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.)

JIO – Shravak Arogyam

Group Health Insurance Policy
6 Saal Khush-haal Pariwar
(6 Year Same Premium & Same Terms)

Policy features:

1. Entry AGE is up to 90 Years and Renewal till LIFETIME

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.

3. NO Health Check-Up Required prior to policy.

4. Policy Terms and Premium shall remain Same for 6 years **

5. Hospital ROOM RENT & ICU CHARGES limitation (Per Day):

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 :

Room, Boarding Expenses in Rs.

Sum Insured
(including Nursing Expenses and all associated charges)
 Normal Room ICU
2,00,000 2000 4000
5,00,000 5000 10000
10,00,000 7500 13000
In case, the insured person is admitted in a room with rent HIGHER than the
eligible room rent limit, the total hospitalization claim shall be deducted in
proportion of eligible room rent limit.
e.g. If you are admitted in 4000 Room and you are eligible for 2000 Room
rent, then your all claim will get deducted by 50%.

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. ***

 Pre-Existing Disease Definition :

Any condition, ailment or injury or related condition(s) for which you had signs or
symptoms, and / or were diagnosed, and / or received medical advice / treatment
within 48 months to prior to the first policy issued by the insurer.
Those new member joining for first time in this year will have one year waiting period and 1st year eclusion
list is applicable.
If a member adds his/her dependent in his family tghan for this newly added dependant Sum Insured will be
treated as fresh Sum Insured. He/she will not get continuity benefit. For Ex.

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

7. 1st year exclusion

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
3 Gynecology genito urinary system
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

Stone in Gall Bladder and Bile Cholestectomy / Surgery for Gall

duct Bladder
Cholecystitis
Pancreatitis
Fissure, Fistula in ano,
hemorrhoids (piles), Pilonidal
Sinus, Ano-rectal & Perianal
Gastroenterology Abscess
5 (Alimentary Canal Rectal Prolapse
Surgery for Ulcers (Gastric /
and related Organs) Gastric or Duodenal Erosions or Duodenal)
Ulcers + Gastritis & Duodenitis
Gastro Esophageal Reflux Disease
(GERD)
Cirrhosis
Acute & Chronic Appendicitis,
Appendicular lump, Appendicular
abscess
Stones in Urinary system (Stone
in the Kidney, Ureter, Urinary
Bladder)
Prostate Surgery
Benign Hypertrophy /
Urogenital (Urinary
Enlargement of Prostate (BHP /
6 and Reproductive
BEP)
system
Surgery for Hydrocele, Rectocele and
Hernia, Hydrocele,
Hernia
Surgery for Varicocoele /
Varicocoele / Spermatocoele
Spermatocoele
Skin tumour (unless malignant) Removal of such tumour unless
7 Skin
All skin diseases malignant
 Any swelling, tumour, cyst,
Surgery for cyst, tumour, nodule, polyp
nodule, ulcer, polyp anywhere in
unless malignant
the body (unless malignant)
8 General Surgery
Varicose veins, Varicose ulcers
Surgery for Varicose veins and
Congenital Internal Diseases or Varicose ulcers
Anomalies
CABG
Angioplasty
9 Cardiac Surgeries Thoraco Vascular / Cardiac Surgeries
Other Heart Surgeries / Thoraco
Vascular Surgeries
Chemotherapy/ Cancer Surgeries Cancer treatment
10 Other Treatments Radiotherapy Cancer treatment
Dialysis kidney / Liver Failure

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

10. Domiciliary Hospitalisation is NOT COVERED.

11. Emergency Ambulance Charges: up to Rs.2,500 or actuals whichever is less.

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.

15. CASHLESS and REIMBURSEMENT both facility available in policy.

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.

20. CLAIM INTIMATION in case of CASHLESS claims or REIMBURSEMENT Claim, immediate

intimation shall be given to our Call Centre within 48 hours of Hospitalisation.

 Health India Insurance TPA Services Pvt. Ltd. Contact no. / Email ID:

1800220102 / frd@healthindiatpa.com

 Edelweiss Insurance Broker Pvt. Ltd. Contact no. / Email ID:

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

A +2 10 lacs 22,034 3,966 26,000

90 + +4
Parents /
years Self Spouse children
B In Laws 5 lacs 17,034 3,066 20,100
8 members
C +2 10 lacs 18,517 3,333 21,850
Family 60 + +4
Floater
Parents /
years Self Spouse children
D In Laws 5 lacs 13,051 2,349 15,400

E 10 lacs 13,517 2,433 15,950

45 + +2
4 Members
years Self Spouse children
F 5 lacs 9,873 1,777 11,650

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.

