welcome to presentation on “jeevan arogya”. table 904 jeevan arogya

Welcome to

Presentation on

“JEEVAN AROGYA”

Table 904

JEEVAN AROGYA

Details:

This is a Non linked Health Insurance plan which provides for Fixed Benefits for hospitalization for almost all types of surgical procedures.

Why Jeevan Arogya?

• Jeevan Arogya is supplement of Mediclaim .

• Mediclaim covers the expenses incurred on medication.

• Whereas Jeevan Arogya covers the loss of income during hospitalisation/ post operation rest period.

• So for every hospitalisation the benefits doubles.

Benefits:

Hospital Cash Benefit ( HCB) Major Surgical Benefit (MSB)

covering 140 surgeries. Day Care Procedure Benefit (DCPB)

covering 140 surgeries. Other Surgical Benefit (OSB) not covered

under MSB & DCPB.

In case of MSB under category 1 or 2, Ambulance Cost, Premium waiver benefit and Quick Cash facility is also payable.

Advantages: Simple documentation. The Benefits payable are irrespective

of cost incurred, So there is no worry about amount of claim settlement as one knows beforehand about how much amount will be disbursed.

Benefits can be used as top up cover to take care of recovery expenses OR make good the loss of income due to temporary break in employment.

Members:

A person called as Principle Insured (PI) can take the policy covering himself / herself. The Spouse, Parents, Parents in law and dependent children, may also be covered under the same policy.Only PI can claim the Tax Benefits.

Members:

If both Parents/Parents in law are alive and are eligible for cover, then either both of them will be covered or none of them will be covered. If existing Spouse, Parents, Parents in law and dependent children are eligible for inclusion and are not covered at inception of the policy, they will not be covered in future.

Addition of Members:

If the PI gets married/remarried during the term of policy, the spouse and parents in law can be included in the policy within six months from the date of marriage/remarriage.Any child born/legally adopted after taking the policy can be covered from the next immediate policy anniversary date following the date on which the child completes the age of 3 months.

Premium Rates:

Premium for PI and other members are different and shall be based on age at entry, the initial HCB chosen and gender of each insured.Premium rates are Guaranteed for first 3 years from DOC. The premium rates may be revised every three years with prior permission from IRDA. The revised premiums payable will be as per age at entry of all insured.

Features and Conditions:

Minimum age at entry:PI, Spouse & Parents : 18 years lbd.Children : 3 months completed.

Maximum age at entry:PI and Spouse : 65 years lbdParents & Parents in Law : 75 yrs lbdChildren : 17 years lbd.

Cover ceasing age : PI, Spouse, Parents and Parents in law : 80 years lbd.Children : 25 years lbd.


IDB PI Spouse Parents/ Children

Min ` 1000 ` 1000 ` 1000

Max ` 4000Equal to or less

then PIEqual to or less then Spouse/PI

Initial Daily Benefit (IDB) for HCB:

IDB should be in multiples of ` 1000. Both Parents/ All Children should be

covered for equal amount.Max. Health Insurance allowed per life

under all Plans (901, 902, 903 & 904): ` 10 lakhs.


Mode of Payment: Yearly, Half yearly, Quarterly or Monthly ECS only.

Rebates:Mode Rebate: Yearly :2%Half yearly :1%

HCB Rebate: HCB (`) For PI For Members 2000 500 250 3000 1000 500 4000 1500 750

Options:

Insured Spouse to become Principal Insured:PI and Spouse have an option to continue the policy in case of exit of PI from the policy. If option is exercised, then in case of death/expiry of cover of PI, the surviving insured spouse will become the PI and policy will continue. The premium for insured spouse will change from the next due date and would be based on premium rates applicable to PI as per his/her age at entry.

