Policy features ( Aug 2022-2023):

• For June Lot Members:  Your policy expired on 14^th June,2022. You can re-join in August Extension lot as a fresh member. 1^st year waiting period and exclusion clause will be applicable to you. Your policy period will be from 25^th August, 2022 to 1^st August,2023.
• For August Lot Members: Your policy expired on 1^st August, 2022. Since you have paid premium of policy after expiry of your policy during enrolment extension period, your cover will start from 25^th August, 2022. No claim for hospitalisation between 2^nd August, 2022 to 24^th August 2022. However you will get continuity benefit under policy. Your policy period will be from 25^th August, 2022 to 1^st August,2023.
• For New Members: 1^st year waiting period and exclusion clause will be applicable to you. Your policy period will be from 25^th August, 2022 to 1^st August,2023.

1. Entry AGE is up to 90 Years and Renewal till LIFETIME
2. Family floater policy for 8 members. This includes Self, Spouse, 4 unmarried Dependent Children up to 25years, 2 Dependent Parents or Parents-In-Laws (No cross combination will be covered in the policy). All covered members have to be Jain only
Family floater policy for 4 members. This includes Self, Spouse, 2 Dependent Unmarried Children up to 25years.
3. NO Health Check-Up Required prior to policy.
4. Gold Plus Plan has additional COVID cover with Home Care Treatment & Hospitalisation benefit.
5. Hospital ROOM RENT & ICU CHARGES limitation (Per Day):

6. For new members PRE-EXISTING DISEASES is NOT COVERED FOR 1 YEAR 75% covered from 2nd year and 100% from 3rd year subject
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.

7. For new members PRE-EXISTING DISEASES is NOT COVERED FOR 1 YEAR 75% covered from 2nd year and 100% from 3rd year subject reasonable, customary and Medically Necessary charges***.

Knee Replacement / Cataract / Other Chronic disease which are mainly Pre-Existing or the treatment for same can be delayed (the list given in FAQ point no. 37 in FAQ ABOUT TERMS & CONDITIONS) cover starts after 1 year as per T & c.

8. DAY CARE PROCEDURES: covered as per IRDAI list.

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 for new members and for renewal members same is covered subject to a limit of Rs.25,000/- for normal and Rs.35,000/- for caesarean delivery. No Pre-post claim allowed in Maternity claims. Same is for member and spouse.

14. NEW BORN BABY COVER: Request for addition of New Born Baby under the policy shall be allowed provided birth intimation received in mail within 30 days from Date of birth of child on jio.insurance@ajgindia.in email id, 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 within maternity limit amount and thereafter up to Family Sum-Insured limit

15. NEWLY MARRIED SPOUSE COVER: Request for addition of Newly married Spouse under the policy shall be allowed within 30 days from marriage date provided written mail is received on jio.insurance@ajgindia.in email id within 30 days from the date of marriage, Any delay / request coming after 30 days from marriage date for addition of Newly married Spouse to Insurer, shall not be considered.

16. Policy to be renewed as it is with same JIOJAC id and members who were covered in last year. Sum insurance reduction or increasing is not allowed. If found any changes done, all covered members will be considered as a fresh members and all clause and terms applied for fresh member will be applied on all members.

Only new born baby or newly married spouse name can be added if new born birth or marriage is after 15.06.2021.

17. CASHLESS and REIMBURSEMENT both facility available in policy.

18. As per INCOME TAX Act, Proposer will be eligible for exemption under Sec 80D for Mediclaim Premium amount.

19. Dental treatment covered if due to ROAD ACCIDENT ONLY and requiring 24 hours Hospitalisation. Police MLC / FIR is compulsory.

20. In all claim due to Accident (whatever cause, police MLC / FIR is compulsory)

21. MID-TERM ADDITIONS allowed only for newly married spouse and natural additions (new born baby) subject to intimation received within 30 days of marriage or birth (for newly married SPOUSE & new born BABY) in mail on jio.insurance@ajgindia.in. Any delay / request coming after 30 days shall not be considered.

22. 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.

23. Member will be considered as fresh member if premium received after expiry of current policy. No grace period will be considered as this is a group Mediclaim policy.

24. All covered Member will be considered as fresh member if renewed using different JIOJAC is or any changes in covered members name / relation detail of expiring policy, Continuity benefit will be lost for all covered members.

