Salient features. Shravak Arogyam Phase-I (RENEWAL) Mediclaim Scheme

Transcription

1 Salient features Of Shravak Arogyam Phase-I (RENEWAL) Mediclaim Scheme 1 We are happy to announce that the existing ELDERLY MEMBERS covered under the Policy who have already completed 80 years of age, are welcomed to continue the cover in the Renewal also for life time. 2 FAMILY DEFINITION: 1+5 ( Parents or Parents In-Laws can be covered) 3 PRE-EXISTING DISEASES are covered from Day One 4 NO MEDICAL CHECK-UP required PHASE 1 Coverage RENEWAL coverage PREVIOUS YEAR coverage Waiting period for Maternity Benefit Covered from Day 1 for existing members First 9 months not covered Waiting period for Knee Replacement Covered from Day 1 for existing members with limit of Rs.1.25 Lacs per knee First 12 months not covered Emergency Ambulance charges Rs.2,500 Per incidence Rs.2,000 Per incidence Domiciliary Hospitalisation Covered upto 20% of Sum Insured Not Covered Hospitalisation AYUSH Treatment Rs.10,000 Per claim and (AYURVEDIC / HOMEOPATHIC / UNANI) Max. upto Rs.20,000 per family per year Rs.10,000 Per claim Hospitalization arising out of PSYCHIATRIC AILMENTS Covered upto Rs.30,000 Not Covered Liability for Nasal Sinus Surgeries Covered upto Rs.35,000 Not Covered Cyberknife treatment Covered with Co-pay of 50% Not Covered Stem Cell Transplantation Covered with Co-pay of 50% Not Covered Cochlear Implant treatment Covered upto 50% of the Sum Insured Not Covered Parents Covered Covered Parents or Parents in Law Covered for Parents 5 NEW BORN BABY covered from Day 1 subject to intimation within 20 days (Only Reimbursement cases) 6 MID-TERM ADDITIONS allowed only for natural additions subject to intimation received within 20 days of marriage or birth (for newly married SPOUSE & new born BABY) 7 As per INCOME TAX Act deductions under Sec 80D, Proposer will be eligible for exemption. (Exemption for Payment by Cash not applicable) 8 In case of OVERWHELMING response, as per terms & conditions, the primary member (Proposer) may get DISCOUNT ON PREMIUM & the difference in premium shall be refunded accordingly

2 ADDITIONAL CAPPINGS for Renewal on Phase-1 Coverage PHASE 1 Coverage RENEWAL coverage PREVIOUS YEAR coverage Co-payment of 50% on claims due to Cancer related 50% Co-payment on Preexisting CANCER treatment only in case of Pre-existing Disease before Previous year Policy start date Capping on Dialysis in case of Pre-existing Disease Rs.35,000 Per Family Per Year Cataract (Per eye): Rs.24,000 Cataract (Per eye): Rs.24,000 Bypass Surgery (CABG): Rs.250,000 Valve Replacement: Rs.200,000 Angioplasty (PTCA): Rs.175,000 Cholecystectomy (Gall bladder removal): Rs.40,000 Limit on claim amount (Capping) for Diseases / Ailments 10% Co-payment on REMAINING Pre-existing Diseases Deduction of Rs.5,000 Hysterectomy (Removal of Uterus): Rs.40,000 Appendisectomy (Removal of Appendix): Rs.40,000 Fistula / Hernia : Rs.30,000 Angiography: Rs.18,000 Anaemia: Rs.50,000 Knee Replacement (Per Knee): Rs.125,000 All the above mentioned amount inclusive of implant cost, stent, etc 10% co-payment applicable on pre-existing ailment excluding above ALL capped ailments (eg. Cancer, Dialysis, Bypass etc) Deduction of Rs.5,000 for each & every claim above Rs.50,000 excluding above ALL capped and Pre-existing ailments PREMIUM details for Phase-1 RENEWAL No Limit on all other ailments / Diseases No Co-payment No Deduction POLICY TYPE SUM INSURED PREMIUM SERVICE TAX AMOUNT for 12 14% PAYBLE Individual Rs.2 Lacs 2, ,305 Family Floater Rs.5 Lacs 14,899 2,086 16,985 Shravak Arogyam Phase-I (RENEWAL) Group Personal Accident Policy 1. GPA also offers cover to Proposer in which: Death + Permanent Total Disability +Terrorism is covered. 2. Sum Insured for Personal Accident policy is Rs.2 Lacs for Individual Policy s PROPOSER and Rs.5 Lacs for Family floater Policy PROPOSER.