Options:

Term Assurance and Accident Benefit Rider: Allowed for PI and Insured Spouse only. Minimum ` 100000 and Maximum up to MSBSA. An amount equal to Term Assurance Sum Assured will be

payable on natural death during the term of Term Rider. Accident Rider is allowed only if Term Rider is opted for. In case of accidental death, the additional Sum Assured will be

payable as lump sum along with the Term rider Sum Assured. Premium of ` 0.50 per ` 1,000/- of SA for each life is payable for

accident benefit. Age at entry: 18 years lbd to 50 years ndb. Maximum Term: 35 years or up to age 60 years nbd whichever is

earlier. Term rider SA is not to be added for calculation of SUC. Other underwriting guidelines of Term Rider will apply.

Options:Option to Migrate for Children:• Children covered will have the option to take a suitable

new health insurance policy (subject to underwriting) at the end of age of 25 years OR after completion of 18 years of age. The new policy must be purchased within 90 days of

termination. Child shall be eligible for suitable credits gained for pre-

existing conditions and time bound exclusions of all previous years. However the outstanding waiting periods and outstanding period of any Exclusion will apply to new policy.

The credits shall be available up to maximum of the current SA. Other terms and conditions and premium rates will be as

applicable for the new policy

Death Benefits:

No death benefit will be payable on death of any insured unless Term Rider benefit has been opted for.

On death of Principal Insured (PI):a) If option is exercised the surviving

spouse will become the PI. The premium will change from next due date as per age at entry of spouse as PI.

Death Benefits:

b) If insured spouse had predeceased the PI or option is not exercised for insured spouse to become new PI on death of PI, then other insured will have the option to take a new policy and existing policy will terminate.

The conditions for new policy will be as under: New policy will be issued without any underwriting if

the new policy is bought within 90 days of the termination of the existing policy.

The maximum age at entry condition will not apply. The outstanding waiting periods and outstanding

period of any exclusion will apply. Other terms and conditions including premium rates

will be as applicable for the new policy.

Death Benefits:

On death of an insured person other than PI:

The policy will continue after removal of deceased insured and change in premium will apply from premium coinciding/next premium due following the date of intimation.

Maturity Benefit:

No maturity benefit is payable at end of cover.

Hospital Cash Benefit (HCB):If any of the Insured life is hospitalized due to Accidental Body Injury or Sickness then Applicable Daily Benefit (ADB) will be payable regardless of actual cost incurred, subject to following maximum limits:

Non ICU : 30 days in 1st year and 90 days per year thereafter (Inclusive of stay in ICU).

ICU: 15 days in 1st year & 45 days per year thereafter.

Max. Life Time Benefit for each insured: Non ICU: 720 days inclusive of stay in ICU.In ICU: 360 days.

The HCB is not payable in case of insured undergoing DCPB, but payable under MSB and OSB.

Hospital Cash Benefit (HCB): The ADB will be as per initial daily benefit

(IDB) opted during 1st year and will increase by 5% every year maximum up to 1.5 times of IDB.

The ADB will also increase by 5% every 3 years (i.e. during 4th, 7th, 10th year and so on) without any limit as No claim bonus, provided there is no claim between two periods. (e.g: If there is claim in 5th year there will be no addition during 7th year, there will be addition during 10th year if there is no claim between 7th & 10th year).

Hospital Cash Benefit (HCB):

Year ADB Year ADB

1st 4000 9th 5600 + 400

2nd 4200 10th 5800 + 600

3rd 4400 11th 6000 + 600

4th 4600 + 200 12th 6000 + 600

5th 4800 + 200 13th 6000 + 800

6th 5000 + 200 14th 6000 + 800

7th 5200 + 400 15th 6000 + 800

8th 5400 + 400 16th 6000 + 1000

ACB for ` 4000 Initial Cash Benefit


The ADB is paid per day of hospitalization, first 24 hours excluded. Then for any continuous period of 24 hours or part thereof subject to min. 4 hours. (i.e. min. stay should be for 28 hours to claim benefit for 1 day).

The ADB in case of hospitalization in ICU is twice the ADB.


