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Accident insurance provides a cash cover to a policyholder when s/he suffers injuries as a result of an
accident. While insurance helps a policyholder pay off hospital and medical bills in case of accident
injuries, it provides cash benefits to family members if the policyholder dies in the accident. This
insurance, applicable 24 hours a day, 365 days a year, is also commonly referred to as personal
accident insurance.
Insurance may be defined as form of contract between two parties (namely insurer and insured or
assured) whereby one party (insurer) undertakes in exchange for a fixed amount of money (premium)
to pay the other party (Insured), a fixed amount of money on the happening of certain event (death or
attaining a certain age in case of life) or to pay the amount of actual loss when it takes place through
the risk insured (in case of property)
Insured/ Assured – The person who gets his property/life insured is known as insured
Premium – The consideration in return of which the insurer undertakes to make goods the loss
or give a certain amount in case of life insurance is known as premium.
In insurance, Accidental death and dismemberment (also known as AD and D) is a term used
to describe a policy that pays additional benefits to the beneficiary if the cause of death is due
to a non-work related accident.
Is a type of private insurance enabling the policyholder to get a certain sum of money in case
of body injury damage due to the accident.
GENERAL MISCELLANEOUS
INSURANCE INSURANCE
The insurance covers Non-Resident Indians from 3 months of age till 70 years. It is a
comprehensive insurance covering accidental loss, permanent disablement due to accident,
medical expenses incurred due to illness in a foreign country, education fund of dependent
children etc.
In the event of claim, written intimation must be given by the insured/assignee to the
insurance company. The claim can also be reported on company's toll free number. Upon
receipt of the intimation of claim the company deputes its surveyor or claim representative
and process the claim. Copy of the claim format is annexed. The claim process can take
anywhere between 7-15 days.
1. Claim form
2. FIR Form
3. Prescriptions given by the treating doctor
4. Hospital Discharge Card
5. Diagnosis reports like X-Ray report, etc.
6. Disability Certificate
Few people have taken cover to protect themselves against the risk of personal accidents and
the medical complications they entail. Personal accident insurance insurance is an attractive
option; not only does it cost less than other insurance policies, it also covers all accidents.
Personal accident policies cover you for one or more of four contingencies in the event of an
accident: death, permanent total disability, permanent partial disability and temporary total
disability.
Claims are generally settled within four weeks of completion of paperwork along with
supporting medical certificates. In some cases, insurers may depute a panel of doctors to
verify the insurance holders' claims.
1. Claim form
2. FIR Form
3. Prescriptions given by the treating doctor
4. Hospital Discharge Card
5. Diagnosis reports like X-Ray report, etc.
)
Proof of any loss of earnings and other expenses that are the result of your injury.
Any documents relating to insurance policies you may have (household insurance, motor
insurance etc.) as these may cover the legal costs for your claim.
Any other documents that may support your claim. This could be any evidence of similar
accidents arising in the same circumstances or evidence of failings to ensure a duty of care
towards you.
ACCIDENTAL DEATH
Accidental death coverage gives compensation on the policyholder's death caused by bodily injury
resulting out of accident and leading into death. The nominee will receive entire sum assured offered
by the insurer.
ACCIDENTAL DISABLEMENT
It indicates that the insured person is disabled from work, either wholly or partially.
ACCIDENTAL DISMEMBERMENT
The policyholder's body part has been dismembered or severed. It clearly means that the insured
person loses his eyes, legs or hand, then only the insured person would be eligible to receive a claim
under this coverage.
ADDITIONAL BENEFITS
Funeral Expenses in case of accidental death Expenses incurred for transportation of policyholder's
dead body from the accident spot to the residence place.
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.
(iii) Whilst engaging in Aviation or Ballooning whilst mounting into, dismounting from or travelling
in any balloon or aircraft other than as passenger (fare paying or otherwise) in any duly licensed
standard type of aircraft anywhere in the world
(v) Arising or resulting from the insured committing any breach of law with criminal intent.
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
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.