3 Terms & Conditions Of Shravak Arogyam Phase-I (RENEWAL) Mediclaim Scheme 9 INDIVIDUAL / FAMILY FLOATER Mediclaim for JIO Members only 10 INDIVIDUAL POLICY with Sum Insured of Rs.2 Lacs available only for member BELOW 40 years 11 Existing members ABOVE 40 years covered under Individual Policy of Rs.2 Lacs should convert their cover from Rs.2 Lacs to Rs.5 Lacs and they have right to add other family members (Dependents) as per family definition FAMILY FLOATER MEDICLAIM Sum insured of Rs.5 Lacs only 13 FAMILY DEFINITION: Proposer + Spouse (Husband / Wife) + 2 Dependent children upto 25 years of age + 2 Parents OR In-Laws (Any 1 set of Parents to be covered. Combination not allowed) means Maximum 6 members allowed in one family (1+5) 14 If proposer has covered his/her family in family floater Policy and apart from the above mentioned family of 6 members, he / she have 3 rd or 4 th CHILD or any other REMAINING family member below 40 years; he/she can be enrolled as a proposer for another Individual Policy even if his/her age is LESS THAN 18 years 15 AGE LIMIT years (Entry Age of Proposer Between 18 to 80 Years) 16 We are happy to announce that the existing ELDERLY MEMBERS covered under the Policy who have already completed 80 years of age, are welcomed to continue the cover in the Renewal also 17 "ROOM RENT & ICU CHARGES limitation Per Day (Inclusive of Nursing charges) : If insured is admitted in a higher category, then insured will bear difference of all medical expenses as in final hospital bill in same proportion. All other charges to be settled as per room eligibility except pharmacy/medicine charges SUM INSURED RS. 200,000 & RS.500,000 (For both policies) LIMIT per day Rs.2,500 for Regular Room Rs.4,000 for ICU Hospitalisation 18 PRE-EXISTING DISEASES are covered from Day One 19 NO MEDICAL CHECK-UP required 20 DAY CARE PROCEDURES Covered as per Insurance company norms 21 All Internal congenital Diseases are covered 22 TERRORISM Covered from Day One Days Pre Hospitalisation & 60 Days Post Hospitalisation expenses covered 24 Maternity Benefit covered with limit of Rs.30,000 for NORMAL Delivery and Rs.35,000 for CAESARIAN Delivery 25 NEW BORN BABY covered from Day 1 subject to intimation within 20 days (Only Reimbursement cases) 26 Hospitalization expenses for ORGAN TRANSPLANT (excluding cost of organ) : The Insurance Company will pay expenses incurred on the donor and the insured recipient up to the sum insured of the insured recipient 27 DENTAL TREATMENT covered if due to accident only and requiring 24 hours Hospitalisation 28 MID-TERM ADDITIONS allowed only for natural additions subject to intimation received within 20 days of marriage or birth (for newly married SPOUSE & new born BABY)

