INTRODUCTION

Accident insurance provides a cash cover to a policyholder when s/he suffers injuries as a result of an
accident. While insurance helps a policyholder pay off hospital and medical bills in case of accident
injuries, it provides cash benefits to family members if the policyholder dies in the accident. This
insurance, applicable 24 hours a day, 365 days a year, is also commonly referred to as personal
accident insurance.

Insurance may be defined as form of contract between two parties (namely insurer and insured or
assured) whereby one party (insurer) undertakes in exchange for a fixed amount of money (premium)
to pay the other party (Insured), a fixed amount of money on the happening of certain event (death or
attaining a certain age in case of life) or to pay the amount of actual loss when it takes place through
the risk insured (in case of property)

Terminology used in definition of Insurance

 Insurer or insurance company – The agency involved in Insurance business is known as

insurer

 Insured/ Assured – The person who gets his property/life insured is known as insured

 Policy - The agreement or contract which is put in writing is known as a Policy

 Premium – The consideration in return of which the insurer undertakes to make goods the loss
or give a certain amount in case of life insurance is known as premium.

DEFINITIONS OF ACCIDENT INSURANCE

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 In insurance, Accidental death and dismemberment (also known as AD and D) is a term used
to describe a policy that pays additional benefits to the beneficiary if the cause of death is due
to a non-work related accident.

 Is a type of private insurance enabling the policyholder to get a certain sum of money in case
of body injury damage due to the accident.

TYPES OF INSURANCE

GENERAL MISCELLANEOUS
LIFE INSURANCE NON LIFE INSURANCE
INSURANCE INSURANCE
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 Marine insurance  Health insurance
 Fire insurance  .1/456/13-14
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accident
 Motor vehicle
 NRI ACCIDENT INSURANCE AND PERSONAL ACCIDENT
INSURANCE

 NRI ACCIDENT INSURANCE

The insurance covers Non-Resident Indians from 3 months of age till 70 years. It is a
comprehensive insurance covering accidental loss, permanent disablement due to accident,

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 medical expenses incurred due to illness in a foreign country, education fund of dependent
children etc.

Calculation of NRI Accident Insurance Amount/Premium:

The amount of premium depends on a number of factors. Premium is paid on a

monthly/quarterly/half-yearly/yearly basis.

NRI Accident Insurance Claim Procedure:

In the event of claim, written intimation must be given by the insured/assignee to the
insurance company. The claim can also be reported on company's toll free number. Upon
receipt of the intimation of claim the company deputes its surveyor or claim representative
and process the claim. Copy of the claim format is annexed. The claim process can take
anywhere between 7-15 days.

Documents Required for NRI Accident Insurance Claim:

1. Claim form
2. FIR Form
3. Prescriptions given by the treating doctor
4. Hospital Discharge Card
5. Diagnosis reports like X-Ray report, etc.
6. Disability Certificate

List of Some of Insurance Companies offering NRI Accident Insurance:

National Insurance Company Ltd. - Policy For Non-Resident Indians

HDFC - Tricare Plan

 PERSONAL ACCIDENT INSURANCE

Few people have taken cover to protect themselves against the risk of personal accidents and

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the medical complications they entail. Personal accident insurance insurance is an attractive
option; not only does it cost less than other insurance policies, it also covers all accidents.
Personal accident policies cover you for one or more of four contingencies in the event of an
accident: death, permanent total disability, permanent partial disability and temporary total
disability.

Calculation of Personal Accident Insurance Amount/Premium:

The amount of premium depends on the nature of occupation of the individual.

The classification of occupation varies among different insurers.
The premium is far less as compared to other policies. Premium can be paid on a
weekly/monthly/quarterly/half-yearly/yearly basis.

Personal Accident Insurance Claim Procedure:

Claims are generally settled within four weeks of completion of paperwork along with
supporting medical certificates. In some cases, insurers may depute a panel of doctors to
verify the insurance holders' claims.

