ITGI / MS / 05

JAN SWASTHYA (MICRO INSURANCE )BIMA POLICY MANUAL

The Jan Swasthya Bima Policy of ITGI is meant for the Economically weaker sections of the society and the rural masses . In the time of increasing cost of living, the e !enses for medical treatment have gone u! su"stantially and at the same time, the !o!ulation has also "ecome vulnera"le towards contracting disease and sustaining in#ury due to factors of fast life, increased travel e !osure, stress, congestion, !ollution etc. In order to mitigate the financial hardshi! of the !o!ulation who have to s!end a larger sum for taking any treatment and "e driven to !enury many a times , I$$%&'T&(I& General Insurance %om!any )td. has decided to launch this cover, which can "e offered to any Self *el! Grou!s , +G&,s , -nganwadi worker grou!s and any other grou!s not created for the sole !ur!ose of "uying insurance . .. SCOPE OF COVER: The Policy covers *os!italisation/0omiciliary *os!italisation E !enses for illness, disease sustained under the following heads of E !enses, which are reasona"ly and necessarily incurred "y or on "ehalf of Insured !erson1 -2 B2 %2 02 3oom 3ent, Boarding E !enses as !rovided "y the *os!ital/+ursing *ome. +ursing E !enses. Surgeon, -naesthetist 4edical Practitioner, %onsultants, S!ecialist fees. -naesthesia, Blood, & ygen, &!eration Theatre charges, Surgical -!!liances, 4edicines 5 0rug charges, 0iagnostic 4aterials and 6'ray, 0ialysis, %hemothera!y, 3adiothera!y, %ost of Pacemaker, -rtificial )im"s and %ost of organs and similar e !ense.

7.

LIMIT OF LIABILITY: The lia"ility of the com!any in res!ect of all claims admitted during the !eriod of Insurance shall not e ceed the Sum Insured !er Insured !erson as mentioned in the Schedule. IMPORTANT DEFINITIONS: A) HOSPITAL/NURSING HOME1

8.

It means any institution with in India esta"lished for indoor care and treatment of sickness, in#uries and which1 *as "een registered as a *os!ital or +ursing *ome with the local authorities and Is under the su!ervision of a registered and 9ualified 4edical Practitioner. &3 "2 Should com!ly with minimum criteria as under1 i2 ii2 iii2 iv2 It should have at least .: in'!atients Beds. $ully e9ui!!ed o!eration theatre of its own wherever surgical o!eration are carrying out. $ully 9ualified +ursing Staff under its em!loyment round the clock. $ully 9ualified 0octor;s2 should "e in charge round the clock. a2

;In %lass <%, cities, the +o. of "eds "e reduced to .=2 The term >*&SPIT-)/+?3SI+G *&4E@ shall not include an esta"lishment, which is a !lace of rest, a !lace for the aged, a !lace for drug'addicts, or !lace for alcoholics, a hotel or a similar !lace. The re9uirement of o!eration theatre may "e waived for such esta"lishments, which !rovide treatment under disci!line, which do not resort to Surgery such as -yurvedic and Psychiatric treatment. *owever, the other criteria could remain unaltered e ce!t for very emergency situation where the criteria of any of the criteria can "e referred for claim !ur!ose seeing the availa"ility of good *os!ital in the near"y area with minimum +o. of "eds. B) SURGICAL OPERATION1 It 4eans 4anual and/or o!erative !rocedures for correction of deformities and defects, re!airs of in#uries, diagnosis and cure of diseases, relief of suffering and !rolongation of life. MINIMUM PERIOD1 E !enses on hos!italisation for a minimum !eriod of 7A hours are admissi"le. *owever, this limit is not a!!lied to s!ecific treatment i.e. 0ialysis, %hemothera!y, 3adiothera!y, Eye Surgery, 0ental Surgery,
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)ithotri!sy ;(idney stone removal2, Tonsillectomy, 05% taken in the *os!ital/+ursing *ome and the Insured is discharged on the same day, the treatment will "e considered to "e taken under hos!italisation Benefits. $or other treatments, where hos!italisation is less than 7A hours, the following guidelines may "e ado!ted1 a2 The treatment should "e such that it necessitates *os!italisation and !rocedure involved re9uired s!ecialised infrastructure facilities, which are availa"le in the *os!ital. b "2 0ue to technological advances, *os!italisation !eriod re9uired is less than 7A hours. DOMICILIARY HOSPITALISATION1 It means 4edical treatment for a !eriod e ceeding three days for such illness/disease/in#ury which in the normal course would re9uire care and treatment at a hos!ital/nursing home "ut actually taken whilst confined at home in India under any of the following circumstances namely1' i2 The condition of the !atient is such that he/she cannot "e removed to the hos!ital/nursing home or ii2 The !atient cannot "e removed to hos!ital/nursing *ome for lack of accommodation therein. Su"#ect however that domiciliary hos!italisation on "enefits shall not cover1' -2 B2 %2 -ny treatment not e ceeding three days. E !enses incurred for !re and !ost hos!ital treatment and E !enses incurred for treatment for any of the following disease. .2 72 82 A2 :2 B2 C2 D2
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-sthma Bronchitis %hronic +e!hritis and +e!hritic Syndrome 0iarrhoea and all ty!e of 0ysenteric including Gastro'enteritis 0ia"etes 4ellitus and Insi!idious E!ile!sy *y!ertension InfluenEa, %ough and %old
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F2 -ll Psychiatric or Psychosomatic 0isorders .=2 Pyre ia of unknown &rigin for less than .= days ..2 Tonsillitis and ?!!er 3es!iratory Tract infection including )aryngitis and Pharyngitis .72 -rthritis, Gout and 3heumatism Not : Ghen treatment such as 0ialysis, %hemothera!y, 3adiothera!y etc. is taken in the *os!ital/+ursing *ome and the Insured is discharged on the same day, the treatment will "e considered to "e taken under *os!italisation Benefit section. *owever, reasona"le e !enses actually incurred for immunisation in#ection following dog "ite may "e reim"ursed under 0omiciliary *os!italisation. Liability of the Company under this clause is restricted as stated in the Schedule. E) ANY ONE ILLNESS1 -ny one illness will "e deemed to mean continuous !eriod of illness and it includes rela!se within A: days from the date of last consultation with the *os!ital/+ursing *ome where treatment may have "een taken. &ccurrence of same illness after a la!se of A: days as stated a"ove will "e considered as fresh illness for the !ur!ose of this !olicy. PRE!HOSPITALISATION 3elevant medical e !enses incurred during !eriod unto 8= days !rior to hos!italisation on disease/illness/in#ury sustained will "e considered as !art of *os!italisation claim. POST!HOSPITALISATION 3elevant medical e !enses incurred during !eriod unto B= days after *os!italisation on disease/illness/in#ury sustained will "e considered as !art of *os!italisation claim. MEDICAL PRACTITIONER means a !erson who holds a degree/di!loma of a recognised institution and is registered "y 4edical %ouncil of res!ective

