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JIO -
Group Health Insurance Policy
"6 "
(6 ए ए )
----------------------------------------------------------------------------------------------------------------------
A NEW Innovative MEDICLAIM
For all Shravak-Shravika members of JIO
( From all JAIN Sects, like Shwetamber, Digamber, Sthanakwasi, Terapanthi etc.)
Policy features:
2. Family floater policy for 8 members. This includes Self, Spouse, 4 Dependent Children up to
25years, 2 Dependent Parents or Parents-In-Laws (No cross combination will be covered in the
policy).
Family floater policy for 4 members. This includes Self, Spouse, 2 Dependent Children up to
25years.
1% of Sum Insured for Normal Room rent & 2% for ICU charges per day as per Table
Below for 2 lac & 5 lac Sum Insured :
6. PRE-EXISTING DISEASES is NOT COVERED FOR 1 YEAR, 75% covered from 2nd year and
100% from 3rd year, 4th year, 5th year & 6th year. ***
Last year dependent Current Year Sum Insured PED Eligibility PED Waiting period
Self ( Proposer) 500,000 75% NIL
Dependent 1 - Do - 75% NIL
Dependent 2 - Do -- 75% NIL
Dependent 3 - Do -- NIL 1 year
8. DAY CARE PROCEDURES: covered (List mention in FAQ point no. 32 in FAQ ABOUT CLAIM
PROCESS & SETTLEMENT)
9. Internal Congenital diseases are covered maximum up to Rs. 50,000 per family
12. 30 Days Pre- Hospitalisation & 60 Days Post Hospitalisation expenses covered.
13. MATERNITY BENEFIT: Maternity benefits, applicable ONLY AFTER 1 YEAR subject to a limit
of Rs.25,000/- for normal and Rs.35,000/- for caesarean delivery.
14. NEW BORN BABY COVER: Request for addition of New Born Baby under the policy shall be
allowed within 30 days from DOB, Any delay / request coming after 30 days from DOB for
addition of New Borne baby to Insurer, shall not be considered.
Any hospitalization within this period i.e. from DOB of baby to 30 days shall be considered
subject to receipt of the timely intimation to Insurance Company.
New born baby expenses related to Hospitalization shall be covered from Day One of the birth
up to 90 days (with a limit of Rs 35000/-only) and thereafter up to Family Sum-Insured
limit.
16. As per INCOME TAX Act, Proposer will be eligible for exemption under Sec 80D.
17. Dental treatment covered if due to ROAD ACCIDENT ONLY and requiring 24 hours
Hospitalisation.
18. MID-TERM ADDITIONS allowed only for natural additions subject to intimation received
within 30 days of marriage or birth (for newly married SPOUSE & new born BABY).
19. 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.
Health India Insurance TPA Services Pvt. Ltd. Contact no. / Email ID:
1800220102 / frd@healthindiatpa.com
022-67133791 / jio.insurance@edelweissfin.com
Kindly read Terms & Condition properly, if required then only call to call centre.
21. CLAIM SUBMISSION of documents for REIMBURSEMENT claims Within 30 Days from Date of
Discharge.
Annual Premium as per Highest Member’s age in the family per Year ##
P
Final
l Policy Max. Max. Sum
Family Details Premium GST Premium
a Type Person Age Insured
with GST
n
65
G 6,525 1,175 7,700
years
Individual 1 member 2 lacs
Self
45
H 3,153 567 3,720
years
Notes :
Children in the policy are defined as unmarried dependent children up to the age of 25
years
Either Parents or Parents-in-law covered (Cross combination not allowed)
Single person can also opt for Policy up to age of 65 years.
Family members to be covered as per acceptable age of specific plans only
Individual Policy (Plan G & Plan H) is available only for members without any eligible
dependents (self-affidavit or certificate from JIO Director mandatory)
Premium to be transferred to JIO account by members and JIO will subsequently make
consolidated payment to Insurance Company. Hence, considering the time required for
reconciliation and requisite processes, request members to pay premium at the earliest
Premium to be paid through Online Payment only
Additional Rs.250 will be charged by payment gateway (Ease buzz) for providing safe &
secure online money transfer facility.