Documents Required for Personal Accident Insurance Claim:

1. Claim form
2. FIR Form
3. Prescriptions given by the treating doctor
4. Hospital Discharge Card
5. Diagnosis reports like X-Ray report, etc.
6. Disability Certificate

List of Some of Indurance Companies offering Personal Accident Insurance:

Bajaj Allianz - Personal Guard

The New India Assurance Co. - Personal Plans
United India Insurance Co. - Claim Against Personal Injury
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 HSBC - MahaRaksha Personal Injury Policy
Tata AIG General Insurance - Accident Guard

INFORMATION REQUIRED TO MAKE CLAIMS

 The date of accident happened
 The time & day of the accident happened

 Where the accident happened

 How the accident happened

 The contact details of any witnesses to the accident

 The details of your injuries including any medical diagnosis and/or any treatment received.
You should retain evidence of this.

 Whether you are a member of a Trade Union. This may mean that you can receive free or
reduced cost legal representation.

Other documents you may be asked for

 Proof of any loss of earnings and other expenses that are the result of your injury.
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  Any documents relating to insurance policies you may have (household insurance, motor
insurance etc.) as these may cover the legal costs for your claim.

 Any other documents that may support your claim. This could be any evidence of similar
accidents arising in the same circumstances or evidence of failings to ensure a duty of care
towards you.

WHAT DOES THE POLICY COVER?

 ACCIDENTAL DEATH
Accidental death coverage gives compensation on the policyholder's death caused by bodily injury
resulting out of accident and leading into death. The nominee will receive entire sum assured offered
by the insurer.

 ACCIDENTAL DISABLEMENT
It indicates that the insured person is disabled from work, either wholly or partially.

 ACCIDENTAL DISMEMBERMENT
The policyholder's body part has been dismembered or severed. It clearly means that the insured
person loses his eyes, legs or hand, then only the insured person would be eligible to receive a claim
under this coverage.

 ADDITIONAL BENEFITS

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Funeral Expenses in case of accidental death Expenses incurred for transportation of policyholder's
dead body from the accident spot to the residence place.

OBJECTIVE
At the end of this lesson, you will be able to:

 Know the meaning of Personal Accident insurance

 Buy the Personal Accident insurance

 Settle the claim under Personal Accident insurance

 Types of Personal Accident polices

 Know what is not covered under fire insurance.

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 COVERAGE’S / COMPENSATION
A) DEATH: If a person dies due to an accident the risk is covered under the personal accident policy.
His legal heirs are entitled to get the sum insured. Eg. If the sum insured is rs. 1.00 lakhs and in case
of death his legal heirs will get rs.1.00 lakhs as compensation.

B) DISABILITY: Disability can be classified further as follows:

� Permanent Total Disability(PTD)
� Permanent Partial Disability(PPD)
� Temporary Total Disability (TTD)
Permanent Total Disability: As the name indicates the disablement is of permanent and
irrecoverable nature and is absolutely total and the insured is unable to engage in the gainful
employment. Under this disability the compensation is equal to the sum insured. Example of
PTD:
 Loss of sight of both eyes
 Loss by physical separation of two entire hands or entire feet
 Loss of one hand and one foot
 Person in comma for longer period will also be treated as PTD
 Paralysis
Permanent Partial Disability: The disability is not total but partial. e.g. Loss of toe or a finger. The
compensation will be based on the percentage of the disability and it will defined in the policy and if
it not defined then as per doctor certificate the compensation is paid.

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Temporary total disablement: As the name implies this is a disablement which is total but for a
temporary period only. The temporary may be days, weeks, months or even years. The payment is on
weekly basis.

C) CARRIAGE OF DEAD BODY: The expenses incurred for a carriage of dead body of insured
due to accident to place of residence are reimbursed. The reimbursement is some percentage of the
sum insured say 2% of sum insured but maximum Rs 2500/-. This amount will be over & above the
sum insured.

D) EDUCATION AMOUNT FOR CHILDREN: Incase of death or permanent disablement of the

insured person the insurance company also pays the education for two children if the age is below 25
years of those children.

E) MODIFICATION OF THE HOUSE: In case of the permanent disablement of a insured person,

he has to modify his house for his free movement the expenditure of such modification will be
reimbursed by the insurance company up to certain limit of the sum insure.

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 PROBLEMS ASSOCIATED WITH COMPENSATION OF
CLAIMS
No compensation is payable in respect of death, injury or disablement of the insured
(i) From intentional self-injury, suicide or attempted suicide.

