Terms & Conditions

of

JIO SUPER TOP UP MEDICLAIM PART-2

SUPER TOP UP: UNIQUE TYPE OF MEDICLAIM

An ADDITIONAL COVERAGE of Mediclaim BEYOND a Chosen Specified Limit,

SO IT ACTS as a Cushion & Comes in to Action When Such Limit Is Exhausted.

1. Available for All JAIN </Shravak-Shravika Members of JIO.
2. ENHANCE Your MEDICLAIM Sum Insured UPTO Rs.20 Lakh at very Nominal Premium.
3. Available SUPER TOP-UP Sum Insured of Rs.2 Lakh, Rs.5 Lakh and Rs.10 Lakh
4. Family Floater for Maximum 6 Members (1 + 5).

Proposer + Spouse ( Husband/wife)+ 2 Dependent Children Up to 25 years of age

+ 2 Dependent Parents OR Parents In-Laws Up to 85 years

( Any one set of parents to be covered, combination not allowed).

5. Maximum entry age: – Up to 85 Years. Once enrolled LIFE TIME renewal possible.
6. NO Medical Checkup </required
7. PRE-EXISTING Diseases are covered from DAY ONE.
8. NO Waiting Period. (Waiting period for 1st year, 2nd year and 4th year disease are Not Applicable.)
9. NO Capping ( Sub-Limit) </applicable on any disease & on any family member.
10. NO Co-Payment </applicable on any type of claims.
11. Opportunity to Avoid Heavy Deduction </due to ROOM RENT LIMITS.
12. The Policy offers In-Patient HOSPITALIZATION Cover
13. The policy benefit are covered WITHIN INDIA only .
14. Pre-Hospitalization Medical Expenses up to 30 DAYS are also
15. Post-Hospitalization Medical Expenses up to 60 DAY are also COVERED.
16. 562 Types of DAY CARE Procedures are covered
17. Claims Payable on REIMBURSEMENT </Basis only
18. AYUSH TREATMENT is also covered up to limits defined by IRDA.
19. Portability Available for the policy After a Year AT THE TIME OF RENEWAL .
20. PORTABILITY CONDITIONS : </Upon the Insured Person ceasing to be a member of the Policyholder, such Insured Person shall have   the option to migrate to an available retail health insurance policy available with Aditya Birla Health Insurance </in accordance with the Portability guidelines issued by the IRDA, provided that :

• Continuity of benefits will be provided for the period based on the number of years of continuous coverage under this Policy with Us.
• We should have received the application for Portability with complete documentation at least 45 days before ceasing to be an Employee of the Policyholder.
• We may subject such proposal to our medical underwriting and decide the terms and conditions upon which We may offer cover, the decision as to which shall be in Our sole and absolute discretion.

21. Proposer will be eligible for Deduction Under SEC. 80 D of Income Tax Act.
22. Midterm Additions will NOT be allowed under the policy EXCEPT Newly Married Spouse and New Born Baby.
23. INCREASE in PLAN / SUM INSURED will NOT be allowed for Next Three Years. But PROPOSER CAN REDUCE the Sum Insured. Deletion will be only on account of death of primary insured/self. No deletion in between the policy tenure.

ADDITIONAL POLICY : Accidental Relief Cover for PROPOSER is also attached of Rs.10 Lakh and Rs.5 Lakh Sum Insured with extra ordinary features.

## POINTS TO BE NOTED FOR “SUPER TOP UP”

Some more important information about this policy

(Please read it carefully)

24. It ENHANCES your Existing Mediclaim Sum Insured.
25. This plan is ALSO AVAILABLE for members WITHOUT any Existing Mediclaim
26. You can TOP UP ANY TYPE of your existing MEDICLAIM issued by any insurance company like Retail Personal Mediclaim, Family Floater Mediclaim, Group Mediclaim, JIO Mediclaim etc.
27. IRRESPECTIVE of your Existing MEDICLAIM Sum Insured, You Can Choose ANY AMOUNT as DEDUCTIBLE LIMIT (from the available option- Rs.2 lakh, Rs.3 lakh, Rs.5 lakh and Rs.10 lakh).
28. DEDUCTIBLE LIMIT: The chosen amount up to which the AGGREGATE Medical CLAIMS of FAMILY, Incurred During The Policy Period WILL NOT Be Payable by this Super Top Up Mediclaim AND The SAME AMOUNT shall be PAYABLE BY Member’s BASE POLICY OR the EXPENSES will be BORNE BY THE
29. Hospitalization CLAIMS incurred During the Super Top Up Policy Period for the WHOLE Family in ONE OR MORE Occasions will be Considered TO CALCULATE THE DEDUCTIBLE LIMIT.
30. FOR CLAIMS where Base Policy Is AVAILABLE : All Claims will be settled on basis of Settlement Letter of TPA/Insurer & all the claim Documents Attested By Existing Insurer / TPA.
31. FOR CLAIMS where Member DON’T HAVE Base Policy : Need to Submit ORIGINAL Claim Documents to TPA within document submission period (30days from discharge date).
32. Super top up policy are also DOESN’T PAY Non-Medical expense like any other Mediclaim policy as per IRDA rule.
33. JIO Super Top Up Mediclaim Part-2 PREMIUM CHART (2018-19):