4 29 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 30 CLAIM INTIMATION for all reimbursement claims have to be intimated within 7 days of ADMISSION, failure to intimate will lead to rejection of the claim 31 CLAIM SUBMISSION of documents for reimbursement claims have to be submitted within 45 days of date of DISCHARGE from the hospital 32 As per INCOME TAX Act deductions under Sec 80D, Proposer will be eligible for exemption. (Exemption for Payment by Cash not applicable) 33 In case of OVERWHELMING response, as per terms & conditions, the primary member (Proposer) may get DISCOUNT ON PREMIUM & the difference in premium shall be refunded accordingly ADDITIONAL Benefits over Phase-1 Coverage PHASE 1 Coverage RENEWAL coverage PREVIOUS YEAR coverage Waiting period for Maternity Benefit Covered from Day 1 for existing members First 9 months not covered Waiting period for Knee Replacement ADDITIONAL CAPPINGS for Renewal on Phase-1 Coverage Covered from Day 1 for existing members with limit of Rs.1.25 Lacs per knee First 12 months not covered Emergency Ambulance charges Rs.2,500 Per incidence Rs.2,000 Per incidence Domiciliary Hospitalisation Covered upto 20% of Sum Insured Not Covered Hospitalisation AYUSH Treatment Rs.10,000 Per claim and (AYURVEDIC / HOMEOPATHIC / UNANI) Max. upto Rs.20,000 per family per year Rs.10,000 Per claim Hospitalization arising out of PSYCHIATRIC AILMENTS Covered upto Rs.30,000 Not Covered Liability for Nasal Sinus Surgeries Covered upto Rs.35,000 Not Covered Cyberknife treatment Covered with Co-pay of 50% Not Covered Stem Cell Transplantation Covered with Co-pay of 50% Not Covered Cochlear Implant treatment Covered upto 50% of the Sum Insured Not Covered Parents Covered Covered Parents or Parents in Law Covered for Parents PHASE 1 Coverage RENEWAL coverage PREVIOUS YEAR coverage Co-payment of 50% on claims due to Cancer related 50% Co-payment on Preexisting CANCER treatment only in case of Pre-existing Disease before Previous year Policy start date Capping on Dialysis in case of Pre-existing Disease Rs.35,000 Per Family Per Year Cataract (Per eye): Rs.24,000 Cataract (Per eye): Rs.24,000 Bypass Surgery (CABG): Rs.250,000 Valve Replacement: Rs.200,000 Angioplasty (PTCA): Rs.175,000 Cholecystectomy (Gall bladder removal): Rs.40,000 Limit on claim amount (Capping) for Diseases / Ailments 10% Co-payment on REMAINING Pre-existing Diseases Deduction of Rs.5,000 Hysterectomy (Removal of Uterus): Rs.40,000 Appendisectomy (Removal of Appendix): Rs.40,000 Fistula / Hernia : Rs.30,000 Angiography: Rs.18,000 Anaemia: Rs.50,000 Knee Replacement (Per Knee): Rs.125,000 All the above mentioned amount inclusive of implant cost, stent, etc 10% co-payment applicable on pre-existing ailment excluding above ALL capped ailments (eg. Cancer, Dialysis, Bypass etc) Deduction of Rs.5,000 for each & every claim above Rs.50,000 excluding above ALL capped and Pre-existing ailments No Limit on all other ailments / Diseases No Co-payment No Deduction

5 PREMIUM details for Phase-1 RENEWAL POLICY TYPE SUM INSURED PREMIUM SERVICE TAX AMOUNT for 12 14% PAYBLE Individual Rs.2 Lacs 2, ,305 Family Floater Rs.5 Lacs 14,899 2,086 16,985 * PLEASE NOTE below mentioned points before making premium payment 1 Existing members ABOVE 40 YEARS covered under Individual Policy of Rs.2 Lacs SHOULD convert their cover from Rs.2 Lacs to Rs.5 Lacs and they have right to add their family members (Dependents) 2 However Existing members BELOW 40 YEARS covered under Individual Policy of Rs.2 Lacs CAN ALSO convert their cover from Rs.2 Lacs to Rs.5 Lacs and they have right to add their family members (Dependents) 3 Members above 40 years, who are converting policy from Rs.2 Lacs to Rs.5 Lacs, should pay premium within the specified time frame. And addition of data for family members can be enrolled through ONLINE link, which we will sent you within some days 4 Premium of separate Policies should be transferred through separate RTGS Transaction 5 As premium will be transferred first to JIO by members individually and then JIO have to pay premium to insurance company as one consolidated payment, there is a time gap for reconciliation and procedure. So we request you to pay the premium at the earliest to start coverage on time 6 Premium can be PAID only via RTGS / NEFT transfer, 7 In case of OVERWHELMING response, as per terms & conditions, the primary member (Proposer) may get DISCOUNT ON PREMIUM & the difference in premium shall be refunded accordingly Steps for Renewal Enrolment 1 SMS will be sent to the member mentioning the website link for detailed Policy terms and conditions applicable in Renewal 2 Premium can be PAID only via NEFT transfer. For receiving Banking and NEFT Details, member should give missed call on a number 3 After the Payment of Premium by NEFT, member should inform JIO by sending SMS in below mentioned format on number RENEWAL, JIO SA ID , UTR NO Once we receive above SMS of payment, we will proceed ahead. After receiving confirmation from Bank, you will receive SMS from JIO for Payment confirmation. 5 Your detail which were mentioned in previous policy will be enrolled in renewal Policy 6 To ensure continuity in coverage from 31 st Oct, 2015, your SMS with premium payment details should reach us before midnight of 28-Oct-2015