(ii) Whilst under the influence of intoxicating liquor or drug

(iii) Whilst engaging in Aviation or Ballooning whilst mounting into, dismounting from or travelling
in any balloon or aircraft other than as passenger (fare paying or otherwise) in any duly licensed
standard type of aircraft anywhere in the world

(iv) Directly or indirectly caused by venereal diseases or insanity

(v) Arising or resulting from the insured committing any breach of law with criminal intent.

(vi) From service in the armed forces

(vii) Resulting directly or indirectly from child birth or pregnancy.

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 PROCEDURE FOR INSURING UNDER ACCIDENT
INSURANCE POLICY

A) Submission of proposal form

B) Assessment of the proposal form and premium rate to be quoted
C) Payment of the premium
D) Issue of policy document

A) SUBMISSION OF PROPOSAL FORM-. The person who is interested to insure himself under
this policy will submit the information in the prescribed proposal form as follows:
i. Personal details i.e., age, height and weight, full description of occupation and average
monthly income.
ii. Physical condition
iii. Habits and pastimes
iv. Other or previous insurances
v. Previous accidents or illness
vi. Selection of benefits and sum insured
vii. Declaration

B) ASSESSMENT OF THE PROPOSAL FORM AND PREMIUM RATE TO BE QUOTED

While the assessing the proposal form the sum insured is selected by the insured but insurers exercise
some control. The sum insured is compared with the average monthly income of the insured. The age
of a person should be between 5 year to 70 years.

RATING- In personal accident insurance, the rating factor used is the occupation. Generally
speaking exposure to personal accidents at home, on the street etc. Is the same for all persons, but the
risks associated with occupation vary according to the nature of work performed. For example, an
office manager is less exposed to risk at work than a civil engineer working at a site where a building

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is constructed. It is not practicable to fix a rate for each profession or occupation. Hence, occupations
are classified into groups, each group reflecting, more or less, similar risk exposure.
RISK GROUP I: (LOWEST PREMIUM RATE) -Accountants, doctors, lawyers, architects,
consulting engineers, teachers, bankers, persons engaged in administration functions. Persons
primarily engaged in occupations of similar hazards.

RISK GROUP II: (HIGHER PREMIUM RATE) -Builders, contractors and engineers engaged in
superintending functions only, veterinary doctors, paid drivers of motor cars and light motor vehicles
and persons engaged in occupation of similar hazards and not engaged in manual labour.
All persons engaged in manual labour (except those falling under group iii), cash carrying
employees, garage and motor mechanics, machine operators, drivers of trucks or lorries and other
heavy vehicles. Professional athletes, and sportsmen, woodworking machinists and persons engaged
in occupations of similar hazards.

RISK GROUP III : (HIGHEST PREMIUM RATE)-persons working in underground mines,

explosives, magazines, workers involved in electrical installation with high tension supply. Jockeys,
circus personnel, persons engaged in activities like racing on wheels or horseback, big game hunting,
mountaineering, winter sports, skiing, ice hockey, ballooning, hang gliding, river rafting, polo and
persons engaged in occupations/activities of similar hazard.

C) PAYMENT OF THE PREMIUM: based on the above risk category the person will pay the
premium to insurance company to insure himself.

D) ISSUE OF POLICY DOCUMENT: based on the proposal form and the premium amount is
received the policy document is issued which contains the following information.

i. Name of the person and address

ii. Age
iii. Occupation
iv. Sum insured
v. Nominee
vi. Policy conditions

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A) Written notice of claims with full particulars. In case of death written notice must, unless
reasonable cause is shown, be so given before internment or cremation, and in any case, within one
calendar month after the death
B) In the event of loss of sight or amputation of limbs, written notice thereof must be given within
one calendar month after such loss of sight or amputation.

C) Proof of claim satisfactory to the company shall be furnished.

D) Any doctor on behalf of the company shall be allowed to examine the person of the insured on the
occasion of any alleged injury or disablement and as may reasonably be required.

E) A post mortem examination report, if necessary, be furnished within the space of fourteen days
after demand in writing.

F) In the event of loss of sight the insured shall undergo at the insured’s expense such operation or
treatment as the company may reasonably deem desirable.

