Roll No 39

1
PA & HEALTH INSURANCE
INDEX
SR NO
NAME
1.
INTRODUCTION
PAGE
NO
2
2.
MEANING OF PERSONAL ACCIDENT
3.
FEATURES OF PERSONAL ACCIDENT
4.
BENEFITS OF PERSONAL ACCIDENT
11
5.
COVERAGES/COMPENSATION
15
6.
EXCLUSIONS
16
7.
17
8.
PROCEDURE FOR INSURING UNDER PERSONAL

ACCIDENT POLICY
CLAIM PROCEDURE
19
9.
WHY DO YOU NEED THIS POLICY?
20
10.
GROUP PERSONAL ACCIDENT POLICY
26
11.
FEATURES OF GROUP PERSONAL POLICY
28
12.
BENEFITS OF GROUP PERSONAL POLICY
29
13.
EXCLUSIONS
32
14.
CLAIM PROCEDURE
33
15.
HEALTH INSURANCE
35
16.
TYPES OF HEALTH INSURANCE
37
17.
IDEAL COVER FOR HEALTH INSURANCE
38
18.
HEALTH INSURANCE FOR SENIOR CITIZENS
40
19.
HEALTH INSURANCE AWARENESS IN INDIA
43
20.
46
21.
KEY PROCEDURE FOR FILING A HEALTH

INSURANCE CLAIM
FRAUDULENT HEALTH INSURANCE CLAIMS
49
22.
CONCLUSION
51
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INTRODUCTION
An accident can strike at anytime. It takes only a second... but the effects can
last a lifetime! In such cases it is utmost important to ensure that your family
doesnt have to face additional burden of managing their day-to-day basic
needs.
Thats where HDFC ERGO Personal Accident Policy can reassure your family
of the added protection and financial security that they require at such a
crucial time. Any one up to the age of 65 years can avail the cover of this
policy. It is a low cost family package cover, inclusive of broken bones
coverage for your parents up to 70 years. It not only secures you in India but
also provides effective cover worldwide, so that you remain protected no
matter where you are.
This policy offers compensation in case of death or bodily injury to the insured
person, directly and solely as a result of an accident, by external, visible and
violent means. The policy operates worldwide and is a 24 hours cover.
Different coverages are available ranging from a restricted cover of Death
only, to a comprehensive cover covering death, permanent disablements and
temporary total disablements.Family Package cover is available to Individuals
under Personal Accident Policy whereby the proposer, spouse and dependent
children can be covered under a single policy with a 10% discount in
premium.
Group personal accident policies are also available for specified groups with a
discount in premium depending upon the size of the group.
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Individual and group personal accident policies can be extended to cover
medical expenses incurred in the treatment of an accident covered under the
policy, subject to a limit of 10% of the sum insured or 40% of the death /
disability compensation claim payable, on payment of additional premium.
The policy issued to Indian personnel working in foreign countries on civilian
duty can be extended to cover War risk on payment of additional premium.
The policy can also be restricted to cover Personal Accident risk during duty
hours only or during off-duty hours only with discount in premium. It is also
possible to issue group P.A. policy excluding the death benefit subject to a
group life policy covering death benefit being taken for the same group of
persons for the same policy period.
It is very difficult to put a value to a human life. Hence the principle of
indemnity cannot be applied in this policy. However it becomes necessary to
apply some yardstick for fixing the sum insured so that human lives are not
overvalued for ulterior motives.
Hence the capital sum insured is restricted to 72months income from gainful
employment. This means that income from property, shares etc. will not be
taken into account. For non working spouse, the sum insured is restricted to
50% of the sum insured of earning spouse subject to a maximum of Rs.
1,00,000/- and for dependent children to 25% of the sum insured of earning
parents subject to a maximum of Rs. 50,000/-. In case of Gramin Personal
Accident, Student Safety, Raj Rajeshwari, Bhagyashree policies the sum
insured is fixed.
In Individual Personal Accident policy, facility of cumulative bonus is given
whereby the capital sum insured is increased by 5% every year on claim free
renewals subject to a maximum of 50%. This cumulative bonus is available
only under tables A, B & C.
It is an agreement between two parties - the insured and the insurer wherein, the insurer (or the insurance provider) promises to give the insured
or his family a financial compensation in the event of death or permanent
physical disability caused solely & directly from an accident by any external,
violent & visible means.
There are over 20 general insurance companies who offer personal accident
insurance in India.
Different types of personal accident insurance coverages available are as
follows:
Cash payment: In case an injury caused during an accident requires
treatment, your personal accident insurance policy will take care of the
expenses incurred for the same. In addition, if following the injury, caused in
the accident, you have to stay away from your office/job, your personal
accident insurance policy might cover some of your expenses for the period
you are home. Such reimbursement amounts often come handy at the time of
paying rents, groceries, etc.
Death in an accident: Many personal accident insurance policies offer risk
coverage against accidental death of the insured. If any accident results in the
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death of the insured person, then his/her personal insurance policy will pay to
his/her family or beneficiaries a prearranged sum of money.
Disability due to an accident: If following a disability, caused in an accident,
the insured goes out of job, there might be chances that his/her personal
accident insurance policy may provide him/her with some amount as monthly
income.
Before you buy your personal accident insurance policy, as a thumb rule,
make it a point to read and understand the terms & conditions mentioned in
the policy document. In order to know what coverages and risks are you
covered for it is important to understand the intricacies mentioned in your
policy features. It is definitely important to make a note of what are you
covered for under your personal accident insurance policy. However, at the
same time, it is equally important to note that what does the policy does not
cover. This clarity will also assist you in understanding the claim procedure
followed by your insurance provider.
Things to consider while buying personal accident insurance in India
Every individual is exposed to various kinds of risks. Therefore, it is always
wise to ensure protection against different perils that you or your family may
come across. Individuals generally prefer having a life insurance and/or a
health insurance to safeguard themselves from uncertain events. However,
either of the policies might fail to provide you cover in case of uncertainties
like personal accident.
A damage caused by a personal accident can be good enough to burn your
pocket, and your health insurance or life insurance policy may not be able to
provide you any financial security in such point of time. Therefore, ensure
yours and your family's security against uncertain events like personal
accident by insuring yourself and them under a personal insurance plan.
A personal insurance is a potential hedge against unforeseen events. It is
therefore important that before buying an accident insurance policy, you
should to get a better understanding of the same.
On similar lines, we bring you a list of some prime factors that one should
consider before buying a personal accident insurance policy:
1) Opt for a premium amount which suits your budget. This will help you get
best possible coverage at affordable rates. However, in the process make
sure you don't end up being under-covered.
2) There are many general insurance companies which offer personal
insurance cover. Before finalizing on a single company, find out about its
market reputation and check its track record of claim settlements.
3) Generally a standard personal insurance or accident insurance cover offer
benefits accidental death, broken bones, permanent disability, and temporary
disability. Some general insurance companies also offer cost of ambulance
service in their personal insurance policies. In the hour of need, if you take the
medical treatment in the company's network hospital then you might avail
cashless facility as well.
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4) Check if your personal insurance policy also provides coverage outside
India. Such coverage would be an added benefit.
5) In event of accidental death, the accident insurance generally provides
compensation to the family.
6) Make it a point to read through the exclusions mentioned in the accident
insurance policy
MEANING OF PERSONAL ACCIDENT INSURANCE

The purpose of personal accident insurance is to pay fixed compensation for
death or disablement resulting from accidental bodily injury. The personal
accident insurance policy provides that, if at any time during the currency of
this policy, the insured (person
who has taken the policy) shall sustain any bodily injury resulting solely and
directly accident caused by external violent and visible means, then the
insurance company shall pay to the insured or his legal personal
representative(s), as the case may be, the sum or sums set, forth, in the
policy, if resulting in specified contingencies such as death, permanent
disablement etc. Personal Accident is an insurance cover wherein, in the
event of the person sustaining bodily injuries resulting solely and directly from
an accident caused by EXTERNAL, VIOLENT & VISIBLE means , resulting
into death or disablement.
Below is a table which gives you an idea on what kind of situations are
covered under personal accident insurance :
In case of a death due to accident, the policy would pay 100% Sum
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
2.
Permanent company. Example Loss of
Total
both hands or both feet
Disablement one hand and one feet
one (hand or foot) and an eye
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
3.
up to 100 weeks. Example below
Permanent
Loss of Index Finger or thumb
Partial
Loss of hearing in 1 ear
Disablement
Loss of 1 eye sight
Loss of 1 hand
This means that for some weeks or months a person is totally
4.
1. Death
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Temporary disabled and will not be able to work and earn money. In this case
most of the companies pay a part of sum assured , some pay 100%
Total
Disablement and some pay 50% , there is also a cap in this case , like maximum 5
lacs or 10 lacs. Example below
A bed rest of next 3 months
Fracture in hands or legs
Below is a comparison of some good accidental policies. If you see all of them
, you will realise that all the policies have something good or bad in them. This
chart is made with collecting information from different portals and companies
websites
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If you see the above table, you can see that on absolute level Bajaj Allianz
seems to be the best option and its the recommended one . The best part is
that the claim settlement ratio is high and thats the biggest parameter people
look for.
a) Bodily injury: Any disease due to accident is known as bodily injury but
does not include any disease due to natural cause. Mental shock or grief does
not amount to accident unless and until some physical injury is caused. In
current scenario it is noticed that due to grief some disablement i.e paralysis
is taking place and the same is covered under this policy.
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b) Solely & Directly: The bodily injury shall have been caused solely and
directly by an accident and the bodily injury must directly and independent of
any other cause
result in death or disablement.
For eg: 1) A person is thrown from his horse while hunting and so injured that
he cannot walk and he lies on the wet ground until he is pick up. He thus
catches chill which turns pneumonia and dies. Though he dies because of
pneumonia but the actual cause is an accident and it covered under personal
accident insurance policy.
2) If a person breaks a leg in an accident and taken to hospital where he
contracts an infectious disease from another patient which result in to death
and the same is not covered under the personal accident insurance policy.
c) Accident: An accident is an event which is wholly unexpected not intended
or designed. For eg: Snake biting, Drowning suicide and unprovoked murder
are covered
under this policy.
d) External, violent and visible means: The cause of accident i.e. the
means must be within the definitions as a whole but the result may not be
external. In other words the means or cause of accident must be within the
definitions but the result or effect need not be external or visible so long as it
is bodily injury e.g. injury may be internal i.e. inside the body but the result
must be death or disablement.
e) Disablement : When a person is prevented by an accidental bodily injury
from engaging in any occupation or business he is said to be disabled and his
ability to
attend to any occupation or business is call disablement.
PERSONAL ACCIDENT INSURANCE- VALUE ADDED BENEFIT

1.Transportation of dead body
Two per cent of the capital insured will be paid for transportation for accidental
death happening outside of the residence. ( Subject to maximum of Rs 2,500)
2.Education Grant
10 per cent of the sum insured, will be paid for one dependent child below the
age of 25 years. (Subject to maximum of Rs 5,000)
10 per cent of the sum insured, will be paid for two dependent children below
the age of 25 years. (Subject to maximum of Rs 10,000)
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FEATURES OF PERSONAL ACCIDENT INSURANCE