6 GENERAL EXCLUSIONS IN MEDICLAIM POLICY We strive to provide you maximum cover and benefits; however, we would like you to know some of the major exclusions under the policy. 1 External Congenital diseases not covered 2 Any dental treatment unless arising due to an accident 3 Naturopathy treatment not covered. 4 HIV, AIDS and related medical conditions not covered 5 External medical equipment used as post hospitalization care not covered 6 Cost of contact lens, spectacles, hearing aid, cochlear implants not covered 7 General debility, use of drugs or alcohol, intentional self-injury, sterility, venereal disease not covered. 8 Treatment for infertility etc. not covered 9 Hospitalization treatment for less than 24 hrs. Other than specified treatment not covered 10 Lasik Surgery, Septoplasty, Infertility & Related Ailments inclusive of Male sterility; Treatment on trial/experimental basis; Admin/Registration/Service/Miscellaneous Charges; Expenses on fitting of Prosthesis; Any device/instrument/machine contributing/replacing the function of an organ; Holter Monitoring are outside the scope of the Policy 11 Other exclusion as per the Standard Policy Group Personal Accident (GPA) policy is also attached with this policy, applicable for Proposer only ACCIDENTAL DEATH PERMANENT TOTAL DISABLEMENT TERRORISM COVERED WORLDWIDE COVER COVER APPLICABLE for 24/7 Sum Insured for Personal Accident policy is Rs.2 Lacs for Individual Policy s Proposer and Rs.5 Lacs for Family floater Policy Proposer GENERAL EXCLUSIONS IN PERSONAL ACCIDENT POLICY 1 Suicide/ Intentional self injury 2 Death due to Pregnancy/child birth etc. 3 Accident while under influence of alcohol/drugs 4 Sexually Transmitted Infections 5 Participation in a criminal act 6 Participation in a hazardous sport 7 War, civil war, similar situations etc 8 Other exclusion as per the Standard Policy

7 FAQs 1. About JIO JIO is a vibrant organization for total unity of Jains, to serve all living beings & bring all round progress. JIO intends to be the global organization of visionaries who believe in principles and philosophy of Jainism, to bring global harmony, peace & prosperity for total happiness of every living being and to strive for a world free of violence, poverty & disease. JIO is committed to build a corporate environment and social infrastructure for overall growth, development and well-being of family by improving health, wealth, knowledge and spirituality. Also, Provide fair & optimum opportunities for supporting social relationships amongst Jains of all professions. Initiate to create global awareness about Jain philosophy, culture, values and the noble principles which benefits humanity, environment and takes care of all living beings. 2. About Shravak Arogyam Phase-1 (Renewal) Individual Insurance Scheme The 1st phase started by individual policy of 2 lacs each, & various members of the Family had bought individual policies; they can now have the benefit of protecting their entire family under a single floater cover of 5 lacs/ 10 lacs. However If proposer has covered his/her family in family floater Policy and apart from family of 6 members who are already covered under family floater Policy, if he / she have any additional CHILD or any other REMAINING family member below 40 years; They can be enrolled as a proposer for another Individual Policy even if there age is LESS THAN 18 years. Proposer has Personal Accident cover of Rs.2 Lacs. 3. About Shravak Arogyam Family Floater Scheme This is an insurance scheme where a family can renew an insurance plan for Rs.5 Lac & 10 Lac against Mediclaim for Self + Spouse + 2 Dependent Children up to 25 years of Age and Parents or parents in-laws this policy includes personal accident cover for a sum of Rs.5 Lac and Rs. 10 Lac respectively for Proposer 4. If I don t have JIO JAC Id, can I renew? Yes, JAC card as of now is NOT compulsory for renewal, for renewal you have to mention JIO SA Id only which is mentioned in your PHASE I Policy TPA Card. 5. Why Premium Rates raised in Phase I (Renewal) than Phase-I? More than 2,12,000 lives were part of this Phase 1 and more than 20,000 lives were benefited by claiming under the policy. The policy operated at approximate claims of 105 crs against premium collected of 30 crs. The objective of this policy was to ensure all Jains get covered by medical insurance, which would not be available for individuals in the open market at any cost and when we come together as a community it helps us provide benefits to all our brothers & sisters who really need the required protection. This Phase-1 Shravak Arogyam MEDICLAIM RENEWAL is really special for you as we have introduced the following ADDITIONAL benefits 1. Members with 80 years of age and above would get LIFE TIME Continuity 2. Members would have also an option to cover PARENTS IN LAW 3. TAX BENEFIT under section 80 D will be available