G) No sum payable under this policy shall carry interest.

H) No claim is payable if the claim is fraudulent or supported by fraudulent statement.

I) The insured shall give immediate notice to the company of any change in his business or
occupation. The insured shall on tendering any premium of the renewal of this

MISCELLANEOUS FEATURES
I) FAMILY PACKAGE COVER
(a) Earning member and spouse, 100% of the capital sum if earning. (persons insured) insured for
each.
(b) Spouse (if not earning 50% of the capital sum member) whichever is lower insured or rs. 1 lakh.

(c) Children (between the age 25% of the capital sum and of 5 years and 25 years) insured or rs.
50000/-
Whichever is lower per child.
 For children the cover is limited to death and permanent disablement (total or partial)
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  Premium payable for husband and wife will be on the total sum insured for husband and wife.
 A discount of 5% is granted on the gross premium.

II) EXTENSIONS
A personal accident policy can be extended by endorsement, on payment of extra premium to cover
medical expenses incurred by the insured in connection with the accidental bodily injury, subject to
specified limits.

CLAIM PROCEDURE
A) INTIMATION: Immediately the intimation to be sent to the insurance company in writing
mentioning the nature of loss and the policy number.
B) CLAIM FORM: The claim form is designed to elicit information, among other things, on the
following :
 Personal details such as age, occupation, etc.
 Details of accident, nature of injuries, etc.
 Name and address of the attending doctor.
 Medical certificate of the attending doctor (sometimes this is issued as a separate form).

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  Details of other insurances to apply contribution, if applicable and to check whether they had
been disclosed in the proposal form

C) DOCUMENTS: The following documents are sent along with the claim form
 MEDICAL CERTIFICATE : to obtain medical opinion on the cause or extent of incapacity
or progress towards recovery.
 MEDICAL EXAMINER’S REPORT - To corroborate medical certificate in doubtful cases,
or if other causes are in operation.
 RECEIPT / DISCHARGE FORM :- to acknowledge the money and to confirm the finality
of the settlement.
 DEATH CERTIFICATE - To give the date and cause of death. Post mortem reports where a
post-mortem has been done.
 PROBATE OR LETTERS OF ADMINISTRATION - the legal document to prove the title
of an executor or an administrator (i.e. if no assignment is made)

For disablement claims the documents, inter-alia, required are

 Medical Certificate, diagnostic reports etc.

 Prescription, bills and receipts.
 Leave of absence certificate from the employer.
 Medical fitness certificate.

NEED FOR ACCIDENT INSURANCE

Even after an accident, you can enjoy financial stability and peace of mind. This is what Manish
Bhatia discovered after an accident. The advertising professional was heading for a client meeting
when the accident occurred. Another vehicle crashed into his car. Manish sustained fractures on both
his arms. He was bedridden for three months. Luckily, his personal accident insurance took care of
the loss of income. He received weekly payouts, as specified in the policy, until he was back at work.

Imagine if Manish had not opted for a personal accident cover. He would have paid all the medical
expenses from his own pocket. At the same time, he would have to deal with the income loss. Such a
policy works as a buffer against any unforeseen situation. It gives you peace of mind.

Here are the top reasons for getting personal accident insurance
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1. DISABILITY TAKEN CARE OF: Temporary or permanent disability may occur in the
aftermath of an accident. A policyholder can claim a compensation for various kinds of disability.
There may be a loss of both hands or feet, one hand or one foot, or one hand or foot and an eye. Say,
a person has partially lost their hearing in one ear or suffered vision loss in one eye. He can file a
claim. Loss of speech, loss of eyesight in both eyes, or a hearing loss in both ears is covered too.
What if the policyholder has lost an index finger, a thumb, or a hand? He can approach the insurer
with a claim. He will receive compensation for the income loss.

2. MAJOR HOSPITAL AND OTHER EXPENSES ARE SORTED: This policy takes care of the
hospital bills and medical treatment, of course. But it also covers other expenses. These include
repatriation charges, funeral expenses in case of the policyholder’s demise, and ambulance charges.