25. Sum insured cannot be reduced or increased than previous year policy under the same plan.

26. If proposer had died then please renew the policy as it is and informed jio.insurance@ajgindia.in with death certificate of proposer within 5 days from payment. Respective team will get JIOJAC number transferred to Spouse of the deceased name. This will ensure continuity under the policy. Your continuity under the policy is tracked by JIOJAC number only. Any claim in deceased proposer’s family, amount will be released in sequence covered Spouse, covered Elder child, father, mother name.

27. The insured can make a claim if her/his hospitalized stay is for over 24 hours. However, for certain treatments, such as dialysis, chemotherapy, cataract surgery, etc. the stay could be less than 24 hours.

28. CLAIM INTIMATION in case of CASHLESS claims or REIMBURSEMENT Claim, immediate intimation shall be given to TPA Call Centre within 48 hours of Hospitalisation. • Ericson Insurance TPA Services Pvt. Ltd.
Contact no. / Email ID: 022-41548300 / 1800222034 / jiointimation@ericsontpa.com / jio@ericsontpa.com / KP@ericsontpa.com
• Gallagher Insurance Brokers Private Ltd. Email ID:
jio.insurance@ajgindia.in

Extra COVID cover :
a) For Family Floater Policy 2 lakh Sum-Insured is on Floater basis. All Family members will be automatically covered.
b) For Individual Policy 2 Lakh is for on Individual Member.
c) COVID Insurance (2 Lakh Sum-Insured) allow: Hospitalization Benefit and Home Care Treatment.
d) Waiting period applicable for COVID claims for all newly covered members. Patient should be diagnosed COVID positive after 30 days from policy cover start date. All renewal member will not have waiting period.
e) In case of claim for Corona treatment, patient’s diagnosis report should be from Government approved laboratory is compulsory and patient’s report should be COVID POSITIVE. Also note that treatment should be only taken in Government approved hospital to treat COVID Positive patient.
f) COVID treatment claims will be settled as per GIC guidelines or Govt. notification issued by the State Govt. where the hospital is situated.
Kindly read Terms & Condition properly, if required then only call to call centre

29. CLAIM SUBMISSION of documents for REIMBURSEMENT claims Within 30 Days from Date of Discharge
If hospitalisation intimation is not provided by member within 48 hours from the date of hospitalisation or original claim file not submitted within 30 days from the date of discharge, or deficiency documents are not provided within 7 days, claim will get rejected. Hence timely submission of detail and documents is must to avoid rejection.
No correction in provided detail will be done after 5 days from the date of payment.

30. REASONABLE AND CUSTOMARY CHARGES mean the charges for services or supplies, which are the standard charges for the specific provider and consistent with the prevailing charges in the geographical area for identical or similar services, taking into account the nature of the Illness / Injury involved. Insurance company will process claim as per reasonably and Customarily and Medically Necessarily charges.

31. Premium Chart :
Khushhal Parivar Policy Annual Premium as per Highest Member’s age in the family per Year ##

Rs 1000/- + GST will be charged additional per financial year for JIO Membership fees, if not paid
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)
• COVID Insurance is for all family under floater plan.
• Single person can also opt for Policy up to age of 65 years. Without maternity benefit.
• 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 living spouse, children, Parents or parent in law (self-affidavit or certificate from JIO Director mandatory). No Maternity benefit for individual policy.
• 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. No changes or cancellation allowed after payment.
• Additional Payment Gateway fees shall be charged by Gateway Company for providing safe & secure online money transfer facility.
* For detail terms and condition, rejections and sub-limits refer JIO website.
www.jio.net.in/KP22.php

** Policy terms and rates shall be reviewed annually and necessary corrective action shall be taken (if required) to keep the portfolio viable
## 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: GALLAGHER INSURANCE BROKERS PRIVATE LIMITED (CIN: U72200MH2000PC124096)
• TPA Name :- Ericson Insurance TPA Services Pvt.

33. GENERAL EXCLUSIONS ( Not Payable ) IN any type of MEDICLAIM POLICY by Universal Sompo General Insurance Co. Ltd.

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.

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.