8 4. Additional NEW COVERAGES like Psychiatric Treatment, Nasal Sinus, Cyber Knife Treatments, Stem Cell Transplantation, Cochlear Implant & Domiciliary Hospitalization are COVERED 5. You can also increase your Sum Insured UPTO 10 Lac Also in spite of the 300% + claim ratio KNEE REPLACEMENT & MATERNITY BENEFITS are COVERED from Day 1 so it affected the Premium Rate. As the Policy expires on 30th Oct, please don't miss out the opportunity to Renew, as such Insurance Benefits will not be available in the Open Market at any Price. 6. Can a member above age of 40years can take individual policy take Rs.2 lac individual policy? No. Individuals above the age of 40 would compulsory need to buy a 5 lac /10 lac cover which at no additional cost can be converted to a 5 lac/ 10 lac family floater to protect the entire family. 7. What are the differences between Shravak Arogyam Phase 1 Previous Year & Renewal? Difference between Shravak Arogyam Phase-1Expiry & Renewal as per below comparison Chart:- ADDITIONAL BENEFITS OVER PHASE I RENEWAL PHASE 1 Coverage RENEWAL coverage PREVIOUS YEAR coverage Waiting period for Maternity Benefit Covered from Day 1 for existing members First 9 months not covered Waiting period for Knee Replacement Covered from Day 1 for existing members First 12 months not with limit of Rs.1.25 Lacs per knee covered Emergency Ambulance charges Rs.2,500 Per incidence Rs.2,000 Per incidence Domiciliary Hospitalisation Covered upto 20% of Sum Insured Not Covered Hospitalisation AYUSH Treatment Rs.10,000 Per claim and Rs.10,000 Per claim (AYURVEDIC / HOMEOPATHIC / UNANI) Max. upto Rs.20,000 per family per year Hospitalization arising out of PSYCHIATRIC Covered upto Rs.30,000 Not Covered AILMENTS Liability for Nasal Sinus Surgeries Covered upto Rs.35,000 Not Covered Cyberknife treatment Covered with Co-pay of 50% Not Covered Stem Cell Transplantation Covered with Co-pay of 50% Not Covered Cochlear Implant treatment Covered upto 50% of the Sum Insured Not Covered Parents Covered Covered Parents or Parents in Law Covered for Parents CAPPINGS UNDER THE RENEWAL POLICY PHASE 1 Coverage RENEWAL coverage PREVIOUS YEAR coverage 50% Co-payment on Preexisting CANCER Capping on Dialysis in case of Pre-existing Disease Limit on claim amount (Capping) for Diseases / Ailments Co-payment of 50% on claims due to Cancer related treatment only in case of Pre-existing Disease before Previous year Policy start date Rs.35,000 Per Family Per Year Cataract (Per eye): Bypass Surgery (CABG): Valve Replacement: Angioplasty (PTCA): Cholecystectomy (Gall bladder removal): Hysterectomy (Removal of Uterus): Appendectomy (Removal of Appendix): Rs.24,000 Rs.250,000 Rs.200,000 Rs.175,000 Rs.40,000 Rs.40,000 Rs.40,000 Cataract (Per eye): Rs.24,000

