Terms and conditions (January 2024)

New community service program only for Jain community families belonging to all four secs Like Shwetambar, Terapanthi, Digmabar, Sthanakwasi etc.

Group community Service contribution Offer

Khushhal Parivar now changes to January Base Health Plan (January 2024-2025) :           

Start Date :  29th jan 2024 to 14th jan 2025.

No cover benefits will be provided for pre-post hospitalization and hospitalization from 15th Jan 2024 to 28 Jan 2024 for renewal members.

Specialised Health Coontribution in which JIO member & Its family member will get 15% discount on Prescribed Medicine, Doctor consultation, Diagnostic test order through Kenko Health app.

In case of hospitalisation of a member or its family member. JIO has made arrangements for Cashless and reimbursement claims settlement through Third party administrator - Vidal Healthcare Private Limited. The OPD Benefits are offered by Kenko Through the app.

There are two ways by which hospitalisation expenses will be process.

1. Cashless Hospitalisation benefit:

• JIO Members must intimate the date of hospitalisation with Hospital details on Kenko App.
• Members are requested to coordinate with the TPA Desk of the hospital.
• Pre-auth will be given by Vidal Healthcare Pvt. Ltd.
• At the time of discharge, the final amount will be transferred to hospital by JIO, after uploading requisite documents by the hospital to Vidal.

2. In the Reimbursement claim again the member has to intimate the claim on the Kenko App. 

• All the documents related to hospitalisation have to be uploaded on the Kenko App.
• Vidal TPA will process the hospitalisation expenses documents and if any query is raised the member has to solve the query through Kenko App only.
• JIO wants its members to enjoy the benefit of Digital India and hence using the Kenko app for ease of operation to members.  Vidal is processing the hospitalisation expenses.

Terms of Eligibility for participating in Community Service Program

1. Entry AGE is up to 90 Years for Jain Community Members.

2. Family floater Contribution offer with OPD medical benefit & Hospitalisation expenses reimbursement for 8 members. This includes Self, Spouse, 4 unmarried Dependent Children up to 25 years, 2 Dependent Parents or Parents-In-Laws (Only either of the jodi to be covered under family).

3. Family floater for 4 members. This includes Self, Spouse, 2 Dependent Unmarried Children up to 25 years.

4. NO Health Check-Up Required prior to Joining community Service Program.

5. Home care treatment for COVID allowed on reimbursement basis only. Maximum limit for home care COVID treatment is 25,000 per person on reimbursement basis only.

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

Those Jain community families which will be joining from this year under community service program will be not paid for the Old disease i.e. pre-existing disease in this program for this year. 

Members Who were enrolled under Khushaal Parivar Plan will get continuity benefit.

7. PRE-EXISTING DISEASE will be covered after 1 year.

25% co-pay applicable in second year on pre-existing diseases except capped ailment which are paid up to capping limit.

No co-pay for pre-existing diseases in 3^rd year except capped ailment which are paid up to capping limit.

10% co-pay on medical management diseases (Other than surgery cases e.g. Fever etc.) are applicable irrespective of PED co-pay.

All PED claims covered subject to ailment capping , reasonable, customary and Medically Necessary charges***.

For community service plan member hospitalisation expenses benefits for knee Replacement / Cataract / Other Chronic disease which are mainly Pre-Existing or the treatment for same can be delayed (the list given in point no. 33) cover starts after 1 year as per T & C even if they are diagnosed after Community Service Plan inception.

Excluded Hospital - Hinduja- Khar, Breach Candy, Kokilaben Hospital. Tratment taken in this hospital are not payable in this contributory community service program. 

• 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.

8. 1st Year Exclusion Disease :

• For New members: 1st year exclusion applicable (the list given in point no. 33)
• From 1st Year renewal members benefits are capped at 75% of benefit amount except for capped ailments, which will be paid up to the capping limit subject to reasonable, customary and Medically Necessary charges***.
• The detailed list of 1st Year exclusion disease is given under point no. 33

10% co-pay on medical management diseases (Other than surgery cases e.g. Fever etc.) are applicable on all medical management cases.