1) Offer & Acceptance; It is a prerequisite of any contract. Similarly the
person will be insured under personal accident insurance policy after the offer
is accepted by the insurance company. Example: A proposal submitted to the
insurance company along with premium on 1/1/2011 but the insurance
company accepted the proposal on 15/1/2011. The risk is covered from
15/1/2011 and any loss prior to this date will not be covered under fire
Insurance.
2) Payment of premium: An owner must ensure that the premium is paid
well in advance so that the risk can be covered. If the payment is made
through cheque and it is dishonored then the coverage of risk will not exist. It
is as per section 64VB of Insurance Act 1938.
3) Contract of Indemnity: This principle is not applicable to personal
accident policy. This is so because life is invaluable and no amount of money
can compensate the death or disablement of a human being. When polices
are issued to employer to reimburse under service conditions the amounts of
compensation paid by them to their employees or their dependents on the
disablement or the death of their employees i:e the insured are
indemnified with the exact amount of compensation paid by them.
4) Utmost good faith: The person must disclose all the relevant information
to the insurance than company while insuring himself because none other him
knows about his health and other relevant particulars. Any change in
profession or occupation during the policy should also be informed to the
insurance company. e.g. A person is working in the office in administrative job
and took the personal accident policy but later on he becomes pilot then he
should inform o the insurance company otherwise the insurance company can
refuse the claim in case it arises.
5) Insurable Interest: A person is having an unlimited interest in his own life
and as such this feature is valid in this policy. Similarly the wife has unlimited
interest in the life of husband and vice versa. The employer has the insurable
interest in the life his employees.
6) Contribution: As the principle of indemnity is not applicable to this policy
therefore the principle of contribution will also not apply. The person will get
sum insured of all personal insurance policies irrespective of number of
polices.
7) Period of Insurance: The period of insurance is to be defined in the policy
which varies form one year to five years. Some times this policy is issued for
specific rail/ road/sea journey.
8) The cover under this policy is for 24 hours and on a worldwide basis. Even
if the insured person dies in foreign country due to accident the compensation
will be paid in India in Indian rupees up to the sum insured.
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9) Claims: To get the compensation under personal accident insurance the
legal heirs should inform to the insurance company about the death of the
insured and incase of disability the person himself can inform the insurance
company.
10) Accidental Death - Pays 100% of the Sum Insured if bodily injury results
in death from an accident
11) Permanent Total Disablement - Pays up to 100% of the Sum Insured if
bodily injury results in permanent disablement due to an accident
12) Broken Bones Pays up to 10% of Sum Insured in the event of bodily
injury resulting in broken bones due to an accident
13) Hospital Cash (Accident & Sickness) - Provides a daily benefit up to a
maximum of 45 days in case of hospitalization due to an accident or sickness
14) Burns - Pays up to 5% of Sum Insured if an accident results in
hospitalization and treatment of burns
15) Ambulance Costs - Pays up to the Sum Insured towards the
reimbursement of costs for ambulance charges.
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.
(i) For children the cover is limited to Death and Permanent Disablement (total
or partial)
(ii) Premium payable for husband and wife will be on the total sum insured for
husband and wife.
(iii) 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.
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BENEFITS OF PERSONAL ACCIDENT INSURANCE

Benefit 1. Accidental Death
1) Accidental Death
If an Insured Person suffers an Accident during the Policy Period and this is
the sole and direct cause of his death within 365 days from the date of the
Accident, then We will pay the Sum Insured.
2) Transportation of Mortal Remains
If We have accepted a claim under 1), then We will in addition reimburse the
lower of 2% of the Sum Insured under 1) and the actual amount incurred in
transporting the mortal remains of the Insured Person from the place of the
Accident or the Hospital to his residence or Hospital or to a cremation or burial
ground.
Benefit 2. Permanent Total Disablement
1) If an Insured Person suffers an Accident during the Policy Period and within
365 days from the date of the Accident this is the sole and direct cause of his
permanent total disablement in one of the ways detailed in the table below,
then
We will pay the percentage of the Sum Insured shown in the table
Loss of 2 Limbs (both hands or both feet or one hand and one foot)
100%
Loss of a Limb and an eye 100%
Complete and irrecoverable loss of sight of both eyes 100%
Complete and irrecoverable loss of speech & hearing of both ears
100%
Loss of a Limb 50%
Complete and irrecoverable loss of sight of an eye 50%
2) In this Benefit:
a) Limb means a hand at or above the wrist or a foot above the ankle.
b) Loss of Limb means:
i) the physical separation of a Limb above the wrist or ankle
respectively, or
ii) the total loss of functional use of a Limb for at least 365 days from the date
of onset of such disability provided that We must be satisfied at the expiry of
the 365 days that there is no reasonable medical hope of improvement.
Benefit 3. Permanent Partial Disablement
1) If an Insured Person suffers an Accident during the Policy Period and within
365 days from the date of the Accident this is the sole and direct cause of his
permanent partial disablement in one of the ways detailed in the table below,
then We will pay the percentage of the Sum Insured shown in the table.
Loss of: % of Sum Insured
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Each arm at the shoulder joint 70%
Each arm to a point above elbow joint 65%
Each arm below elbow joint 60%
Each hand at the wrist 55%
Each thumb 20%
Each index finger 10%
Each other finger 5%
Each leg above center of the femur 70%
Each leg up to a point below the femur 65%
Each leg to a point below the knee 50%
Each leg up to the center of tibia 45%
Each foot at the ankle. 40%
Each big toe 5%
Each other toe 2%
Each eye 50%
Hearing in each ear 30%
Sense of smell 10%
Sense of taste 5%
2) In this Benefit:
a) Loss means:
i) the physical separation of a body part, or
ii) the total loss of functional use of a body part or organ provided this
has continued for at least 365 days from the onset of such disability
provided that we are satisfied at the expiry of the 365 days that there
is no reasonable medical hope of improvement.
3) If an Insured Person suffers a Loss not mentioned in the table above, then
We will assess the degree of disablement with our medical advisors and
determine the amount of payment to be made.
4) If a claim in respect of a whole member (any organ, organ system or a
limb) also encompasses some or all of its parts, Our liability to make payment
will be limited to the member only and not any of its parts or constituents.
Benefit 4. Temporary Total Disablement
If an Insured Person suffers an Accident during the Policy Period which is the
sole and direct cause of a temporary disability which completely prevents him
from performing each and every duty pertaining to his employment or
occupation, then We will pay a weekly benefit, provided that:
1) The temporary total disablement is certified by a Doctor, and
2) Our liability to make payment will be limited to of 1% of the Sum Insured for
each week during the period of temporary total disablement for a period not
exceeding 100 weeks from the date of the Accident and if the Insured Person
is disabled for a part of a week, then only a proportionate part of the weekly
benefit will be payable, and
3) We will not pay any amount in excess of the Insured Persons base weekly
income excluding overtime, bonuses, tips, commissions, or any other special
compensation.
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Benefit 5. Emergency Ambulance Charges
If we have accepted a claim under this Policy and following the Accident it is
necessary to immediately transfer the Insured Person to the nearest Hospital
by ambulance offered by a healthcare or an ambulance service provider, then
We will in addition reimburse the actual expenses of the transfer using the
shortest route.
Benefit 6. Education Fund
If we have accepted a claim under Benefit 1 or 2, then we will in addition pay
50%of the Sum Insured per Dependent Child up to a maximum of 2
Dependent Children provided that such Dependent Child is pursuing an
educational course as a full time student in an educational institution.
Benefit 7. Family Transportation
If we have accepted a claim under Benefit 1 or 2, then we will in addition
reimburse the actual expenses incurred in transporting one Immediate Family
Member to the Hospital where the Insured Person is admitted following an
Accident, provided that such Hospital is located at least 200 kms from the
Insured Persons residence.
Note: In this Benefit, Immediate Family Member means the Insured Persons
legal spouse, children, parents, parents-in-law, legal guardian, ward, step
child or adopted child.
Benefit 8. Purchase of Blood
If we have accepted a claim under Benefits 1-4, then we will in addition
reimburse the actual expenses incurred in purchasing blood through a
Hospital or lawful blood bank for the purpose of the Insured Persons medical
or surgical treatment provided that such treatment is necessitated by the
Accident.
Benefit 9. Transportation of Imported Medicine
If We have accepted a claim under Benefits 1-4, then We will in addition
reimburse the actual expenses incurred on freight charges for importing
medicines to India, provided that:
a) Such medicines, formulations or their alternatives are not available in India,
and
b) Such medicines are necessary for the medical or surgical treatment of the
Insured Person in a Hospital following the Accident.
c) Such medicines shall not include any drugs under clinical trial or medicines,
formulations or molecules of unproven efficacy.
Benefit 10. Accident Hospitalisation (Inpatient)
If any Insured Person suffers an Accident during the Policy Period that
requires that Insured Persons Hospitalisation as an inpatient, then We will in
addition reimburse the Medical Expenses incurred for the in-patient treatment
of such Insured Person provided that the Hospitalisation commences within
the same Policy Period. Our liability to meet Medical Expenses caused by
such Accident will be limited to the Sum Insured of that Policy Period.
Benefit 11. Broken Bones
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If an Accident causes an Insured Person to suffer a fracture (a break in the
continuity of a bone) and this is certified by a Doctor and also confirmed by
imaging investigations such as by X-ray, then we will pay the percentage of
the Sum Insured specified in the table below.
Injury to vertebral body resulting in spinal cord damage 100%
Pelvis 100%
Skull (excluding nose and teeth) 30%
Chest (all ribs and breast bone) 50%
Shoulder (collar bone and shoulder blade) 30%
Arm 25%
Leg 25%
Vertebra vertebral arch (excluding coccyx) 30%
Wrist (collies or similar fractures) 10%
Ankle (Potts or similar fracture) 10%
Coccyx 5%
Hand 3%
Finger 3%
Foot 3%
Toe 3%
Nasal bone 3%
a) If an Insured Person suffers a fracture not mentioned in the table above,
then we will assess the fracture with Our medical advisors and determine the
amount of payment to be made.
b) Our maximum liability is limited to the Sum Insured, irrespective of the
number of fractures that the Insured Person suffers caused by the same
Accident.
c) If a claim in respect of any fracture of a whole bone also encompasses
some or all of its parts, Our liability to make payment will be limited to the
whole bone only and not any of its parts.
Note: In this Benefit:
a. Pelvis means all pelvic bones, which shall be treated as one bone. The
sacrum is part of the vertebral column.
b. Skull means all skull and facial bones, (excluding nasal bones and teeth)
which shall be treated as one bone.
Benefit 12. Modification of Residence/Vehicle
If We have accepted a claim under Benefit 2, then We will in addition
reimburse the reasonable expenses incurred to modify the Insured Persons
residential accommodation and/or vehicle as long as the modifications have
been carried out in India and certified by a Doctor to be necessary and directly
required as a result of the Accident for which We accepted the claim.
Note: This is only applicable for Benefits 1-3.
If no claim has been made under this Policy and the Policy is renewed with
Us without any break, we will apply a cumulative bonus to the next Policy
Year by automatically increasing the Sum Insured for the next Policy Year by
5% of the Sum Insured for this Policy Year.
The maximum cumulative bonus shall not exceed 50% of the Sum Insured in
any Policy Year for benefits under Benefits 1-3.
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If a cumulative bonus has been applied and a claim is made, then in the
subsequent Policy Year the cumulative bonus will automatically reduce to
zero in that following Policy Year.
COVERAGES/ 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.
e.g. 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 an 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.
Type of loss
% of Capital
Loss of toes-all
20 %
Loss of toes great-both
5%
Loss of toes great-one Phalanx
2%
Loss of toes other than great if
1%
Loss of hearing-both ears
75 %
Loss of hearing-one ear
30 %
Loss of four fingers and thumb of one