 PARTNERS for JIO MEDICLAIM POLICY

 Insurance Company: UNIVERSAL SOMPO GENERAL INSURANCE Co. Ltd. (CIN-
U66010MH2007PLC166770 UIN- UNIHLGP08001V020708)
 Insurance Broker: EDELWEISS INSURANCE BROKERS LIMITED (CIN:
U72200MH2000PLC124096)
 TPA Name :- Health India Insurance TPA Services Pvt. Ltd.

22. GENERAL EXCLUSIONS ( Not Payable ) IN any type of MEDICLAIM POLICY by

Universal Sompo General Insurance Co. Ltd.

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.

22.2. SUICIDE attempt, CRIME etc. : An Insured Person committing or attempting to

commit a breach of law with criminal intent, intentional self-Injury or attempted
suicide while sane or insane.
22.3. Risky Sports, Military etc. :Wilful or deliberate exposure to danger, intentional
self-Injury, participation or involvement in naval, military or air force operation, circus
personnel, racing in wheels or horseback, diving, aviation, scuba diving, parachuting,
hang-gliding, rock or mountain climbing, bungee jumping, paragliding, parasailing,
ballooning, skydiving, river rafting, polo, snow and ice sports in a professional or semi-
professional nature.

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

22.5.Weight management programs or treatment in relation to the same including

vitamins and tonics, treatment of obesity (including morbid obesity).

22.6. Correction of eyesight : Treatment for correction of eyesight due to refractive

error including routine examination.

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.

22.9. Circumcision (unless necessitated by Illness or Injury and forming part of

treatment); aesthetic or change-of-life treatments of any description such as sex
transformation operations.

22.10. Non allopathic treatment

22.11. Hospitalisation not required : Conditions for which treatment could have been
done on an outpatient basis without any Hospitalization.

22.12. Experimental treatment: Investigational treatments, Unproven /

Experimental treatment, or drugs yet under trial, devices and pharmacological
regimens.

22.13. Diagnostic Only : Diagnostic tests/procedures/treatment/consumables not

related to Illness for which Hospitalization has been done.

22.14. REST CURE : Convalescence, cure, rest cure, sanatorium treatment,

rehabilitation measures, private duty nursing, respite care, long-term nursing care or
custodial care, treatment taken in a clinic, rest home, convalescent home for the addicted,
detoxification centre, home for the aged, mentally disturbed remodelling clinic or any
treatment taken in an establishment which is not a Hospital.

22.15. PREVENTIVE CARE, vaccination including inoculation and immunizations

(except in case of post-bite treatment); any physical, psychiatric or psychological
examinations or testing.

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.

22.17. Hearing aids, contact lenses or spectacles including optometric therapy,

multifocal lens.

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.

22.20. External durable medical equipment: Any expenses incurred on prosthesis,

corrective devices external durable medical equipment of any kind, like wheelchairs
crutches, instruments used in treatment of sleep apnea syndrome or continuous
ambulatory peritoneal dialysis (C.A.P.D.), devices used for ambulatory monitoring of
blood pressure, blood sugar, glucometers, nebulizers and oxygen concentrator for
bronchial asthma/ COPD conditions, cost of cochlear implant(s) unless necessitated by an
Accident or required intra-operatively. Cost of artificial limbs, crutches or any other
external appliance and/or device used for diagnosis or treatment (except when used
intra-operatively). Sleep-apnea and other sleep disorders.

22.21. Psychiatric Treatment : or psychological disorders, mental disorders (including

mental health treatments), Parkinson and Alzheimer’s disease, general debility or
exhaustion (“rundown condition”).

22.22. External Congenital Anomalies or diseases or defects.

22.23. Stem cell therapy or Surgery, or growth hormone therapy.

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.

22.26. Complications arising out of pregnancy (including voluntary termination),

miscarriage (except as a result of an Accident or Illness), maternity or birth (including
caesarean section) except in the case of ectopic pregnancy for in-patient only. This
exclusion is applicable for 1 yr. only. After 1st renewal Maternity is covered as per
limit.