The Member who DOES NOT HAVE BASE POLICY (Existing Mediclaim) their deductible limit starts from Rs 3 Lakh and more.

They can also choose following option apart from the table above.

34. Deductible Limit for Proposer WITHOUT ANY EXISTING MEDICLAIM has to be Minimum of 3 Lakh.
35. Deductible limit of Minimum3 Lakh is also Applicable for that Particular Member of family Who Does Not Have Any Base Policy AT THE TIME OF CLAIM.
36. HIGHER of the ROOM RENT is applicable,

1. 1.          1% and 2% of SUPER TOP-UP Sum Insured

1. 1.                                            OR

1. 1.          1% and 2% of BASE POLICY Sum Insured

• 1. • Member with Base Policy : As per Base Policy or 1% for Normal Room & 2 % for ICU Room per day on Base Policy SI or 1% for Normal Room and 2 % for ICU per day on Super top up sum insured, whichever is higher.
     • Member without Base Policy : 1% for Normal Room and 2 % for ICU per day on Super top up deductible limit for the First year and 1% for Normal and 2% for ICU of Super top-up Sum-Insured from second year.
     • If the Insured occupies a room with a room rent limit higher than his eligibility, then all the other charges except medicine, implants etc. shall be processed on proportionate basis.

37. After the INCEPTION of Super Top Up Mediclaim, the Expenses incurred thereafter shall only be considered TO CALCULATE THE DEDUCTIBLE LIMIT.
38. After CROSSING the Chosen Deductible LIMIT, Due To Aggregate Claims falling WITHIN POLICY PERIOD of super top up Mediclaim Shall Be Payable under this policy Upto the Sum Insured.
39. IF Base Policy Sum Insured is exhausted or partially Exhausted Before Inception of Super Top Up Mediclaim then the same WILL NOT BE Considered IN CALCULATION OF DEDUCTIBLE LIMIT.
40. Organ Donor Expenses :-

• Policy will cover the Medical Expenses incurred for an organ donor’s treatment for the harvesting of the organ donated up to the limit as specified in the Policy Schedule or Certificate of Insurance provided that the donation confirms to The Transplantation of HUMAN ORGANS ACT 1994 and the organ is FOR THE USE OF THE INSURED PERSON.
• Policy will NOT cover the Pre-hospitalization Medical Expenses or Post-hospitalization Medical Expenses of the organ donor; Screening expenses of the organ donor; Any other Medical Expenses as a result of the harvesting from the organ donor; Costs directly or indirectly associated with the acquisition of the donor’s organ; Transplant of any organ/tissue where the transplant is experimental or investigational; Expenses related to organ transportation or preservation; Any other medical treatment or complication in respect of the donor, consequent to harvesting.

101. This is an INDIVIDUAL Basis POLICY.
102. This additional policy is COMPULSORY for all PROPOSER of Super Top-Up Mediclaim with nominal additional premium.
103. Cover is available on optional basis for OTHER FAMILY MEMBERS on Individual basis with additional premium.
104. Premium Table for Accidental Relief Cover ( 2018-19 ) for JIO Members

105. Accidental Relief Cover AVAILABLE to members between 5 Years to 85 years of age.
106. Accidental Relief Coverage details :-

Spouse and other Dependents can be covered on Individual Basis for all benefits except benefit Number 7,8 & 9 which is applicable only for Primary Insured Person.