3. Risky Sports, Military :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.

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 Person's intellectual faculties by abuse of stimulants or depressants

5. Weight management programs or treatment in relation to the same including vitamins and tonics, treatment of obesity (including morbid obesity).

6. Correction of eyesight: Treatment for correction of eyesight due to refractive error including routine examination.

7. Health check-ups: All routine examinations and preventive health check-ups, including corona virus when hosptizalation is not done

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.

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.

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

11. Experimental treatment: Investigational treatments, Unproven / Experimental treatment , or drugs yet under trial, devices and pharmacological regimens.

12. Diagnostic Only: Diagnostic tests/procedures/treatment/consumables not related to Illness for which Hospitalization has been done.

13. 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.

14. PREVENTIVE CARE/Vaccination including inoculation and immunizations (except in case of post-bite treatment); any physical, psychiatric or psychological examinations or testing.

15. 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.

16. Hearing aids & contact lenses or spectacles including optometric therapy, multifocal lens.

17. Baldness: Treatment for alopecia, baldness, wigs, or toupees, and all treatment related to the same.

18. Diabetic test strips etc.: Medical supplies including elastic stockings, diabetic test strips, and similar products.

19. 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 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.

20. External Congenital Anomalies or diseases or defects.

21. Stem cell therapy etc. : Genetic disorders and stem cell implantation / Surgery, or growth hormone therapy.

22. 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.

23. "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.

24. Voluntary termination, miscarriage (except as a result of an Accident or Illness)

25. 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.

26. Organ donor screening: Expenses for organ donor

27. Illegal Organ Transplantation: Admission for Organ Transplant but not compliant under the Transplantation of Human Organs Act, 1994 (amended).

28. Spinal subluxation: Treatment and supplies for analysis and adjustments of 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.

29. Dental Treatment: Dentures, implants and artificial teeth, Dental Treatment and Surgery of any kind, unless requiring Hospitalization due to an Accident.

30. 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.

31. Artificial life maintenance including life support machine use, where such treatment will not result in recovery or restoration of the previous state of health.

32. Treatment for developmental problems, learning difficulties eg. Dyslexia, behavioural problems including attention deficit hyperactivity disorder (ADHD).

33. 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,

34. 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.

35. 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.

36. Treatment charges or fees charged by any Medical Practitioner acting outside the scope of license or registration granted to him by any medical council.

37. 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.

38. 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.

39. -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).

40. Non-Medical Expenses :(3)including but not limited to RMO, CMO, DMO charges, Bio-Medical waste charges , Infection Control Charges etc. surcharges, night charges, service charges levied by the Hospital under any head are not payable because they are part of Nursing Charges and as specified in the Annexure for Non- Medical Expenses Click Here for more details

41. Treatment taken outside India

42. 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.

43. Robotic surgery (whether invasive or non-invasive) and Any form of Laser Surgery

44. All forms of Bariatric surgery.

45. Use of Radio Frequency (RF) probe for ablation or other procedure.

46. Admission primarily for diagnostic purposes not consistent with the treatment taken.

47. 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.

48. Treatment provided by anyone with the same residence as Insured Person or who is a member of the Insured Person's immediate family.

49. Holmium Laser Enucleation of Prostate, KTP Laser Surgeries, Femto laser surgeries, bio-absorbable stents, bioabsorbable valves, bioabsorbable implants, oral chemotherapy, Hormonal Chemotherapy, Adjuvant Chemotherapy, Neo-adjuvant Chemotherapy, Immuno-therapy, use of Trastuzumab , Antibody cocktail , Infliximab, rituximab, avastin, lucentis group of drugs.

50. Domiciliary Hospitalisation, OPD treatment is not covered

Treatment not covered in 1st Year:

FAQ 22-23 ABOUT MISUNDERSTANDINGS AND MYTHS OF JIO HEALTH PLAN
FAQ 22-23 ABOUT ENROLLMENT PROCESS
FAQ 22-23 ABOUT TERMS & CONDITIONS
FAQ 22-23 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 Gallagher Insurance Brokers Private 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.

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 enrolment and claims has been assigned to the brokers by JIO. The brokers are required to maintain appropriate number of contact points in the form of helpline numbers and email id for helping members and resolving their queries. For any help or assistance at the time of enrolment the members can contact the brokers helpline numbers. For any assistance at the time of claim, the members can contact the 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 “Khushhal Pariwar Policy”, has been negotiated with the Insurance Co to Continue for long period 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, 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. Therefor JIO will never think about discontinuing the scheme.