In case of Hospitalization for a continuous period of 7 days or more, the Daily Hospital Cash Benefit would also be paid for first 24 hours (day one) of hospitalization.

Hospitalization for 6 days and 4 hours or more will be considered as 7 days.


Example: An insured is hospitalized for illness for 10 days during 4th year of policy. Stay includes 2 days and 5 hours in ICU. The initial HCB opted is `4000.

Considering no claim in first 3 years, ADB during 4th year will be `4800.

HCB for ICU will be payable for 3 days (4800x 2 x 3) : `28800

HCB for Non ICU will be payable for 7 days (4800 x 7) : ` 33600

Major Surgical Benefit (MSB):

The Major Surgical Benefit is the amount paid to the insured in the event of his/her undergoing any of the listed 140 surgeries only, irrespective of actual expenses incurred, subject to following maximum limits:

Basic MSBSA : 100 Times of ADB

Max Benefit per annum : 100% of MSBSAMax life time Benefit : 800% of MSBSA


The benefit payable will be as the percentage of MSBSA as under:

• Category 1: 100% under 15 Surgeries.• Category 2: 60% under 42 Surgeries. • Category 3: 40% under 60 Surgeries.• Category 4: 20% under 23 Surgeries.

Total 140 Surgeries as per Annexure.

The MSB is payable only once for the same Surgery during lifetime.


Example: An insured is hospitalized for MSB under Category-1 for 10 days during 2nd year of policy. The initial HCB opted is `4000.

The following benefits are payable: ADB during 2nd year will be `4200. HCB will be payable for 10 days (4200 x 10)

: `42000 MSB payable will be 100% of MSBSA :

` 420000


In case of MSB falling under Category 1 or 2 is payable, the following additional benefits are also available:

1. Ambulance Cost: An additional lump sum of `1000 will be payable in lieu of ambulance expenses once in a policy year for each insured.

2. Premium Waiver Benefit: The total annualized premium i.e. total one year premium coinciding/following the date of surgery will be waived.


3. Quick Cash facility:Under this option 50% of eligible MSB amount would be paid as advance even during the period of hospitalization of any of the insured, Provided surgery is performed in any of listed hospitals, subject to approval from the TPA . PI has to apply in prescribed format and amount will be credited in his/her bank account directly.

Day Care Procedure Benefit (DCPB):

The DCPB is the amount paid to the insured in the event of his/her undergoing any of the listed 140 day care surgeries only. The amount payable will be 5 (five) times of ADB irrespective of actual expenses incurred, subject to following maximum limits:

Basic DCPB : 5 Times of ADB.Max Benefit per annum : 3 Surgeries.Max life time Benefit : 24 Surgeries.

If a DCPB is performed no Hospital Cash Benefit shall be paid.

Day Care Procedure Benefit (DCPB):

Example:

An insured is hospitalized for DCPB during 1st year of policy. The initial HCB opted is `4000.

ADB during 1st year will be `4000. The DCPB payable will be (4000 x 5): `20,000

Other Surgical Benefit (OSB):

In the event of an Insured under this Policy undergoing any Surgery not listed under MSB or DCPB, due to Accidental Bodily Injury or Sickness a Daily Benefit equal to 2 (two) times of ADB, shall be payable regardless of the actual costs incurred, subject to following maximum limits:

Basic OSB : 2 times of ADBMax Benefit per annum : 15 days in 1st

year and 45 days per annum thereafter.Max life time Benefit : 360 days.


OSB is payable for each continuous period of 24 hours or part thereof provided any such part stay exceeds a continuous period of 4 hours of Hospitalization. OSB is payable from day one of hospitalization, subject to minimum stay of 24 hours. HCB is also payable as per rules.


Example: An insured is hospitalized for OSB for 5 days during 3rd year of policy. The initial HCB opted is `4000.

