LIC JEEVAN AROGYA Benefits

LIC JEEVAN AROGYA Benefits

Benefits offered under the plan are
• Hospital cash benefit (HCB)
• Major Surgical Benefit (MSB)
• Day Care Procedure Benefit
• Other Surgical Benefit
• Ambulance Benefit
• Premium waiver Benefit (PWB)
A) Hospital Cash Benefit: If you or any of the insured lives covered under the policy is hospitalised due to Accidental Body Injury or Sickness and the stay in hospital exceeds a continuous period of 24 hours, then for any continuous period of 24 hours or part thereof, provided any such part stay exceeds a continuous period of 4 hours (after having completed the 24 hours as above) in a non-ICU ward/room of a hospital, an amount equal to the Applicable Daily Benefit (ADB) available under the policy during that policy year shall be payable subject to benefit limits and conditions mentioned in Para 11A) and exclusions mentioned in Para 15 below.
During the first year of cover commencement in respect of each insured, the Applicable Daily Benefit shall be the Initial Daily Benefit amount chosen by you and mentioned in the policy Schedule.
The amount of ADB for each policy year, after the first policy year, shall consist of 2 parts:
• An arithmetic addition of an amount equal to 5% (five percent) of the Initial Daily Benefit to the Applicable Daily Benefit of the previous Policy Year. Such increase in the Applicable Daily Benefit shall be effected on each policy anniversary during the Cover Period and shall continue until it attains a maximum amount of 1.5 times the Initial Daily Benefit. Thereafter, this amount in each Policy Year in future shall remain at that maximum level attained.
• Further arithmetic addition of an amount equal to “No Claim Benefit” (as described in Para 1.G) below) provided the policy attracts and is eligible for it. There shall be no maximum limit for such increase which means that if this policy is eligible for “No Claim Benefit”, the same shall be granted throughout the Cover Period without any maximum limit.
For members included subsequently under the policy, the benefit in the first year shall be equal to Initial Daily Benefit amount and thereafter the Applicable Daily Benefit shall increase as above.
If any of the member insured is required to stay in an Intensive Care Unit of a hospital, two times the Applicable Daily Benefit will be payable subject to benefit limits and conditions mentioned in Para 11A) and exclusions mentioned in Para 15 below.
During one period of 24 continuous hours (i.e. one day) of Hospitalisation (after having completed the 24 hours as above), if the said Hospitalisation included stay in an Intensive Care Unit as well as in any other in-patient (non-Intensive Care Unit) ward of the Hospital, the Corporation shall pay benefits as if the admission was to the Intensive Care Unit provided that the period of Hospitalisation in the Intensive Care Unit was at least 4 continuous hours.
No benefit will be payable for the first 24 hours of hospitalisation. However, for every Hospitalization that extends 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, regardless of whether the Insured was admitted in a general or special ward or in an intensive care unit.
B) Major Surgical Benefit: In the event of an Insured under this plan, due to medical necessity, undergoing one of the surgeries defined in Major Surgical Benefit Annexure, within the cover period in a hospital due to Accidental Bodily Injury or Sickness, the respective benefit percentage of the Major Surgical Benefit Sum Assured, as specified against each of the eligible surgeries mentioned in Major Surgical Benefit Annexure, shall be paid subject to benefit limits and conditions mentioned in Para 11B) and exclusions mentioned in Para 15 below.
C) Day Care Procedure Benefit: In the event of an Insured under this Plan undergoing any specified Day Care Procedure mentioned in the Day Care Procedure Benefit Annexure due to medical necessity, a lump sum amount equal to 5 (five) times the Applicable Daily Benefit shall be paid, regardless of the actual costs incurred, subject to benefit limits and conditions mentioned in Para 11C) and exclusions mentioned in Para 15 below.
D) Other Surgical Benefit: In the event of an Insured under this Plan, due to medical necessity, undergoing any Surgery not listed under Major Surgical Benefit or Day Care Procedure Benefit, causing the Insured’s Hospitalization to exceed a continuous period of 24 hours within the Cover Period, then, a daily benefit equal to 2 (two) times the Applicable Daily Benefit shall be paid for each continuous period of 24 hours or part thereof provided any such part stay exceeds a continuous period of 4 hours of Hospitalization, subject to benefit limits and conditions mentioned in Para 11D) and exclusions mentioned in Para 15 below.