FAQ ABOUT ENROLLMENT PROCESS

1. What is the procedure to enrol into this Health Plan?
A member is required to visit the designated website for enrolment 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 (spelling and birth date as per govt. id) 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 enrolment 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 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.jio.net.in/KP22.php
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 – Khushhaal Pariwar New Mediclaim Policy is issued by which the Insurance Company ?
Universal Sompo General Insurance Company issued the policy.

6. What is Gallagher Broker in this Mediclaim Policy ?
Gallagher Insurance Brokers Private 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 – Khushhaal Pariwar, New Mediclaim Policy is serviced by which TPA ?
This policy is serviced by Ericson Insurance TPA 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 Enrol Online only, however payment can be done via Online through PayU 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.jio.net.in/KP22.php
3) Select “SIGN IN / REGISTER”
4) Select “ FOR SIGN UP CLICK HERE “
5) Fill your details to get JO membership (member spelling, date of birth should be as per govt. id, no correction will be done after payment)
6) Make membership payment ONLINE
7) You download membership card after registration. No physical copy is send by JIO.
8) Use provided membership id and password to enrol for policy.
9) Make policy premium payment ONLINE
10) Policy cover certificate and TPA card will be sent in registered email id after policy starts.

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.
- Enrol 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 enrolment.
· 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 – Enrolment : 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 enrolment 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. 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.

19. Can I change my Sum insured amount or covered dependent detail in renewal of policy?
No. Policy to be renewed as it is with same members who were covered in last year. Sum insurance reduction or increasing is not allowed. If found any changes done, all covered members will be considered as a fresh members and all terms applied for fresh member will be applied on all members.
Only new born baby or newly married spouse name can be added if new born birth or marriage is after 15.06.2021.

20. Can I do any correction in family member detail after payment?
No such correction is permitted in proposer’s detail however, changes of only Spelling correction or birth date correction can be done in the covered dependent member only within 5 days from date of payment. Email for such correction should be sent on jio.insurance@ajgindia.in with government issued photo id with full date of birth mentioned on the same.
Any correction request received after 5 days from payment date will not be considered which may lead to rejection of claim. To avoid such rejection, we request all members to check spelling and birth date before making payment of all dependents. Same should be as per govt. issued id.

21. Can I Cancel policy after payment and get refund of paid premium?
No. Cancellation is not allowed after making payment, hence no refund will be done.

22. What to do if proposer is died before renewal of policy or during policy period?
If proposer had died then please renew the policy as it is and informedjio.insurance@ajgindia.in with death certificate of proposer within 5 days from the date of payment. Respective team will get JIOJAC number transferred to Spouse of the deceased name. This will ensure continuity under the policy. Your continuity under the policy is tracked by JIOJAC number only.
Any claim in deceased proposer’s family, amount will be released in sequence : covered Spouse, covered Elder child, father, mother name.

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. Maternity benefit will not be provided in individual policy.

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 Unmarried 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. Your in-law cannot be covered as they are not Jain. All covered members has to be Jain only. Insurance company may reject claim or suspend policy benefit if found non jain member covered.

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 unmarried 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 enrol 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 65 years take individual policy of Rs.2 lac?
No. Individuals above the Age of 65 years 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 and for 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 onwards, PED gets covered 100%.
1. 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.
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 advice or done any investigation
2. If you are already been diagnosed with any disease (within 48 months 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. Can I take my married daughter in policy?
No. As she is now not part of your family.

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. No Pre-post claim allowed in Maternity claims.
New born baby expenses related to Hospitalization shall be covered from Day One of the birth up to 90 days within a limit of maternity only. Subject to new born birth intimation is given in mail on jio.insurance@ajgindia.in within 30 days from the date of birth. Birth intimation received after 30 days will not be considered.
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. Birth intimation received after 30 days will not be considered.
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.
· Guaranteed renewal
· IT tax benefit under section 80 D for premium amount.

15. What is the name of Insurance Company & Broker ?
Universal Sompo General Insurance Co. Ltd. And Gallagher Insurance Brokers Private Limited.