22.27. Infertility: Treatment for sterility, infertility, sub-fertility or other related

conditions and complications arising out of the same, assisted conception, surrogate or
vicarious pregnancy, birth control, and similar procedures; contraceptive supplies or
services including complications arising due to supplying services.

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.

22.34. Treatment for developmental problems, learning difficulties eg. Dyslexia,

behavioural problems including attention deficit hyperactivity disorder (ADHD).

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.

22.39. Treatments rendered by a Medical Practitioner who is a member of the Insured

Person’s family or stays with him, except if pre- approved by Us .

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

22.43. Treatment taken outside India

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.

22.45. Robotic surgery (whether invasive or non-invasive)

22.46. All forms of Bariatric surgery.

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.

22.49. Blacklisted Hospital, Doctor : Treatment in any Hospital or by any Medical

Practitioner or any other provider of services that We have blacklisted as listed on Our
website.

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.)

JIO – Shravak Arogyam

Group Health Insurance Policy
6 Saal Khush-haal Pariwar
(6 Year Same Premium & Same Terms)

PARTNERS for JIO MEDICLAIM POLICY

Insurance Company: UNIVERSAL SOMPO GENERAL INSURANCE Co. Ltd. (CIN-
U66010MH2007PLC166770 UIN- UNIHLGP08001V020708)
Insurance Broker: EDELWEISS INSURANCE BROKERS LIMITED (CIN:
U72200MH2000PLC124096)
TPA Name :- Health India Insurance TPA Services Pvt. Ltd.
 FAQ ABOUT MISUNDERSTANDINGS AND MYTHS OF JIO HEALTH PLAN
 FAQ ABOUT ENROLLMENT PROCESS
 FAQ ABOUT TERMS & CONDITIONS
 FAQ ABOUT CLAIM PROCESS

FAQ ABOUT MISUNDERSTANDINGS AND MYTHS OF JIO

HEALTH PLAN
1. Is JIO Insurance Company?
No. 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.

2. Is JIO is making profits from the policies?

No. 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.

3. Who manages the Insurance Policy?

The Policy is serviced by the following three entities:
Insurance Brokers (Like Edelweiss Insurance Brokers ltd , 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 , Universal Sompo, Aditya Birla 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.

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.

5. Why do Insurance Companies, brokers or TPA change at time of each renewal?

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.
However, under the “6 Saal Khush-haal Pariwar Policy”, the Insurance Co and Broker will not
change for at least 6 years.

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.

9. Whether premium will increase on renewal. ?

NO. JIO Shravak Arogyam – 6 Saal Khush-haal Pariwar Mediclaim Policy will have fixed
premium for six years. Premium will change in case of age group change.
*Policy Terms & Rate shall remain the same for six years. However we will review the policy from time to time and shall take
corrective action ( if required) to keep portfolio viable.

FAQ ABOUT ENROLLMENT PROCESS

1. What is the procedure to enroll into this Health Plan?
A member is required to visit the designated website for enrollment and login with JIO JAC ID.
The member has to fill-up the details of proposer, family members . 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 premium and complete the process.

2. Is the Enrolment process very complex?

NO. 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 be filled.

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.

Fourthly, they can contact JIO volunteers of their city.

The hierarchy should be as follows:-

1. JIO call center

2. TPA
3. Broker
4. JIO volunteer

4. How do I enroll ?

Please follow the below mentioned steps

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.

6. What is Edelweiss Broker in this Mediclaim Policy ?

Edelweiss Insurance Brokers Pvt. Ltd. is an insurance Broker, and not an Insurance
company.
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.

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.

8. Can I submit physical form?

NO

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.

1) Please follow the below mentioned steps to get JIO JAC ID

2) Please go on www.jiojac.com
3) Select “SIGN IN / REGISTER”
4) Select “ FOR SIGN UP CLICK HERE “
5) Fill your details
6) Make payment ONLINE
7) You will get E card after registration. No physical copy is send by JIO.

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:

 - 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.

12. Why JIO JAC number is compulsory?

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 / Shravikas and take full advantage of the
JIO Global network.

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.

14. Whether offline forms are available ?

No. Offline forms are not available. You have to do enrollment via online method only.

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.

17. Why was the commencement of Policy delayed in 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.

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.