F)

G)

H)

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State of India. The term 4edical Practitioner would include Physician, S!ecialist and Surgeon. I) "UALIFIED NURSE means a !erson who holds a certificate of recognised +ursing %ouncil and who is em!loyed on recommendations of the attending 4edical Practitioner. PRE!E#ISTING CONDITION: It means an in#ury and/or sickness and/or its sym!toms which e ists when the cover ince!ts for the first time. %om!lication arising from !re' e isting disease will "e considered !art of !re'e isting condition. COMPANY: It means I$$%&'T&(I& GE+E3-) I+S?3-+%E %&4P-+H )T0.

J)

$)

A.

E#CLUSIONS: The %om!any shall not "e lia"le to make any !ayment under this !olicy in res!ect of any e !enses whatsoever incurred "y any Insured Person in connection with or in res!ect of1 ' i. -ll diseases in#uries, which are in !re'e isting condition when the cover ince!ts for the first time. -ny disease other than those stated in clause c2 "elow, contracted "y the insured !erson during the first 8= days from the commencement date of the !olicy. This e clusion shall not however, a!!ly if in the o!inion of !anel of medical !ractitioners constituted "y the com!any for the !ur!ose, the insured !erson could not have known of the e istence of the disease or any sym!toms or com!laints thereof at the time of making the !ro!osal for insurance to the com!any. This condition shall not however a!!ly in case of the insured !erson having "een covered under this scheme or grou! insurance scheme with any of the Indian insurance com!anies for a continuous !eriod of !receding .7 months without any "reak. 0uring the first year of the o!eration of the !olicy, the e !enses on treatment of diseases such as %ataract, Benign Prostetic *y!erthro!hy, *ysterectomy for 4enorrahagia or $i"romyoma, *ernia, *ydrocele, %ongenital
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Jan Swasthya Bima Manual

Internal 0isease, $istulainanus, Piles, Sinusitis and related disorders are not !aya"le. If these diseases are !re'e isting at the time of !ro!osal they will not "e covered even during su"se9uent !eriod of renewal too. iv. v. Gar and +uclear 3isk1 %ircumcision unless necessary for treatment of a disease not e cluded hereunder or as may "e necessitated due to an accident, Iaccination or inoculation or change of life or cosmetic or aesthetic treatment of any descri!tion, !lastic surgery other than as may "e necessitated due to an accident or as a !art of any illness. The cost of s!ectacles and contact lenses, hearing aids. 0ental treatment or surgery of any kind unless re9uiring hos!italisation. %onvalescence, general de"ility, 3un'down condition or rest cure, congenital e ternal disease or defects or anomalies, sterility, venereal disease, intentional self'in#ury and use of into icating drugs/alcohol. -ll e !enses arising out of any condition directly or indirectly caused to or associated with H%&'( T!C )) L*&+,ot-o+./ V.-%0 Ty!e III ;*T)I'III2 or L*&+,'1.(o+'t,* A00o/.'t 1 V.-%0 ;)-I2 or the M%t'(t0 D -.2't.2 or V'-.'t.o(0 D 3./. (/* S*(1-o& or any S*(1-o& or condition of a similar kind commonly referred to as AIDS. %harges incurred at *os!ital or +ursing *ome !rimarily for diagnostic, 6' ray or la"oratory e aminations or other diagnostic studies not consistent with or incidental to the diagnosis and treatment of the !ositive e istence or !resence of any ailment, sickness or in#ury, for which confinement is re9uired at a *os!ital/+ursing *ome or at home under 0omiciliary *os!italisation as defined. E !enses on vitamins and tonics unless forming !art of treatment for in#ury or disease as certified "y the attending Physician. Treatment arising from or tracea"le to !regnancy, child"irth including caesarean section.

vi. vii. viii.

i .

i.

ii.

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iii.

Ioluntary medical termination of !regnancy during the first .7 weeks from the date of conce!tion. +aturo!athy Treatment. Note: -cu!uncture/4agnetic treatments are not covered.

iv.

:4

AGE LIMIT1 This insurance is availa"le to !ersons "etween the age of : years and D= years. %hildren "etween the age of 8 months and : years of age can "e covered !rovided one or "oth !arents are covered concurrently. Though !ersons a"ove C: years have to "e avoided if they want coverage on stand'alone "asis. *owever, GE will grant coverage to !ersons a"ove C: years of age if they are cases of renewals and have "een covered with us for a !eriod of at least 8 years.

B.