* For detail terms and condition, rejections and sub-limits refer JIO website.
www.jiojac.com/6Saal
** Policy terms and rates may be continued for next 6 years and shall be reviewed annually and necessary corrective
action shall be taken (if required) to keep the portfolio viable
*** Pre- Existing Diseases against each insured / beneficiary, needs to be declare while filling up
forms, If not disclose can be used as non- disclosure at time of claim & in court of law.
## However, The portfolio will be reviewed by Insurance company on periodic basis & to balance the claim
ratio the Insurance company will offer Motor, Travel, Group Personal Accident, Home Insurance etc. policies to
JIO members along with this policy.
22.1. WAR like situation etc. : : Treatment directly or indirectly arising from or
consequent upon war or any act of war, invasion, act of foreign enemy, war like
operations (whether war be declared or not or caused during service in the armed forces
of any country), civil war, public defence, rebellion, uprising, revolution, insurrection,
military or usurped acts, nuclear weapons / materials, chemical and biological weapons,
ionizing radiation, contamination by radioactive material or radiation of any kind,
nuclear fuel, nuclear waste.
22.4. Alcohol, Addiction etc. : Abuse or the consequences of the abuse of intoxicants
or hallucinogenic substances such as intoxicating drugs and alcohol, including alcohol
withdrawal, smoking cessation programs and the treatment of nicotine addiction or any
other substance abuse treatment or services, or supplies, impairment of Insured Pe rson’s
intellectual faculties by abuse of stimulants or depressants
22.7. Health check-ups : All routine examinations and preventive health check-ups.
22.8. Cosmetic surgery, aesthetic and re-shaping treatments and Surgeries. Plastic
Surgery or cosmetic Surgery or treatments to change appearance unless medically
necessary and certified by the attending Medical Practitioner for reconstruction following
an Accident, cancer or burns.
22.11. Hospitalisation not required : Conditions for which treatment could have been
done on an outpatient basis without any Hospitalization.
22.16. Admission for enteral feedings (infusion formulas via a tube into the upper
gastrointestinal tract) and other nutritional and electrolyte supplements unless certified
to be required by the attending Medical Practitioner as a direct consequence of an
otherwise covered claim.
22.18. Baldness : Treatment for alopecia, baldness, wigs, or toupees, and all treatment
related to the same.
22.19. Diabetic test strips etc.: Medical supplies including elastic stockings, diabetic test
strips, and similar products.
22.24. Venereal disease, all sexually transmitted disease or Illness including but not
limited to HPV, Genital Warts, Syphilis, Gonorrhoea, Genital Herpes, Chlamydia, Pubic
Lice and Trichomoniasis.
22.25. “AIDS” (Acquired Immune Deficiency Syndrome) and/or infection with HIV
(Human Immunodeficiency Virus) including Opportunistic infections but not limited to
any conditions related to or arising out of HIV/AIDS such as ARC (AIDS Related Complex),
Lymphomas in brain, Kaposi’s sarcoma, tuberculosis, Pneumocystis Carinii Pneumoniae
etc.
22.28. Organ donor screening: Expenses for organ donor screening, or save as and to
the extent provided for in the treatment of the donor (including Surgery to remove
organs from a donor in the case of transplant Surgery).
22.29. Illegal Organ Transplantation : Admission for Organ Transplant but not
compliant under the Transplantation of Human Organs Act, 1994 (amended).
22.30. Spinal subluxation :Treatment and supplies for analysis and adjustments o f
spinal subluxation, diagnosis and treatment by manipulation of the skeletal structure;
muscle stimulation by any means except treatment of fractures (excluding hairline
fractures) and dislocations of the mandible and extremities.
22.31. Dental Treatment: Dentures, implants and artificial teeth, Dental Treatment and
Surgery of any kind, unless requiring Hospitalization due to an Accident.