1) - Various levels of negotiations with the Insurance Companies through insurance

brokers.
2) - Drafting of MOU for terms with the insurance company
3) - Intimation of the policy terms to the members
4) - Collection of premium by JIO from members
5) - Sending detailed list of members with amounts of coverage by JIO to Insurance
Company
6) - Issue of payment for Premium by JIO to Insurance Company
7) - Commencement of Group Insurance Policy.

18. How is the premium calculated for group policy?

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.

FAQ ABOUT TERMS & CONDITIONS

1. Can I opt individual policy in JIO Mediclaim ?
Yes. This is an Insurance scheme, where an Eligible Individual can opt for an Insurance Plan for
Rs.2 Lacs only against Mediclaim for Self only. But he/she should be single eligible member in
family with self affidavit or certification from JIO Director. Individuals above the age of 65years
 can’t opt for Individual Policy. Single eligible person can also take family floater Policy of 5 lac
/10 lac cover.

2. Can I opt Family Floater policy in JIO Mediclaim ?

-Yes.
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 + 2 /or 4 Dependent Children up to 25 years of Age and
Parents or parents in-laws up to age of 90 years as per available option in the plan.

3. I am a Jain but my wife is not a Jain? Can I insure my wife?

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.

4. If I have only 3 members in my family can I buy a Family Floater Policy?

Family Floater Policy is available for family size ranging between 2 to 8 members i.e. Proposer
+ Spouse + 2 / 4 Dependent Children up to 25 years of Age + Parents/or Parents or Laws.

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)

7. Can I take my married daughter in policy?

No. As she is now not part of your family.

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

9. Is this Applicable on Pan India basis?

Yes this policy is for Pan India Jain population only.

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%.

1. Pre-Existing Disease Definition :

1. Any condition, ailment or injury or related condition(s) for which you had signs
or
2. symptoms, and / or were diagnosed, and / or received medical advice /
treatment
3. within 48 months to prior to the first policy issued by the insurer.
2. Pre-existing disease means :
1. If you have any sign or symptom(within 48months) prior to policy
 inception even-if you do-not have taken any medical advise or done any
investigation
2. If you are already been diagnosed with any disease(within 48months
prior to policy) through any medical reports.
3. If you are already been taken any medical advice or treatment (within
48months prior to policy) related to condition which occur prior to
policy inception .

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.

12. Is it necessary to declare Pre Existing 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.

14. What are the major features of this policy?

PED has waiting period of one year.

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.

 No Medical check-up upto 90years.

 6 year same terms and same premium**
  Hence guaranteed renewal
 IT tax benefit under section 80 D.

15. What is the name of Insurance Company & Broker ?

Universal Sompo General Insurance Co. Ltd. And Edelweiss Insurance Brokers Limited.

16. What is the premium?

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

 IT tax benefit available on above premium.

 Additional Rs.250 will be charged from payment gateway vendor to transfer money to JIO
account.

17. Does this scheme have cashless as well as Reimbursement facility?

Yes, cashless facility is available in Health India Network of hospitals and Member can avail
 Cashless as well as reimbursement facility. In all case of cashless claims and reimbursement
claims, immediate intimation shall be given to Call Centre within 24 hours of Hospitalisation.

Health India Insurance TPA Services Pvt. Ltd. Contact no. / Email ID

1. 1800220102 / frd@healthindiatpa.com

Edelweiss Insurance Broker Pvt. Ltd. Contact no. / Email ID

2. 022-67133791 / jio.insurance@edelweissfin.com

18. When will I be eligible for my maternity claim?

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

19. What shall be the next year premium?

The next year premium will be Same.

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.

20. Is there any tax rebate?

Yes, under section 80 D you can claim TAX Rebate

21. Can I have the policy number?

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

22. Do we get no claim bonus if we do not claim in the existing year?

No, as this is a Group scheme, you will not get NO Claim Bonus

23. If my wife is the proposer can she cover her parents?

Yes, only if she is a Jain by birth.

24. How different is TPA from Insurance Company?

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.

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.

26. Will the change in names in between policy period matters?

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.

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.

28. Can I claim my dentist's bills? Is it covered in any policy ?

No. You can do so, except in cases arising from Road Accidents requiring hospitalization.

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.

30. What are Sub-limits in this policy?

 Internal congenital disease are covered for only Rs.50,000.