3. HOME ALTERATION AND VEHICLE MODIFICATION BENEFIT: Imagine a scenario

where you have to go to work despite being wheelchair-bound. Here, you will need a vehicle to
transport you. So, it has to have suitable modifications. This ensures that you travel comfortably. You
could also ask the insurer to compensate you for those changes. Similarly, you may need to carry out
modifications in your house like setting up ramps. You can facilitate this through an insurance claim.

4. DEATH OF THE POLICYHOLDER: In this situation, the policy disburses compensation to the
family. If you have young children, then the insurer takes care of their education. The insurer pays
10% of the sum insured or the actual tuition fee charged by the institution, whichever is lower.

5. FAMILY TRANSPORTATION: Following an accident, say, you are hospitalised more than 150
km of your residence. Do not worry. The insurer company will reimburse the transportation costs
incurred by a family member to reach you.

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 IMPORTANCE OF ACCIDENT INSURANCE

Cash for accidents-Certain policies pay you in cash in case you get into an accident to cover for your
medical bills and other expenses like rent and groceries, especially if you end up missing work
because of your injuries.

Accidental death-An accidental death policy is a less expensive alternative to life insurance, but it
will only cover deaths from an accident. This is a good option for those who are otherwise in good
health and are not at any risk of dying from any medical condition in the near future.

Disability insurance-In the event that you get severely injured and could no longer work, a disability
coverage will pay you a monthly stipend to survive on.

Accidents can happen to anyone at any time, which could lead to minor inconveniences to major
losses, especially if you incurred a disability that prevents you from working. You may also end up
using your entire life savings getting treatment since it’s no secret how expensive quality healthcare
is in the Philippines.

No one can predict when an accident might occur, but you can make all necessary preparations for it
so that you and your family won’t suffer if it does happen. A personal accident insurance will help
cover your hospital bills without affecting your lifestyle and burdening your family.

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 FEATURES OF ACCIDENT INSURANCE

1. ENTRY AGE – For Adults: Minimum age- 5 years

Maximum age – 70 years.
For Children: Minimum age - 5 years
Maximum age - 18 years.
2. BASIS- Family package cover as well as individual cover.

3. RENEWABILITY- The policy can be renewed.

4. SPECIAL FEATURES- The key features of the policy include:

 Policy period is 1, 2 and 3 years.

 Policy provides Family Package cover as well and Individual Cover.

 Sum assured for dependents and spouses are limited to 20% and 50% respectively.

 Sum assured can be renewed.

 Get renewal bonus if you renew the policy within 30 days from its date of expire.

5. PREMIUM-Premiums vary based on the following factors :

 Sum Insured opted.

 Your occupation.

 Table of cover taken.

 Optional Extensions Chosen By You.

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6. POLICY COVERAGE-The policy offers multiple options to choose from. You can choose
among the following options:

 Accidental Death only

 Permanent Total Disability/ Accidental Death

 Accidental Death/Permanent Partial/ Total Disability

 Accidental Death/Permanent Total Disability/Permanent Partial Disability/ Temporary Total

Disability

7. BENEFITS-The policy provides the following benefits:

 It provides compensation for a physical loss such as death or disablement caused by

accidental injury within a period of 12 months from the date of accident.
 Education benefits- It cover the cost of education for children, in case the policyholder meets
with an accident.

 Loss of employment benefits.

 It also cover the cost involved in transportation, ambulance service and outpatient medical
expense.

 Medical extension benefits

 The cost of travel to your home or any other place is covered. Get paid 2% of the sum assured
or up Rs. 10,000 as cost of travel.

 Medical extension benefits

8. DISCOUNT- Family discount of 10% on the premiums paid for Family Package cover and
Individual cover.

9. EXCLUSION- The policy does not cover any existing disability, claims for more than one
categories mentioned in the policy document. It also does not cover death and disablement caused
due to self-injury, suicide or attempted suicide, consumption of alcohol or drugs, childbirth,
pregnancy etc.

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 TYPES OF PERSONAL ACCIDENT INSURANCE POLICIES
There are eight common types of personal accident insurance policies:

 Individual: This policy can be taken by any individual. The benefits usually enclose partners
and children. Since several activities are excluded from this policy, it is not as useful for
people who love adventurous sports, like mountaineering and rock climbing.