hand
40 %
Loss of four fingers
35 %
Loss of thumb-both phalanges
25 %
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Loss of thumb-one phalanges
10 %
Loss of index fingers-anyone or three

phalanges
6%
Loss of ring finger - anyone or three

phalanges
5%
Loss of middle finger - anyone or three

phalanges
4%
Loss of metacarpals-first or second

(additional) or 3rd, 4th or 5th (additional)
3%
Any other permanent partial disablement
% as assessed by
Panel Doctor
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.
f) 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.
g) 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 insured.
EXCLUSIONS
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 traveling 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
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(vii) Resulting directly or indirectly from child birth or pregnancy
PROCEDURE FOR INSURING UNDER PERSONAL ACCIDENT

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 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
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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
a) Written notice of claims with full particulars. In case of death written notice
must, unless reasonable ause 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 Insureds
expense such operation or treatment as the company may reasonably deem
desirable.
g) No sum payable under this policy shall carry interest.
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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 policy give notice in writing to the company of any disease,
physical defect or infirmity with which he has become affected since the
payment of last preceding premium.
j) The policy is cancelable by either party. Pro-rata refund of premium is made
if cancelled by insurers and short period refund of premium, subject to no
claim under the policy, if cancelled by the insured.
k) The Company shall not be bound to take notice or be affected by any
notice of any trust, charge, lien, assignment or other dealing with or relating to
this policy but the receipt of the Insured or his legal personal representatives
shall in all cases be an effective discharge to the Company.
l) The Company treats the insured as the absolute owner of the policy.
Receipt of the insured or his legal personal representatives that is, those with
a Succession Certificate etc. granted by a court of law will be an effective
discharge to the Company.
m) Differences regarding amount of loss (not question of liability) are to be
referred to arbitration. The award of arbitration is a precedent to suit in Court
of Law.
n) If the insurers disclaim liability the insured has to file a suit in a Court of
Law within 12 months from the date of such disclaimer.
o) The insurer is not liable for
(a) Compensation under more than one of causes (death or disability)
(b) Once a claim is settled under one of the causes the policy becomes
inoperative. No further claim can be admitted under the policy.
(c) Payment of weekly compensation (until the total amount shall have been
ascertained and agreed).Although, the benefit is known as weekly
compensation the payment is generally made in one lump sum after the
quantum of liability is agreed. It is felt that periodical part payments may
encourage a claimant to deliberately prolong the disablement. In genuine
hardship cases however on account payment is made which is then adjusted
against the final payment due.
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.
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b) Claim form: The claim form is designed to elicit information, among other
things, on the following :
1. Personal details such as age, occupation, etc.
2 .Details of accident, nature of injuries, etc.
3. Medical certificate of the attending doctor (sometimes this is issued as a
separate form).
4. 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
1. Medical Certificate : to obtain medical opinion on the cause or extent of
incapacity or progress towards recovery.
2. Medical examiners Report - To corroborate medical certificate in doubtful
cases, or if other causes are in operation.
3. Receipt / Discharge form :- to acknowledge the money and to confirm the
finality of the settlement.
4. Death Certificate - To give the date and cause of death. Post mortem
reports where a post-mortem has been done.
5. 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
1 .Medical Certificate, diagnostic reports etc.
2. Prescription, bills and receipts.
3. Medical fitness certificate.
4. Leave of absence certificate from the employer.
WHY DO YOU NEED PERSONAL ACCIDENT POLICY ?

You need a life insurance policy to cover the risk of death and a health
insurance policy as a cushion against hospitalisation expenses. While most
readers are bound to be familiar with these essential covers, very few would
have heard of the personal accident cover. Personal accident schemes cover
the policyholder against death or disability due to an accident. All general
insurance companies offer these policies , but it's very unlikely that an agent
will try to sell you one. These low-priced policies are not very popular because
the agent earns barely 20-30 as commission from selling such a policy.
However, you should buy a personal accident policy because it plugs an
important hole in your insurance portfolio. Firstly, it will provide financial
support to the policyholder if he is disabled after an accident. Secondly, the
magnitude of the mishap doesn't matter; even minor ones like falling off a
bicycle and breaking an arm, or fracturing a leg while playing football are
covered by the policy. "A personal accident cover is very essential, especially
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for young people who are at greater risk of an accident than others," says
Tapan Singhel, CEO and managing director, Bajaj Allianz General Insurance.
If you thought term insurance policies were cheap, wait till you find out about
the premium rates of a personal accident policy. For as little as 225 a year,
you can get a cover of 5 lakh. The daily cost works out to about 60 paise.
However , this is the rate for a basic cover from a PSU insurer and will only
cover death and permanent disability. If you want enhanced protection, you
will have to shell out more (see graphic).
One way to get the agent interested is to buy it along with your health or
motor insurance. "Since agents get very low commissions, they usually try to
bundle the personal accident cover with some other insurance product.
However, this doesn't mean that you will pay a lower premium, though some
companies may give you a discount," says Sanjay Datta, head of underwriting
and claims, ICICI Lombard General Insurance. A basic personal accident
cover against death and permanent total disability is already built into a motor
insurance policy. You can enhance the cover by paying extra.
While PSU insurers offer cheap personal accident covers, private insurance
companies offer a wider range of benefits, but the premium rates are higher
too. You can take a cover of up to 8 times your annual salary. Apart from the
basic death and permanent disability cover , you can buy additional protection
against partial and temporary disability , even loss of livelihood. "A personal
accident policy covers the buyer against costs that can shatter him
financially," says Subrahmanyam B, senior vice-president , health &
commercial lines, Bharti AXA General Insurance.
It's important to understand the terms and conditions clearly before you buy a
policy. For example, hospitalisation benefit can be availed of only if the
policyholder is admitted within seven days of the accident and is hospitalised
for at least 24 hours. A fractured leg is a temporary disability, and if you have
taken a cover against it, your policy will pay a weekly sum of 5,000 for up to
two years. However, this weekly cash benefit is paid only if you are unable to
go to work and the payment starts only 60 days after the accident. One also
has to submit proof, including a doctor's certificate for the disability that
prevents one from attending work.
Also, be very clear about the definition of disability. When a Delhi-based
policyholder lost his index finger in a car accident, the hospital gave him a
certificate of 15% disability. Yet, the life insurance company denied his claim
because he had a cover against total disability. "The policy document defines
the loss of hand as total disability. The loss of one digit, even though it was
the index finger , was not covered," he says.
Permanent total disability is defined as total loss of sight in both eyes, or total
loss of use, or dismemberment of both hands or legs, or one hand and one
leg. Losing one eye is a permanent, but not total, disability. Ask the insurance
company or agent to explain the exclusions clearly to you.
Most companies offer personal accident insurance to their employees through
a group cover. However, this is a very basic cover and may not offer the
benefits offered by a standalone policy. "I recommend an individual policy only
if one can afford it and if his company's cover is insufficient," says Jayant Pai,
head, marketing, Parag Parikh Financial Advisory Services.
You can also buy an accident cover with a rider along with a life insurance
policy. However, these riders come with strings attached and don't offer
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certain covers. "Since life insurance companies cannot offer anything but life
cover, you will not be covered against other damages, such as hospitalisation
expenses ," says Sanjay Tiwari, vicepresident , strategy and
product,HDFC Life. "Riders can never be as comprehensive as a standalone
policy," he adds.
A plain vanilla personal accident cover is not very expensive, but it can come
handy in case of a mishap. Self-employed professionals who travel a lot
during the course of their work will find this especially useful. Buy one right
away so that there is nothing left to chance in your insurance portfolio.
THINGS TO LOOK OUT WHILE BUYING THIS POLICY