 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.
 Room, Boarding Expenses including Nursing Expenses and all associated charges as
provided by the Hospital/Nursing Home is subject to a limit of 1% of the Basic Sum Insured
per day and for Intensive Care Unit 2% of the Basic Sum Insured per day for SI of Rs.2.00
Lakh and Rs.5.00 Lakh .
 Room, Boarding Expenses including Nursing Expenses and all associated charge as
provided by the Hospital/Nursing Home is subject to a limit of Rs. 7,500/- per day and for
Intensive Care Unit Rs.13,000/- per day for SI of Rs.10.00 Lakh
 In case, the insured person is admitted in a room with rent higher than the eligible room
rent limit, the total hospitalization claim shall be reduced in proportion of eligible room
rent to the actual room rent paid.
 Ambulance charges : Up to Rs.2,500 or actuals whichever is less.
 Maternity benefits, applicable ONLY AFTER 1 YEAR subject to a limit of Rs.25,000/- for
normal and Rs.35,000/- for caesarean delivery.

31. What is my room rent eligibility under both the schemes?

1. Room, Boarding Expenses including Nursing Expenses and all associated charges
as provided by the Hospital/Nursing Home is subject to a limit of 1% of the Basic
Sum Insured per day and for Intensive Care Unit 2% of the Basic Sum Insured per
day for SI of Rs.2.00 Lakh and Rs.5.00 Lakh .
2. Room, Boarding Expenses including Nursing Expenses and all associated charge
as provided by the Hospital/Nursing Home is subject to a limit of Rs. 7,500/- per
day and for Intensive Care Unit Rs.13,000/- per day for SI of Rs.10.00 Lakh
3. In case, the insured person is admitted in a room with rent higher than the
eligible room rent limit, the total hospitalization claim shall be reduced in
proportion of eligible room rent to the actual room rent paid.

Room, Boarding Expenses in Rs.

Sum Insured (including Nursing Expenses and all associated charges)
 Normal Room ICU
2,00,000 2000 4000
5,00,000 5000 10000
10,00,000 7500 13000
In case, the insured person is admitted in a room with rent higher than the
eligible room rent limit, the total hospitalization claim shall be reduced in
proportion of eligible room rent to the actual room rent paid.
e.g. If you are admitted in 4000 Room and you are eligible for 2000
Room rent, then your all claim will get deducted by 50%.

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.

35. What are the first year exclusions?

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

Stone in Gall Bladder and Bile Cholestectomy / Surgery for Gall

duct Bladder
Cholecystitis
Pancreatitis
Fissure, Fistula in ano,
hemorrhoids (piles), Pilonidal
Sinus, Ano-rectal & Perianal
Gastroenterology Abscess
5 (Alimentary Canal Rectal Prolapse
Surgery for Ulcers (Gastric /
and related Organs) Gastric or Duodenal Erosions or Duodenal)
Ulcers + Gastritis & Duodenitis
Gastro Esophageal Reflux Disease
(GERD)
Cirrhosis
Acute & Chronic Appendicitis,
Appendicular lump, Appendicular
abscess
Stones in Urinary system (Stone
in the Kidney, Ureter, Urinary
Bladder)
Prostate Surgery
Benign Hypertrophy /
Urogenital (Urinary
Enlargement of Prostate (BHP /
6 and Reproductive
BEP)
system
Surgery for Hydrocele, Rectocele and
Hernia, Hydrocele,
Hernia
Surgery for Varicocoele /
Varicocoele / Spermatocoele
Spermatocoele
Skin tumour (unless malignant) Removal of such tumour unless
7 Skin
All skin diseases malignant
 Any swelling, tumour, cyst,
Surgery for cyst, tumour, nodule, polyp
nodule, ulcer, polyp anywhere in
unless malignant
the body (unless malignant)
8 General Surgery
Varicose veins, Varicose ulcers
Surgery for Varicose veins and
Congenital Internal Diseases or Varicose ulcers
Anomalies
CABG
Angioplasty
9 Cardiac Surgeries Thoraco Vascular / Cardiac Surgeries
Other Heart Surgeries / Thoraco
Vascular Surgeries
Chemotherapy/ Cancer Surgeries Cancer treatment
10 Other Treatments Radiotherapy Cancer treatment
Dialysis kidney / Liver Failure

FAQ ABOUT CLAIM PROCESS & SETTLEMENT

1. What are the documents required to be submitted to TPA to claim under
reimbursement procedure ?

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

2. How to send reimbursement claims?

Under this Policy, You can avail Reimbursement facility and claims can be submitted to Health
India Insurance TPA Services Pvt. Ltd. office through registered post / courier. The address is
as mentioned on website – www.healthcare-india.com. Head Office address is as follows.