 Children: The purpose of this policy is to provide financial help to parents if they are unable
to work or if they incur expenses as a result of an accident.

 Group: This policy is used by companies to cover employees for expenses related to
accidents.

 Self-employed: Since self employed individuals are not eligible for employee benefits, they
are worse off when injured in an accident.

 Team: Through a team accident insurance policy, organizers can seek cover for all the
members of a sports team.

 Professional: This policy is specifically for self employed professionals, such as a

sportsperson, actor, lawyer or doctor, who have special requirements.

 Over 50: This policy targets people over 50 years of age, as accidents can cause more
grievous injuries to them.

 Travel accidents: This policy offers benefits in case the policyholder meets with an accident
while traveling.
There are varied accident insurance policies to suit different needs. One should understand and
choose the policy with utmost care.

WHAT AN ACCIDENTAL INSURANCE POLICY GIVES

YOU ?
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Think for a moment , what all can happen if one meets an accident , what can happen , what are
different kind of end results of it ? An Accidental Insurance policy covers almost all of them. Below
is table which given you an idea on what kind of situations are covered by accidental policies.

In case of a death due to accident, the policy would pay 100% Sum
1. Death Assured to the nominee. Some companies also pay a “Children?s
Education Bonus” of 5000 or 10000 for maximum of 2 children.

This means that in case there is a permanent total disability, in which a

person is disabled for life, the SUM assured is paid to the person. Some
companies also pay around 125% or 110% , depending on the company.
2.
Example – Loss of
Permanent
1. both hands or both feet
Total
2. one hand and one feet
Disablement
3. one (hand or foot) and an eye

4. loss of sight of both eyes OR speech OR Hearing of both ears

In this case, a small percentage of SUM assured is paid on weekly or

monthly basis . For example – 1% of sum insured is paid every week up to
3. 100 weeks. Example below
Permanent 1. Loss of Index Finger or thumb
Partial 2. Loss of hearing in 1 ear
Disablement
3. Loss of 1 eye sight

4. Loss of 1 hand

4. This means that for some weeks or months a person is totally disabled and
Temporary will not be able to work and earn money. In this case most of the
Total companies pay a part of sum assured , some pay 100% and some pay 50% ,
Disablement there is also a cap in this case , like maximum 5 lacs or 10 lacs. Example
below

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 1. A bed rest of next 3 months

2. Fracture in hands or legs

Other Features:-

 Some companies covers claims arising out of Terrorism or acts of Terrorism

 No health check-up required for policy issuance

 Worldwide coverage of the policy

 It gives coverage starting from 5 lacs to 50 lacs

 Free lookup period of 15 days

 5% per claim free year to a maximum of 50%.

 Family discount of 10%

HOW TO BUY PERSONAL ACCIDENT INSURANCE

 Available with almost all general insurance companies

 Available without any medical tests of any kind

 Amount of insurance is restricted and is linked to the annual income of the person

 Salaried people have to provide their salary slip and others are expected to provide their
income tax returns by the help of which the insurance company can decide the amount of
insurance cover to give

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  In most of the companies there is also a provision of a cumulative bonus for every claim free
year.

Accident insurance is the cheapest and smartest way of filling the insurance gap especially for the
young who are aware of the importance of insurance and whose salaries are still not very high.

ADVANTAGES OF AN ACCIDENT INSURANCE POLICY

1. ACCIDENTAL DEATH

If an insured died due to an accident his nominees will get 100% sum insured. So it’s very
important to have right nominee in any kind of insurance policy whether accidental or life.

2. PERMANENT TOTAL DISABLEMENT

Some time a person met with an accident & loses his body parts – may not be able to work in
future. In case of Permanent total disability 100% sum insured is given to the insured person.
It covers:
 Loss of both hands or both feet or one hand and one foot
 Loss of a Limb (hand/foot) and an eye
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  Complete and irrecoverable loss of sight of both eyes
 Complete and irrecoverable loss of speech & hearing of both ears

3. PERMANENT PARTIAL DISABLEMENT

As the name suggest this benefit is given if someone losses one hand or one leg or even small
body part like finger/toe. For this every insurance company have their own tables – what they
will cover & how much they will pay depends upon the age limit of the person as per policy
documents.