E) Ambulance Benefit: In the event that a Major Surgical Benefit falling under Category 1 or Category 2 (as mentioned in the Major Surgical Benefit Annexure) is payable and emergency transportation costs by an ambulance have been incurred, an additional lump sum of ` 1,000 will be payable in lieu of ambulance expenses.
F) Premium Waiver Benefit: In the event that a Major Surgical Benefit falling under Category 1 or Category 2 (as mentioned in the Major Surgical Benefit Annexure) is payable in respect of any Insured covered under the policy, the total annualized premium i.e. total one year premium in respect of that Policy from the date of instalment premium due coinciding with or next following the date of the Surgery will be waived.
G) No claim benefit: A no claim benefit will be paid in the event that during the period between Date of Commencement of policy and next Automatic Renewal Date or between two Automatic Renewal Dates (described in Para 4 below) there are no claims in respect of any Insured covered under your policy. The amount of the no claim benefit would be equal to 5% (five percent) of the Initial Daily Benefit in respect of each Insured and the resulting amount shall be added to arrive at the Applicable Daily Benefit in respect of each Insured for the Policy Year next following the most recent Automatic Renewal Date.

i) Benefit Limits and Conditions:
A) Hospital Cash Benefit:
i) The Hospital Cash Benefit shall be payable only if Hospitalisation has occurred within India.
ii) The total number of days for which hospital cash benefit would be payable, in respect of each Insured, in a Policy Year would be restricted to -
a) A maximum of 30 (thirty) days of Hospitalization out of which not more than 15 (fifteen) days shall be in an Intensive Care Unit in the first Policy Year following the date of commencement of cover in respect of that Insured
b) A maximum of 90 (ninety) days of Hospitalization out of which not more than 45 (forty five) days shall be in an Intensive Care Unit in the second and subsequent Policy Years following the date of commencement of cover in respect of that Insured
iii) The total number of days of Hospitalization for which Hospital Cash Benefit is payable during the Cover Period, in respect of each and every Insured covered under the policy, shall be limited to a maximum of 720 (seven hundred and twenty) days out of which not more than 360 (three hundred and sixty) days shall be in an Intensive Care Unit. Upon attainment of this limit by an Insured, the Hospital Cash Benefit in respect of that Insured shall cease immediately.
iv) The Benefit Limits specified in the above clauses in respect of an Insured under this Policy, shall solely and exclusively apply to that Insured. Any unclaimed Hospital Cash Benefit of any one Insured is not transferable to any other Insured.
v) The Hospital Cash Benefit shall not be payable in the event of an Insured under this Policy undergoing any specified Day Care Procedure (as mentioned in the Day Care Procedure Benefit Annexure).
B) Major Surgical Benefit:
i) If more than one Surgery is performed on the Insured, through the same incision or by making different incisions, during the same surgical session, the Corporation shall only pay for that Surgery performed in respect of which the largest amount shall become payable.
ii) The Major Surgical Benefit shall be paid as a lump sum as specified for the benefit concerned and is subject to providing proof of Surgery to the satisfaction of the Corporation.
iii) All Surgical Procedures claimed should be confirmed as essential and required, by a qualified Physician or Surgeon, to the satisfaction of the Corporation.
iv) The Major Surgical Benefit will be payable only after the Corporation is satisfied on the basis of medical evidence that the specified Surgery covered under the Policy has been performed.
v) The Major Surgical Benefit shall be payable only if the Surgery has been performed within India.
vi) The amount in lieu of ambulance expenses shall be payable only once in respect of each Insured in any Policy Year and is subject to providing satisfactory evidence to the Corporation.
vii) The total amount payable in respect of each Insured under the Major Surgical Benefit in any Policy Year during the Cover Period shall not exceed 100% of the Major Surgical Benefit Sum Assured in that Policy year.
viii) The total amount payable in respect of each Insured during the Cover Period under the Major Surgical Benefit shall not exceed a maximum limit of 800% of the Major Surgical Benefit Sum Assured. If the total amount paid in respect of an Insured equals this lifetime maximum limit, the Major Surgical Benefit in respect of that Insured will cease immediately.
ix) The Benefit Limits specified in the above clauses in respect of an Insured under this Policy, shall solely and exclusively apply to that Insured. Any unclaimed Major Surgical Benefit of any one Insured is not transferable to any other Insured.
x) The Major Surgical benefit for any surgery cannot be claimed and shall not be payable more than once for the same surgery during the term of the policy.