CANCELLATION: The !olicy may "e renewed "y mutual consent. The %om!any shall not however "e "ound to give notice that it is due for renewal and the %om!any may at any time cancel this !olicy "y sending the Insured 8= days notice "y registrered letter at the Insureds, last known address and in such event the %om!any shall refund to the Insured a !ro'rata !remium for une !ired !eriod of Insurance. The com!any shall, however, remain lia"le for any claim which arose !rior to the date of cancellation. The Insured may at any time cancel this !olicy and in such event the com!any shall allow refund of !remium after retaining the !remium at com!any,s short !eriod rate only;ta"le given here"elow2 !rovided no claim has occurred u!to the date of cancellation1 P -.o1 o( R.05 R't o3 P- &.%& to 6 /,'-7 1: P -.o1 o3 /o2 ?! to &ne 4onth ?! to Three 4onths ?! to Si 4onths Preceding Si 4onths R't o3 P- &.%& to 6 - t'.( 1 7:J of the -nnual 3ate :=J of the -nnual 3ate C:J of the -nnual 3ate $ull -nnual 3ate

C.

ELIGIBILITY1
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Jan Swasthya Bima Manual

Persons of any +ationality may avail the "enefits of the !olicies "ut claims for treatment in India to "e covered under the Policy. D. ELIGIBILITY FOR COVERAGE UNDER GROUP POLICY: The Grou! Policy for J-+ SG-ST*H- BI4- can "e offered to any !ro!osed Grou! which falls clearly under any of the following categories1 i2 ii2 iii2 iv2 v2 vi2 vii2 Em!loyer'Em!loyee relationshi! including de!endants of the em!loyee. Pre'identified Segment/Grou! where the !remium is !aid "y the State/%entral Govt. 4em"ers of 3egistered Service %lu"s. *olders of %redit %ards of Bank/0iners/4aster/Iisa Travel related Services. *olders of 0e!ositor %ertificate "y Banks/+B$%s. Shareholders of Banks/Pu"lic )imited %om!anies. -ll mem"ers who have common identification, interest "ut this common identification, interest should not "e initiated for the !ur!ose of having "enefit of Insurance Policy and availing Grou! 0iscount.

F.

GROUP DISCOUNT: The Grou! discount is !ermissi"le as !er the following scale de!ending u!on the total num"er of Insured !ersons covered under the Grou! Policy at the ince!tion. Increase/0ecrease in the siEe of the Grou! during the currency of the Policy is !ermissi"le. The final Grou! discount ;Increase/0ecrease2 will "e ad#usted on the last day of the Policy Posted !rovided that the Policy is renewed for the ne t .7 months1 Tot') (o4o3 & &6 -0 7: '.== .=. ':== :=. '.=== .==. '7:== 7:=. ' :=== :==. ' .:=== .:==. ' 7:=== 7:==. ' :==== :===. K .===== G-o%+ D.0/o%(t :J C.:J .=J .7.:J .:J 7=J 7:J 8=J 8:J
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Not : 4inimum +o. in a Grou! to "e eligi"le for this Policy is .:. *owever, the discount would "e availa"le if +o. of !ersons in the Grou! is 7: and a"ove. *owever, if the +o. of Increase takes !lace during the year, then Grou! discount will not "e ad#usted according to flat discount for e tra year, the sla" for 0iscount will "e counted from the day when the total +o. has reached ne t sla". T, '6o2 1.0/o%(t o( (%&6 - o3 + -0o(0 /o2 - 1 8.)) 6 3o))o8 14 Ho8 2 -9 1 + (1.(7 o( 0+ /.3./ - :%.- & (t '(1 & -.t o3 t, /'0 9 .t /'( 6 ')t - 1 6* CEO o3 ITGI4

.=.

BONUS/MALUS LOW CLAIM RATIO DISCOUNT(BONUS) )ow %laim 3atio 0iscount at the following scale will "e allowed on the Total !remium at renewal only de!ending u!on the incurred claims ratio for the entire grou! insured under the Jan Swasthya Bima Insurance Policy for the !receding 8 com!leted years e cluding the year immediately !receding the date of renewal. Ghere the Jan Swasthya Bima Insurance Policy has not "een in force for 8 com!leted years such shorter !eriod of com!leted years e cluding the year immediately !receding the date of renewal will "e taken into account. Incurred %laims ratio under the Jan Swasthya D.0/o%(t Bima !olicy ; +ot e ceeding B=J : +ot e ceeding :=J .: +ot e ceeding A=J 7: +ot e ceeding 8=J 8: +ot e ceeding 7:J A= HIGH CLAIM RATIO LOADING (MALUS) The Total Premium !aya"le at renewal of the Jan Swasthya Bima !olicy will "e loaded at the following scale de!ending u!on the incurred claims ratio for the entire grou! insured under the Jan Swasthya Bima Insurance Policy for the !receding 8 com!leted years e cluding the year immediately !receding the date of renewal. Ghere the Jan Swasthya Bima Policy has

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not "een in force for the 8 com!leted years, such shorter !eriods of com!leted years, e cluding the year immediately !receding the date of renewal will "e taken into account. Incurred %laims 3atio under the Jan Lo'1.(7 ; Swasthya Bima Between D=J and .==J 7: Between .=.J and .7:J :: Between .7BJ and .:=J F= Between .:.J and .C:J .7= Between .CBJ and 7==J .:= &ver 7==J %over to "e reviewed Not 1 .. )ow %laim 3atio 0iscount ;Bonus2 or *igh %laim 3atio )oading ;4alus2 will "e a!!lica"le to the Premium at renewal of the Policy de!ending on the incurred %laims 3atio for the entire Grou! insured. 7.Incurred claim would mean claims !aid !lus claims outstanding in res!ect of the entire grou! insured under the Policy during the relevant Period. *owever, the claim ratio for the !ur!ose of a"ove Bonus/)oading is indicative and ?/G *ead at %or!orate &ffice alone will have discretion to change it according to situation. ... DETAILS OF INSURED PERSON: The Insured shall "e re9uired to furnish a com!lete list of Insured Persons in the following format according to Sum Insured. -ny additions and deletions during the currency of the !olicy should "e intimated to the %om!any in the same format. SUM INSURED1 4inimum 3s..:,===/' with multi!les of 3s. :,===/' thereafter, with ma imum Sum Insured of 3s.8=,===/'on Individual or family floater "asis. PAYMENT OF PREMIUM 0e!ending u!on the age of the insured !erson;s2 and sum insured selected for that !erson, Premium ta"le is attached.