16. What about Gold Plus Plan?
· Any Group Mediclaim policy including Khushhal Policy do not cover Home quarantine cover/ Home care treatment under the policy. 80% of the COVID positive patient are having home quarantine treatment. These expenses will be covered under COVID Insurance.
· In Group Mediclaim certain expenses which are necessary for COVID treatment are not payable for ex. PPE kits, sanitasation. They are covered under COVID policy
· This is additional separate policy for 2 lakh Sum-Insured
· In India COVID policy was available only up to age of 65 years of age but for JIO the policy is available up to age of 90 years. The senior citizens in our families are more vulnerable to COVID and hence it is best opportunity to get them covered.
· Tele Medicine, Video Consultation charges will be paid under COVID policy
· Gold Plus Plan will have additional COVID policy covering Home Care Treatment (Home quarantine Treatment) & Hospitalisation benefit.
· In case of COVID hospitalisation first claim will be processed under COVID policy so that non admissible amount payable under COVID policy but not payable under Group Mediclaim Policy ( Khushhal Parivar) will be paid to member.
a) For Family Floater Policy 2 lakh Sum-Insured is on Floater basis
b) For Individual Policy 2 Lakh is for on Individual Member.
c) It is for all Family.
d) Gold Plus Plan (2 Lakh Sum-Insured ) allow: Hospitalization Benefit and Home Care Treatment
e) Waiting period applicable for COVID claims for all newly covered members. Patient should be diagnosed COVID positive after 30 days from policy cover start date. All renewal member will not have waiting period.
f) In case of claim for Corona treatment, patient’s diagnosis report should be from Government approved laboratory is compulsory and patient’s report should be COVID POSITIVE. Also note that treatment should be only taken in Government approved hospital to treat COVID Positive patient.
g) COVID treatment claims will be settled as per GIC guidelines or Govt. notification issued by the State Govt. where the hospital is situated.

17. What is the premium for Khushhal Parivar Policy Gold & Gold Plus Plan?

*Rs 1000/- (GST extra) will be charged additional per financial year for JIO Membership fees, if not paid.

· IT tax benefit available on above premium to proposer.
· Additional Payment Gateway fees shall be charged by Gateway Company (PayU) for providing safe & secure online money transfer facility.

18. Does this scheme have cashless as well as Reimbursement facility?
Yes, cashless facility is available in Ericson Insurance 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 in mail on jiointimation@ericsontpa.com or to Ericson Call Centre within 48 hours of Hospitalisation.
Ericson Insurance TPA Services Pvt. Ltd.
Contact no. / Email ID: 022-41548300 /1800222034 / jiointimation@ericsontpa.com / jio@ericsontpa.com / KP@ericsontpa.com
Gallagher Insurance Brokers Private Ltd. Email ID:
jio.insurance@ajgindia.in

19. 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. Pre and post expenses claim in maternity claim is not allowed. Same is for policy proposer and spouse only. No maternity for 2 Lacs Sum Insured individual policy.

20. What shall be the next year premium?
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.

21. Is there any tax rebate?
Yes, under section 80 D policy proposer can claim TAX Rebate for paid premium amount.

22. Can I have the policy number?
No, you will not get Policy Number. However you will receive Health ID card and cover certificate which you can show in Network Hospitals to avail Cashless Benefit under this Policy.

23. 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

24. If my wife is the proposer can she cover her parents?
Yes, only if she is a Jain by birth. i.e., her parents also has to be Jain.

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 if there is any alterations in the name or birth date, same has to be intimated on jio.insurance@ajgindia.in in mail within 5 days from premium paid date for the change in name or birth date needs to be passed by Insurance co. This has to be done first hand and not only if any claim arises.

28. Dependent child daughter name change due to marriage during policy period can be done?
No. since married children’s cannot get cover under the policy. Married child will not get policy cover benefit.

29. 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 for which you were hospitalized. Such expenses are termed as pre and post hospitalization, except for Maternity Claims.

30. 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. Police MLC / FIR is compulsory for all claims due to accident (all types).

31. If I have a health insurance policy in Mumbai, can I make a claim if I am transferred to Delhi?
Yes, your health insurance policy is valid all over INDIA.

32. What are 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, RMO 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, RMO 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.