Following are some top-of-the-mind tips I thought to share with you, to ensure
at the time of buying a personal accident policy:
Look for coverage first go for product that offers maximum coverage. Since
this product is cheap, select product with maximum possible coverage
As regards sum assured, while there is no such ground rule, sum assured
should be min. 5 times of your annual income.
Opt for insurers which offer cover for maximum age, or if cover is lifetime
renewable, nothing like it. Generally as people get old, they become more
riskier for insurance company, but that is when you need a cover the most
Though health insurance terms and conditions are complicated even for
advisors, its your duty to read the terms and conditions in brochure, before
taking a final call even I will advise checking the policy wordings for clauses
not covered in the brochure.
Remember to fully disclose the medical history of the family so that there are
no rejections at claims stage. Also, remember to fill the proposal form
yourself.
PA rider attached with life insurance policy offers a very limited cover. Hence,
go for a stand-alone personal accident policy only, so that you get proper
coverage for the amount spent.
GENERAL CONDITIONS
1) Condition precedent
The fulfilment of the terms and conditions of this Policy (including the payment
of premium by the due dates mentioned in the Schedule) insofar as they
relate to anything to be done or complied with by You or any Insured Person
shall be conditions precedent to Our liability.
2) Insured Person
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Only those persons named as an Insured Person in the Schedule shall be
covered under this Policy. Any person may be added during the Policy Period
as an Insured Person after his application has been accepted by us,
additional premium has been paid and We have issued an endorsement
confirming the addition of such person as an Insured Person. We will not
cover any person under Age 91 days or above the Age 70 years.
3) Notification of Claims
a) We must be informed of any event or occurrence that may give rise to a
claim under this Policy within 30 days of it happening. The Company may
accept claims where documents have been provided after a delayed interval
only in special circumstances and for the reasons beyond the control of the
insured.
b) For all benefits contingent on Our prior acceptance of a claim under
Benefits 1-4, We must be informed within 30 days of the event or occurrence
that may give rise to a contingent benefit claim.
c) If any time period is specifically mentioned in Benefits 1-12, then this shall
supersede the time periods mentioned at a) & b) above.
4) Claims Payment Supporting Documentation & Examination
a) We must be provided with any documentation and information We may
request to establish the circumstances of the claim, its quantum or Our liability
for it including, in English, Our claim form duly completed and all reports,
including but not limited to death certificate, disability certificate, medical
reports, case histories, investigation reports, treatment papers and discharge
summaries
b) The Insured Person additionally hereby consents to:
i) The disclosure to Us of documentation and information that may be held by
medical professionals and other insurers.
ii) The Insured Person shall be examined by any medical practitioner We
authorise for this purpose when and so often as We may reasonably require.
5) Claims Payment
a) We shall be under no obligation to make any payment under this Policy
unless We have been provided with the documentation and information We
have requested to establish the circumstances of the claim, its quantum or
Our liability for it, and unless the Insured Person has complied with his
obligations under this Policy.
b) All payments made shall be subject to an applicable Deductible (if any) for
such payment.
c) If We accept a claim and become liable to make payment under Benefits 2,
3, 4, or 11, (the first claim) and there is a subsequent claim under another of
these Benefits or Benefit 1 in respect of the same Insured Person and the
same Accident within 365 days of the date of the Accident (the second claim),
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then We will only be liable to pay the difference between the amount payable
for the first claim and the amount payable for the second claim.
d) We will only make payment to or at Your direction. If an Insured Person
submits the requisite claim documents and information along with a
declaration in a format acceptable to Us of having incurred the expenses, this
person will be deemed to be authorised by You to receive the concerned
payment. In the event of the death of an Insured Person, We will make
payment to the Nominee (as named in the Schedule).
e) Payments under this Policy shall only be made in Indian Rupees
irrespective of the location of accident which has given rise to the claim.
f) We are not obliged to make payment for any claim or that part of any claim
that could have been avoided or reduced if the Insured Person could
reasonably have minimised the costs incurred, or that is brought about or
contributed to by the Insured Person failing to follow the directions, advice or
guidance provided by a Doctor.
6) Fraud
If any claim is in any manner dishonest or fraudulent, or is supported by any
dishonest or fraudulent means or devices, whether by you or any Insured
Person or anyone acting on behalf of You or an Insured Person, then this
Policy shall be void and all benefits paid under it shall be forfeited.
7) Other Insurance
a) If at the time when any claim arises under this Policy, there is in existence
any other policy effected by or on behalf of any Insured Person which covers
that claim in whole or in part (or which would cover any claim made under this
Policy if this Policy did not exist) then We shall not be liable to pay or
contribute more than Our rateable proportion of the claim. If that other policy
is one issued by Us, then Our maximum liability under all policies issued by
Us shall cumulatively not exceed the most payable under one policy.
b) 7)a) shall not apply to claims made under Benefits 1, 2 or 3.
8) Subrogation
You and/or any Insured Persons shall at Your own expense do or concur in
doing or permit to be done all such acts and things that may be necessary or
reasonably required by Us for the purpose of enforcing and/or securing any
civil or criminal rights and remedies or obtaining relief or indemnity from other
parties to which We are or would become entitled upon Us making payment
under this Policy, whether such acts or things shall be or become necessary
or required before or after Our payment. Neither You nor any Insured Person
shall prejudice these subrogation rights in any manner and shall provide Us
with whatever assistance or cooperation is required to enforce such rights.
Any recovery We make pursuant to this clause shall first be applied to the
amounts paid or payable by Us under this Policy and our costs and expenses
of effecting a recovery, whereafter We shall pay any balance remaining to
You.
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9) Change of Occupation
You will give us notice of any change in the business or occupation of any
Insured Person within 30 days of such change and We will issue an
endorsement to this effect. If at the time a claim arises under this Policy the
Insured Person has changed his occupation without Us being notified, then
Our maximum liability will be limited to the amount that would have been
payable for the premium paid and the new occupation.
10) Geography
This Policy applies to events or occurrences taking place anywhere in the
world unless limited by Us in a particular Benefit or definition or through an
endorsement.
11) Alterations to the Policy
This Policy constitutes the complete contract of insurance. This Policy cannot
be changed or varied by any one (including an insurance agent or broker)
except us, and any change We make will be evidenced by a written
endorsement signed and stamped by Us
.
12) Renewal
This Policy will automatically terminate at the end of the Policy Period. We are
under no obligation to give notice that it is due for renewal, or to renew it, or to
renew it on the same terms whether as to premium or otherwise. We shall be
entitled to call for and receive any information or documentation before
agreeing to renew the Policy, and in renewing We are not bound to renew for
all Insured Persons.
13) Notices
Any notice, direction or instruction under this Policy shall be in writing and if it
is to:
i) Any Insured Person, then it shall be sent to You at Your address specified in
the Schedule and You shall act for all Insured Persons for these purposes.
ii) Us, it shall be delivered to Our address specified in the Schedule. No
insurance agents, brokers or other person or entity is authorised to receive
any notice, direction or instruction on Our behalf unless We have expressly
stated to the contrary in writing.
14) Dispute Resolution Clause
Any and all disputes or differences under or in relation to this Policy shall be
determined by the Indian Courts and subject to Indian law.
15) Nomination
You can change the nominee to whom such payment is to be made at any
time during the Policy Period, provided that such change shall only be
effective when You have notified Us and We have recorded the change by an
endorsement to this effect.
16) Termination
a) You may terminate this Policy at any time by giving Us written notice, and
the Policy shall terminate when such written notice is received. If no claim has
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been made under the Policy then We will refund premium in accordance with
the table below:
Length of time Policy in force Refund of premium
up to 1 month 75%
up to 3 months 50%
up to 6 months 25%
exceeding 6 months 0%
b) We may terminate this Policy on grounds of misrepresentation, fraud, nondisclosure of material facts or non-cooperation by You or any Insured Person
or anyone acting on Your behalf or on behalf of an Insured Person upon 30
days notice by sending an endorsement to Your address shown in the
Schedule, and We shall refund a rateable proportion of the premium as long
as no claim has been made under the Policy
GROUP PERSONAL ACCIDENT POLICY
In the above paras we have studied about eh individual personal accident

insurance policy but the said policy can be issued where there is some
common relationship among the persons to be insured and a central point for
the administration of the insurance scheme. Accordingly, these policies can
be granted only to groups clearly following under any one of the following
categories:
1. Employer - employee relationship including dependants of the employee.
2. Pre identified segments / groups where the premium is to be paid by the
State / Central Governments.
3. Members of a registered co-operative society.
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4. Members of Registered Service Clubs.
5. Holders of credit card of Banks / Diners / Master / Visa
6. Holders of Deposit Certificates issued by Banks / NBFCs
7. Shareholders of Banks / Public Limited Companies.
Sr.
no.
A.
B.
C.
D.
E.
F.
Contingency
Amount of
compensation payable
Death
Rs. 1 lakh (100% of capital
sum insured)
Loss of 2 limbs, both eyes Rs. 1 lakh (100% of capital
or 1 limb & 1 eye
sum insured)
Loss of 1 limb or 1 eye
Rs. 50,000 (50% of capital
sum insured)
Permanent total
100% of capital sum
disablement other than
insured
the above (e.g. Paralysis
due to an accident)
Permanent partial
% as shown in the table in
disablement (e.g. loss of
the policy
a finger)
Temporary total
Weekly payment of Rs.
disablement
1,000 (1% of capital SI)
subject to maximum 100
weeks.
Geographical limit: 24-hour world-wide coverage, except for part-time

undergraduates, whose cover shall be limited to Accident in consequence of
thefollowing:
a. In the premises or on the grounds of the University while attending lessons
orworkshops,or
b. Whilst travelling between the undergraduate's residence / employer's (if
working) premises and the University to attend lessons or training conducted
in the University
Eligibility
(1) Without prejudice to Item (3) below, the Policy shall cover all matriculated
or registered students who are required to pay the tuition fees due to the
University or the host university of an exchange or attachment program for the
period of coverage (for administrative purposes, the period of coverage for
Semester One shall be deemed to commence from 1 July 2013).
(2) The Policy shall also cover any matriculated or registered student who
incurs medical expenses occasioned by or arising from an Accident that
results in his or her being granted leave of absence and hence waiver of
tuition fee by the University.
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(3) The Policy shall not cover any matriculated or registered student who has
not paid the premium collected by the University. Nevertheless, without
prejudice to Item (1) above, the Policy shall cover any matriculated or
registered student awaiting the collection of his or her premium by the
University in the period of coverage, subject to the subsequent successful
collection of the premium.
(4) Coverage for each student being covered shall terminate upon his / her
ceasing to be a student of the University. Coverage for students being
covered who are in their final year of study at the University shall lapse when
they cease to be students of the University and, without prejudice to Items (1)
and (3) above, shall be renewed automatically upon their status as students of
the University being reinstated for specific purposes in the period of coverage.
(5) Without prejudice to Items (1) and (3) above, matriculated or registered
students who join the University after 1 July 2013 shall be covered from the
date he or she officially joins the University.
Note: For administrative purposes, we regard final-year students who have
passed all the examinations to cease being matriculated students of the
University on the day after the release of their final-year examination results
and for post-graduate students, on the day they receive their conferment
letter.
FEATURES OF GROUP PERSONAL ACCIDENT POLICY

The coverage is the same as under individual P.A. policy except that
a. cumulative bonus and education grant do not apply. However, medical
expenses and war risks extensions are available.
b. The sum insured is fixed separately for each insured person.
c. Rates of premium applicable to named employees as per the classification
of risks. Where it is not possible to obtain details of occupation for each
insured person, insurers use their discretion in applying the rates.
d. If P.A. cover is required only for the restricted hours of duty (and not for all
the 24 hours of the day), a reduced premium equivalent to 75% of the
appropriate premium is charged. The cover applies to accident to employees
arising out of and in the course of employment only. If cover is required only
for the restricted hours, when the employee is not at work and / or not on
official duty, the reduced premium of 50% of the appropriate premium is
charged.
e. It is possible to exclude the Death benefit, subject to following conditions;
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(i) A group life policy covering Death benefit for the same group of persons is
in existence.
(ii) Group P.A. Policy covers a group of 100 persons or more
BENEFITS OF GROUP PERSONAL ACCIDENT INSURANCE