22.32. Cost incurred for any health check-up or for the purpose of issuance of medical
certificates and examinations required for employment or travel or any other such
purpose.
22.33. Artificial life maintenance, including life support machine use, where such
treatment will not result in recovery or restoration of the previous state of health.
22.35. Treatment for Age Related Macular Degeneration (ARMD), Rotational Field
Quantum Magnetic Resonance (RFQMR), External Counter Pulsation (ECP), Enhanced
External Counter Pulsation (EECP), Hyperbaric Oxygen Therapy, high intensity focused
ultrasound, balloon sinuplasty, Deep Brain Simulation,
22.36. Non-Medical Expenses (1) : Expenses which are medically not necessary such
as items of personal comfort and convenience including but not limited to television (if
specifically charged), charges for access to telephone and telephone calls (if specifically
charged), food stuffs (save for patient’s diet), cosmetics, hygiene articles, body care
products and bath additives, barber expenses, beauty service, guest service as well as
similar incidental services and supplies, vitamins and tonics unless certified to be
required by the attending Medical Practitioner as a direct consequence of an otherwise
covered claim.
22.37. Treatment taken from a person not falling within the scope of definition of
registered Medical Practitioner with any state medical council/ medical council of India.
22.38. Treatment charges or fees charged by any Medical Practitioner acting outside the
scope of license or registration granted to him by any medical council.
22.40. Any treatment or part of a treatment that is not of a reasonable charge, not
medically necessary; drugs or treatments which are not supported by a prescription.
22.41. Non-Medical Expenses: (2) Administrative charges related to a Hospital stay not
expressly mentioned as being covered, including but not limited to charges for admission,
discharge, administration, registration, bio-medical, linen, documentation and filing,
including MRD charges (medical records department charges).
22.42. Non-Medical Expenses: (3) including but not limited to RMO, CMO, DMO charges,
surcharges, night charges, service charges levied by the Hospital under any head and as
specified in the Annexure for Non- Medical Expenses and on Our website
adityabirlacapital.com
22.44. Insured Person whilst flying or taking part in aerial activities except as a fare -
paying passenger in a regular scheduled airline or air charter company.
22.47. Use of Radio Frequency (RF) probe for ablation or other procedure unless
specifically approved by Us in writing in advance.
22.48. Admission primarily for diagnostic purposes not consistent with the treatment
taken.
22.50.Treatment provided by anyone with the same residence as Insured Person or who
is a member of the Insured Person’s immediate family.
22.51. Holmium Laser Enucleation of Prostate, KTP Laser Surgeries, cyber knife
treatment, Femto laser surgeries, bio-absorbable stents, bioabsorbable valves,
bioabsorbable implants, oral chemotherapy, use of Infliximab, rituximab, avastin,
lucentis.
JIO -
( , , ,
)
ए ….
JIO -
Group Health Insurance Policy
"6 "
(6 ए ए )
---------------------------------------------------------------------------------------------------------------------------
A NEW Innovative MEDICLAIM
For all Shravak-Shravika members of JIO
( From all JAIN Sects, like Shwetamber, Digamber, Sthanakwasi, Terapanthi etc.)
4. Whether JIO is responsible for answering queries on claims disbursal and deductions?
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 Insurance Company.
In cases, where the grievances of the policy members remain unresolved by the Insurance
Company, the members can escalate such urgent / important issues with the Broking Company
or 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.
6. When will the new phase be introduced and how will the Shravaks be informed about
the same?
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.
7. Why there are no proper contact details for call or email for filing grievances?
Why No one answers the call or proper answers are not received from helpline?
The responsibility for coordination of enrollment 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 enrollment the members can contact the brokers
helpline numbers.
For any assistance at the time of claim, the members can contact the Insurance Company
helpline. The details of contact numbers and emails for policy are available on JIO's website.
8. Whether the policy is a temporary affair or will continue for several years to come?
The JIO group policy is NOT a temporary affair and will continue in future like all other
insurance policies.
Also, the new “6 Saal Khush-haal Pariwar Policy”, has been negotiated with the Insurance Co to
Continue for at least 6 years on the same premium amount and terms.