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?nder Section BAIB, it is allowed to have collection of Premium under Jan Swasthya Bima Policy in instalments. -ccordingly it will "e !rovided. .:. MATERNITY E#PENSES BENEFIT: This is an o!tional cover, which can "e o"tained on !ayment of .=J of the total "asic !remium for all the Insured Persons under the Policy. Total "asic !remium means the total !remium com!uted "efore a!!lying Jan Swasthya Bima 0iscount and/or *igh %laim 3atio )oading. )ow %laim 0iscount and s!ecial discount in lieu of agency commission. &!tion for 4aternity Benefits has to "e e ercised at the ince!tion of the !olicy !eriod and no refund is allowa"le in case of Insured,s cancellation of this o!tion during currency of the !olicy. The ma imum "enefit allowa"le under this clause will "e u!to .=J of the sum insured o!ted "y the mem"er of the grou! as an individual / as a family floater sum insured . S!ecial conditions a!!lica"le to 4aternity E !enses Benefit E tension These "enefits are admissi"le only if the e !enses are incurred in *os!ital/+ursing *ome as in'!atients in India.

- waiting !eriod of F months is a!!lica"le for !ayment of any claim relating to normal delivery or caesarean section or a"dominal o!eration for e tra uterine Pregnancy. The waiting !eriod may "e rela ed only in case of delivery, miscarriage or a"ortion induced "y accident or other medical emergency. %laim in res!ect of only first two children and/or o!erations associated therewith will "e considered in res!ect of any one Insured Person covered under the Policy or any renewal thereof. Those Insured Persons who are already having two or more living children will not "e eligi"le for this "enefit. Pre'natal and !ost'natal e !enses are not covered unless admitted in *os!ital/+ursing *ome and treatment is taken there.

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E#TENSIONS UNDER JAN SWASTHYA BIMA POLICY

.2 a2

EDUCATION COST1 COVERAGE: This Policy can "e e tended to cover the education cost of the Insured Person !rovided that the Insured !erson is attending ?niversity, %ollege or School and such Insured !erson who is a student falls sick or sustains in#ury leading to admission of lia"ility under J-+ SG-ST*H- BI4- Policy and solely and directly as a result of such sickness or in#ury, the student ;Insured Person2 is una"le to com!lete the Semester/-cademic year of education he/she is !ursuing and does not get 0egree/0i!loma/%ertificate/Promotion to ne t class/semester/academic year with the rest of classmates, then in that case GE will !ay for i2 ii2 iii2 -ny Tuition fees for re!eating the academic year/semester/class. -ny E amination fees. -ny fi ed monthly "oarding/lodging E !enses not e ceeding =.:J of the Sum Insured for School Education and ..=J of Insured in %ase of ?niversity, %ollege Education. &ther necessary incidental cost su"#ect to !roof "eing su"mitted "y H&?.

iv2

"2

MA#IMUM AMOUNT PAYABLE1 The 4a imum amount GE will !ay is 3s.B=,===/' ;3u!ees si ty Thousand2 in case of college/?niversity education in Indemnity !eriod and 3s.8=,===/';3u!ees Thirty Thousand2 in case of School Education in the Indemnity !eriod. BASIS OF CLAIM SETTLEMENT1 i2 GE will !ay for actual cost incurred su"#ect to necessary !roofs such as 4edical Practitioner %ertificate, %ertificate of *ead of Institution/0e!artment, 4ark sheet su"#ect to our lia"ility not e ceeding the 4a imum -mount !aya"le as a"ove. ii2 If the !eriod of Insurance and Session of -cademic year is not coincident, then in that case the non com!letion of course would de!end u!on sickness, in#ury sustained during the !eriod of Insurance. In such an event, it will "e seen that whether such in#ury/sickness was sole and direct cause for non com!letion of the course or not.
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d2

INDEMNITY PERIOD1 The 4a imum !eriod for which GE will !ay is .7 months or till the day when the student who is attending the course com!lete it and moves to ne t semester/class/academic year whichever is earlier. E#CLUSIONS1 GE will not "e lia"le for i2 Books and 3eading 4aterial. ii2 -ny cost as a conse9uence of alteration in the course !rogramme. iii2 -ny fi ed cost/e !enses, which has already "een incurred "y student in !revious academic year/semester/class. iv2 %ost and e !enses if such student is not insured under J-+ SG-ST*HBI4- of this Policy and the claim has not "een admitted there. RATE: .23s..== !er School going Student c 723s.7== for %ollege going Student CEO 8.)) ,'2 1.0/- t.o( to /,'(7 t, ).&.t o3 I(1 &(.t*9 P- &.%& -'t .( </ +t.o(') /'0 04

e2

=2

AMBULANCE CHARGES1 In case of Insured !erson falling sick and getting hos!italised, and the claim having "een admitted and "ecome !aya"le "y us GE will !ay for -m"ulance charges u! to 3s..===/' for Insured Person for *os!italisation. This amount is !aya"le only if the Insured !erson has "een admitted following Emergency situation. 3-TE1 This "enefit is !aya"le at the rate of 3s.:/' !er Insured Person. CEO 8.)) ,'2 1.0/- t.o( to /,'(7 t, ).&.t o3 I(1 &(.t*9 P- &.%& -'t .( </ +t.o(') /'0 04