C) Day Care Procedure Benefit:
i) If more than one Day Care Procedure is performed on the Insured, through the same incision or by making different incisions, during the same surgical session, the Corporation shall only pay for one Day Care Surgical Procedure.
ii) The Day Care Procedure Benefit shall be paid as a lump sum and is subject to providing proof of Surgery to the satisfaction of the Corporation.
iii) All Surgical Procedures claimed should be confirmed as essential and required, by a qualified Physician or Surgeon, to the satisfaction of the Corporation.
iv) The Day Care Procedure Benefit will be payable only after the Corporation is satisfied on the basis of medical evidence that the specified Surgical Procedure covered under the policy has been performed.
v) The Day Care Procedure Benefit shall be payable only if the Surgical Procedure has been performed within India.
vi) In respect of each Insured, the Day Care Procedure Benefit will be payable only up to a maximum of 3 (three) Surgical Procedures in any Policy Year during the Cover Period.
vii) In respect of each Insured during the Cover Period, the Day Care Procedure Benefit will be payable only up to a maximum of 24 (twenty four) Surgical Procedures. If the number of Surgical Procedures eligible for the Day Care Procedure Benefit in respect of an Insured equals this lifetime maximum limit, the Day Care Procedure Benefit in respect of that Insured will cease immediately.
viii) The Benefit Limits specified in the above clauses in respect of an Insured under this Policy, shall solely and exclusively apply to that Insured. Any unclaimed Day Care Procedure Benefit of any one Insured is not transferable to any other Insured.
ix) If a Day Care Procedure Benefit is performed no Hospital Cash Benefit shall be paid.
D) Other Surgical Benefit:
i) If more than one Surgical Procedure is performed on the Insured, through the same incision or by making different incisions, during the same surgical session, the Corporation shall only pay for one Surgical Procedure.
ii) The Other Surgical Benefit shall be paid as a Daily Benefit and is subject to providing proof of Surgery to the satisfaction of the Corporation.
iii) All Surgical Procedures claimed should be confirmed as essential and required, by a qualified Physician or Surgeon, to the satisfaction of the Corporation.
iv) The Other Surgical Benefit will be payable only after the Corporation is satisfied on the basis of medical evidence that the specified Surgical Procedure covered under the policy has been performed.
v) The Other Surgical Benefit shall be payable only if the Surgical Procedure has been performed within India.
vi) The total number of days of Hospitalization for which the Other Surgical Benefit is payable during a Policy Year in respect of each and every Insured covered under the Policy shall not exceed 15 (fifteen) days in the first Policy Year following the date of commencement of cover in respect of that Insured and 45 (forty five) days for the second and subsequent Policy Years following the date of commencement of cover in respect of that Insured.
vii) The total number of days of Hospitalization for which the Other Surgical Benefit is payable during the Cover Period, in respect of each and every Insured covered under the Policy shall not exceed a maximum limit of 360 (three hundred and sixty) days. Upon attainment of this lifetime maximum limit, the Other Surgical Benefit in respect of that Insured will cease immediately.
viii) The Benefit Limits specified in the above clauses in respect of an Insured under this Policy, shall solely and exclusively apply to that Insured. Any unclaimed Other Surgical Benefit on any one Insured is not transferable to any other Insured.
ii) Commencement And Termination Of Benefit Covers:
The Hospital Cash Benefit, Major Surgical Benefit, Day Care Procedure Benefit and Other Surgical Benefit cover in respect of each Insured covered under your policy shall commence on the Date of Cover Commencement individually stated in the Policy Schedule.