However, as discussed earlier, the terms of the policies and the premiums are subject to change
at the time of renewal after the 6 year period, 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 a bout
discontinuing the scheme.
3. 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 / Shravikas 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 JIO call
center. Alternatively, the members can also take help from any insurance agent because the
process of claim is same as retail insurance policies.
First member can get all information & handholding from JIO call center.
Kindly read Terms & Condition properly, if required then only call to call centre.
Secondly, he can get in touch with TPA helpline no. TPA office address are also available
on JIO website.
Thirdly, they can also get in touch with city where Edelweiss Broking office is available
which is also reflecting at JIO website.
4. How do I enroll ?
1. Please go on www.jiojac.com/6Saal
2. Select “To apply ” Scheme
3. Read revise Terms & Conditions carefully
4. Enter JIOJAC ID
5. Fill your enrolment details
6. Make payment ONLINE
5. JIO Shravak Arogyam – 6 Saal Khush-haal Pariwar New Mediclaim Policy is issued by
which the Insurance Company ?
Universal Sompo General Insurance Company issued the policy.
7. JIO Shravak Arogyam – 6 Saal Khush-haal Pariwar, New Mediclaim Policy is serviced by
which TPA ?
This policy is serviced by Health India Insurance TPA Services Pvt. Ltd. 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.
9. What are the options for making payment I am not aware of online procedure?
You need to Enroll Online only, however payment can be done via Online through Easybuzz
after completing Online Enrolment Procedure.
10. If I don’t have JIO JAC Id, can I opt for Mediclaim Policy under this Phase ?
No, You can’t opt for MEDICLAIM Policy without JIOJAC ID. Please register online for JIOJAC ID.
11. Why so much importance is given to online process which may be difficult for a common
man ?
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:
13. Why does the policy coverage starts very late after payment of insurance premium to
JIO?
Step 1 -Negotiation : JIO negotiate with Insurance Company for the Best TERMS and
Lowest PREMIUM based on a commitment of certain Minimum NUMBERS of
enrollment.
Step 2 – Announcement : To provide necessary information for availing maximum
benefit of the members JIO sends message to Shravaks / Shravika residing all over
India.
Step 3 – Enrollment : 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.
Step 4 – Verification : 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.
Step 5 - Data Transfer : JIO pays the insurance premium to the Insurance Company
through a single payment for all the members together for commencing policy.
Step 6 -Policy Issuance : 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.
Step 7 – Card Delivery : 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.
15. What are the options for making payment of premium amount?
The members can choose to make payment of premium amount from following options such as
Online payment through credit / debit card or net banking
16. 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.
The important point – For Renewal is that the same insurance company or some other should
get ready to renew, But due to high claim ratio insurance companies refused to renew, so many
a times the delay occur.
5. Can I and my brother / sister cover our parents under our individual family floater
schemes?
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
6. 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. (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)
8. Can a member above age of 65years years take individual policy of Rs.2 lac?
No. Individuals above the Age of 65years would compulsory need to buy a 5 lacs /10 lacs cover
10. What if I am or my family member is already suffering from a disease? Can I yet get
myself or my family members covered?
Yes. You can take the policy but Pre‐Existing Diseases are covered from second year of policy .
In second year policy offer 75% coverage to PED disease and from third year to Sixth year -
PED gets covered 100%.
On hospitalisation doctor gets all medical test done. If the report show any existence of PED
disease than you claim can be related on grounds of Non-disclosure of facts.
However, if it to be noted that minor incidence of Vomiting , giddiness, weakness does -not all
time indicators of major disease . Sometimes they occur due to circumstances prevalent at that
point of time. Hence while giving your history to doctor at the time of hospitalisation, it is
requested that only patient or his near dependent member should be allowed to give the
information. Because of you tell something extra which is not required than your claim may get
rejected.
11. If I am having high sugar or high BP, but I am not taking any medicine. Is this considered
as Pre-existing disease
YES . As per the condition mentioned above , You were aware of the signs or were diagnosed.
