LATEST NEWS HERE

JIO Star New Mediclaim Policy 2018 – Claim Procedure

  1. Can I opt individual policy in JIO NEW POLICY Mediclaim?
    -No.he/she would compulsory need to buy a 2 Lac/ 5 lac /10 lac cover.
  2. Can I opt Family Floater policy in JIO New Mediclaim?
    -Yes.This is an insurance scheme where a family can opt for an insurance plan for Rs.2, Lac Rs.5 Lac & 10 Lac against Mediclaim for Self + Spouse + 4 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.2 Lac, Rs.5 Lac and Rs. 10 Lac respectively for Proposer.
  3. I am a Jain but my wife is not a Jain? Can I insure my wife?
    Under the family floater policy you can cover your wife as long as the proposer is Jain and because now she is a part of the Jain family.
  4. If I have only 3 members in my family can I buy a Family Floater Policy?
    Family Floater Policy is available for family size ranging between 2 to 8 members i.e. Proposer + Spouse + 4 Dependent Children up to 25 years of Age + Parents/or Parents or Laws.
  5. Can I and my brother / sister cover our parents under our individual family floater schemes?
    Yes you can but any person can’t be covered more than once under whole group in JIO Policy. If declared more than once, benefit would be payable under one Sum Insured only
  6. We are two brothers & we have two different policies, Can we enroll our Parents in both policies?
    No. One person can be covered only once in a JIO policy.
  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 40 years take individual policy of Rs.2 lac?
    No. Individuals above the Age of 40 would compulsory need to buy a 5 lacs /10 lacs cover
  9. Is this Applicable on Pan India basis?
    Yes this policy is for Pan India Jain population only.
  10. What if I am or my family member is already suffering from a disease? Can I yet get myself or my family members covered?
    Pre‐Existing Diseases are covered since day 1, however Co-pay of 25% will be applicable for PRE-EXISTING Ailments and Co pay will not be applied on capped ailments / inner limits including Cataract & Maternity (No Co-pay on sublimited cases.) which is mentioned in point no.243
  11. 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. What is the name of Insurance Company?
    Star Health and Allied Insurance Company Limited
  13. How do i renew?
    Please follow the below mentioned steps
    1. Please go on jiojac.com/renewal2018
    2. Read revise Terms & Conditions carefully
    3. Enter JIOJAC ID
    4. Fill your enrolment details
    5. Make payment ONLINE Or by DD
  14. Can i submit physical form?
    You can only enroll Online as per the Procedure mentioned in Point No.214. You can’t submit Physical Form
  15. What are the options for making payment I am not aware of online procedure?
    You need to Enroll Online only, however payment can be done via Online or by submitting Demand Draft along with Printout of Online Form to JIO Office after completing Online Enrolment Procedure.
  16. If I don’t have JIO JAC Id, can I opt for Mediclaim Policy ?
    No, You can’t opt for MEDICLAIM Polic . JIOJAC ID is compulsory. Please register online for JIOJAC ID.
  17. What is the premium?

FAMILY SIZE

SUM INSURED

PREMIUM FOR

12 MONTHS

GST

@ 18%

AMOUNT PAYABLE

Family Floater of size 1+7

Rs.10 Lacs

32,500

5,850

38,350

Family Floater of size 1+7

Rs. 5 Lacs

19,500

3,510

23,010

Family Floater of size 1+7

Rs. 2 Lacs

16,250

2,925

19,175

 