>2

COST OF TRAVEL1 The Policy can "e e tended to cover the %ost of Travel for one of relation of Insured Person, friend or colleague to meet the Insured !erson who has "een
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admitted in a *os!ital outside the city, town or the village where his !rinci!al !lace of residence is located and also for return travel e !enses for the sick Insured !erson. The scheme is as under1 a2 COST
OF

TRAVEL

FOR ANY RELATION9 FRIEND9 COLLEAGUE OR ANY OTHER

NOMINATED PERSON:

In the event of Insured !erson falling sick outside the !rinci!al !lace of residence and claim having "een admitted under *os!italisation and 0omiciliary *os!italisation claim, then GE would !ay for cost of travel e !enses for one of the relation, friend, colleague of Insured !erson or a nominated !erson "y the Insured Person or his/her s!ouse to #oin him/her for "oth outward/return #ourney. This "enefit is availa"le only if the Insured !erson has "een hos!italised as a conse9uence of emergency sickness and the tri! has "een !lanned for !rofessional "usiness or holiday !ur!ose, "ut not for treatment of disease or any related disease or a conse9uential com!lication thereof, following which the Insured !erson has "een hos!italised. The 4a imum lia"ility would "e restricted to 3s..:,===/' or actual e !enses whichever is lower in any one !eriod of Insurance. The !rescri"ed rate would "e 3s.8=/' !er Insured !erson. CEO 8.)) ,'2 1.0/- t.o( to /,'(7 t, ).&.t o3 I(1 &(.t*9 P- &.%& -'t .( </ +t.o(') /'0 04

"2

COST OF TRAVEL FOR INSURED PERSON: In the event of Insured Person falling sick and getting hos!italised outside the city/town/village, where his/her !rinci!al !lace of residence is located and claim having "een admitted under *os!italisation and 0omiciliary *os!italisation and "ecome !aya"le, GE would reim"urse the cost of return #ourney for Insured !erson to !rinci!al !lace of residence. This "enefit is availa"le only if the Insured !erson is hos!italised as a conse9uence of emergency sickness and the tri! had "een !lanned for !rofessional, "usiness or holiday !ur!oseL "ut not for treatment of disease or any related disease or a conse9uential com!lication thereof, following which the Insured !erson has "een hos!italised. The 4a imum lia"ility of the %om!any would "e restricted to 3s.C:==/' or actual E !enses whichever is lower in any one !eriod of insurance. The !rescri"ed rate would "e 3s..: !er !erson.

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CEO 8.)) ,'2 1.0/- t.o( to /,'(7 t, ).&.t o3 I(1 &(.t*9 P- &.%& -'t .( </ +t.o(') /'0 04

?2

COST OF SUPPORTING ITEMS: In the event of insured !erson having "een hos!italised and the claim having "een admitted under *os!italisation or 0omiciliary *os!italisation, a and claim "ecomes !aya"le, GE would reim"urse the cost of !urchase of su!!orting items such as %rutches, Stretcher, tricycle, wheel chairs, Intra ocular )ens, s!ectacles or any other items which in the o!inion of 3egistered 4edical Practitioner is necessary for Insured !erson. The com!any,s ma imum lia"ility would "e limited to 3s..=,===/' or actual e !enses whichever is lower in addition to Sum Insured. The !rescri"ed rate would "e 3s.7:/' !er Insured Person. CEO 8.)) ,'2 1.0/- t.o( to /,'(7 t, ).&.t o3 I(1 &(.t*9 P- &.%& -'t .( </ +t.o(') /'0 04

5)

DISCOUNTS FOR REDUCING PRE AND POST HOSPITALISATION PERIOD1 The Jan Swasthya Bima Policy !rovides for reim"ursement of Pre' *os!italisation E !enses u!to 8= days and Post *os!italisation !eriod u!to B= days. *owever, in the Policy designed "y ITGI, the !re and !ost *os!italisation !eriod can "e reduced to +il days. -ccordingly for every reduction in this Pre *os!italisation !eriod "y . week, the discount would "e =.:J of the !remium and it can "e done !ro'rata "asis for remaining days thereof. $urther for the !ost *os!italisation !eriod, the reduction in the !eriod "y every week would entitle the Insured to earn the discount of .J at the rate of !er week and !ro'rata of .J for remaining days thereof. D.0/o%(t0 8.)) 6 3o))o8 1 .( &'@o-.t* o3 /'0 09 6%t CEO o3 ITGI 8.)) ,'2 1.0/- t.o( to /,'(7 .t4

A)

HOSPITAL DAILY CASH1 The Jan Swasthya Bima Policy offers the Sum Insured on overall "asis without any su" limit for various E !enses nor for any limitation or e !enses on no. of days "asis. *owever, the Policy designed "y ITGI has this fle i"ility that the &verall Sum Insured chosen "y Insured can "e a!!ortioned for +o. of days and a *os!ital daily %ash cover can "e granted. Su!!osing there is Sum Insured of 3s..:=== and no. of days is 8= days then the cover can "e granted for 3s.:==/'
.: of7A

