JIO Star New Mediclaim Policy 2018 – Terms and Conditions

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JIO Mediclaim Policy 2018-19 Our Insurance Partners Are: STAR Health & Allied Insurance Co. Brokers – Alliance Insurance Brokers Pvt. Ltd.

(1) FAMILY FLOATER MEDICLAIM: Sum Insured of Rs.2 Lacs,Rs.5 Lacs and Rs.10 Lacs.

(2) FAMILY DEFINITION: Proposer + Spouse (Husband / Wife) + 4 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 8 members allowed in one family (1+7)

(3) AGE LIMIT: 0-80 years (Entry Age of Proposer Between 18 to 80 Years)

(4) 1st year entry age is up to 80 years and upon renewal they can continue in the policy till LIFETIME

(5) ROOM RENT & ICU CHARGES: Room Rent limitation Per Day will be capped as below:

Sum Insured

Per Day Limit (Inclusive of Nursing charges)

Normal Room

ICU

200,000

2,500

3,500

500,000

3,000

5,000

10,00,000

4,000

5,000

 

**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**

(6) DAY CARE PROCEDURES: 405 day care procedures to be covered (List enclosed in the annexure)

(7) All Internal congenital Diseases are covered

(8) Domiciliary Hospitalisation is not Covered

(9) HOSPITALISATION AYUSH TREATMENT (AYURVEDIC / HOMEOPATHIC / UNANI): Covered upto Rs. 10,000/- per claim maximum up to Rs. 20,000/- per year per family subject to the treatment being taken in a Government hospital or in any institute recognized by Government and / or accredited by Quality Council of India or National Accreditation Board on Health.

(10) Hospitalization arising out of PSYCHIATRIC AILMENTS Covered upto Rs.30,000

(11) Cyber knife treatment: Covered with Co-pay of 50%

(12) Cochlear Implant: Covered with Co-pay of 50%

(13) Joint Replacement / Knee Replacement: One Year Waiting period applicable

(14) Emergency Ambulance Charges: upto Rs.2,500 Per incidence

(15) TERRORISM: Covered from Day One

(16) 30 Days Pre Hospitalisation & 60 Days Post Hospitalisation expenses covered within Family Sum Insured

(17) MATERNITY BENEFIT: Maternity benefits, applicable only for the Member or Dependent Spouse, subject to a limit of Rs.25,000/- for normal and Rs.30,000/- for caesarean delivery.

(18) MATERNITY WAITING PERIOD: Waiting period of 9 months for maternity waived off for all existing members & Members covered under Phase 7 of National; however waiting period of 9 months is applicable for new members enrolled under this policy.

(19) NEW BORN BABY COVER: Baby Cover covered from Day 1 SUBJECT TO INTIMATION WITHIN 20 DAYS

(20) Pre Post Natal Expenses: Covered on IPD Basis only and within Maternity limits. These Expenses are not covered on OPD Basis

(21)CO PAYMENT:

Sum Insured

Non Pre Existing  Diseases

Pre Existing  Diseases

200,000

NO-COPAY

25%

500,000

NO-COPAY

25%

1,000,000

NO-COPAY

25%

a) NO CO-PAY will be applied on all NON-PRE EXISTING DISEASE.

b) 25% CO-PAY on all PRE-EXISTING DISEASE CLAIMS irrespective of age

c) Co pay will not be applied on capped ailments / inner limits including Cataract & Maternity.

(**If it is proved during Cashless that the ailment is NON-PED e.g in case of Fever or Accidental cases, etc. then no CO-Payment will be applied by Star)

(**In case if 25% Co-pay is deducted in cashless for PED claim, and the member can prove the concerned ailment was NON-PED, Insurer will pay difference of 25% on Reimbursement basis. This claim will not be construed as Reimbursement claim**)

d) Co pay will not apply on maternity, maternity related and Cataract claims.

e) Reimbursement Claims: – Reimbursement of claims will be entertained. Subject to admission SHOULD BE intimated to STAR WITH IN 24 HOURS (If member fails to intimate to STAR within 24 Hours then the claim is to be rejected).

#Note: No additional co-pay will apply for reimbursement

(22)DISEASE WISE CAPPING ( UPPER LIMIT ):

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

Cerebral- 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

Anemia (Not for evaluation)

               50,000

        50,000

                                  50,000

Angiogram

               18,000

        21,000

                                  24,000

All Major Surgeries

 No capping

*All other major surgeries – Acute/Sub Acute/Chronic, Bilo Pancreatic Surgery, Gastro-Intestinal Surgeries, Surgeries on Prostate, and Surgery related to Genito Urinary Tract.

(I) If Claim is PED but falling under 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
——————

ii) If Claim is PED but not falling under 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/-.

(23) ORGAN TRANSPLANT : The Insurance Company will pay expenses incurred on the Donor expenses for organ transplantation where the insured person is the recipient are payable provided the claim for transplantation is payable and subject to the availability of the sum insured. Donor screening expenses and post-donation complications of the donor are not payable. This cover is subject to a limit of 10% of the Sum Insured or Rupees One lakh, whichever is less
(24) DENTAL TREATMENT: covered if due to Road accident only and requiring 24 hours Hospitalisation

(25) 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)

(26) 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

(27) CLAIM INTIMATION in case of cashless claims, immediate intimation shall be given to our Call Centre within 72 hours of Hospitalisation. In case of reimbursement claims, immediate intimation shall be given to Call Centre within 24 hours of Hospitalisation.

(28) CLAIM SUBMISSION of documents for reimbursement claims Within 30 Days from Date of Discharge.

(29) In case of Road accident where FIR copy is provided, capping of Breakage of bone will not apply.

(30) As per INCOME TAX Act deductions under Sec 80D, Proposer will be eligible for exemption. (Exemption for Payment by Cash not applicable)

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

(31) PLEASE NOTE:
· 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
· Premium can be PAID only via Online Payment Or Demand Draft

(32) 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.
a) External Congenital diseases not covered
b) Any dental treatment unless arising due to Road accident
c) Naturopathy treatment not covered.
d) HIV, AIDS and related medical conditions not covered
e) External medical equipment used as post hospitalization care not covered
f) Cost of contact lens, spectacles, hearing aid, cochlear implants not covered
g) General debility, use of drugs or alcohol, intentional self-injury, sterility, venereal disease not covered.
h) Treatment for infertility etc. not covered
i) Hospitalization treatment for less than 24 hrs. Other than specified treatment not covered
j) Lasik Surgery, Septoplasty, Infertility & Related Ailments inclusive of Male sterility; Treatment on trial/experimental basis; Admin/Registration/Service/
k) 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
l) Other exclusion as per the Standard Policy

(33) Group Personal Accident (GPA) policy is also attached with this policy, applicable for Proposer only
a. ACCIDENTAL DEATH
b. TERRORISM COVERED
c. WORLDWIDE COVER
d. Accidental Death cover to the main member upto the Health Sum Insured.
e. GENERAL EXCLUSIONS IN PERSONAL ACCIDENT POLICY:
· Suicide/ Intentional self-injury
· Death due to Pregnancy/child birth etc.
· Accident while under influence of alcohol/drugs
· Sexually Transmitted Infections
· Participation in a criminal act
· Participation in a hazardous sport
· War, civil war, similar situations etc
· Other exclusion as per the Standard Policy