  • Does this scheme have cashless as well as Reimbursement facility?
    Yes, cashless facility is available in 8000 Network of hospitals and Member can avail Cashless as well as reimbursement facility.In all case of cashless claims, immediate intimation shall be given to our Call Center within 72 hours of Hospitalisation. In case of reimbursement claims, immediate intimation shall be given to Call Centre within 24 hours of Hospitalization.
  • When will I be eligible for my maternity claim?Maternity benefit is available after completion of 9 months from the date of enrolment in JIO – Shravak Arogyam scheme.
  • Are pre & post-natal expenses under Maternity benefits covered?
    Covered for the Hospitalization for more than 24 hours within Maternity Limit, But Pre & Post Natal expenses on OPD bases are not covered
  • What shall be the next year premium?
    The next year premium will be decided after the end of the policy tenure based on the Claim Experience of the current Policy
  • Is there any tax rebate?
    Yes , under section 80 D you can claim TAX Rebate
  • Can I have the policy number?
    No, you will not get Policy Number. However you will receive Health ID card, which you can show in Network Hospitals to avail Cashless Benefit under this Policy
  • 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
  • If my wife is the proposer can she cover her parents?
    Yes only is she is a Jain by birth.
  • 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.
  • 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.
  • Will the change in names in between policy period matters?
    Yes, According to the Insurance Company the claim will not be settled (unless prior intimation to Insurance company) if there is any alterations in the name It has to be intimated to your respective Insurance Co. within 15 days on receipt of your cards & requisite Endorsement for the change in name needs to be passed by Insurance co. This has to be done first hand and not only if any claim arises.
  • 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:
    • Original completely filled in Claim form
    • Covering letter stating your complete address, contact numbers and email address (if available), along with Schedule of Expenses
    • Copy of the TPA ID card or current policy copy and previous years’ policy copies(if any)
    • Original Discharge Card/ Summary
    • Original hospital final bill
    • Original numbered receipts for payments made to the hospital
    • Complete breakup of the hospital bill
    • All bills for investigations done with the respective Doctor
    • All bills for medicines supported by relevant prescriptions
    • Bank Details with Cancel Cheque
    • You are advised to keep Photo Copy of the entire set of claim documents submitted to us.
  • How to send reimbursement claims?
    Under this Policy, You can avail Reimbursement facility and claims can be submitted to Star Health office through registered post / courier. The address is as mentioned in STAR web site.
    Star Health & Allied Insurance Company Limited

________________________________

  • 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.
  • 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.
  • Can I claim my dentist’s bills?
    No. You can do so only in cases arising from Road Accidents.
  • 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.
  • 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.
  • Will my claims be reimbursed even if I do not get myself treated at a network hospital
    Yes, you can avail Reimbursement facility.
  • 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.
  • 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.
  • 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.
  • 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:
    • 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.
  • 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.
  • What are Sub-limits in this policy?
  • Sum Insured Bracket

                200,000

                   500,000

                                     1,000,000

    Ailments / Procedures

     Limits of Insurance Company’s Liability Per Person in Rs.

    Cataract (per eye)

                  15,000

                     24,000

                                          25,000

    Cerebro- vascular Accident

                120,000

                   220,000

                                        280,000

    Cardiovascular Diseases

                120,000

                   220,000

                                        280,000

    Cancer

                120,000

                   220,000

                                        280,000

    Treatment for Breakage of Bones

                120,000

                   220,000

                                        280,000

    Renal Complications

                120,000

                   220,000

                                        280,000

    Genito Urinary Calculus

                  40,000

                     50,000

                                          60,000

    Dialysis in case of PED cases only

                  35,000

                     45,000

                                          50,000

    Cholecystectomy

                  40,000

                     50,000

                                          60,000

    Hysterectomy

                  40,000

                     50,000

                                          60,000

    Appendectomy

                  40,000

                     50,000

                                          60,000

    Fistula (Anal)

                  30,000

                     40,000

                                          45,000

    Hernia (All types)

                  30,000

                     40,000

                                          50,000

    Anaemia (Not for evaluation)

                  50,000

                     50,000

                                          50,000

    Angiogram

                  18,000

                     21,000

                                          24,000

    All Major Surgeries

     No capping

    Co-pay will Not apply on sub limit / Inner Limit Claims

     

    #NOTE:  1. In case of Road accident where FIR copy is provided, capping of Breakage of bone will not apply.

             

    Sample claim process:

  • (I)If Claim is PED But falling in Sublimit ailment

In case of claim relating to PED; but falling in sublimit ailment. Say the hospital bill is Rs. 5 lakhs for the disease CVA which has sublimit of Rs.2,80,000/- (sum insured opted is Rs.10 lacs), the following procedure is adopted :

 

First the amount payable to the insured is worked out after adjusting the non-medicals and non-payables, room rent difference if any, proportionate deduction if the insured occupied a room with room rent more than his eligible amount.