9. AYUSH Treatment:  covered up to 25,000.00 on reimbursement basis only.

10. Internal Congenital diseases are covered maximum up to Rs. 50,000 per family.

11. Domiciliary Hospitalisation is NOT COVERED.

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

13. 30 Days Pre- Hospitalisation & 60 Days Post Hospitalisation expenses covered.

14. MATERNITY BENEFIT (for self & Spouse) : Maternity benefits, applicable ONLY AFTER 1 YEAR.  From first year renewal onwards same is covered subject to overall limit of  Rs.25,000/- for normal and Rs.30,000/- for caesarean delivery (for first 2 live children). In case the member has already 2 or more living children, then they will not be eligible for Maternity Benefit. No Pre-post claim allowed in Maternity claims. No Maternity benefit for individual  Contribution.
    
     15. NEW BORN BABY COVER: Any newborn baby is a bundle of joy. The same baby will be covered under community Service plan as a family member, Provided the baby's birth is intimated to JIO within 30 days of the birth with birth certificate.

Request for addition of New Born Baby under the  shall be allowed provided birth intimation received in mail within 30 days from Date of birth of child on  claimhelp@jio.net.in  email id with child birth proof, Any delay / request coming after 30 days from DOB for addition of Newborn baby, shall not be considered.

Any hospitalisation within this period i.e. from DOB of baby to 30 days shall be considered subject to receipt of the timely intimation to claimhelp@jio.net.in

New born baby expenses related to Hospitalisation shall be covered from Day One of the birth up to 90 days up to 35000 limit and thereafter up to Family Sum-Insured limit.

16. NEWLY MARRIED SPOUSE COVER: Request for addition of Newly married Spouse under the Contribution shall be allowed within 30 days from marriage date provided written mail is received on  claimhelp@jio.net.in  email id within 30 days from the date of marriage with marriage proof, Any delay / request coming after 30 days from marriage date for addition of Newly married Spouse, shall not be considered.

17. Only new born baby or newly married spouse name can be added if new born birth or marriage is after 29th jan 2024.

18. Cashless SETTLEMENT and REIMBURSEMENT both facilities available in  community Service Plan for hospitalisation benefit.

19. As this is a community Service Plan there is no Income Tax deduction under Sec.80-D.

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

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

22. 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 claimhelp@jio.net.in. Any delay / request coming after 30 days shall not be considered.
23. This is a community based plan hence, Any family or individual member cannot take (i) multiple benefits under any JIO Plan & (ii) under multiple JIO Plans.  If declared more than once, benefit would be payable under one Sum Insured only.

24. No grace period will be considered as this is a Community Service Plan. 

25. In JIO all Jain Members are identified through a unique JIOJAC number offered by. Jain International Organization. From first year renewal onwards all covered Members will be considered as fresh members if renewed using different JIOJAC ID or any changes in covered members name / relation detail of expiring , Continuity benefit will be lost for all covered members.

26. Kindly read Terms & Condition properly, if required then only call to call centre number 1800 1211 63177

27. 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. Your claim will be process as per reasonably and Customarily and Medically Necessarily charges.

28. If the proposer had died then please renew enrol for subscription offer as it is and inform  claimhelp@jio.net.in with the death certificate of proposer within 5 days from payment. Respective team will get the JIOJAC number transferred to Spouse of the deceased. This will ensure continuity under the . Your continuity under the  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.

29. The insured can make a claim if her/his hospitalised 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.

30. 80D benefit, GST invoice and COI not available in community service plan.

31. 10% co-pay will be deducted in each & every case of medical management (Other than Surgical Cases)

           5,000 compulsory deductible applicable on every claim of 30,000 and above. Compulsory deductible not applicable on capped ailment.

           Cochlear Implant allowed upto 25% of Family Hospitalisation Benefit.
           For Fresh Families capped ailments is excluded if it is a pre-existing condition and It will be paid from 1st year of renewal onwards.