The following benefits are payable: • ADB during 3rd year will be ` 4400.• HCB will be payable for 4 days (4400 x 4 ) :

` 17600 • OSB will payable for 5 days (4400 x 2 x 5)

: ` 44000• Total : ` 17600 + ` 44000 = ` 61600

Other Common conditions applicable under all the Benefits i.e. HCB, MSB, DCPB & OSB:

The Benefit Limits in respect of an Insured under this Policy, shall solely and exclusively apply to that Insured. Any unclaimed Benefit of any one Insured is not transferable to any other Insured.

The Benefit shall be payable only if Hospitalisation/ surgical procedure has occurred within India.


General Waiting period: • 90 days for new policy.• 45 days if revival request is received within

90 days of FUP.• 90 days if revival request is received after

90 days of FUP.• There is no waiting period in cases of

accident.


Specific Waiting period:

The specific waiting period in respect of the treatments specified as per list shall be as follows:

• 2 years from DOC for each insured for new policy.

• 2 years from DOC for each insured if revival request is received within 90 days from FUP.

• 2 years from date of revival if revival request is received after 90 days of FUP.

Other Terms and Conditions:

Termination Of Policy:A. If policy is issued on single life:

The policy shall terminate at the earliest of the following:

• Non-payment of premiums within the revival period.

• On death.• On the Date of Cover Expiry.• On exhausting all the lifetime maximum

Benefit Limits.


B. If policy is issued on more than one life:The policy shall terminate at the earliest of the following:

• Non-payment of premiums within the revival period.

• On PI exhausting all the lifetime maximum Benefit Limits.

• On death or Date of Cover Expiry of the Principal Insured and if the Policy does not continue with the Insured Spouse as the PI.

• On the death or Date of Cover Expiry of Insured Spouse after the Policy continues with the Insured Spouse as the PI after the PI dies.


Important Exclusions :

• Any Pre-existing Condition unless disclosed to and accepted by the Corporation prior to the Date of Cover Commencement or the Date of Revival (if the Policy is revived after lapsation).

• Removal or correction or replacement of any material/prosthesis/medical devices that was implanted in a former surgery before Date of Cover commencement or Date of Revival (if the Policy is revived after discontinuance of the Cover).


Important Exclusions :

• Any diagnosis or treatment or surgery arising from or traceable to pregnancy (whether uterine or extra uterine), childbirth including caesarean section, medical termination of pregnancy and/or any treatment related to pre and post natal care of the mother or the new born.

• Hospitalisation expenses related to non-allopathic methods of treatment or surgery.


Days of Grace:

A grace period of one calendar month but not less than 30 days will be allowed for payment of yearly or half-yearly premiums and 15 days for monthly (ECS).

If the due premiums are not paid within the days of grace the policy will lapse.

Other Terms and Conditions: Revivals/Reinstatement of Discontinued Policies:• The Policy can be revived by the Principal Insured

anytime during a period of two years from the due date of first unpaid premium called the “period of revival” or “revival period”.

• The revival will be subject to payment of outstanding premiums with interest & Submission of evidence of good health.

• Waiting periods and Exclusions as earlier will apply on revival.

• Further, if the premiums are revised during the period of lapse the premium before and after the revival may be different.

• Revival/reinstatement is not allowed after the revival period.


Surrender:

No surrender value will be available under the policy.

Income Tax Benefits

Income Tax benefits are available for premiums paid towards health insurance including Mediclaim under Section 80D of IT Act as under:

• For Self/Spouse/Dependent Children :`15000• For Parents, whether Dependent or not :`15000• Additional Amount for Sr. Citizen :`5000

Cooling-off PeriodPolicyholder may return the policy within 15 days if one is not satisfied with “Terms and Conditions” subject to deduction of following charges:•Stamp Duty on the policy.•Actual Cost of Medical Examination and Special Reports.•Mortality Charges if opted for Term Rider.•4.17 paisa per month per thousand SA for Accident Benefit Rider if opted for.

Morbidity Charges shall not be deducted as there is no cover for first 90 days of policy.

