft along with Printout of Online Form to JIO Office after completing Online Enrolment Procedure.
You can’t opt for MEDICLAIM Policy for PHASE-1. JIOJAC ID is compulsory. Please register online for JIOJAC ID.
Sum Insured (Rs.)
Premium per family
INCLUDING Service Tax @15% (Rs.)
Rs.2,00,000/- INDIVIDUAL UPTO 40 YEARS
Rs.5,00,000/- FAMILY FLOATER
Rs.10,00,000/- FAMILY FLOATER
ONLY cashless facility is available in 8000 Network of hospitals. No Reimbursement facility available. However in the case of Medical Emergencies & Accidents treatment can be taken in other Hospitals and seek reimbursement. Such claims are subject to ADDITIONAL COPAY OF 30% (after adjusting all the inner limits and copay indicated for a normal cashless claims) In all cases immediate intimation shall be given to our Call Center within 24 hours of Hospitalization.
For Existing Members, Maternity Benefit is covered from Day 1. However for New Members, Maternity benefit is available after completion of 9 months from the date of enrolment in JIO – Shravak Arogyam scheme.
Covered for the Hospitalization for more than 24 hours within Maternity Limit, But Pre & Post Natal expenses on OPD bases are not covered
The next year premium will be decided after the end of the policy tenure based on the Claim Experience of the current Policy
Yes , under section 80 D you can claim TAX Rebate
No, you will not get Policy Number. However you will receive Health ID card, which you can show in Network Hospitals to avail Cashless Benefit under this Policy
No, as this is a Group scheme you will not get NO Claim Bonus
Yes only if she is a Jain by birth.
Third Party Administrator (TPA) in Health Insurance Sector servicing all insurance companies. Health Insurance policies for individuals are basic products of Insurance Companies on which TPA adds value and facilitates smooth operation through its value-addition like network of healthcare service providers, medical care standardization, Claims management, Client servicing, expert opinion etc. Thus TPA administers a `healthcare package’ for its clients with customized healthcare delivery.
No, Location does not affect the operational activities, main member or the dependent member can avail same and equal benefits irrespective of their location. TPA Network of Healthcare Service Providers is across the country. These accredited healthcare providers would assure qualitative healthcare delivery to TPA members.
Yes, According to the Insurance Company the claim will not be settled (unless prior intimation to Insurance company) if there is any alterations in the name It has to be intimated to your respective Insurance Co. within 15 days on receipt of your cards & requisite Endorsement for the change in name needs to be passed by Insurance co. This has to be done first hand and not only if any claim arises.
Documents that you need to submit for a hospitalization reimbursement claim are:
- Original completely filled in Claim form
- Covering letter stating your complete address, contact numbers and email address (if available), along with Schedule of Expenses
- Copy of the TPA ID card or current policy copy and previous years’ policy copies(if any)
- Original Discharge Card/ Summary
- Original hospital final bill
- Original numbered receipts for payments made to the hospital
- Complete breakup of the hospital bill
- All bills for investigations done with the respective Doctor
- All bills for medicines supported by relevant prescriptions
- Bank Details with Cancel Cheque
- You are advised to keep Photo Copy of the entire set of claim documents submitted to us.
Under this Policy, only Cashless Facility is provided. However in case of Medical emergencies & Accidents, you can avail Reimbursement facility and claims can be submitted to Star Health office through registered post / courier. The address is as mentioned below
Star Health & Allied Insurance Company Limited
Your health insurance policy pays for reasonable and necessary medical expenditure. There are several items that do not classify as medical expenses during hospitalization. These items will not be payable and expenditure towards such items will have to be borne by you.
You can claim medical expenses incurred 30 days before and 60 days after hospitalization (as specified in your policy), provided they are related to the ailment/treatment for which you were hospitalized. Such expenses are termed as pre and post hospitalization, except for Maternity Claims.
No. You can do so only in cases arising from Road Accidents.
335. If I have a health insurance policy in Mumbai, can I make a claim if I am transferred to Delhi?
Yes, your health insurance policy is valid all over INDIA.
336. Are all the tests prescribed by the doctor at a hospital reimbursed under the Health Insurance Plan?
Expenses incurred at a hospital or a nursing home for diagnostic purposes such as X-rays, blood analysis, ECG, etc. will be reimbursed if they are consistent with or incidental to the diagnosis and treatment of the ailment for which the policy holder has been hospitalized. In any other scenario, these expenses will not be reimbursed.
Only Cashless Facility is provided. However in case of Medical emergencies & Accidents, you can avail Reimbursement facility. However in case of reimbursed additional Copay of 30% will be applicable in addition to other Sub Limits and Copay applicable under the Policy.
Typically, the insured can make a claim if her/his hospitalized stay is for over 24 hours. However, for certain treatments, such as dialysis, chemotherapy, eye surgery, etc. the stay could be less than 24 hours.
If the insurance limit i.e. the sum insured is exhausted in a particular year due to large medical expenses, the insurer is not liable to bear/reimburse the insured for any further expenses.
The claim amount is paid to the nominee of the insured. If no nominee has been assigned under the policy, the insurance company will insist upon a succession certificate from a court of law for disbursing the claim amount. Alternatively, the insurers can deposit the claim amount in the court for disbursement to the legal heirs of the deceased.