Health India Insurance TPA Services Pvt. Ltd.

Neelkanth Corporate Park,
Office No. 406 to 412, 4th Floor, Kirol Road / Village,
Vidya Vihar Society, Vidya Vihar (West),
Mumbai – 400086

3. WHAT ARE “NON-MEDICAL EXPENSES?

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.

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.

8. What is the procedure for availing cashless facility?

In case of planned hospitalization, TPA / insurers require Pre-authorization form 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.

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:

 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: F or Class 'C' towns, the
number of beds relaxed to ten.

12. What is meant by hospitalization?

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.

13. Is maternity benefit available under an individual Health Insurance Plan?

No. Maternity benefit is not payable under Individual Health Insurance Plan. Even in Family
floater plan it is covered from second year of policy.

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.

15. Why the Claims process is complex?

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.
16. Whether insurance companies wrongly make huge deductions 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.

17. Is weight management, Cosmetic treatment covered?

NO. It is not covered in any Mediclaim policy.

18. Is OPD or Oral treatment covered

NO. It is not covered in any Mediclaim policy.
19. Whether Parkinson , Alzheimer’s disease, Psychiatric disorder, general debility is
covered ?
NO
20. Is dental treatment is covered
NO. Dental treatment is not covered in any Mediclaim. It gets covered only in case of accident
and requiring hospitalization.
21. Whether AIDS / HIV related treatments covered.
NO
22. Whether Infertility / Sterility treatment covered.
NO
23. Is external Congenital disease, Steam Cell treatment is covered or not. Whether oral
chemo therapy, Robotic surgery, laser surgery, RF probe, Bioabsorbable device etc.
covered or not.
NO
24. Artificial life management treatment covered or not
NO
25. Treatment by doctor within family or treatment given by medical practitioner out side
scope of his license or black listed hospital is covered or not.
NO
26. Whether ARMD, RFQMR, ECP, EECP, HBOT etc. covered or not.
NO
27. External durable medical equipment, corrective device, prosthesis, hearing aid etc. is
covered or not.
NO
28. Whether substance intoxication, alcohol, tobacco, addiction related treatment covered
or not.
NO
29. Treatment taken out side India, or criminal injury, attempted suicide etc. covered or not.
NO
30. Knee Replacement, Cataract, Delivery will be covered or not.
YES, it is covered after one year.

31. How you ensure that there won’t be any hassle in claim settlement or processing?

We will provide 100% support in claim settlement via below channel

1. TPA : Details of all office and contact no mention over Website.
2. Broker : Details of all office and contact no mention over Website.
3. Insurance Company : Details of all office and contact no mention over Website.
 4. Claim settlement office : Detail and contact number we would share with you.
5. JIO : Details of all office and contact no mention over Website.

32. How many procedure are covered in Day Care treatment.

Day care procedure are covered as per Universal Sompo General Insurance Co. list. (Daycare
list 141)

33. Whether Health declaration is compulsory?

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.

34. What are common reason of deduction / Repudiation of claim.

 Policy holder reasons: 1) Mistake in name / age / sex in Policy
Please check above detail when receiving documents for the first time &
correct it if required
2) Give claim Intimation within 48 hrs. in Cashless as well as
Reimbursement.
3) Submit claim documents within 30 days.
4) Submit query documents as early as possible, otherwise file get close
due to
Non-submission of documents.
 Treating Doctor related : 1) OPD converted in IPD

2) Hospitalisation Not Justified.

3) Admission only for Investigation

 Hospital related : 1) Not registered Hospital / Not fulfilling Hospital Definition.

2) Non Payable items

3) Inflated bill

4) Prolonged Stay etc.

35. Whom to approach in case of Grievances / Legal help.

JIO will help in providing legal aid to its member in filing grievance before any forum.
Edelweiss Insurance Brokers Ltd will provide all legal guidance, procedural help,
documentation for filling such legal complaints.

* 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.