Many times, you adopt to home remedy for such treatment . However you are having PED
disease.
Yes, it is necessary to declare all existing and past health issue while doing online
enrollment. At time of claim if we found that you have non-disclose certain illness your claim
may get rejected on basis of non-disclosure of material fact.
13. 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.
In second year policy offer 75% coverage to PED disease and from third year PED gets covered
100%.
First two year Special disease has waiting period of one year only.
Maternity covered after one year . From 1st renewal onwards Maternity will be covered up to a
maximum of Rs.25,000/- for Normal delivery and Rs.35,000/- for Caesarean section delivery
including its complications , Limited to first two delivery only
New born baby expenses related to Hospitalization shall be covered from Day One of the birth
up to 90 days with a limit of Rs 35000/-only.
New born baby of the insured person shall be covered from 91st day from date of birth under
family floater Sum Insured, subject to intimation within 30 days from DOB to Insurer.
From Day 1 under the policy all hospitalization expenses for accident, disease other than PED
for all 8 members on floater basis are covered under the policy.
Annual Premium as per Highest Member’s age in the family per Year ##
P
Final
Policy Max. Max. Sum
l Premiu Premiu
Family Details Insure GST
a Type Person Age d
m m
with GST
n
10
A +2 22034 3966 26000
90 +4 lacs
Self + Spouse Parents /
years children
B In Laws 5 lacs 17034 3066 20100
8 members
10
C +2 18517 3333 21850
Family 60 +4 lacs
Self + Spouse Parents /
Floater years children
D In Laws 5 lacs 13051 2349 15400
10
E 13517 2433 15950
45 +2 lacs
4 Members Self + Spouse
years children
F 5 lacs 9873 1777 11650
65
G 6525 1175 7700
years
Individua
l
1 member Self 2 lacs
45
H 3153 567 3720
years
Health India Insurance TPA Services Pvt. Ltd. Contact no. / Email ID
1. 1800220102 / frd@healthindiatpa.com
2. 022-67133791 / jio.insurance@edelweissfin.com
Maternity covered after one year. From 1st renewal onwards Maternity will be covered up to a
maximum of Rs.25,000/- for Normal delivery and Rs.35,000/- for Caesarean section delivery
including its complications, Limited to first two delivery only
However we will review the policy from time to time and shall take corrective action ( if
required) to keep portfolio viable. The portfolio includes motor, Travel, Mediclaim and GPA
policy.
25. Will location of dependent family matter in availing services under TPA?
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.
27. Can I claim medical expenses incurred before and after a surgery?
Yes, 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 fo r which you
were hospitalized. Such expenses are termed as pre and post hospitalization, except for
Maternity Claims.
29. 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.
32. What are the age limit restrictions under both the policies?
1. For Individual Health Insurance Policy of Rs.2 Lacs, only Proposer up to 65 years can
opt.
2. In case of Family Floater of Rs.5 Lacs & 10 Lacs, below age limit will apply
1. For Dependent Children maximum age allowed is 25 years. After completion of
25 years, Child will not be covered in next year
2. For Parents maximum entry age is 90 years. Once enrolled you can continue till
LIFETIME.
33. Can one prepare a Jain Certificate?
The Jain certification has to be from Gyati / Samaj / Sang only.
34. If I have existing policy with other Insurance company, Should I close that policy to take
policy with JIO
NO. JIO will never advise to close your existing policy. You can take JIO new policy along with
your old policy. But You will get claim in only one policy. You can claim in other policy only if
Sum Insured is exhausted / or deductibles of one policy can be claim in other policy as per
terms & condition of Insurance Company.
Sl
Body System Illness Treatment/ Surgery
No.