1. Coverage
If whilst this Policy is in force, the Insured Person suffers an Accidental
Bodily Injury, which directly and independently of all other causes, results in
death or Permanent Total Disablement, the Company will pay the Benefit
stated in the table of benefits.
2. Extended Benefits
Bodily Injury as a victim of assault, hijack or murder, which directly and
independently of all other causes, results in death or Permanent Total
Disablement, the Company will pay the Benefit stated in the table of
benefits, provided that such injury does not arise out of the Insured Persons
own participation or provocation of any such act. Disappearance If whilst this
Policy is in force, the Insured Person disappears and after 365 days, it is
reasonable to believe that such Insured Person has died as a result of
Accidental Bodily Injury, the Company will pay the death Benefit stated in
the table of benefits, subject to a signed undertaking by the Named Insured
that if the Insured Person is subsequently found alive, such death Benefit
shall be refunded to the Company. Drowning and Suffocation by Gas,
Poisonous Fumes or Smoke If whilst this Policy is in force, the Insured
Person suffers an Accidental Bodily Injury due to drowning or suffocation
by gas, poisonous fumes or smoke, which directly and independently of all
other causes, results in death or Permanent Total Disablement, the
Company will pay the Benefit stated in the table of benefits, provided that
such injury does not arise out of the Insured Persons wilful and Intentional
act. Exposure If whilst this Policy is in force, the Insured Person suffers an
Accidental Bodily Injury due to unavoidably exposure to the elements,
which directly and independently of all other causes, results in death or
Permanent Total Disablement, the Company will pay the Benefit stated in
the table of benefits. Strike, Riot, Civil Commotion and Terrorism If whilst
this Policy is in force, the Insured Person suffers an Accidental Bodily
Injury due to Strike, Riot, Civil Commotion or Terrorism, which directly and
Disablement, the Company will pay the Benefit stated in the table of
benefits, provided that such injury does not arise out of the Insured Persons
wilful and intentional act.
3. Automatic Increase in Benefit
The Capital Sum Insured for each Insured Person in respect of Benefits
(A) and (B) of this Policy will increase each year by 5% of Capital Sum
Insured in the prior year provided that : a. no claim has been made under this
Policy during the last period of insurance by any Insured Person;
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b. there has been no interruption of cover in the current or prior periods of
insurance;
c. the maximum period for increase in the Capital Sum Insured shall be
limited to five consecutive years;
d. the total increase in Capital Sum Insured in respect of any one Insured
Person shall not exceed SGD500,000 or its equivalent and
e. the amount payable under this provision is subject to this Policy's
aggregate limit (if any is applicable). Insofar as any Insured Person is
concerned, the Benefit of this provision shall accrue only from the time such
Insured Person was first insured by the Company and such Insured Person
has been continuously employed by the Name Insured for at least 12 months
prior to the incident giving rise to the claim.
4. Mobility Extension
If whilst this Policy is in force, an Insured Person suffers an Accidental
Permanent and can operate:
a. a self-powered, climbing wheelchair; and/or
b. his/her motor vehicle with the controls suitably adjusted; and/or
c. a lift, necessary ramps, railings and holds to usual place of residence
the Company will reimburse the actual cost of such equipment and
installation thereof incurred by the Insured Person up to five thousand dollars
(SGD5,000) or its equivalent. Specific Loss definition
Specific Loss under this clause shall mean the following Permanent
Disablement payable under Part III : Benefits, Clause 1 of this Policy:1) Loss of or the Permanent total loss of use of two limbs; or
2) Loss of or the Permanent total loss of use of one limb; or
3) Permanent total loss of sight of both eyes; or
4) Permanent total loss of sight of one eye; or
5) Loss of or the Permanent total loss of use of one limb and loss of sight of
one eye; or
6) Loss of speech and hearing
5. Ambulance Costs
Bodily Injury necessitates the use of an ambulance during the Policy
Period, the Company will reimburse the actual ground ambulance costs
incurred by the Insured Person up to five hundred dollars (SGD500) or its
equivalent, for transportation to the hospital.
6. Funeral Expenses
death, the Company will pay a lump sum of two thousand dollars (SGD2,000)
or its equivalent towards funeral expenses.
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7. Child Education Fund
death, and at the date of the Accident, had any Dependent Child enrolled in
a kindergarten, primary or secondary school, institution for vocational or
tertiary education licensed by the local government, the Company will pay a
one time lump sum of five thousand dollars (SGD5,000) or its equivalent per
child.
8. Simple or Other Fractures
a Simple Fracture or Other Fracture of the nature as specified herein, the
Company will pay the relevant Benefit of up to five thousand dollars
(SGD5,000) or its equivalent, provided always that:
a. this Benefit shall not be payable to any Insured Person who has been
diagnosed as having osteoporosis prior to the date on which he or she was
first covered under this Policy;
b. if any Insured Person is diagnosed as having osteoporosis after the date
on which he or she was first covered under this Policy, the Company will
only be liable to pay this Benefit in respect of the first occasion on which a
Simple Fracture or Other Fracture is sustained, and this Benefit shall not
be payable in respect of subsequent incidents. Maximum Benefit payable in
respect of any one Accidental Bodily Injury resulting in Simple Fracture or
Other Fracture % of Benefit amount up to SGD5,000 The aggregate amount
of Benefits payable in respect of all Simple and/or Other Fractures resulting
from any one Accidental Bodily Injury shall not exceed the maximum
amount of SGD5,000 as indicated above.
9. Accidental Death Benefit Due to Natural Catastrophe
Bodily Injury due to a Natural Catastrophe, which directly and
Disablement, the Company will pay an additional ten percent (10%) of the
Capital Sum Insured or SGD50,000.00 (or its equivalent), whichever is
lesser.
10. Comatose State Lump Sum Benefit
If whilst this Policy is in force, during the Policy Period, an Insured Person
suffers an Accidental Bodily Injury, which directly and independently of all
other causes, results in the Insured Person being in a Hospital and in a
Comatose State, within thirty (30) days of the date of the Accident, the
Company will pay the following Benefit: Benefit percentage of
Duration of Comatose State Comatose State sum insured
At least 3 months 25%
Comatose State sum insured will be 10% of the Capital Sum Insured or
maximum of SGD50,000.00 (or its equivalent), whichever is the lesser. This
K C COLLEGE
32

extended Benefit is payable in addition to the compensation, if any, under
Part III: Benefits, Clause 1 of this Policy but does not cover any duration of
the Comatose State extending beyond the Policy Period.
Specific Provision In case of successive Comatose State with less than 10
days between each one for a same cause, the Comatose State will be
deemed as one. Conditions The Insured Person must be in a hospital for the
duration of the Comatose State for any benefits to be payable.
11. Accidental Hospital Recuperation Benefit
Bodily Injury and within 30 days, is confined as a Resident In-patient in a
Hospital for at least twenty-four (24) hours, the Company will pay a one time
payment of two hundred and fifty dollars (SGD250.00) or its equivalent.
Subsequent hospitalization resulting from the same Accidental Bodily Injury
is not payable.
EXCLUSIONS OF GROUP PERSOANL ACCIDENT POLICY

Exclusions
The Insurance Company shall not be liable to pay for any claim directly or
indirectly consequent upon the following causes:
a) Civil War or Foreign War;
b)Insured person engaging in naval, military or air force service or operations
(except peacetime reservist training or operationally ready national service
under Section 14 of the Enlistment Act, Cap.93 of the Republic of Singapore);
c) Self-inflicted injury, suicide or any attempts thereat, suicide pacts or
agreement while sane or insane;
d) Insured person engaging in racing on wheels;
e) Injury directly or indirectly resulting from sickness, disease, or pregnancy
including any complications, related conditions or treatment thereof;
f) Injury occurring during or as a direct or indirect result of any surgery except
when such surgery was necessary to treat or restore function after an
Accidental injury covered by this Policy.
Additional Exclusion
Under the Group Personal Accident Insurance Scheme, students who are
required to be onboard a vessel are not covered except for Maritime Studies
students or students in any other related disciplines who are required by the
company of their official attachment program to be onboard a vessel sailing in
open sea for a day visit, and Policy benefits for such are based on the
General Cover above.
Although the above additional exclusion does not refer to leisure cruise trips,
students going on such trips are encouraged to purchase Travel Insurance on
their own (please refer to the section below titled "Note on Travel Insurance").
CLAIM PROCEDURE
K C COLLEGE
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1. Notice of Claim
Any occurrence or loss, which may give rise to a claim under this Policy,
should be reported to the Company in writing within thirty (30) days after the
occurrence or loss. GPA3E Standard (1 Jan 2012) Page 8 of 11 Failure to
furnish notice within the time provided in this Policy shall not invalidate any
claim if it shall be shown not to have been reasonably possible to furnish such
notice and that such notice was furnished as soon as was reasonably
possible.
2. Proof of Loss
Written proof of loss must be given to the Company as soon as possible and,
in any event, within 30 days of notice of claim together with original copies of
all relevant documentation. The Insured Person or the Name Insured shall,
at their own expense, furnish the Company such certificates, information and
evidence as the Company may from time to time require in the form
prescribed by the Company. The Company shall have the right but not the
obligation, at its own expense, to require the Insured Person to submit to
medical examinations as often as may be necessary during the pendency of a
claim hereunder and to have an autopsy performed in case of death, unless
prohibited by law.
3. Payment of Claim
Indemnity for Accidental death and Permanent Total Disablement will be
paid to the Named Insured. Unless otherwise instructed by the Named
Insured, all other benefits shall be payable to the Named Insured. Any
receipt by the Named Insured/Insured Person of any Benefit payable under
this Policy shall in all cases be deemed final and complete discharge of all
liability of the Company in respect of such benefit.
4. Fraudulent Claims
If any claim under this Policy shall be fraudulent in any respect, or if any
fraudulent means or devices shall be used by the Named Insured, the
Insured Person, or anyone acting on their behalf to obtain benefits under this
Policy, the Company shall be under no liability in respect of such claim
OTHER POLICY PROVISIONS

1. Geographical Limits
The coverage under this Policy is 24 hours a day, worldwide unless
otherwise endorsed or amended.
2. Compliance with Policy Provisions
Failure to comply with any of the provisions contained in this Policy shall
invalidate all claims hereunder.
3. Conditions Precedent to the Validity of Policy
The validity of this Policy is subject to the condition precedent that:
K C COLLEGE
34

a. for the risk insured, the Named Insured has never had any insurance
terminated in the last twelve (12) months due solely or in part to a breach of
any premium payment condition; or
b. if the Named Insured has declared that it has breached any premium
payment condition in respect of a previous Policy taken up with another
insurer in the last twelve (12) months:
i. the Named Insured has fully paid all outstanding premium for time on risk
calculated by the previous insurer based on the customary short period rate in
respect of the previous Policy; and
ii. a copy of the written confirmation from the previous insurer to this effect is
first provided by the Named Insured to the Company before cover incepts.
4. Premium Payment Warranty
a. Notwithstanding anything herein contained but subject to clause b hereof, it
is hereby agreed and declared that if the period of insurance is 60 days or
more, any premium due must be paid and actually received in full by the
Company (or the intermediary through whom this Policy was effected) within
60 days of the inception date of the coverage under this Policy, Renewal
Certificate or Cover Note.
b. In the event that any premium due is not paid and actually received in full
by the Company (or the intermediary through whom this Policy was effected)
within the 60-day period referred to above, then:i. the cover under this Policy, Renewal Certificate or Cover Note is
automatically terminated immediately after the expiry of the said 60- day
period; GPA3E Standard (1 Jan 2012) Page 9 of 11
ii. the automatic termination of the cover shall be without prejudice to any
liability incurred within the said 60-day period; and
iii. the Company shall be entitled to a pro-rata time on risk premium subject to
a minimum of SGD25.00.
c. If the period of insurance is less than 60 days, any premium due must be
paid and actually received in full by the Company (or the intermediary
through whom this Policy was effected) within the period of insurance.
5. Cancellation of Policy
The Company may terminate this Policy prior to the Policy anniversary by
giving written notice of at least 30 days prior to such termination date. In such
event the Named Insured shall be entitled to a return of actual paid premium
less pro-rata premium for the time this Policy has been in force, but only to
the extent and in the amount that such pro-rata premium exceeds SGD500
(excluding GST). No refund will be made once a claim has been paid under
this Policy. Termination shall be without prejudice to coverage for any claim
arising prior to the date of termination. The Named Insured may terminate
the Policy prior to the policy anniversary by giving seven (7) days notice to
the Company. In such event the Named Insured shall be entitled to a return
of actual paid premium less premium at the following short period rates for the
time this Policy has been in force, but only to the extent and in the amount
that such short period premium exceeds SGD500 (excluding GST). No refund
K C COLLEGE
35