33. What is my room rent eligibility under both the schemes?
1. Room, Boarding Expenses including Nursing, RMO 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, RMO 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.

34. What are the age limit restrictions under both the policies?
For Individual Health Insurance Policy of Rs.2 Lacs, only Proposer up to 65 years can opt. No Maternity benefit allowed.
In case of Family Floater of Rs.5 Lacs & 10 Lacs, below age limit will apply For Dependent unmarried Children maximum age allowed is 25 years. After completion of 25 years, Child will not be covered in next year.
For Parents / in-laws maximum entry age is 90 years. Once enrolled you can continue till LIFETIME. All covered members has to be Jain only.

35. Can one prepare a Jain Certificate?
The Jain certification has to be from Gyati / Samaj / Sang only.

36. 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.

37. What are the first year exclusions?

38. What is REASONABLE AND CUSTOMARY CHARGES ?
REASONABLE AND CUSTOMARY CHARGES mean the charges for services or supplies, which are the standard charges for the specific provider and consistent with the prevailing charges in the geographical area for identical or similar services, taking into account the nature of the Illness / Injury involved. All claims are processed as per reasonable and customary charges.
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:
1. All Insured person claiming the benefit under this policy has to be certified as JAIN, by Derasar or Jain Mandir or JIO.
2. All dependant claimant has to share the proof of their relationship with the proposer
3. Person covered under the policy as single member, has to be certified by the JIO director.
4. All the claim intimations has to be intimated within 48 hrs of hospitalization to Insurer , to avoid deductions & / or rejections
5. All the claim documents as per the check list has to be submitted to the Insurer within 30 days from discharge of the hospitalization to avoid deductions & / or rejections
6. Duly filled original Claim Form.
7. Original Discharge summary of the treating hospital clearly indicating the 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
13. Original Copies of prescription for diagnostic test, treatment advise, medical references etc.
14. Details of the implants including the sticker indicating the type as well as invoice towards the cost of implant
15. Hospital registration number/the number of beds available with the hospital verified by the authorised signatory of the Hospital.
16. KYC documents of patient
17. NEFT Mandate & Cancelled Cheque / Passbook (containing IFSC Number)
18. Any other documents as and when requested by the claim settling authority.
19. All single member covered under the policy ,claiming the benefits has to 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 Ericson Insurance TPA Services Pvt. Ltd. office through registered post / courier. The address is as mentioned on website – www.ericsontpa.com Head Office address is as follows.
Ericson Insurance TPA Services Pvt. Ltd.
Address: 11C, 2nd Floor Corporate Park, Sion - Trombay Rd, Chembur, Mumbai, Maharashtra 400071.

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, cataract 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 proposer of the policy. In case of proposer’s death, 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.

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 hospitalisation intimation in mail to Ericson Insurance TPA Pvt. Ltd. on jiointimation@ericsontpa.com / jio@ericsontpa.com / KP@ericsontpa.com

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 hospital:
with at least 15 patient beds
With a fully equipped operation theatre of its own if surgical procedures need to be carried out
Employing fully qualified nursing staff around the clock
Having fully qualified doctors in charge around the clock Note: For Class 'C' towns, the number of beds relaxed to ten.

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. Police MLC / FIR is compulsory in all claims due to accident.

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 outside scope of his license or black listed hospital is covered or not.
NO

26. Whether ARMD, RFQMR, ECP, EECP, HBOT, Lase treatment 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.

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.
Ø 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.
Ø Treating Doctor related : 1) OPD converted in IPD
2) Hospitalisation Not Justified.
3) Admission only for Investigation
Ø Hospital related : 1) Not registered Hospital / Not fulfilling Hospital Definition.
2) Non Payable items
3) Inflated bill
4) Prolonged Stay etc.
If hospitalisation intimation is not provided by member within 48 hours from the date of hospitalisation or original claim file not submitted within 30 days from the date of discharge, or deficiency documents are not provided within 7 days, claim will get rejected. Hence timely submission of detail and documents is must to avoid rejection.

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.
Gallagher Insurance Brokers Private Ltd. will provide all legal guidance, procedural help, and documentation for filling such legal complaints.
* For detail terms and condition, rejections and sub-limits refer JIO website.
www.jio.net.in/KP22.php www.jio.net.in/KP22.php