Jan Swasthya Bima Manual

!er day. This Policy will have same terms, conditions as that for Jan Swasthya Bima Policy 1 D.0/o%(t '2'.)'6) I( t, P- &.%& If the overall Sum Insured is a!!ortioned for 8= days ' If the overall Sum Insured is a!!ortioned for A: days ' If the overall Sum Insured is a!!ortioned for B= days ' The coverage should "e for all or none. CLAIM SETTLEMENT PROCEDURE &n admission of Insured !erson in the *os!ital, our 4edical 3e!resentative will visit the *os!ital and discuss the e !enses with -ttendant 0octor and accordingly the claim will "e settled on agreement with sum Insured. *os!ital and us without asking the "ills on the "asis of our limit !er day is o!ted "y Insured. T, 1'.)* ).&.t 3.< 1 '(1 1.0/o%(t .( ). % o3 t,'t 8.)) 6 /,'(7 1 '//o-1.(7 to 0.t%'t.o( 't t, 1.0/- t.o( o3 CEO9.( </ +t.o(') /'0 09 '(1 ')0o t, /)'.& 0 tt) & (t +-o/ 1%- 4 B) FLOATER POLICY1 W,.) o%- +- 3 - (/ 8.)) 6 (ot to '))o8 t, 3)o't - /o2 -'7 9 ,o8 2 - 6t, +-o2.0.o( ,'0 6 ( &'1 3o- 3'&.)* /o2 -'7 8, - .( '(* .(0%- 1 & &6 .( t, 3'&.)* /o%)1 '2'.) %+to t, 3%)) 3'&.)* ).&.t 4O%- ).'6.).t* .( ' Po)./* * '- 0,')) 6 - 0t-./t 1 to t, 3'&.)* 3)o't - 0%& .(0%- 14 *owever the family floater cover cannot "e given for a sum insured less than 3s 7:=== and more than 3s 8=,===.. T, &'<.&%& 3'&.)* 0.C 0,o%)1 (ot </ 1 A & &6 -0 T, )o'1.(7 o( t, +- &.%& 8o%)1 6 '12.0 1 6* t, H '1 R t'.) U(1 -8-.t.(7 't Co-+o-'t O33./ o()* 5 +.(7 .( &.(1 t, 7-o%+ +-o3.) 9 0.C o3 3'&.). 0 '(1 (%&6 - o3 3'&.). 0 /o2 - 1 T, &.(.&%& )o'1.(70 '- 7.2 ( 6 )o8 $amily floater for 7 mem"ers 1' 7=J on overall !remium. $amily floater for 8 mem"ers 1' 7:J on overall !remium
Jan Swasthya Bima Manual .B of7A

7:J 8:J :=J

$amily floater for A mem"ers 1' $amily floater for : mem"ers 1' $amily floater for B mem"ers 1'

8=J on overall !remium 8:J on overall !remium A=J on overall !remium

In this family floater, the underwriting should "e done in a such way that the average age of the Insured !ersons should not "e more than := years in case of family siEe of A mem"ers and a"ove, and A: years in case of !eo!le with family siEe of 8 and A: years in case of family of 7 !ersons. RATING FOR FLOATER POLICY: The Premium must "e taken for each individual Insured !erson de!ending u!on their age and the Sum Insured and the family floater would "e loaded on total !remium for all mem"ers of the family. $urther for !ur!ose of floater, there will not "e selectivity such as in the family of A !ersons covered under Jan Swasthya Bima Policy, the floater family with loading would not "e a!!lied for only 7 !ersons and the remaining 7 !ersons can "e left. It will "e for all mem"ers covered under the Jan Swasthya Bima Policy. Ho8 2 - t, CEO 8.)) ,'2 t, 1.0/- t.o( to 8'.2 t,.0 /o(1.t.o( o3 &.(.&%& 0%& .(0%- 1 '//o-1.(7 to t, 0.C o3 t, 3'&.)* '(1 '))o8 t, )o'1.(7 o( 3)'t 6'0.0 t'5.(7 .(to '//o%(t t, '2 -'7 0.C o3 t, 7-o%+ 8.t,o%t '(* %++ - ).&.t o3 .(1.2.1%') + -0o(4 D) ADDITIONAL OPTIONAL COVER FOR BOARDING E LODGING E#PENSES: In the event of an admissi"le claim under hos!italisation section of the !olicy, the e !enses not e ceeding 3s..,:==/' !er week shall "e reim"ursed towards "oarding 5 lodging e !enses in the hos!ital for one of the family mem"ers or ne t of kin who accom!anies the insured !erson during the !eriod of hos!italisation. This weekly com!ensation will not "e availa"le for more than D weeks in res!ect of any one covered illness / disease / in#ury !er !olicy !eriod. P- &.%& R't : 3s..==/' !er Insured Person

CEO 8.)) ,'2 1.0/- t.o( to /,'(7 t, ).&.t o3 I(1 &(.t*9 P- &.%& -'t .( </ +t.o(') /'0 04

Jan Swasthya Bima Manual

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F)

INCLUSION OF PRE!E#ISTING DISEASE E REMOVAL OF FIRST YEAR E#CLUSION OF DISEASES MENTIONED IN THE POLICY: The Pre e isting diseases e isting at the ince!tion of the Insurance %over for the first time are under e clusions along with e clusions for treatment of diseases such as cataract, *ernia, *ydrocele, $istula in -nus, Piles, sinusitis etc. *owever, on !ayment of additional !remium, the !re'e isting diseases along with first year e clusions can "e covered only in Grou! Policies if following conditions are met1 a2 "2 The -verage -ge of the Grou! is not more than A: years. The loading of the Premium will "e done in following ways. $or the !eo!le u!to the -ge of 8= years ' .:J of the Premium $or the !eo!le u!to the age of 8.'A= years ' 7=J of the Premium $or the !eo!le u!to the -ge of A.':= years ' 7:J of the Premium Beyond := years u!to :: years ' 8:J of the Premium The Pre e isting %over will not "e !rovided for any !erson "eyond :: years e ce!t for e ce!tional circumstances when the !remium will "e loaded "y :=J. *owever, this coverage will "e the discretion of the *ead 3etail ?nderwriting at %or!orate office. If the !re'e isting disease along with first year e clusions are covered then in that case the !ersons covered under the !olicy of ITGI or any other insurance for the renewal cover will have full coverage right from the commencement of the !eriod of insurance. *owever, the !ersons who have "een covered in this !olicy for the first time will have a waiting !eriod of 8 months in res!ect of any !re'e isting disease. This waiting !eriod will not "e a!!lica"le for other disease or in#ury su"#ect to other terms, conditions of this Policy. The e cess will "e first .=J of the claim in each and every case of Pre'e isting disease and for a"ove A: years ' 7=J of the claim will "e "orne "y the Insured. 4a#or 4edical cover1 T, /o(1.t.o( o3 </ 00 o3 G0; o- =0; o3 t, /)'.& '(1 t, </ 00 o3 > &o(t,0 3o- +- ! <.0t.(7 1.0 '0 9 +- &.%& )o'1.(7 /'( 6 ')t - 1 1 + (1.(7 o( t, - :%.- & (t /). (t9 +- 2.o%0 +o)./*4