will be made once a claim has been paid under this Policy. Termination shall
be without prejudice to coverage for any claim arising prior to the date of
termination.
Period Covered Short Period Rates
Not exceeding:
1 week 1 month
1 month 3 months
2 months 4 months
3 months 6 months
4 months 7 months
6 months 9 months
8 months 10 months
Above 8 months Full Annual Premium
6. Legal Action
No legal action may be brought to recover on this Policy until sixty (60) days
after the Company has been given written proof of loss. No such action may
be brought after two (2) years from the date of loss.
7. Contracts (Rights of Third Parties) Act (Cap 53B)
A person who is not a party of this policy contract shall have no right under
the Contracts (Rights of Third Parties) Act (Cap 53B) to enforce any of its
terms.
8. Compliance with Applicable Economic and Trade Sanctions Laws
This insurance does not apply to the extent that trade or economic sanctions
or other laws or regulations prohibit the Company, or the Companys parent
company or ultimate controlling entity from providing insurance.
9. Governing Law and Jurisdiction
This Policy shall be construed according to and governed by the laws of the
Republic of Singapore. The Courts of the Republic of Singapore shall have
exclusive jurisdiction.
10. Policy Owners Protection Scheme
This Policy is protected under the Policy Owners Protection Scheme which is
administered by the Singapore Deposit Insurance Corporation (SDIC).
Coverage for your Policy is automatic and no further action is required from
you.
HEALTH INSURANCE
The term Health Insurance is used to describe a form of insurance that pays
for medical expenses. It is used more broadly to include insurance that covers
disability or long-term nursing or custodial care needs. In simple words, if you
are covered under Health Insurance, you pay some amount of premium every
year to an insurance company and if you have an accident or if you have to
K C COLLEGE
36

undergo an operation or a surgery, the insurance company will pay for the
medical expenses.
It takes just one visit to a hospital to make us realize how vulnerable we

are. It is a tough ordeal if you are diagnosed with an illness and need to be
hospitalized, no matter if you are rich or poor, male or female, young or old.
The list of lifestyle diseases like heart problems, diabetes, stroke, renal failure,
some cancers just seems to get longer and more common these days.
Thankfully there are more specialty hospitals and specialist doctors but all
that comes at a cost. The super rich can afford such costs, but what about an
average middle class person? For an illness that requires hospitalization /
surgery, costs can easily run into 5 figures. A Health Insurance Policy can
cover such expenses to a large extent.
Health insurance is a contract between a policyholder and a third-party payer
or goverment program for the purpose of providing reimbursement of all or a
portion of medical and heath care costs. Automobile insurance coverage
includes medical payments and PIP; disability insurance provides an
individual with reimbursement for lost wages; liability insurance covers losses
to a third party caused by the insured or on premises owned by the insured.
The history of health care reimbursement can be traced back to 1860, when
the Franklin Health Assurance Company of Massachusetts wrote the first
health insurance policy.
Subsequent years, through the present, have seen great changes and
advances in health care insurance and reimbursement, from the development
of the first Blue Cross and Blue Shield plans to legislation that resulted in
government health care programs (e.g., to cover individuals age 65 and
older),
payment systems to control health care costs (e.g., diagnosis-related groups),
and regulations to govern privacy, security, and electronic transaction
standards for health care information.
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37
TYPES OF HEALTH INSURANCE

There are mainly 3 types of Health Insurance covers which are as follows.
1.mediclaim
The simplest form of health insurance is the Individual Mediclaim policy. It
covers the hospitalization expenses for an individual for upto the sum assured
limit. The premium is dependent on the sum assured. It is a cover which takes
care of medical expenses following Hospitalization / Domiciliary
Hospitalization of the insured in case of sudden illness, accident and any
surgery which is required in respect of any disease which has arisen during
the policy period.
This cover is a hospitalization cover and reimburses the medical expenses
incurred in respect of covered disease / surgery while the insured was
admitted in the hospital as an inpatient. The cover also extends to prehospitalization and post- hospitalization for periods of 30 days and 60 days
respectively.
Example: If a family has 4 members you can take an individual cover of Rs.
2 lakhs each for each member. Each member is now covered for 2 lakhs. If all
the 4 members are hospitalized, all 4 of them can get expenses recovered
upto Rs 2 lakhs each. All the 4 policies are independent.
2. Family Floater Policy:
Family Floater Policy is an enhanced version of the mediclaim policy. The
policy covers each family member and the entire familys expenses are
covered up to the sum assured limit. The family floater plans premium is less
than the separate insurance cover for each family member.
Example: If a family of 4 takes a family floater policy of Rs. 8 lakhs, they can
claim medical expenses upto Rs. 8 lakhs in that policy year. If one person is
hospitalized and claims Rs. 3 lakhs, it will be paid, but they will be left with
only Rs. 5 lakh worth of medical expenses that can be reimbursed in that
year. The next year, the policy will start with a fresh Rs. 8 lakhs. So, in many
ways the family floater plan offers flexibility in terms of utilizing the overall
insurance coverage among the group.
3. unit Linked Health Plans:
Health Insurance Companies have introduced Unit Linked Health Plans
which combine health insurance with investment and pay back an amount at
the end of the insurance term. The returns are dependent on market
performance. These plans are new and still in development phase. People
who can handle market linked products like ULIP and ULPP are only
recommended to take this plan.
K C COLLEGE
38

For a number of reasons, it is advisable to stay clear of unit linked health
plans. Treat insurance purely as an expense. Opt for an Individual Mediclaim
policy if you are single and opt for a Family Floater policy if you have family.
Health insurance premiums come under tax exemption under section 80D for
a maximum of Rs.15,000/-.
IDEAL COVER FOR HEALTH INSURANCE

The cost of Health Insurance depends on the sum assured, age, current
health condition and your previous medical history. The premium will be high
if the sum assured is high. So what should be the ideal health insurance cover
requirement? There is no standard answer for this. If health insurance is
important, one has to look at ones own lifestyle, health condition, age, family
history of illnesses and affordability. Most insurance companies limit the sum
assured to a maximum of Rs. 5 lakhs. Many health insurance policies provide
additional benefits such as daily allowance, ambulance charges, etc. for
hospitalization which are superfluous and a high premium should be paid for
this. Hence avoid such plans and take something simple and basic.
Health Insurance Provided By the Employer:
Many employers provide health cover for their employees. There are 3
aspects which need to be considered in such a case Is that cover sufficient?
Is the insurer good enough? What happens if you change your job? Health
insurance is provided as perk to the employees. So understand the policy in
detail and check for coverage. Ask the HR Department for policy details. Get
into details and find out what is covered and what is not covered. Often
employees just think that the employer has given them health insurance and
are relaxed. Later they find out that it does not cover A and covers B only upto
a limit, which can be a painful situation.
Health Insurance for the Aged:
Health insurance companies were reluctant to provide cover for the aged till a
few years back. But these days, a lot of insurance companies are providing
policies for senior citizens. Additional tax exemption of up to Rs.20,000/- is
provided for the insurance cover paid for a person of age 65 years and above.
But the senior citizens have to pay high premium rates. For the employed,
another option is to approach the employer to negotiate with the official
insurer to provide an option for additional cover to parents. Since the volumes
are high, the insurer can provide such added cover at attractive premium
rates.
Tax Exemption from Health Insurance Premiums:
Sec 80D covers Health Insurance. You can get exemptions of:
K C COLLEGE
39

Upto Rs. 15,000 paid for self + spouse + children.
Upto Rs 15,000 paid for Parents (Rs 20,000 if parents are senior citizens)
So in total if you pay your health insurance and your parents health insurance
premiums, you can save upto maximum of Rs.35,000/-.
Third Party Administrators
TPA stands for Third Party Administrator. TPA is a middleman between
Insurer and the Customer. At the time of claim, the customer can directly deal
with the TPA and the TPA will help them with all the process of claim
settlement. A TPA is a specialized health service provider providing a variety
of services like networking with hospitals, arranging for hospitalization and
claim processing and settlement. The concept was introduced by the
Insurance Regulatory and Development Authority of India (IRDA) for the
benefit of both the insured and the insurer. While the insured is benefited by
quicker & better health service, insurers are benefited by reduction in their
administrative costs, fraudulent claims and ultimately bringing down the claim
ratios. An insurance company can have more than one TPA and a TPA can
serve more than one insurance company.
Some of the services provided by the TPA are:
Maintaining database of policyholders
Issuing of ID cards to all policyholders
Providing ambulance service
Providing information to policyholders about hospitals
Checking various investigations
Providing cashless service
Processing claims
Health Insurance Claims Settlement Process:
In most cases, the Insurance companies appoint a Third Party Administrator
(TPA) for claims processing. That means once the health insurance policy is
sold, the insurer passes on the complete details to the TPA. In case of a
claim, the insured has to get in touch with the TPA for all verification and
formalities.
Two Ways By Which Health Insurance Claims Are Settled:
Cashless:
For planned hospitalization at authorized network hospitals, the TPA has to be
notified in advance for availing cashless treatment or within the stipulated time
limits for emergencies. The insurance desk at hospitals will generally help with
all the paper work. The TPA has to approve the claim amount and the hospital
settles the amount with the TPA / Insurer. There will be exclusions which will
have to be settled directly at the hospital by the insured.
K C COLLEGE
40

Reimbursement:
Reimbursement facility can be availed at both the network and non-network
hospitals. The hospital bills are directly settled at the hospital after the insured
avails the treatment. The insured can then claim reimbursement for
hospitalization by submitting relevant bills / documents for the claimed amount
to the TPA.
The TPA mode of claims settling has its own problems. The TPA is
incentivized to limit insurance claims and they are not the ones who sell the
policy. There are many cases where the insured had a tough time to claim for
his hospital expenses. So before taking a health insurance policy, check who
the TPA is and how good they are when it comes to claims processing.
Internet search and a friendly chat with the hospital staff can give you good
insight on the insurer / TPA. There are also some health insurance providers
who do not employ TPAs and manage claims settlement directly which is
called In-House TPA.
HEALTH INSURANCE FOR SENIOR CITIZENS