1. 106. Details of Coverage
2. 1. 106.1 Accidental In-patient Hospitalization (limited to India)If an Insured Person suffers an Injury due to an Accident and such Injury requires the Insured Person to be Hospitalized as an In-patient in a Hospital room ( Shared/ Twin Sharing AC), then policy will cover the costs incurred on Medical Expenses up to the limit specified in the Policy Schedule or Certificate of Insurance provided that:
      
      1. The Insured Person is Hospitalized in India;
      2. The Hospitalization is for Medically Necessary Treatment and is on the written advice of a Medical Practitioner.
      3. The Insured Person is admitted to Hospital within 7 days of the occurrence of the Accident.
3. 1. 106.2. Recovery BenefitIf the Insured Person suffers an Injury due to an Accident and such Injury results in the Hospitalization of the Insured Person during the Policy Period for at least 10 consecutive days ( Minimum continuous 10 days), then policy will pay the lump sum amount as specified in the Policy Schedule or Certificate of Insurance.
4. 1. 106.3. Permanent Partial DisablementIf the Insured Person suffers an Injury due to an Accident that that results in the permanent partial disablement of the Insured Person of the nature as specified in the table below, then policy will pay the percentage of the Sum Insured as specified in the table below.

1. Table of Benefits	Percentage of the Sum Insured payable
   Type of Permanent Partial Disablement
   i)    Total and irrecoverable loss of sight of one eye	50%
   ii)   Loss of one hand or one foot	50%
   iii)  Loss of all toes – any one foot	10%
   iv)  Loss of toe great – any one foot	5%
   v)  Loss of toes other than great, if more than one toe lost, each	2%
   vi) Total and irrecoverable loss of hearing in both ears	50%
   vii)  Total and irrecoverable loss of hearing in one ear	15%
   viii)  Total and irrecoverable loss of speech	50%
   ix)   Loss of four fingers and thumb of one hand	40%
   x)  Loss of four fingers	35%
   xi) Loss of thumb –both phalanges	25%
   xii)  Loss of thumb – one phalanx	10%
   xiii) Loss of index finger-three phalanges	10%
   – two phalanges	8%
   – one phalanx	4%
   xiv)Loss of middle/ring/little finger-three phalanges	6%
   – two phalanges	4%
   – one phalanx	2%

1. In case the Insured Person suffers a loss not mentioned in the table above, then an external medical advisor will determine the degree of disablement and the amount payable, if any. 

1. 106.4. Permanent Total DisablementIf the Insured Person suffers an Injury due to an Accident that results in the permanent total disablement of the Insured Person of the nature as specified in the table below, policy will pay 100% of the Sum Insured.

1. Table of Benefits

   Type of Permanent Total Disablement

   1) Total and irrecoverable loss of sight of both eyes

   2) Loss by physical separation or total and permanent loss of use of both hands or both feet

   3) Loss by physical separation or total and permanent loss of use of one hand and one foot

   4) Total and irrecoverable loss of sight of one eye and loss of a Limb

   5) Total and irrecoverable loss of hearing of both ears and loss of one Limb/loss of sight of one eye

   6) Total and irrecoverable loss of hearing of both ears and loss of speech

   7) Total and irrecoverable loss of speech and loss of one Limb/loss of sight of one eye

   8) Permanent total and absolute disablement (not falling under the above) disabling the Insured Person from engaging in any employment or occupation or business for remuneration or profit, of any description whatsoever which results in Loss of Independent Living

1. For the purpose of this Benefit,– Limb means a hand at or above the wrist or a foot above the ankle;– Physical separation of one hand or foot means separation at or above wrist and/or at or above ankle, respectively.Once a claim has been accepted and paid under this Benefit then cover under this Benefit shall immediately and automatically cease in respect of that Insured Person.

1. 106.5. Accidental DeathIf the Insured Person suffers an Injury due to an Accident that results in the death of the Insured Person, Policy will pay 100% of the Sum Insured provided that:
   1. Once a claim has been accepted and paid under this Benefit then cover under this Policy shall immediately and automatically cease in respect of that Insured Person.

1. 106.6. Funeral ExpensesIf We have accepted a claim under Accidental Death in accordance with Sections II.1 then in addition to the amount payable under that Section, POLICY WILL PAY A LUMPSUM AMOUNT as specified in the Policy Schedule or Certificate of Insurance towards funeral, cremation/ or burial and transportation of the body to the place of the funeral ceremony for the Insured Person.