Underwriting Rules:

Age nbdNMG NMS

SUC SUC

Upto 35 yrs 5 lakhs 5 lakhs

36 to 45 yrs 2 lakhs 5 lakhs

46 to 50 yrs 2 lakhs 4 lakhs

NON MEDICAL RULES

Underwriting Rules:

Medical and Special Reports:

Wherever TPA service is available FMR and special reports by TPA is must.

Non-Standard Age proof :

Only NSAP-I allowed.

Term restriction of 25 years will not be applicable.

Underwriting Rules:

Female Lives : All Allowed.

• House wives without income are allowed as PI. Max Cover: ` 5 lakhs subject to equal husband’s health insurance, otherwise Max ` 2 lakhs.

• Pregnant females allowed upto 24 weeks of pregnancy with Latest Gynecologist report & no complications. Otherwise 3 months after delivery.

• Widows with no income proof can be considered as PI, Max Cover: ` 2 lakhs. With income proof: Max. 5 times of income. No restriction if beneficiary.

Underwriting Rules:

Minor Lives: Up to Class II built extra.Major students:Allowed as PI, Max cover: ` 5 lakhs subject to equal parents’ health insurance, otherwise ` 2 lakhs.Retired Lives: With income Proof: 5 times of income as PI, otherwise ` 2 lakhs.

Underwriting Rules:

Sub Standard Lives:

upto EMR +100.

Exclusions:

Max. 2 Exclusions allowed.

Actual Sum Assured (ASA) for SUC:

• For NM/Medical & Special Reports:

• MSBSA under 902,903 and 904 during last 2 calendar years.

Underwriting Rules:

Financial Underwriting: MSB of PI only will be considered, Max. 5 times of income. No income proof required. Occupation Rating: Refer Annexure.NRI Residence Group: Only Group III to VII Allowed without extra, For Treatment in India only.Dating Back: Not Allowed

Sr. No.

Insured Age

Yearly Premium for HCB

1000 2000 3000 4000

1. Principal Insured- Male 38 2603 4706 6809 8912

2. Spouse - Female 36 1976 3702 5428 4034

3. Child 1 - Female 12 812 1373 1935 2496

4. Child 2 - Male 10 796 1342 1888 2434

Basic Premium ` 6187 ` 11123 ` 16060 ` 17876

Add Service Tax @ 12.36% ` 765 ` 1375 ` 1985 ` 2209

Total Premium Payable ` 6952 ` 12498 ` 18045 ` 20085

Premium Payable for family of four Members

Sr. No.

Benefit

Maximum Life Time Benefit Payable for HCB

1000 2000 3000 4000

1

HCBNon ICU

10,80,000( 720 x 1500)

21,60,000( 720 x 3000)

32,40,000( 720 x 4500)

43,20,000( 720 x 6000)

HCBAddl for

ICU

5,40,000( 360 x 1500)

10,80,000( 360 x 3000)

16,20,000( 360 x 4500)

21,60,000( 360 x 6000)

2 MSB12,00,000

(100 x 1500 x 8)

24,00,000(100 x 3000 x 8)

36,00,000(100 x 4500 x

8)

48,00,000(100 x 6000 x

8)

3 DCPB1,80,000

(5 x 1500 x 24)3,60,000

(5 x 3000 x 24)5,40,000

(5 x 4500 x 24)7,20,000

(5 x 6000 x 24)

4 OSB10,80,000(2 x 1500 x

360)

21,60,000(2 x 3000 x 360)

32,40,000(2 x 4500 x

360)

43,20,000(2 x 6000 x

360)

TOTAL per Member

` 40,80,000 ` 81,60,000 ` 1,22,40,000 ` 1,63,20,000

Total for 4 Members

` 1.632 Crores ` 3.264 Crores ` 4.896 Crores ` 6.528 Crores

Maximum Benefits Payable per Member

welcome to presentation on “jeevan arogya”. table 904 jeevan arogya

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