4. TEMPORARY TOTAL DISABLEMENT

Sometime it can happen that anyone met with some serious accident but there is no permanent
loss. But doctor suggested a complete bed rest of 5 weeks or a complete checkup of any part
of the body. This will impact an earning for a small period so in such case accidental
insurance can compensate for this income loss. Weekly benefit is normally 1% of your sum
assured for maximum 100 weeks. There is also a maximum limit according to your income.

5. OTHER SMALL BENEFITS

There are few other benefits that one can get from insurance company – few are priced in the
premium & for others you need to pay additional premiums. These can be like emergency ambulance
charges, education fund for kids, medical expenses, family transportation, imported medicines etc.

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 DISADVANTAGES OF AN ACCIDENT INSURANCE
POLICY

1. CAUSE OF DEATH

Accident life insurance coverage only pays out if your death can be directly attributed to an
accident. If you were to suffer a heart attack when driving, the policy won't pay out.

2. HIGH RISK HOBBIES AND ACTIVITIES :

Some policies don't cover accidents that occur due to the participation in high risk activities,
such as bungee jumping, hang gliding and rock climbing. Always check the terms and
conditions if you intend to participate in these activities.

3. PERSONAL ACCOUNTABILITY :

If you die in an accident when intoxicated, on drugs or breaking the law, your accidental death
life insurance policy won't pay out.

4. TIME FRAME :

Most policies specifically state that your death or dismemberment must occur within 3 months
of the accident taking place.

CASE STUDY

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Case Study: Insurance company
wants accident victim to submit irrelevant documents, faces heat
By Jehangir B Gai, | Updated: Jul 21, 2014, 08.37 AM IST

There were five occupants in the car. Police identified one of the deceased as Syed Abu, 23, a native
of
Alwarthirunagar in Chennai.

BACKGROUND
Insurance companies often delay payment of a claim and harass a consumer by demanding
documents which are not necessary for the settlement of the claim. The consumer cannot be faulted
for
not furnishing irrelevant documents, demanded piecemeal. The insurer would be liable for deficiency
in
service.

Case study: Harpreet Singh Oberoi was working with Mirasu Marketing as a sales representative. He
was
covered under a personal accident policy obtained by his employer through Oriental Insurance Co.

On June 7 2004, Oberoi met with an accident, for which an FIR was registered at the Jalandhar police
station. Oberoi suffered several injuries and was hospitalized for a week. Following discharge, he
continued treatment, but suffered 50% disability. Oberoi lodged a claim of Rs 1,85,000 with
supporting
)

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documents such as bills, prescription slips, payment receipts etc. But the claim was neither settled nor
rejected, prompting Oberai to file a complaint before the Jalandhar district forum against the
insurance
company and his employer.

The employer refuted its liability as the policy was a contract between Oberoi and Oriental Insurance
Co.
The employer also questioned the jurisdiction of the Jalandar forum as Oberoi was working in
Mumbai
when the accident occurred. The insurance company stated that it could not decide on the claim as
Oberoi had not submitted all necessary documents. The Forum held the insurance company liable to
pay
Rs 1,85,000, while the employer was asked to pay 9% interest, Rs 5,000 in compensation and Rs
3,000
toward costs.

The insurance company appealed to the Punjab State Commission; the employer did not. The state
commission observed that the employer had failed to furnish relevant documents. It held the insurer
and employer jointly and severally liable to pay Rs 1,85,000.

Meanwhile, Mirasu Marketing amalgamated with Femcare Pharma, and later with Dabur. The state
commission's order was challenged by Dabur before the national commission. The national
commission

observed that two documents not supplied: Oberoi's salary certificate and leave sanction order.
While
these may have been relevant to compute disability, they were irrelevant for for reimbursement of
medical expenses. All supporting documents had been submitted to substantiate the claim.

The commission concluded that the conduct of the insurance firm asking for these documents for a
medical reimbursement claim was unjustified and amounted to a deficiency in service. The
commission
further said the contract of insurance required the insurance company to make payment under the
policy, so the employer could not be saddled with this liability.
)

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The state commission's order holding the employer liable for payment of the claim amount was
set
aside, and this liability was fastened on the insurance firm alone. The commission said the order of
the
District Forum directing the employer to pay interest, compensation and costs had not been
challenged
in appeal. Since the employer had not appealed, this order had attained finality and could not be
challenged. Dabur was held liable for interest payment, compensation and costs. (Judgment dated
May12, 2014.)