1. 106.7. Education Fund for ChildrenIf We have accepted a CLAIM UNDER ACCIDENTAL DEATH OR PERMANENT TOTAL DISABLEMENT, then in addition to the amount payable under that Section, Policy will PAY A LUMP SUM AMOUNT as specified in the Policy Schedule or Certificate of Insurance in respect of each surviving Dependent Child, UP TO 2 DEPENDENT CHILDREN, if specified in the Policy Schedule or Certificate of Insurance irrespective of whether the child is an Insured Person under this Policy.
   This Benefit shall be payable subject to the Dependent Child being up to 25 years of Age as on date of occurrence of the event irrespective of whether the child is an Insured Person under this Policy and PROVIDED THAT THE DEPENDENT CHILD DOES NOT HAVE ANY INDEPENDENT SOURCE OF INCOME.

1. 106.8. Marriage Fund for ChildrenIf We have accepted a CLAIM UNDER ACCIDENTAL DEATH OR PERMANENT TOTAL DISABLEMENT, then in addition to the amount payable under that Section, We will PAY A LUMP SUM AMOUNT as specified in the Policy Schedule or Certificate of Insurance in respect of the Dependent Child that is UNMARRIED, UP TO 2 DEPENDENT CHILDREN, if specified in the Policy Schedule or Certificate of Insurance, irrespective of whether the child is an Insured Person under this Policy.

1. 106.9. Orphan Benefit for ChildrenIf We have accepted a CLAIM UNDER ACCIDENTAL DEATH for the INSURED PERSON and that INSURED PERSON’S SPOUSE (who may or may not be an Insured Person) is also deceased in the SAME POLICY YEAR at the time of death of the Insured Person, and the CHILD BECOMES ORPHAN, then in addition to the amount payable under that Section, POLICY WILL PAY A LUMP SUM AMOUNT as specified in the Policy Schedule or Certificate of Insurance in respect of the DEPENDENT CHILD, up to 2 Dependent Children, if specified in the Policy Schedule or Certificate of Insurance, irrespective of the whether the child is an Insured Person under this Policy.This Benefit shall be payable subject to the DEPENDENT CHILD BEING UP TO 25 YEARS OF AGE as on date of occurrence of the event and provided that the Dependent Child does not have any independent source of income.Any claim towards Orphan Benefit where the Dependent Child is a minor, shall be payable to the legal guardian of the Dependent Child.

41. PERMANENT EXCLUSIONS (Not Payable) FOR JIO SUPER TOP UP MEDICLAIM As Per Insurance Company Under IRDA Guidelines

We shall not be liable to make any payment for any claim under any Benefit in respect of any Insured Person directly or indirectly caused by, based on, arising out of, relating to or howsoever attributable to any of the following:

1. 41.1. Injury/Disease contracted due to war and allied perils

1. 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 defense, 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.

1. 41.2. Injury while attempting suicide or criminal activity

1. Committing or attempting to commit a breach of law with criminal intent, intentional self- Injury or attempted suicide while Insured Person is sane or insane.

1. 41.3. Participation in hazardous activity and military operation

1. Willful or deliberate exposure to danger, intentional self- Injury, non- adherence to Medical Advice, 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, parasailing, ballooning, skydiving, river rafting, polo, snow and ice sports in a professional or semi- professional nature.
   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.

1. 41.4. Treatment due to intoxication of drug and alcohol

1. Abuse or the consequences of the abuse of intoxicants or hallucinogenic substances such as intoxicating drugs and alcohol, including smoking cessation programs and the treatment of nicotine addiction or any other substance abuse treatment or services, or supplies.

1. 41.5. Weight management programme and treatment of obesity

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

1. 41.6. Lasik treatment of Eye

1. Treatment for correction of eye sight due to refractive error including routine examination.

1. 41.7. Health Check-up and Evaluation

1. All routine examinations and preventive health check-ups.
   Admission primarily for diagnostic purposes not related to Illness for which Hospitalization has been done.
   Preventive care, vaccination including inoculation and immunizations (except in case of post-bite treatment); any physical, psychiatric or psychological examinations or testing .
   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.

1. 41.8. Plastic Surgery or Cosmetic Surgery

1. Cosmetic, aesthetic and re-shaping treatments and Surgeries:
   Plastic Surgery or cosmetic Surgery or treatments to change appearance unless medically required and certified by the attending Medical Practitioner for reconstruction following an Accident, cancer or burns.
   Treatment for alopecia, baldness, wigs, or toupees, and all treatment related to the same.

1. 41.9. Circumcision

1. Circumcisions (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.
   Non- allopathic treatment, except as per coverage of AYUSH Treatment.