The Indian health insurance market for senior citizens has grown and there
are many companies that offer policies. All the policies have their plus and
minus points. Before deciding to buy a policy you should know what you want
from your insurance cover. Discuss it with your friends and families, do some
reading yourself before making the commitment. Whatever the outcome,
taking a policy for health is a great investment for elderly; though the
premiums to be paid maybe a higher than normal.
A medical insurance for senior citizens provides such individuals with financial
benefits besides offering monetary help in case of unforeseen medical
emergencies. A health insurance policy empowers an elderly person to go for
health check-ups, financial help during emergency health problems as well as
long-term medical treatment. The policyholder enjoys tax benefits for
premiums up to a certain level under Section 80D of the Income Tax Act. A
good number of insurance companies in India are trying to overcome the
challenges concerning the senior citizens.
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41
Comparative Premium rates of Insurance Companies offering Insurance

policies for senior citizens
Premium Comparative Rate Chart for Senior Citizens:
Bajaj
National Oriental
Star
The New United
Age
Allianz
Insurance Insurance Health
India
India
1
2
1
2
1
2
1
2
1
2
1
2
Lakh Lakh Lakh Lakh Lakh Lakh Lakh Lakh Lakh Lakh Lakh Lakh
61-65 7170 11203 4180 6187* 4500 8700 4450 8455 3850 5720 66-70 10755 16805 5196 7326* 4800 9100 4450 8455 4250 6310 71-75
5568 7768* 5700 11400
4700 6980 76-80
6890 9178* 6100 12000
5150 7650 Above
6400 12600
80
When deciding on a policy one should look at certain parameters and
these include
1.Salient features
2.Scope of cover/ benefits
3.Premium rates/ charts
4.Terms and conditions
5. Exclusions
We have compared four popular policies and highlighted what we think
are good and bad points in each policy.
National
Star Red
Star Medi
Varishtha Age
Carpet Age 60 Classic Age 2
60 yrs. and
to 69 yrs.
to 80 yrs.
above
No Major Sub- Blood
No Medical
Lowest Cost
Limits in this Pressure and Test Instant
Wide SI (Sum
policy
Diabetes
Issuance For Insured)
Bajaj Silver
Age 55 yrs.
onwards
Special
Feature
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42
Maximum
70 Years
Entry Age
Maximum Exit
75 Years
Age
1st Year for
Pre-existing
50% of Sum
Covered after
Assured
Co-Payment
No
Non Network
20% CoHospital
Payment
Treatment
rules
Patients can Age 60-69

be covered
from inception
with a loading
of 10%.
Options
70 Years
69 Years
75 Years
90 Years
Life Long
80 Years
2nd Year with

1st Claim Free
50% CoYear
payment
10% on all
30% on all
claims.
Claims50% on
20% on all
Pre-existing
claims with
from 2nd year
pre-existing
diseases.
4 years
61 to 65
Years 20%
66 to 70
Years 30%
71 to 80
Years 40%
Can be carried Can be carried Can be carried

out
out
out
2% of Sum
Assured up to
Rs. 4000/Rs. 10000/Rs. 15000/Rs. 12000/Cataract Limit No Limit
61 to 65
YearsCVD
restricted to
50% of SI
66 to 70
Years - CVD
Heart: Rs.
and CVA
150000/restricted to
Bones: Rs.
Lifetime
Sub-Limits
50% of SI
Benign
150000/Indemnity Limit
for the
Breakage of
Prostrate: Rs. Renal: Rs.
highest Sum of 3 times the
bones
20000/150000/Coverage
Insured
71 to 80
Major
Years
Surgeries: Rs.
CVD
120000/ CVA
Breakage of
bones
Lung
Diseases/
Infections
Joint
Special
Replacement
Exclusions
Surgery
No Room Rent 1% of Sum
Room Rent
Assured
Limit per day Limit
K C COLLEGE
1% of Sum
Assured
43

Excluded for 4
Years
Family
Discount
5%
NIL
NIL
General
Blood/Urine
Medical Exam,
Sugar, Blood
Fasting Blood
Pressure,
Sugar, Urine
EchoNO MEDICAL
Medical Tests
exam for
cardiogram
TESTS
Required
Albumin/Sugar,
and eye check
ECG & Cardiac
up including
Evaluation
radioscopy.
Report
Very stringent
Policy
Medical Tests
issuance is not
How easy it is Screening.
a problem, but
No Issues
to get this
Close to 60%
the coverage
policy
of proposals
offered is too
submitted have
low.
been rejected
Premium for
Rs. 5166
Rs. 5000
Age 65 Rs. 1 Rs. 8056
Lakh Cover
NIL
General
Medical Exam,
Fasting Blood
Sugar, Urine
exam for
Albumin/Sugar,
ECG & Cardiac
tests
No Issues.
Policies are
issued with
ample
restrictions
Rs. 3372
[Note: Cells highlighted in Red gives negative aspects and the Blue
gives positive aspects of the policy]
HEALTHCARE INSURANCE AWARENESS IN INDIA

Insurance may be described as a social device to reduce or eliminate risk of
life and property. Under the plan of insurance, a large number of people
associate themselves by sharing risk, attached to individual insurance plan
that exclusively covers healthcare costs and is called Health Insurance.
Since the past two decades, there has been a phenomenal surge in
acceleration of healthcare costs. This has compelled individuals to have a relook on their actual monthly expenditures, spending patterns and
simultaneously allocate a proportion of their income towards personal
healthcare. This has resulted in individuals availing healthcare insurance
coverage not only for themselves but also for their family members including
their dependants. In short, healthcare insurance provides a cushion against
medical emergencies. The concept of insurance is closely concerned with
security. Insurance acts as a shield against risks and unforeseen
circumstances. In general, by and large, Indians are traditionally riskaverse rather than risk lovers by nature.
K C COLLEGE
44

Some major health insurance companies in India include National Insurance
Company, New India Assurance, United India Insurance, ICICI Lombard, Tata
AIG, Royal Sundaram, Star Allied Health Insurance, Cholamandalam DBS,
Bajaj Allianz Apollo, AG Health Insurance Company among others.
Categories
Indian Health Insurance is primarily classified into 2 categories:
Cashless Hospitalization
Medical Reimbursement
a) Cashless Hospitalization
Cashless hospitalization is a specialized service provided by an insurer
wherein an individual is not required to pay the hospitalization expenses at the
time of discharge from the concerned hospital. The settlement is done directly
by the insurance company (or insurer). However, prior approval is a must from
the TPA (Third Party Administrator) before availing the benefits under this
option.
Cashless hospitalization can be of two types:
Planned hospitalization: This is a planned hospitalization wherein the
insured is aware of the hospitalization in advance. This duration period may
vary from case to case. Examples include: FTND (Full Term Normal Delivery),
Chemotherapy treatment for carcinoma (cancer), for cataract surgery,
tonsillectomy (removal of tonsils).
Emergency hospitalization: It is a sudden hospitalization that may be
either an emergency or due to unforeseen circumstances. In short,
hospitalization is not anticipated in advance. Examples include RTA (Road
Traffic Accident), Myocardial infarction (heart attack), Acute Appendicitis.
b) Medical Reimbursement
Re-imbursement means to repay or to compensate. Thus, Medical Reimbursement means to repay the products/services availed during
hospitalization and more importantly after the completion of the treatment.
Under this procedure, the insured has to bear the entire expenses incurred
during hospitalization. After getting discharged from hospital, the
insured/policy holder can claim medical reimbursement. For availing benefits
under this option, the insured has to approach the concerned TPA under
which he/she is covered, fill the requisite form and satisfy all the requirements
as mentioned. This includes submission of TPA card, policy paper, discharge
summary, prescriptions, diagnostic laboratory reports, OPD treatment details
etc. A sum is granted as reimbursement for treatment expenses.
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A recent survey conducted in 2008 showed that only 3% of the entire Indian
population has availed some sort of insurance policy and enjoys benefits
included under its coverage. This miniscule percentage constitutes both
PSUs (Public Sector Undertakings) and Private insurance companies.
Since, the general public are by and large ignorant about the benefits of
availing healthcare insurance policies, there lies an urgent need to educate
the masses regarding the importance of Healthcare Insurance and
the benefits derived on account of it.
There are numerous reasons for not availing health insurance. There is a lack
of knowledge regarding the existing insurance products/services in the
markets. On top of it, there are numerous misconceptions about Insurance
prevalent in the Indian Markets. Also there are numerous fly-by-night agents
out to fleece the gullible Indian public.
In India, public funded healthcare is available only to a miniscule section of
BPL (Below Poverty Line) groups, low-income groups and to government
employees. The Indian Government has formulated Employee State
Insurance Scheme (ESIS) that focuses on the public healthcare policy for lowincome groups. The government employees can avail Central Government
Health Scheme (CGHS) that offers medical treatment at a subsidized cost.
With the opening up of insurance sector for private participation, numerous
players have entered the healthcare segment, but inspite of the entry of
private sector, penetration of insurance coverage in India is abysmally low.
Recently a legislature has been passed in the Indian Parliament allowing 49%
of FDI in insurance industry.
Essential Guidelines for Availing individual Health Insurance Policy:
The following points should be borne in mind while purchasing an individual
health policy:
Understanding the policy coverage: The policyholder should be able to
clearly comprehend the extent of medical coverage being offered under the
particular health insurance policy before opting for it. The individual should
check whether pre-existing diseases and its resultant complications are
covered or not, as well as the extent of the coverage under that particular
policy.
Keeping an eye for medical expenses that are not covered/reimbursable under the policy: Before availing a particular health insurance
policy, the prospective policyholder should note the medical expenses not
covered under that Insurance policy. It is important to note that deductibles
are a part and parcel of any insurance coverage and the expenses incurred
as part of the medical treatment need to be borne by the individual. Generally
this list includes aprons, sterilization charges, gloves, Dettol, gloves etc.
To understand whether it is a co-insurance policy: Before availing a
health policy, the prospective customer should understand whether it is a coK C COLLEGE
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insurance policy or not. It is advisable to get an individual health insurance
policy with a co-insurance payment option. The maximum amount does not
exceed 15% of the entire medical coverage for a particular disease.
Understanding and updating oneself about expiry period regarding the
policy cover: An individual health insurance cover entails regular premium
payments on a monthly, half yearly or annual basis before the expiry of a
particular policy. Non-payment of premium within the stipulated time results in
the lapsing of the policy with subsequent break in the policy coverage of the
concerned individual. Even though the concerned individual holds policy with
an Insurance company for many years together, a break in the policy
coverage (which generally does not exceed more than 15 days) is treated as
a fresh policy cover.
Importance of Health Insurance
The importance of Health Insurance can never be undervalued for the
following reasons:
Provides security to human life which is of prime importance to any
individual.
Closely bonds Insurance Companies, Hospitals, Policyholders and TPAs
together for the benefit of Indian masses.
An answer to the solution of uncertainties and risks that are prevalent and
ever-pervading in human life.
Prevention and minimization of unforeseen losses.
Access to quality healthcare.
Means of savings and a safe investment option.
Provides financial stability in life.
A tax-saving instrument that significantly contributes in reduction of tax
deductions.
Reduces tensions and stress caused on account of hospitalization.
Greatly contributes in leading a stress-free life.
KEY PROCEDURES FOR FILING A HEALTHCARE INSURANCE

