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
Children
Maximum age at entry:
PI and Spouse
Parents & Parents in Law
Children
: 18 years lbd.
: 3 months completed.
: 65 years lbd
: 75 yrs lbd
: 17 years lbd.
Cover ceasing age :
PI, Spouse, Parents and Parents in law : 80 years lbd.
Children
: 25 years lbd.
Features and Conditions:
Initial Daily Benefit (IDB) for HCB:
IDB
PI
Spouse
Parents/ Children
Min
` 1000
` 1000
` 1000
Max
` 4000
Equal to or less
then PI
Equal to or less
then Spouse/PI
 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.
Features and Conditions:
Mode of Payment:
Yearly, Half yearly, Quarterly or Monthly ECS only.
Rebates:
Mode Rebate:
Yearly
:2%
Half yearly :1%
HCB Rebate:
HCB (`)
For PI
2000
500
3000
1000
4000
1500
For Members
250
500
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 preexisting 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):
ACB for ` 4000 Initial Cash Benefit
Year
1st
2nd
3rd
ADB
4000
4200
4400
Year
9th
10th
11th
ADB
5600 + 400
5800 + 600
6000 + 600
4th
5th
6th
4600 + 200
4800 + 200
5000 + 200
12th
13th
14th
6000 + 600
6000 + 800
6000 + 800
7th
8th
5200 + 400
5400 + 400
15th
16th
6000 + 800
6000 + 1000
Hospital Cash Benefit (HCB):
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.
Hospital Cash Benefit (HCB):
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.
Hospital Cash Benefit (HCB):
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 MSBSA
Max life time Benefit
: 800% of MSBSA
Major Surgical Benefit (MSB):
•
•
•
•
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.
Major Surgical Benefit (MSB):
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
Major Surgical Benefit (MSB):
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.
Major Surgical Benefit (MSB):
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 ADB
Max Benefit per annum : 15 days in 1st year
and 45 days per annum thereafter.
Max life time Benefit
: 360 days.
Other Surgical Benefit (OSB):
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.
Other Surgical Benefit (OSB):
Example:
An insured is hospitalized for OSB
days during 3rd year of policy.
The initial HCB opted is `4000.
for 5
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.
Other Common conditions applicable under all
the Benefits i.e. HCB, MSB, DCPB & OSB:
 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.
Other Common conditions applicable under all
the Benefits i.e. HCB, MSB, DCPB & OSB:
 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.
Other Terms and Conditions:
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.
Other Terms and Conditions:
 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).
Other Terms and Conditions:
 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.
Other Terms and Conditions:
 Days of Grace:
A grace period of one calendar month
but not less than 30 days will be
allowed for payment of yearly or halfyearly 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.
Other Terms and Conditions:
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
• For Parents, whether Dependent or not
• Additional Amount for Sr. Citizen
:`15000
:`15000
:`5000
Cooling-off Period
Policyholder 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:
NON MEDICAL RULES
Age nbd
Upto 35 yrs
36 to 45 yrs
46 to 50 yrs
NMG
NMS
SUC
5 lakhs
2 lakhs
2 lakhs
SUC
5 lakhs
5 lakhs
4 lakhs
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
Premium Payable for family of four Members
Yearly Premium for HCB
Sr.
No.
Insured
1.
Principal Insured- Male
2.
Age
1000
2000
3000
4000
38
2603
4706
6809
8912
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
Maximum Benefits Payable per Member
Sr.
No.
Maximum Life Time Benefit Payable for HCB
Benefit
HCB
Non ICU
1
HCB
Addl for
ICU
1000
2000
3000
4000
10,80,000
( 720 x 1500)
21,60,000
( 720 x 3000)
32,40,000
( 720 x 4500)
43,20,000
( 720 x 6000)
5,40,000
( 360 x 1500)
10,80,000
( 360 x 3000)
16,20,000
( 360 x 4500)
21,60,000
( 360 x 6000)
24,00,000
(100 x 3000 x 8)
36,00,000
(100 x 4500 x
8)
48,00,000
(100 x 6000 x
8)
2
MSB
12,00,000
(100 x 1500 x
8)
3
DCPB
1,80,000
(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)
OSB
10,80,000
(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
4