1. 41.10. OPD claims

1. Conditions for which treatment could have been done on an out-patient basis without any Hospitalization.

1. 41.11. Unproven and Experimental treatment

1. Unproven/Experimental treatment, investigational treatment, devices and pharmacological regimens.Treatment for Age Related Macular Degeneration (ARMD) , treatments such as Rotational Field Quantum Magnetic Resonance (RFQMR), External Counter Pulsation (ECP), Enhanced External Counter Pulsation (EECP), Hyperbaric Oxygen Therapy.

1. 41.12. Convalescence and Old age condition

1. Convalescence (except as per the coverage as coverage defined in Section 11 – Recovery Benefit), cure, rest cure, sanatorium treatment, rehabilitation measures, private duty nursing, respite care, long-term nursing care or custodial care.

1. 41.13. Enteral feeding

1. 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.

1. 41.14. Hearing aids, Spectacles and multifocal lens

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

1. 41.15. External device and Non Medical items

1. Medical supplies including elastic stockings, diabetic test strips, and similar products.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.) and oxygen concentrator for bronchial asthmatic condition, cost of cochlear implant(s) unless necessitated by an Accident or required intra-operatively. Cost of artificial limbs, crutches or any other external appliance and/or device used for diagnosis or treatment (except when used intra-operatively).Expenses which are medically not required 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.Charges related to a Hospital stay not expressly mentioned as being covered, including but not limited to charges for admission, discharge, administration, registration, documentation and filing, including MRD charges (medical records department charges).Non-medical expenses including but not limited to RMO charges, surcharges, night charges, service charges levied by the Hospital under any head and as specified in the Annexure V for non- medical expenses.

1. 41.16. Mental Disease and Parkinsonism

1. Psychiatric or psychological disorders, mental disorders (including mental health treatments), Parkinson and Alzheimer’s disease, general debility or exhaustion (“rundown condition”), sleep-apnea, stress.

1. 41.17. External Congenital Disease and Genetic Disease

1. External Congenital Anomalies, diseases or defects, genetic disorders.

1. 41.18. Stem Cell therapy or surgery

1. Stem cell therapy or surgery, or growth hormone therapy

1. 41.19. Sexually transmitted disease & AIDS

1. Venereal disease, all sexually transmitted disease or Illness including but not limited to genital warts, Syphilis, Gonorrhea, Genital Herpes, Chlamydia, Pubic Lice and Trichomoniasis.“AIDS” (Acquired Immune Deficiency Syndrome) and/or infection with HIV (Human Immunodeficiency Virus) including but not limited to conditions related to or arising out of HIV/AIDS such as ARC (AIDS Related Complex), Lymphomas in brain, Kaposi’s sarcoma, tuberculosis.

1. 41.20. Maternity

1. Complications arising out of pregnancy (including voluntary termination), miscarriage (except as a result of an Accident or Illness), maternity or birth (including caesarean section) except in the case of ectopic pregnancy for In-patient only.

1. 41.21. Family Planning and Surrogacy

1. 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.

1. 41.22. Illegal Organ Transplant Surgery

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

1. 41.23. Surgery of dislocation

1. 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.

1. 41.24. Dental treatment

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

1. 41.25. After Brain death treatment

1. Artificial life maintenance, including life support machine used to sustain a person, who has been declared brain dead, as demonstrated by:Deep coma and unresponsiveness to all forms of stimulation; orAbsent pupillary light reaction; orAbsent oculovestibular and corneal reflexes; or Complete apnea.

1. 41.26. Developmental Issue

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

1. 41.27. Medical Practitioner

1. Treatment taken from a person not falling within the scope of definition of Medical Practitioner.Treatment charges or fees charged by any Medical Practitioner acting outside the scope of license or registration granted to him by any medical council.Treatments rendered by a Medical Practitioner who is a member of the Insured Person’s family or stays with him, save for the proven material costs are eligible for reimbursement as per the applicable cover.Any treatment or part of a treatment that is not of a reasonable charge, is not a Medically Necessary Treatment; drugs or treatments which are not supported by a prescription.

1. 41.28. Treatment taken Out of India

1. Treatment taken outside India not covered in the policy.

PARTNERS for JIO Super Top Up Mediclaim Part-2:

Insurance Company: ADITYA BIRLA HEALTH INSURANCE CO.LTD.

Insurance Brokers: EDELWEISS INSURANCE BROKERS LTD.

Third Party Administrator: Vidal Healthcare TPA Pvt.Ltd.