In case of planned hospitalization, insurers require the first prescription with the details of the case history indicating following details:
- Provisional diagnosis or reason for getting admitted in hospital
- Proposed date of admission
- Approximate expenses
- Name of the hospital and consultants
- Approximate duration of stay at the hospital
- Attached doctor’s prescription with admission note
- The above documents need to be delivered to the TPA/insurer at least 72 hours before admission.
342. If I avail of the cashless facility, will the insurance company pay the entire bill at the hospital?
No. From the Bill amount, Non-Medical Expenses will be deduced and if any, Copay, sub limits & Deductible is applicable that will be deducted. Also if the Room Rent limit is more than the eligible limits as per the respective Sum Insured, then all other eligible Medical Expenses will be paid in proportion to eligible Room Rent Category. And the balance amount will have to be borne by the insured if any.
Sum Insured Bracket
Ailments / Procedures
Limits of Insurance Company’s Liability Per Person in Rs.
CABG (Coronary Artery Bypass Graft)
PTCA (Percutaneous Transluminal Coronary Angioplasty)
CAG (Coronary Angiography)
CVA requiring surgery
CVA not requiring surgery
Cancer (All treatment inclusive)
Breakage of Bones / Arthro Plasty
Renal (other than Genito Urinary Calculus & Dialysis)
Genito Urinary Calculus
Hernia (All types)
Anaemia (Not for evaluation)
Other Major Surgeries
*All other major surgeries – Acute/Sub Acute/Chronic, Bilo Pancreatic Surgery, Gastro-Intestinal Surgeries, Surgeries on Prostate, Surgery related to Genito Urinary Tract.
In case of PRE-EXISTING Ailments / Procedures, First above mention capping 50% will be deducted then above mentioned sub limit will be applied if Ailment / Procedure is falling under above mentioned categories
- If Final Bill Amount for Cancer under Sum Insured of Rs.2 Lac is Rs.280,000. Non-Medical expenses of Rs.20,000 will be deducted
- On Eligible expenses of Rs.260,000, PED Copay 50% will be applied. Amount will be Rs.130,000
- Then, Sub limit Rs.120,000 will be applied. Rs.10,000 will deducted.
- Final amount of Rs.120,000 will be paid.
In Case of Non-PRE-EXISTING Ailments / Procedure, First above mention capping 10% will be deducted then above mentioned sub limit will be applied if Ailment / Procedure is falling under above mentioned categories
- If Final Bill Amount for Cancer under Sum Insured of Rs.2Lac is Rs.280,000. Non-Medical expenses of Rs.20,000 will be deducted
- On Eligible expenses of Rs.260,000, PED Copay 10% will be applied. Amount will be Rs.234,000.
- Then, Sub limit Rs.120,000 will be applied. Rs.114,000 will deducted.
- Final amount of Rs.120,000 will be paid.
344. What happens in case of an Emergency hospitalization where Cashless facility is not authorized to me?
The liability for paying the hospital will be on the individual member. However, the insurance company will reimburse the admissible amount as per T & C of Policy with 30 % copay
Any institution established for indoor care and treatment of sickness and/or injuries, which is duly registered and supervised actively by a registered medical practitioner.
Any establishment that satisfies the following criteria can qualify as a hospital:
- with at least 15 patient beds
- With a fully equipped operation theatre of its own if surgical procedures need to be carried out
- Employing fully qualified nursing staff around the clock
- Having fully qualified doctors in charge around the clock Note: For Class ‘C’ towns, the number of beds relaxed to ten.
An instance where the insured individual is hospitalized for a minimum period of 24 hours can be termed as hospitalization. Specific treatments like dialysis, chemotherapy, radiotherapy, laser eye surgery, dental surgery, etc. when the patient is discharged on the same day are also considered hospitalization.
No. Maternity benefit is not payable under Individual Health Insurance Plan.
- For Sum Insured of Rs.2 Lakhs – Room Rent – 2,500 and ICU capped at 3,500
- For Sum Insured of Rs.5 Lakhs – Room Rent – 2,500 and ICU capped at 4,000
- For Sum Insured of Rs.10 Lakhs – Room Rent – 3,500 and ICU capped at 4,000
Room rent limit is inclusive of Nursing Charges. If the Insured occupies a room with a room rent limit other than his eligibility as per the insurance policy, then all the other charges shall be limited to the charges applicable for the eligible room rent or actuals, whichever is lower.
- For Individual Health Insurance Policy of Rs.2 Lacs, only Proposer upto 40 years can opt.
- In case of Family Floater of Rs.5 Lacs & 10 Lacs, below age limit will apply
- For Dependent Children maximum age allowed is 25 years. After completion of 25 years, Child will not be covered in next year
- For Parents maximum entry age is 80 years, However ELDERLY MEMBERS who have completed 80 years on or after 30th Oct, 2014 can continue in the Policy till LIFETIME
The Jain certification has to be from Gyati / Samaj / Sang only.
Only Death Benefit is covered under personal accident cover
CLAIM DOCUMENTS REQUIRED FOR PERSONAL ACCIDENT CLAIM – ALL DOCUMENTS HAVE TO BE DULY ATTESTED / CERTIFIED / NOTARIZED
- Compete Filled Claim Form
- Photocopy Of ID Proof
- Death Certificate or Permanent Total Disability certified from Government Hospital / Government Board
- Post Mortem Report
- Police FIR Copy
- Driving license (if self driving)
- Police Panchnama Copy
- Panchayat Certificate wherever applicable
- Income Proof
- Bank Account Details of Nominee