9 10% Co-payment on REMAINING Pre-existing Diseases Deduction of Rs.5,000 Fistula / Hernia : Rs.30,000 Angiography: Rs.18,000 Anaemia: Rs.50,000 Knee Replacement (Per Knee): Rs.125,000 All the above mentioned amount inclusive of implant cost, stent, etc 10% co-payment applicable on pre-existing ailment excluding above ALL capped ailments (eg. Cancer, Dialysis, Bypass etc) Deduction of Rs.5,000 for each & every claim above Rs.50,000 excluding above ALL capped and Pre-existing ailments No Limit on all other ailments / Diseases No Co-payment No Deduction 7. Where can I renew my policy and can I pay online? Steps for Renewal Enrolment is as follows 1 SMS will be sent to the member mentioning the website link for detailed Policy terms and conditions applicable in Renewal 2 Premium can be PAID only via RTGS/NEFT transfer. For receiving Banking and RTGS/NEFT Details, member should give missed call on a After the Payment of Premium by NEFT, member should inform JIO by sending SMS in below mentioned format on number. Note: JIO SA Id is the ID mentioned in your Phase I Health Card. RENEWAL, JIO SA ID , UTR NO Once we receive above SMS of payment, we will proceed ahead. After receiving confirmation from Bank, you will receive SMS from JIO for Payment confirmation. 5 Your detail which were mentioned in previous policy will be enrolled in renewal Policy 6 To ensure continuity in coverage from 31 st Oct, 2015, your SMS with premium payment details should reach us before midnight of 28-Oct-2015 OR RTGS/NEFT Details are as below Name of Account: Jain International Organisation A/c Shravak Arogyam Bank: Axis Bank Ltd A/C No.: IFSC: UTIB Branch: Pedder Road,Mumbai MICR: A/C Type: Current 8. Is this Applicable on Pan India basis? Yes this policy is for Pan India Jain population only. 9. What if I am or my family member is already suffering from a disease? Can I yet get myself or my family members covered? Pre Existing Diseases are covered since day 1, except for new member the Total Knee Replacement is covered only after a year from the date of their enrolment in the policy.

10 10. 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. 12. Does this scheme have cashless facility? Yes cashless facility is available in Network of hospitals 13. When will I be eligible for my maternity claim? Covered from day one for existing members, for new member after completion of 9 months from the date of enrolment in JIO Shravak Arogyam scheme. 14. Are pre & post natal expenses under Maternity benefits covered? Covered for the Hospitalization for more than 24 hours within Maternity Limit but OPD Pre & Post Natal is not covered 15. 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. 16. 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 6 members i.e. Proposer + Spouse + 2 Dependent Children up to 25 years of Age + Parents/or Parents or Laws. 17. Can I upgrade my policy to higher value of phase-i in phase-i ( Renewal )? Yes. You can upgrade to higher value in phase-i ( Renewal ). 18. 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 19. What shall be the next year premium? The next year premium will be decided after the end of the policy tenure. 20. Can anybody renew the policy after 28th of Oct. after the closing of the last date? The enrollment can only be done as per the date scheduled by the JIO 21. Is there any tax rebate? Yes, under section 80 D. 22. Can I have the policy number? All this information shall be available online once the policy start date has been declared.

11 23. Do we get no claim bonus if we do not claim in the existing year? No as this is a group scheme 24. If my wife is the proposer can she cover her parents? Yes only is she is a Jain by birth. 25. 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. 26. 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. 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. & 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. 28. Should the claim be submitted with the insurance company or with TPA? Preferably with the TPA only. 29. 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: 1. Original completely filled in Claim form 2. Covering letter stating your complete address, contact numbers and address (if available), along with Schedule of Expenses 3. Copy of the TPA ID card or current policy copy and previous years' policy copies(if any) 4. Original Discharge Card/ Summary 5. Original hospital final bill 6. Original numbered receipts for payments made to the hospital 7. Complete breakup of the hospital bill 8. All bills for investigations done with the respective Doctor 9. All bills for medicines supported by relevant prescriptions 10. Bank Details with Cancel Cheque You are advised to keep Photo Copy of the entire set of claim documents submitted to us. 30. How to send reimbursement claims to TPA? Reimbursement claims can be submitted to us through registered post / courier or can be handed over at any of THE TPA Branch offices.

12 31. 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. 32. Can I claim medical expenses incurred before and after a surgery? You can claim medical expenses incurred 30 days before and 60 days after hospitalization (as specified in your policy), provided they are related to the ailment/treatment for which you were hospitalized. Such expenses are termed as pre and post hospitalization, except for Maternity Claims. 33. Can I claim my dentist's bills? No, you cannot 34. 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 the country. 35. 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. 36. Will my claims be reimbursed even if I do not get myself treated at a network hospital? Yes, claims will be reimbursed even if insured is not treated in network hospital. These claims shall be settled as per TPA Negotiated RATES. 37. 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. 38. 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. 39. 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 from a court of law for disbursing the claim amount. Alternatively, the insurers can deposit the claim amount in the court for disbursement to the legal heirs of the deceased. 40. What is the procedure for availing cashless facility? In case of planned hospitalization, insurers require the first prescription with the details of the case history indicating following details:

13 1. Provisional diagnosis or reason for getting admitted in hospital 2. Proposed date of admission 3. Approximate expenses 4. Name of the hospital and consultants 5. Approximate duration of stay at the hospital 6. Attached doctor's prescription with admission note The above documents need to be delivered to the TPA/insurer at least 72 hours before admission. 41. If I avail of the cashless facility, will the insurance company pay the entire bill at the hospital? No, claim will be paid as per limits mentioned in the policy, claim will be paid and a part of the bill will have to be borne by the insured if it consists of the inadmissible amounts that are listed by the hospital. 42. What are Sub-limits in this policy? CAPPINGS UNDER THE RENEWAL POLICY PHASE 1 Coverage RENEWAL coverage PREVIOUS YEAR coverage 50% Co-payment on Preexisting CANCER Capping on Dialysis in case of Pre-existing Disease Limit on claim amount (Capping) for Diseases / Ailments 10% Co-payment on REMAINING Pre-existing Diseases Deduction of Rs.5,000 Co-payment of 50% on claims due to Cancer related treatment only in case of Pre-existing Disease before Previous year Policy start date Rs.35,000 Per Family Per Year Cataract (Per eye): Rs.24,000 Bypass Surgery (CABG): Rs.250,000 Valve Replacement: Rs.200,000 Angioplasty (PTCA): Rs.175,000 Cholecystectomy (Gall bladder removal): Rs.40,000 Hysterectomy (Removal of Uterus): Rs.40,000 Appendisectomy (Removal of Appendix): Rs.40,000 Fistula / Hernia : Rs.30,000 Angiography: Rs.18,000 Anaemia: Rs.50,000 Knee Replacement (Per Knee): Rs.125,000 All the above mentioned amount inclusive of implant cost, stent, etc 10% co-payment applicable on pre-existing ailment excluding above ALL capped ailments (eg. Cancer, Dialysis, Bypass etc) Deduction of Rs.5,000 for each & every claim above Rs.50,000 excluding above ALL capped and Pre-existing ailments Cataract (Per eye): Rs.24,000 No Limit on all other ailments / Diseases No Co-payment No Deduction 43. What happens in case of an Emergency hospitalization where Cashless facility is not authorized to me? The liability for paying the hospital will be on the individual member. However, the insurance company will reimburse the admissible amount on submission of the claim file. 44. 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.

14 OR Any establishment that satisfies the following criteria can qualify as a hospital: 1. with at least 15 patient beds 2. With a fully equipped operation theatre of its own if surgical procedures need to be carried out 3. Employing fully qualified nursing staff around the clock 4. Having fully qualified doctors in charge around the clock Note: For Class 'C' towns, the number of beds relaxed to ten. 45. 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. 46. Is maternity benefit available under an individual Health Insurance Plan? Maternity benefit will be available from day one except for new members 9 month waiting period Normal Rs and Rs In case of C-sec. 47. What is my room rent eligibility under both the schemes? Room Rent restriction to Rs. 2500/ or below per day for Normal & Rs. 4000/ or below for ICU / ICCU and in case of Floater 10 Lacs it is Rs. 3500/ or below per day for Normal & Rs. 4000/ or below for ICU / ICCU and all other charges to be settled as per room rent eligibility 48. Can I get interest till the policy is not issued? No 49. What are the age limit restrictions under both the policies? Entry Age Limit restrictions are 0 80 years under both the schemes. We are happy to announce that the existing ELDERLY MEMBERS covered under the Policy who have already completed 80 years of age, are welcomed to continue the cover in the Renewal also 50. Can one prepare a Jain Certificate? The Jain certification has to be from Gyati / Samaj / Sang only. 51. What is covered under Personal accident Cover? Only Death & Permanent Total Disability is covered under personal accident cover. 52. What claim documents do I need under a Personal Accident Claim? CLAIM DOCUMENTS REQUIRED FOR PERSONAL ACCIDENT CLAIM ALL DOCUMENTS HAVE TO BE DULY ATTESTED / CERTIFIED / NOTARIZED a. Compete Filled Claim Form

15 b. Photocopy Of ID Proof c. Death Certificate or Permanent Total Disability certified from Government Hospital / Government Board d. Post Mortem Report e. Police FIR Copy f. Driving license (if self driving) g. Police Panchnama Copy h. Panchayat Certificate wherever applicable i. Income Proof j. Bank Account Details of Nominee