 

Hospital bill                                                    Rs. 5.00  lakhs

Deductions due to Non-payables –             Rs. 2.00  lakhs

                                                                           ——————

                                                                          Rs. 3.00  lakhs

                                                                          ——————

 

Since the assessed amount is more than the sub-limit of Rs.2,80,000/- the claim amount is restricted to the sub-limit viz. Rs.2,80,000/-

(ii)          If Claim is PED but not falling in any Sublimit ailment

In case of claim relating to PED; but not falling in any sublimit ailment. Say the hospital bill is Rs. 5 lakhs. (sum insured opted is Rs.10 lacs), the following procedure is adopted :

 

First the amount payable to the insured is worked out after adjusting the non-medicals and non-payables, room rent difference if any, proportionate deduction if the insured occupied a room with room rent more than his eligible amount.

 

Hospital bill                                                Rs. 5.00  lakhs

Deductions due to Non-payables –        Rs. 2.00  lakhs

                                                                      ——————

                                                                      Rs. 3.00  lakhs

Deduct 25% Co-payment for PED  –     Rs. 75 Thousand

                                                                      ——————

                                                                      Rs. 2.25  lakhs

                                                                 ——————

 

Since the diseases is not falling in any sublimit ailment; If on the contrary the assessed amount after co-pay is Rs.2,25,000/-, the claim payable is Rs.2,25,000/-.

 

(iii)          If Claim is Non- PED & Not Falling in any sublimit ailment:

In case of claim is not relating to PED & not falling in any sublimit ailment. Say the hospital bill is Rs. 5 lakhs. (sum insured opted is Rs.10 lacs), the following procedure is adopted :

First the amount payable to the insured is worked out after adjusting the non-medicals and non-payables, room rent difference if any, proportionate deduction if the insured occupied a room with room rent more than his eligible amount.

 

Hospital bill                                                Rs. 5.00  lakhs

Deductions due to Non-payables –        Rs. 2.00  lakhs

                                                                      ——————

                                                                      Rs. 3.00  lakhs

                                                                      ——————

Since the diseases is NON-PED & not falling in any sublimit ailment; the claim payable is Rs.3,00,000/-.

  • What happens in case of an Emergency hospitalization where Cashless facility is not authorized to me?
    The liability for paying the hospital will be on the individual member and member can avail reimbursement facility by giving mandatory within 24 hours intimation to star toll free no.
  • 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.
  • 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.
  • What is my room rent eligibility under both the schemes?
    • I. Rs.2 Lakhs – Room Rent – 2,500 and ICU capped at 3,500
    • I. Rs.5 Lakhs – Room Rent – 3,000 and ICU capped at 5,000
    • I. Rs.10 Lakhs – Room Rent – 4,000 and ICU capped at 5,000

    Room rent limit is inclusive of Nursing Charges. If the Insured occupies a room with a room rent limit other than his eligibility as per the insurance policy, then all the other charges shall be limited to the charges applicable for the eligible room rent or actuals, whichever is lower.

  • What are the age limit restrictions under both the policies?
    • For Individual Health Insurance Policy of Rs.2 Lacs, only Proposer upto 40 years can opt.
    • In case of Family Floater of Rs.5 Lacs & 10 Lacs, below age limit will apply
    • For Dependent Children maximum age allowed is 25 years. After completion of 25 years, Child will not be covered in next year
    • For Parents maximum entry age is 80 years, However ELDERLY MEMBERS who have completed 80 years on or after 30th Oct, 2014 can continue in the Policy till LIFETIME
  • Can one prepare a Jain Certificate?
    The Jain certification has to be from Gyati / Samaj / Sang only.
  • What is covered under Personal accident Cover?
    Only Death Benefit is covered under personal accident cover
  • 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
      1. Compete Filled Claim Form
      2. Photocopy Of ID Proof
      3. Death Certificate or Permanent Total Disability certified from Government Hospital / Government Board
      4. Post Mortem Report
      5. Police FIR Copy
      6. Driving license (if self driving)
      7. Police Panchnama Copy
      8. Panchayat Certificate wherever applicable
      9. Income Proof
      10. Bank Account Details of Nominee