Annual subscription amount as per Highest Member’s age in the family per Year ##

Health Subscription for JIO Jan 2024-2025

*Rs 2000/- + GST (non-refundable/non-transferrable) will be charged additional per financial year for JIO Membership fees, if not paid.

Notes:

• Self-managed health benefit scheme is run by Jain International Organisation for its members. Vidal Health Services will be running the adjudication as per scheme rules as above. Kenko will run the only OPD discount program for its subscribers and help in administration of the self-managed scheme of the NGO.

• Children are defined as unmarried dependent children up to the age of 25 years.
• Either Parents or Parents-in-law covered (Cross combination not allowed)
• Single continuing person can also opt for subscription up to age of 65 years. Without maternity benefit.
• Family members to be covered as per acceptable age of specific plans only
• Individual   Subscription (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 Subscription. Available only for renewal members.
• subscription amount 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.https://jio.net.in/Janbase2324.php
• **  Subscription terms and rates shall be reviewed annually and necessary corrective action shall be taken (if required) to keep the portfolio viable.

32. Not Payable benefit.

In Patient Hospitalisation (This exclusion is related to – Hospitalisation benefit)

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.: A 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: Willful or deliberate exposure to danger, intentional self-Injury, Suicide, 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, tobacco chewing, smoking cessation programs and the treatment of nicotine addiction or any other substance abuse treatment or services, or supplies, impairment of Covered  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 coronavirus when hospitalisation 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 Hospitalisation.

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 Hospitalisation 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 Hospitalisation 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 Counterpulsation (ECP), Enhanced External Counterpulsation (EECP), Hyperbaric Oxygen Therapy, high intensity focused ultrasound, balloon sinuplasty, Deep Brain Stimulation,

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 Covered 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. Non-Medical Expenses (2): Administrative charges related to a Hospital stay not expressly mentioned as being covered, including but not limited to charges for admission, discharge, administration, registration, bio-medical, linen, documentation and filing, including MRD charges (medical records department charges).

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. Covered 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. Excluded Hospital - Hinduja- Khar, Breach Candy, Kokilaben Hospital. Tratment taken in this hospital are not payable in this contributory community service program. 

48. Treatment provided by anyone with the same residence as Insured Person or who is a member of the Covered  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 Monoclonal antibody e.g. Trastuzumab , Antibody cocktail , Infliximab, rituximab, avastin, lucentis group of drugs.

50. Domiciliary Hospitalisation, OPD treatment is not covered.

51.Consumables are not payable.

52.Any consequential or indirect loss arising out of or related to Hospitalization.

53.Air Ambulance.

OPD Discounts-out of Scope

Vision Corrections, Contact lens, and cost of spectacles

All Dental treatments

Mental health consultations

Any Cosmetic treatments

Nonprescription medicines and diagnostic tests

Consultation, Medicines or diagnostic tests purchased out of network unless agreed in advance.

Physiotherapy sessions

Medicines, diagnostic tests on prescriptions written before scheme start date.

Cost of Insulin

Medicine, doctor consultation or diagnostic test cost covered by any insurance of beneficiary are outside the scope

Cost of equipment for disabled people

Orthopaedic equipment cost

Cost of dialysis (excluded for OPD but is included in In Patient as Day Care)

Cost of Oral Cancer Drugs and cancer related diagnostics

Abortion, Miscarriage, Termination of Pregnancy (Voluntary/Accidental)

Medicines administered at hospital or medical facility.

33. Treatments excluded in 1st Year: Even if diagnosed after Subscription Inception.
     For 1st Year renewal members benefits are capped at 75% of payable, except capped ailment which are paid up to capping limit mentioned below from 2nd Year renewable member benefits are capped 100% of payable except capped ailment mentioned below.

List of Capping Ailments:

5,000 compulsory deductible applicable on every claim of 30,000 and above. Compulsory deductible not applicable on capped ailment 

10% co-pay will be deducted in each & every case of medical management (Other than Surgical Cases like Fever, Breathlessness)