CLAIMS
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In certain circumstances health insurance claims can be a frustrating process
and more so if there is no help from the healthcare provider. Often People are
left to fend for themselves while filing a health claim for a medical
reimbursement procedure which occurs after hospitalization. In such a
situation cashless facility will not provided by the hospital or nursing home.
The expenses incurred on hospitalization can be claimed only after the patient
gets discharged from the hospital or on completion of treatment.
a)Keeping all receipts in order
You are advised to keep not only all receipts, bills and medical reports as
part of the hospitalization but also the ones obtained during 30 days prior to
hospitalization and 60 days (only relevant bills) subsequent to hospitalization.
The medical services availed during this period as part of the same
treatment..
These medical bills, receipts etc. should contain name of the serviceprovider (establishment), document number, name of the patient, name of the
treating consultant, date on which product was purchased, name of the
product/services availed, batch number, serial number, quantity, cost price of
the product along with taxes (includes MRP and VAT) and signature of the
authorized person.
. It is always preferable to indicate the receipts with a serial number for
convenience and quick retrieval of the document, incase it is required.
While filing the claim, all the receipts, bills, discharge summaries,
investigation reports, consultation sheets etc. should be submitted in original.
In addition, a set of xerox copies of the original documents need to be
submitted too.
Remember, it is of utmost importance to retain a set of Xerox documents
with the claimant, incase the documents are misplaced or lost. This is vital for
establishing proof of the medical treatment sought during the illness.
b) Get the claim form from the insurance company
In order to file your health claim, the next step in the series is to get the claim
form from the insurance company. Alternatively, the claim form can be
downloaded from the official website of the insurer (or insurance company).
Claim form is then filled which is usually self-explanatory in nature. In this
claim form, queries such as the individuals health-insurance cover details,
reimbursement of the medical expenses statement details, purpose of
hospitalization, personal details and identification proof and similar details are
asked from the customer. Relevant and up-to date data must be submitted to
avoid a goof-up in the process.
Claim form will carry additional instruction details which you must read
carefully. It must be signed by you or the policyholder and by the treating
consultant. The claim form should be stamped with an-official hospital seal for
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48

authentication.
After filling the necessary details, it must be accompanied with the relevant
documents. These relevant documents can be further classified into 2
groups:
i Discharge Summary from the concerned hospital which contains name of
the patient, date of admission, date of discharge, time of admission, time of
discharge, main diagnosis and relevant investigations carried out during the
hospitalization
All the documents pertaining to the ailment for which the hospitalization was
sought which incorporates first detection date of the ailment accompanied
with solid/ample proof such as physicians consultation sheets, pharmacy
bills or receipts, investigation reports, cash memos and proper prescriptions.
Nature of the surgery or operation performed on the individual, information
regarding the surgeons consultation fees, surgery fees, Operation theatre
charges accompanied with relevant bills and receipts.
Inception (beginning) of the policy-cover document (health-insurance policy)
to indicate since when the patient is covered under the policy. The inception
date of the policy cover makes it easier for insurance companies to deliver
opinion on a particular claim.
First health-insurance policy inception details must be provided to the
concerned TPA (Third Party Administrator) for avoiding customer disputes
and grieviances. This is an important step in the submission of policy
documents.
This claim document must be accompanied with TPA (Third Party
Administrator) card for validation and verification purposes.
c) To prepare copies of the original for the purpose of claim submission
Remember that while submitting the claim documents, they should be in
original. In absence of original documents, claims will not usually be
entertained.
By doing so, the errors occurring in the claim process would be minimized.
Keep an additional set of xerox copies for your own file as suggested earlier
as proof in case the documents are lost or misplaced.
d) Review and dispatch of documents
After completing the compilation of the claim to be reimbursed, re-check
your documents.
Verify the documents and see that no document issued during the treatment
process is missing. This is necessary to avoid a claim shortfall.
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Check whether all the documents (paperwork) are relevant to the treatment
for which the claim is to be submitted.
Ask the insurance company to which TPA the claim documents have to be
submitted.
Ask the customer care executive to check whether the submission of
documents is appropriate or not. In case any modifications are to be made,
note it down and follow the instructions as advised by the customer-care
executive.
After completing the pre-requisite formalities, the claim is then submitted to
the Customer Care Executive in the concerned TPA.
Inform the Insurance Company regarding the submission of the claim by
sending a set of xerox-documents to them.
e) Understanding the fine print in the policy document
Remember that insurance companies will not honor claims in case the
documents are not as per their terms and conditions.
Make a note of the deductions or the medical expenses that are not included
in the cover. Understand and get a clear picture of the entire process. This is
of utmost importance as such expenses incurred as part of the medical
treatment will not be reimbursed to the claimant.
FRAUDULENT HEALTH INSURANCE CLAIMS

An insurance claim prepared with the intention to deceive, conceal or distort
relevant information that eventually accounts for health care benefits for an
individual or a particular group is defined as fraudulent health insurance claim.
Frauds can be committed by anybody either by a policyholder, a healthcare
provider or even its employees.
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50
Frauds committed by a policyholder could consist of members that are not

eligible, concealment of age, concealment of pre-existing diseases, failure to
report any vital information, providing false information regarding self or any
other family member, failure in disclosing previously settled or rejected claims,
frauds in physicians prescriptions, false documents, false bills, exaggerated
claims etc
Frauds by Healthcare Provider or its employees include preparation of bogus
claims by fake physicians, billing for products or services not rendered,
exaggerated claims submission, billing prepared for higher level of services,
modifications or alterations made in submission of claims, change in
diagnosis of the patient, fake documentation, and fraud committed by the
employees of a hospital or any other healthcare product/service provider in
order to make a quick buck.
Fraudulent and dishonest claims are a major morale and a moral hazard not
only for the insurance industry but even for the entire nations economy.
Concrete proof as evidence including documentation, statements made by the
policyholder and his family members and even neighbors are taken into
consideration.
Essential Components of Fraud
The essential components of fraud include intention to deceive, derive
benefits from Insurance industry, preparation of exaggerated or inflated claims
or medical bills and malafide intention to induce the firm to pay more than it
otherwise would. Devising innovative methods and tactics including pressure
tactics, favoritism, nepotism etc form a part of fraud which is a hazard growing
by leaps and bounds since the last decade.
To establish that a fraud has been committed requires furnishing of relevant
proof. An in-depth analysis of the policyholders intention may also be taken
into consideration.
Statistics in India and USA
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According to a recent survey it is estimated that the number of false claims in
the industry is approximately 15 per cent of total claims. The report suggests
that the healthcare industry in India is losing approximately Rs 600-Rs 800
crores incurred on fraudulent claims annually. Health insurance is a bleeding
sector with very high claims ratio. Hence, in order to make health insurance a
viable sector, it is essential to concentrate on elimination or minimization of
fake claims.
Insurance companies in USA incur losses over 30 billion USD annually to
healthcare insurance frauds.
Enactment of HIPAA by USA to deal with Health Insurance Fraud
Due to fraudulent cases especially health claims on the rise in USA, a special
legislation was enacted by Congress with the introduction of HIPAA (Health
Insurance Portability and Accountability Act) in 1996. This act specially deals
with healthcare fraud which is treated as a Criminal Offence accompanied
with rigorous imprisonment up to 10 years with additional financial penalties
depending on the fraud intensity.
CONCLUSION
The personal accident insurance policy is issued to cover the risk of accidents
by external means resulting in the death or bodily injury. The bodily injury may
result in to the permanent total disability or partial disability or temporary total
disability. This policy can be issued to an individual or in group. The premium
rates depend upon the person engaged in activities to earn his livelihood. The
sum insured will depend upon the income of the person. The premium of
accidental policy does not depend on age . So if you are 25 yrs old or 50 yrs
old , the premiums would be same, rather it would depend on your working
conditions and nature of your job. If you are a software engineer working in
Bangalore , then your chances of meeting the accident is different from an
army personal working in border or a worker in a factory which has dangerous
machineries
WEBLIOGRAPHY
Sources taken from :
http://www.medindia.net/patients/insurance/awareness-healthcare-insuranceindia.htm#ixzz2fcVmJibG
http://www.orientalinsurance.org.in/faqPA.jsp
http://www.jagoinvestor.com/2011/12/accidental-insurance-policies-inindia.html
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1

PA & HEALTH INSURANCE

MEANING OF PERSONAL ACCIDENT

FEATURES OF PERSONAL ACCIDENT

BENEFITS OF PERSONAL ACCIDENT

PROCEDURE FOR INSURING UNDER PERSONAL

WHY DO YOU NEED THIS POLICY?

GROUP PERSONAL ACCIDENT POLICY

FEATURES OF GROUP PERSONAL POLICY

BENEFITS OF GROUP PERSONAL POLICY

TYPES OF HEALTH INSURANCE

IDEAL COVER FOR HEALTH INSURANCE

HEALTH INSURANCE FOR SENIOR CITIZENS

HEALTH INSURANCE AWARENESS IN INDIA

KEY PROCEDURE FOR FILING A HEALTH

PA & HEALTH INSURANCE

PA & HEALTH INSURANCE

PA & HEALTH INSURANCE

PA & HEALTH INSURANCE

MEANING OF PERSONAL ACCIDENT INSURANCE

PA & HEALTH INSURANCE

PA & HEALTH INSURANCE

PA & HEALTH INSURANCE

PERSONAL ACCIDENT INSURANCE- VALUE ADDED BENEFIT

PA & HEALTH INSURANCE

FEATURES OF PERSONAL ACCIDENT INSURANCE

PA & HEALTH INSURANCE

PA & HEALTH INSURANCE

BENEFITS OF PERSONAL ACCIDENT INSURANCE

PA & HEALTH INSURANCE

PA & HEALTH INSURANCE

PA & HEALTH INSURANCE

PA & HEALTH INSURANCE

Loss of toes great-both

Loss of toes great-one Phalanx

Loss of toes other than great if

Loss of hearing-both ears

Loss of hearing-one ear

Loss of four fingers and thumb of one

Loss of four fingers

Loss of thumb-both phalanges

PA & HEALTH INSURANCE

Loss of index fingers-anyone or three

Loss of ring finger - anyone or three

Loss of middle finger - anyone or three

Loss of metacarpals-first or second

Any other permanent partial disablement

Temporary total disablement: As the name implies this is a disablement

PA & HEALTH INSURANCE

PROCEDURE FOR INSURING UNDER PERSONAL ACCIDENT

PA & HEALTH INSURANCE

PA & HEALTH INSURANCE

PA & HEALTH INSURANCE

WHY DO YOU NEED PERSONAL ACCIDENT POLICY ?

PA & HEALTH INSURANCE

PA & HEALTH INSURANCE

THINGS TO LOOK OUT WHILE BUYING THIS POLICY

PA & HEALTH INSURANCE

PA & HEALTH INSURANCE

PA & HEALTH INSURANCE

PA & HEALTH INSURANCE

GROUP PERSONAL ACCIDENT POLICY

In the above paras we have studied about eh individual personal accident