c2

d2

Jan Swasthya Bima Manual

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G0)

DELETION OF DOMICILIARY HOSPITALISATION: The J-+ SG-ST*H- BI4- Policy !rovided for 0omiciliary *os!italisation "enefits which is .=J to 7=J of overall Sum Insured. *owever, the deletion of 0omiciliary *os!italisation "enefit will not reduce the "enefit amount, "ut the overall Sum Insured will remain for only *os!italisation "enefits. The discount in lieu of removal of 0omiciliary *os!italisation will "e to the e tent of .=J to .:J de!ending u!on the -ge !rofile and sum Insured. Mo- o- ) 00 t, '6o2 1.0/o%(t 3o- - &o2') o3 Do&./.).'-* ,o0+.t').0't.o( 8.)) 6 3o))o8 14 Ho8 2 - .( </ +t.o(') /'0 0 1 + (1.(7 %+o( t, & -.t o3 t, /'0 9 t, 1.0/o%(t 8.)) 6 '))o8 1 't t, 1.0/- t.o( o3 t, CEO4 ORGANISATIONAL FLOATER: In a Grou! Policy, the family floater can "e !rovided to the !eo!le with family on the same terms, conditions mentioned a"ove under $amily floater. *owever, there can "e situation when in a Grou! Policy there are a no. of !eo!le without family and the Sum Insured for them would "e inade9uate individually. Therefore, for this su" grou! of !eo!le who are without family coverage under Grou! J-+ SG-ST*H- BI4- Policy, an organisational floater scheme can "e considered on following lines1 a.2 There would "e a creation of Buffer Sum Insured for individual insured Person who are without family coverage in that J-+ SG-ST*H- BI4- Scheme or any other J-+ SG-ST*H- BI4- Insurance. ".2 -ny single Insured Person who e hausts his/her own Sum Insured can "e !rovided with coverage from this Buffer Sum Insured !rovided that in anyone single illness/in#ury/disease his own Sum Insured has e hausted and e !enses of hos!italisation for that anyone illness e ceeds his Sum Insured. This "enefit is allowed only twice during the !eriod of Insurance. c.2 That insured !erson can draw from this "uffer Sum Insured an amount e9uivalent to his/her Sum Insured. d.2 The "uffer sum insured for these singles should not "e less than total sum insured of at least .=J of !o!ulation of singles and it should "e in multi!les of -verage Sum Insured. e.2 The !remium rate would "e de!endent u!on same !ro!ortion of age grou! in the "uffer sum insured as the total !o!ulation of "achelors / singles com!rise !lus 3s.7: !er ca!ita minimum.

GG)

Jan Swasthya Bima Manual

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T, CEO 8.)) ,'2 t, 1.0/- t.o( to 8'.2 t, /o(1.t.o( o3 o-7'(.0't.o(') 3)o't - o()* 3o- 0.(7) 09 t, &.(.&%& '&o%(t - :%.- 1 3o- o-7'(.0't.o(') 3)o't - '(1 ')0o t, ).&.t o3 .(1.2.1%') 0%& .(0%- 1 '3t - o( 3.(.0, 0 ,.0/, ).&.t o3 0%& .(0%- 14 G=) E#TENSION UNDER MATERNITY BENEFIT POLICY: The Grou! J-+ SG-ST*H- BI4- Policy has !rovision of 4aternity E !enses Benefit E tension. *owever, there is a waiting !eriod of F months is a!!lica"le for !ayment of any claim relating to +ormal delivery or %aesarean Section or a"normal o!eration for e tra uterine !regnancy. This waiting !eriod may "e retained in case of .. 0elivery, 4iscarriage or -"ortion induced "y accident or medical emergency. 7. &n !ayment of additional !remium on !ayment of .=J of the total "asic !remium for all the Insured Persons during the Policy. This additional !remium will "e in addition to .=J of total "asic !remium charged for 4aternity E !enses Benefit E tension. Therefore, GE may conclude that 4aternity E !enses Benefit E tension with waiver of F months waiting !eriod is availa"le at !ayment of 7=J of the total "asic !remium. T, )o'1.(7 o3 +- &.%& 8.)) 6 /,'(7 1 '//o-1.(7 to /.-/%&0t'(/ 0 't t, 1.0/- t.o( o3 t, CEO4

CLAIM MANAGEMENT GUIDELINES

The following as!ects are im!ortant in loading of claims under J-+ SG-ST*H- BI4- Policy1 .2 I(t.&'t.o( o3 C)'.&1 Preliminary +otice of claim with !articulars relating to Policy +os., +ame of Insured Person in res!ect of whom claim is made. +ature of Illness/In#ury and +ame and address of the attending 4edical Practitioner/*os!ital/+ursing *ome should "e given "y the Insured Person to the com!any with in C days from the date of *os!italisation/0omiciliary *os!italisation.
Jan Swasthya Bima Manual 7= of7A