The Hospital Cash Benefit, Major Surgical Benefit, Day Care Procedure Benefit and Other Surgical Benefit cover in respect of each Insured shall terminate at the earliest of the following:
i. The Date of Cover Expiry mentioned in the Policy Schedule;
ii. On exhausting all the lifetime maximum Benefit Limits as specified in Para 11 above;
iii. On death or Date of Cover Expiry of the Principal Insured and if the Policy does not continue with the Insured Spouse as the Principal Insured;
iv. On death or Date of Cover Expiry of Insured Spouse after the Policy continues with the Insured Spouse as the Principal Insured after the PI dies or reaches his/her Date of Cover Expiry.
v. On death of the Insured;
vi. In respect of the Insured Spouse, on divorce or legal separation from the Principal Insured;
vii. On termination of the Policy due to non-payment of premium or any other reason.
iii) Termination of Policy:
A) If policy is issued on single life:
The policy shall terminate at the earliest of the following:
i) Non-payment of premiums within the revival period;
ii) On death;
iii) On the Date of Cover Expiry mentioned in the Policy Schedule;
iv) On exhausting all the lifetime maximum Benefit Limits as specified in Para 11 above.
B) If policy is issued on more than one life:
The policy shall terminate at the earliest of the following:
i) Non-payment of premiums within the revival period;
ii) On PI exhausting all the lifetime maximum Benefit Limits as specified in Para 11 above.
iii) On death or Date of Cover Expiry, of the Principal Insured and if the Policy does not continue with the Insured Spouse as the Principal Insured.
iv) On the death or Date of Cover Expiry, of Insured Spouse after the Policy continues with the Insured Spouse as the Principal Insured after the PI dies or reaches his/her Date of Cover Expiry.
iv) Waiting Period:
General waiting period:
There shall be no general waiting period in case Hospitalization or Surgery is due to Accidental Bodily Injury. There shall be a general waiting period during which no benefits shall be payable in the event of Hospitalization or Surgery, if the said Hospitalization or Surgery occurred due to Sickness.
i. The general waiting period shall be 90 (ninety) days from the Date of Cover Commencement in respect of each Insured.
ii. If the policy is revived after discontinuance of the Cover then the following shall apply in respect of each Insured:
a) If the request for revival is received by the Corporation within 90 (ninety) days from the due date of the first unpaid premium, then there shall be a general waiting period of 45 (forty five) days from the Date of Revival in respect of each Insured.
b) If the request for revival is received by the Corporation beyond 90 (ninety) days from the due date of the first unpaid premium, then there shall be a general waiting period of 90 (ninety) days from the Date of Revival in respect of each Insured.
Specific waiting period:
In addition, in respect of each Insured, no benefits are available hereunder and no payment will be made by the Corporation for any claim under this Policy on account of Hospitalization or Surgery directly or indirectly caused by, based on, arising out of or howsoever attributable to any of the following during the specific waiting period:
i. Treatment for adenoid or tonsillar disorders
ii. Treatment for anal fistula or anal fissure
iii. Treatment for benign enlargement of prostate gland
iv. Treatment for benign uterine disorders like fibroids, uterine prolapse, dysfunctional uterine bleeding etc
v. Treatment for Cataract
vi. Treatment for Gall stones
vii. Treatment for slip disc
viii. Treatment for Piles
ix. Treatment for benign thyroid disorders
x. Treatment for Hernia
xi. Treatment for hydrocele
xii. Treatment for degenerative joint conditions
xiii. Treatment for sinus disorders
xiv. Treatment for kidney or urinary tract stones
xv. Treatment for varicose veins
xvi. Treatment for Carpal tunnel syndrome
xvii. Treatment for benign breast disorders e.g. fibroadenoma, fibrocystic disease etc
The specific waiting period in respect of the treatments specified in the list above shall be as follows:
i. The specific waiting period shall be 2 (two) years from the Date of Cover Commencement in respect of each Insured.
ii. If the policy is revived after discontinuance of the Cover then the following shall apply in respect of each Insured:
a) If the request for revival is received by the Corporation within less than 90 (ninety) days from the due date of the first unpaid premium, then the specific waiting period shall continue to be till 2 (two) years from the Date of Cover Commencement in respect of each Insured.
b) If the request for revival is received by the Corporation beyond 90 (ninety) days from the due date of the first unpaid premium, then there shall be a specific waiting period of 2 (two) years from the Date of Revival in respect of each Insured.
No charges for this benefit shall be deducted after the benefit ceases.

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