FAQ ABOUT CLAIM PROCESS & SETTLEMENT
1. 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:
1. All Insured person claiming the benefit under this policy has to be certified as JAIN, by Derasar or Jain Mandir or JIO.
2. All dependant claimant has to share the proof of their relationship with the proposer
3. Person covered under the policy as single member, has to be certified by the JIO director.
4. All the claim intimations has to be intimated within 48 hrs of hospitalization to Insurer , to avoid deductions & / or rejections
5. All the claim documents as per the check list has to be submitted to the Insurer within 30 days from discharge of the hospitalization to avoid deductions & / or rejections
6. Duly filled original Claim Form.
7. Original Discharge summary of the treating hospital clearly indicating the Hospital Registration No.
8. Original Diagnostic reports.
9. Death certificate & Death Summary in original in case of Death.
10. Itemized hospital bill in original.
11. Final Hospital Bill
12. Original Payment receipts
13. Original Copies of prescription for diagnostic test, treatment advise, medical references etc.
14. Details of the implants including the sticker indicating the type as well as invoice towards the cost of implant
15. Hospital registration number/the number of beds available with the hospital verified by the authorised signatory of the Hospital.
16. KYC documents of patient
17. NEFT Mandate & Cancelled Cheque / Passbook (containing IFSC Number)
18. Any other documents as and when requested by the claim settling authority.
19. All single member covered under the policy ,claiming the benefits has to submit self-affidavit or certification from the JIO Director
2. How to send reimbursement claims?
Under this Policy, You can avail Reimbursement facility and claims can be submitted to Ericson Insurance TPA Services Pvt. Ltd. office through registered post / courier. The address is as mentioned on website – www.ericsontoa.com Head Office address is as follows.
Ericson Insurance TPA Services Pvt. Ltd.
Address: 11C, 2nd Floor Corporate Park, Sion - Trombay Rd, Chembur, Mumbai, Maharashtra 400071.
3. 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.
4. Will my claims be reimbursed even if I do not get myself treated at a network hospital?
Yes, you can avail Reimbursement facility.
5. 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, cataract surgery, etc. the stay could be less than 24 hours.
6. 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.
7. Who will receive the claim amount if the insured dies at the time of treatment?
The claim amount is paid to the proposer of the policy. In case of proposer’s death, 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.
8. What is the procedure for availing cashless facility?
In case of planned hospitalization, TPA / insurers require Pre-authorization form 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.
9. 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.
10. 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 hospitalisation intimation in mail to Ericson Insurance TPA Pvt. Ltd. on jiointimation@ericsontpa.com / jio@ericsontpa.com /6saal@ericsontpa.com
11. 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.
12. 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.
13. Is maternity benefit available under an individual Health Insurance Plan?
No. Maternity benefit is not payable under Individual Health Insurance Plan. Even in Family floater plan it is covered from second year of policy.
14. 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.
15. Why the Claims process is complex?
The process of filing claims for Cashless or Reimbursement with the Insurance Company is the same for JIO policy like any other retail Mediclaim policies and in accordance with IRDA guidelines. In-fact, the norms for intimation of claim and the period for submitting claim documents after discharge are more beneficial in JIO Policy.
16. Whether insurance companies wrongly make huge deductions in JIO policy?
The deductions from claims are as per the terms of the policy and no ad-hoc deductions are made by the TPA or Insurance Company. The TPA and insurance company are bound by the guidelines of Insurance Regulatory & Development Authority.
However, in case any claims are wrongly deducted or disallowed, then the members can approach grievance department of Insurance company or Ombudsman department of IRDA. These actions are within the rights of every policy holder.
17. Is weight management, Cosmetic treatment covered?
NO. It is not covered in any Mediclaim policy.
18. Is OPD or Oral treatment covered
NO. It is not covered in any Mediclaim policy.
19. Whether Parkinson , Alzheimer’s disease, Psychiatric disorder, general debility is covered ?
NO
20. Is dental treatment is covered
NO. Dental treatment is not covered in any Mediclaim. It gets covered only in case of accident and requiring hospitalization. Police MLC / FIR is compulsory in all claims due to accident.
21. Whether AIDS / HIV related treatments covered.
NO
22. Whether Infertility / Sterility treatment covered.
NO
23. Is external Congenital disease, Steam Cell treatment is covered or not. Whether oral chemo therapy, Robotic surgery, laser surgery, RF probe, Bioabsorbable device etc. covered or not.
NO
24. Artificial life management treatment covered or not
NO
25. Treatment by doctor within family or treatment given by medical practitioner outside scope of his license or black listed hospital is covered or not.
NO
26. Whether ARMD, RFQMR, ECP, EECP, HBOT etc. covered or not.
NO
27. External durable medical equipment, corrective device, prosthesis, hearing aid etc. is covered or not.
NO
28. Whether substance intoxication, alcohol, tobacco, addiction related treatment covered or not.
NO
29. Treatment taken out side India, or criminal injury, attempted suicide etc. covered or not.
NO
30. Knee Replacement, Cataract, Delivery will be covered or not.
YES, it is covered after one year.
31. How you ensure that there won’t be any hassle in claim settlement or processing?
We will provide 100% support in claim settlement via below channel
1. TPA : Details of all office and contact no mention over Website.
2. Broker : Details of all office and contact no mention over Website.
3. Insurance Company : Details of all office and contact no mention over Website.
4. Claim settlement office : Detail and contact number we would share with you.
5. JIO : Details of all office and contact no mention over Website.
32. How many procedure are covered in Day Care treatment.
Day care procedure are covered as per Universal Sompo General Insurance Co. list. (Daycare list 141)
33. Whether Health declaration is compulsory?
Yes, it is necessary to declare all existing and past health issue while doing online enrollment. At time of claim if we found that you have non-disclose certain illness your claim may get rejected on basis of non-disclosure of material fact.
34. What are common reason of deduction / Repudiation of claim.
Ø Policy holder reasons: 1) Mistake in name / age / sex in Policy
Please check above detail when receiving documents for the first time & correct it if required
2) Give claim Intimation within 48 hrs. in Cashless as well as Reimbursement.
3) Submit claim documents within 30 days.
4) Submit query documents as early as possible, otherwise file get close due to
Non-submission of documents.
Ø Treating Doctor related : 1) OPD converted in IPD
2) Hospitalisation Not Justified.
3) Admission only for Investigation
Ø Hospital related : 1) Not registered Hospital / Not fulfilling Hospital Definition.
2) Non Payable items
3) Inflated bill
4) Prolonged Stay etc.
35. Whom to approach in case of Grievances / Legal help.
JIO will help in providing legal aid to its member in filing grievance before any forum.
Edelweiss Gallagher Insurance Brokers Ltd. will provide all legal guidance, procedural help, documentation for filling such legal complaints.
* For detail terms and condition, rejections and sub-limits refer JIO website.
www.jiojac.com/6SAAL2020
** Policy terms and rates may be continued for next 6 years and shall be reviewed annually and necessary corrective action shall be taken (if required) to keep the portfolio viable
*** Pre- Existing Diseases against each insured / beneficiary, needs to be declare while filling up forms, If not disclose can be used as non- disclosure at time of claim & in court of law.
## However, The portfolio will be reviewed by Insurance company on periodic basis & to balance the claim ratio the Insurance company will offer Motor, Travel, Group Personal Accident, Home Insurance etc. policies to JIO members along with this policy. |