Cataract Cataract Surgery
1 Eye Glaucoma Glaucoma Surgery
Other Eye Surgeries Other Eye Surgeries
Serous Otitis Media
Sinusitis Sinus Surgery
Rhinitis Surgery for the nose
Tonsillitis Tonsillectomy
Ear Nose Throat Tympanitis Tympanoplasty
2
(ENT) Deviated Nasal Septum Surgery for Deviated Nasal Septum
Otitis Media Surgery or Treatment for Otitis Media
Adenoiditis Adenoidectomy
Mastoiditis Mastoidectomy
Cholesteatoma Resection of the Nasal Concha
All Cysts & Polyps of the female
Dilatation & Curettage
genito urinary system
3 Gynecology
Polycystic Ovarian Disease Myomectomy
Uterine Prolapse Uterine prolapsed Surgery
Hysterectomy unless necessitated by
Fibroids (Fibromyoma)
malignancy
Breast lumps
Prolapse of the uterus
Dysfunctional Uterine Bleeding
(DUB) Any treatment for Menorrhagia
Endometriosis
Menorrhagia
Pelvic Inflammatory Disease
Gout Joint replacement Surgery
Rheumatism, Rheumatoid Surgery for Prolapse of the
Arthritis intervertebral disc
Non infective arthritis
Orthopedic /
4 Osteoarthritis
Rheumatological
Osteoporosis
Prolapse of the intervertebral
disc
Spondylopathies
Documents that you need to submit for a hospitalization reimbursement claim are:
All Insured person claiming the benefit under this policy has to be certifie d
1
as JAIN , by Derasar or Jain Mandir or JIO.
All dependant claimant has to share the proof of their relationship with the
2
proposer
Person covered under the policy as single member, has to be certified by
3
the JIO director
All the claim intimations has to be intimated within 48 hrs of
4
hospitalization to Insurer , to avoid deductions & / or rejections
All the claim documents as per the check list has to be submitted to the
5 Insurer within 30 days from discharge of the hospitalization to avoid
deductions & / or rejections
6 Duly filled original Claim Form.
Original Discharge summary of the treating hospital clearly indicating the
7
Hospital Registration No.
8 Original Diagnostic reports.
9 Death certificate & Death Summary in original in case of Death.
10 Itemized hospital bill in original.
11 Final Hospital Bill
12 Original Payment receipts
Original Copies of prescription for diagnostic test, treatment advise,
13
medical references etc.
Details of the implants including the sticker indicating the type as well as
14
invoice towards the cost of implant
Hospital registration number/the number of beds available with the
15
hospital verified by the authorised signatory of the Hospital.
16 KYC documents of patient
17 NEFT Mandate & Cancelled Cheque / Passbook (containing IFSC Number)
Any other documents as and when requested by the claim settling
18
authority.
All single member covered under the policy ,claiming the benefits has to
19
submit self affidavit or certification from the JIO Director
4. Will my claims be reimbursed even if I do not get myself treated at a network hospital?
Yes, you can avail Reimbursement facility.
5. Is there a minimum time limit for stay within the hospital under the health insurance
plan?
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.
6. What happens when the limit of insurance is exhausted under a Health Insurance
Policy?
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.
7. Who will receive the claim amount if the insured dies at the time of treatment?
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 fro m 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.
9. 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.
10. 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 and member can avail
reimbursement facility by giving mandatory within 24 hours intimation to Health India
Insurance TPA Services Pvt. Ltd. toll free no. 1800220102
11. How a hospital is defined with regards to the health insurance policies?
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.
OR
Any establishment that satisfies the following criteria can qualify as a hosp ital:
14. 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.
31. How you ensure that there won’t be any hassle in claim settlement or processing?
3) Inflated bill
* For detail terms and condition, rejections and sub-limits refer JIO website.
www.jiojac.com/6Saal
** Policy terms and rates may be continued for next 6 years and shall be reviewed annually and necessary
corrective action shall be taken (if required) to keep the portfolio viable
*** Pre- Existing Diseases against each insured / beneficiary, needs to be declare while filling up
forms, If not disclose can be used as non- disclosure at time of claim & in court of law.
## However, The portfolio will be reviewed by Insurance company on periodic basis & to balance the
claim ratio the Insurance company will offer Motor, Travel, Group Personal Accident, Home Insurance
etc. policies to JIO members along with this policy.