$inal claim along with recei!ted Bills/%ash 4emos, %laim form and list of documents as listed in the %laim form should "e su"mitted to the com!any within 8= days from the date of com!letion of treatment. 7) P-o/ 00.(7 o3 C)'.&0: The following su!!orting documents are re9uired for the !ur!ose of scrutiny1 The claims could "e serviced on %ash less "asis through TP- +etwork or reim"ursement "asis. -2 i2 ii2 iii2 iv2 Ho0+.t').0't.o( C)'.&0 0uly com!leted claim form. Bills, recei!ts and discharge certificate/card from the hos!ital. %ash memos from the hos!ital/chemist;s2, su!!orted "y !ro!er !rescri!tion. 3ecei!t and Pathological test re!orts from a Pathologist su!!orted "y the note from the attending medical Practitioner/Surgeon demanding such !athological tests. Surgeons, certificate stating nature of o!eration !erformed and surgeons, "ill and recei!t. -ttending doctors,%onsultants,/S!ecialists/-naesthetists etc. "ill and recei!t is fully cured. Do&./.).'-* Ho0+.t').0't.o( C)'.&0 In case of domiciliary *os!italisation %laims, a!art from I2 to iv2 and vi2 as shown a"ove the following documents is also re9uired1' %ertificate from the attending 4edical Practitioner, giving reasons like severity of disease, for allowing treatment at home. To confirm whether 0omiciliary *os!italisation as in fact re9uired. Similarly, clinical notings contained in the certificate is to "e verified. The a"ove documents are normally re9uired to "e su"mitted within .: days of com!letion of the treatment. 82 T, +o)./* .0 0%6@ /t to 3o))o8.(7 t.& ).&.t01 a2 "2
Jan Swasthya Bima Manual

v2 vi2

B2

Pre'*os!italisation 1 8= days Post'*os!italisation 1 B= days

7. of7A

Ghere recurrence of same disease is within A: days the B= days limit will a!!ly overall. A2 T, 3o))o8.(7 .00% 0 &'* 6 0+ /.'))* )oo5 1 .(to1 a2 "2 c2 d2 e2 f2 family doctors fre9uent visits to the hos!ital. That claim does not fall within waiting !eriod and first year e clusion. That continuity of the cover has "een maintained. That the *os!ital/+ursing home should conform to re9uirement of the !olicy. That the disease for which claim has "een made is not e cluded under the !olicy. In case, !revious medical history is not shown on discharge card/narrative/discharge summary of the hos!ital/admission !a!ers of the hos!ital should "e called for after taking authority letter from the insured. En9uiries with family !hysician of the claimant to ensure that claim is not in res!ect of !re'e isting disease for which he was consulted earlier. Period of treatment in case of 0omiciliary *os!italisation %laim since com!any is lia"le only if !eriod of treatment e ceeds three days. That all cash memos for !urchase of medicines are in conformity with the !rescri!tion of attending medical !ractitioner/surgeon during the !eriod of treatment. That all "ills of the hos!ital are su!!orted "y corres!onding recei!ts. That figures and/or dates of !urchase in the cash memos are not altered "y way of eraser su!er im!osition of writing or added writing with a different ink. That admission to hos!ital is not for routine check u!. That treatment taken is in line with nature of disease. That !athological re!orts are su"mitted in case of o!eration. That hos!italisation and domiciliary hos!italisation "enefit is not clu""ed together.

g2

h2

i2

#2 k2

l2 m2 n2 o2

Jan Swasthya Bima Manual

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In case of death of insured after having incurred medical e !enses the amount of admissi"le claim should "e reim"ursed to legal re!resentative of the deceased or any other insured family mem"er su"mitting original "ills cash memos etc. after o"taining !ro!er declaration "y that !erson to the effect that the !erson claiming reim"ursement of e !enses actually incurred such e !enses for the treatment of the insured !erson. :2 O( '//o%(t P'*& (t H JAN SWASTHYA BIMA Po)./*: In e ce!tional circumstances where the claim is in res!ect of ma#or diseases on account of !ayment u! to D=J of the e !enses/eligi"le amount whichever is lower may B2 P'( ) Do/to-0: a2 In case of difference of o!inion "etween claimants doctor and com!any,s !anel doctor which can not "e resolved should "e referred to a s!ecialist for decision. "2 Ghere sus!icions are aroused in relation to disease allegedly suffered linked to !re'e isting condition, such claims may "e referred to a doctor for investigation from !anel maintained "y regional office. 3eference to !anel doctor/referee for investigation should not "e made in routine "ut selectively on merits. c2 To ensure that !anel doctors o!inion is conclusive. C2 C)'.&0 M.(.&.0't.o(: a2 $or fre9uent claims and for the same ailment consideration may "e given whether to renew or otherwise. ?nderwriting de!artment and 3.&. should "e ke!t informed. "2 In case of claim under grou! J-+ SG-ST*H- BI4- Policy, em!loyees record should "e verified to ensure that he has taken leave for the !eriod for which he is claiming. D2 C)'.&0 Co(t-o) Bo'-1: To monitor claims outgo, it is desira"le to maintain a >%laims %ontrol %ard@ !er insured !erson se!arately under the !olicy indicating there in !ayments made under Su" Sections of the Ta"le of "enefits of the !olicy.

Jan Swasthya Bima Manual

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P3E4I?4 S%*E0?)E L.&.t o3 S%& L.'6.).t* 3oI(0%- 1 U+to =0 Do&./.))'-* (O2 -')) * '-0 Ho0+.t').0't.o L.'6.).t*) (

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Jan Swasthya Bima Manual

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