IMPACT
Insurance firms must focus on documents relevant to decide the claim, and not harass
consumers by asking for irrelevant documents and piecemeal information.

(The author is a consumer activist and has won the Govt of India's National Youth Award for
Consumer
Protection. His email is: jehangir.gai.articles@hotmail.com)

DOCUMENTS REQUIRED

 ACCIDENTAL DEATH DOCUMENTS

Copy of Claim intimation given to Company together with xerox of policy & premium
receipt
Duly filled Claim Form
Post mortum report
Death Certificate
Police Panchnama/First Information Report/Final Investigation Report
Medical report & details of medical expenses
Wage Certificate from employer
Proof of Age

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 PERMANENT DISABILITY/INJURY CLAIM DUE TO ACCIDENT
Copy of Claim intimation given to Company together with xerox of policy & premium
receipt
Police Panchnama/First Information Report/Final Investigation Report
Medical Certificate & details of medical expenses & disability certificate
Leave certificate from employer
Duly filled Claim Form
Wage Certificate from employer

 TEMPORARY TOTAL DISABILITY (TTD) (WEEKLY COMPENSATION) CLAIM

DUE TO ACCIDENT
Copy of Claim intimation given to Company together with xerox of policy & premium
receipt
Duly filled Claim Form
Police Panchnama/First Information Report/Final Investigation Report
Medical report
Leave certificate from employer
Details of medical expenses

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 ORIENTAL INSURANCE COMPANY LIMITED PERSONAL
ACCIDENT CLAIM FORM

ISSUING OFFICE

The Oriental Insurance Company Limited

Head Office, A-25/27, Asaf Ali Road, New Delhi-110
002 ISSUING OFFICE

PERSONAL ACCIDENT POLICY (INDIVIDUAL)

CLAIM
FORM

This form is issued without admission of liability and must be completed and returned within 7
)

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days after its receipt. No claim can be admitted unless a medical overleaf be furnished at the
expense of the claimant.

Claim No. Policy No.

1. Name in Full Present Age
Residence
Business Address Year
Permanent Business or Occupation if more than
one Height ft. Inc

state all

Wt. st lbs
2. a) When did the accident occur? State day, date
and hour

b) Where did it occur?

c) Give full particulars of the cause and the

injuries sustained.
3. Give name and address of the witness of
the accident.
4. a) Give name and address of the Doctors
who attended you.

b) Name and address of your ordinary

Medical Attendant.
5. State where and when a Medical or other officer
of the Company can visit you, if necessary.
6.(a) State the number of days you have been 6. (a) confined for …day……….
necessarily and entirely confined to Bed, Room From
or House as the sole and direct result of the ………….to
Injuries (b)
sustained.

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 (b) If still confined, state probable
duration of confinement.
(c) Have you in any way attended to business or c)
work during the above period?
Have you been able to attend to any portion of d)
you.
7. Have you previously claimed or received
compensation under an Accident and/or
Sickness Policy? If so, give Particulars

8. a) Are you insured elsewhere? a)

b) If so give the name of each Company or
Insurer and the amount you are entitled to Claim b)

I HEREBY DECLARE that I have received the injuries above described and warrant the truth of
the foregoing particulars in every respect, and I agree that if I have made, or if shall make false
or untrue statement, suppression or concealment, my right to compensate shall be absolutely
forfeited.

I claim to be paid sum of………………..per week, or the total sum of …………which I agree to
accept in full settlement of my claim on the company.

Dated Signature

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 CONCLUSION

Accident Insurance should taken by every person or individual who possess a vehicle so that he can
be insured form the risk raises by accident taken place .Accident insurance provides a cash
cover to a policyholder when he/she suffers injuries as a result of an accident. While insurance
helps a policyholder pay off hospital and medical bills in case of accident injuries, it provides
cash benefits to family members if the policyholder dies in the accident. This insurance
applicable 24 hours a day, 365 days a year, is also commonly referred to as personal accident
insurance.

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)

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