)
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.
A) Written notice of claims with full particulars. In case of death written notice must, unless
reasonable cause is shown, be so given before internment or cremation, and in any case, within one
calendar month after the death
B) In the event of loss of sight or amputation of limbs, written notice thereof must be given within
one calendar month after such loss of sight or amputation.
D) Any doctor on behalf of the company shall be allowed to examine the person of the insured on the
occasion of any alleged injury or disablement and as may reasonably be required.
E) A post mortem examination report, if necessary, be furnished within the space of fourteen days
after demand in writing.
F) In the event of loss of sight the insured shall undergo at the insured’s expense such operation or
treatment as the company may reasonably deem desirable.
I) The insured shall give immediate notice to the company of any change in his business or
occupation. The insured shall on tendering any premium of the renewal of this
MISCELLANEOUS FEATURES
I) FAMILY PACKAGE COVER
(a) Earning member and spouse, 100% of the capital sum if earning. (persons insured) insured for
each.
(b) Spouse (if not earning 50% of the capital sum member) whichever is lower insured or rs. 1 lakh.
(c) Children (between the age 25% of the capital sum and of 5 years and 25 years) insured or rs.
50000/-
Whichever is lower per child.
For children the cover is limited to death and permanent disablement (total or partial)
Premium payable for husband and wife will be on the total sum insured for husband and wife.
A discount of 5% is granted on the gross premium.
II) EXTENSIONS
C) DOCUMENTS: The following documents are sent along with the claim form
MEDICAL CERTIFICATE : to obtain medical opinion on the cause or extent of incapacity
or progress towards recovery.
MEDICAL EXAMINER’S REPORT - To corroborate medical certificate in doubtful cases,
or if other causes are in operation.
RECEIPT / DISCHARGE FORM :- to acknowledge the money and to confirm the finality
of the settlement.
DEATH CERTIFICATE - To give the date and cause of death. Post mortem reports where a
post-mortem has been done.
PROBATE OR LETTERS OF ADMINISTRATION - the legal document to prove the title
of an executor or an administrator (i.e. if no assignment is made)
Even after an accident, you can enjoy financial stability and peace of mind. This is what Manish
Bhatia discovered after an accident. The advertising professional was heading for a client meeting
when the accident occurred. Another vehicle crashed into his car. Manish sustained fractures on both
his arms. He was bedridden for three months. Luckily, his personal accident insurance took care of
the loss of income. He received weekly payouts, as specified in the policy, until he was back at work.
Imagine if Manish had not opted for a personal accident cover. He would have paid all the medical
expenses from his own pocket. At the same time, he would have to deal with the income loss. Such a
policy works as a buffer against any unforeseen situation. It gives you peace of mind.
Here are the top reasons for getting personal accident insurance
1. DISABILITY TAKEN CARE OF: Temporary or permanent disability may occur in the
aftermath of an accident. A policyholder can claim a compensation for various kinds of disability.
There may be a loss of both hands or feet, one hand or one foot, or one hand or foot and an eye. Say,
a person has partially lost their hearing in one ear or suffered vision loss in one eye. He can file a
claim. Loss of speech, loss of eyesight in both eyes, or a hearing loss in both ears is covered too.
What if the policyholder has lost an index finger, a thumb, or a hand? He can approach the insurer
with a claim. He will receive compensation for the income loss.
2. MAJOR HOSPITAL AND OTHER EXPENSES ARE SORTED: This policy takes care of the
hospital bills and medical treatment, of course. But it also covers other expenses. These include
repatriation charges, funeral expenses in case of the policyholder’s demise, and ambulance charges.
5. FAMILY TRANSPORTATION: Following an accident, say, you are hospitalised more than 150
km of your residence. Do not worry. The insurer company will reimburse the transportation costs
incurred by a family member to reach you.
Cash for accidents-Certain policies pay you in cash in case you get into an accident to cover for your
medical bills and other expenses like rent and groceries, especially if you end up missing work
because of your injuries.
Accidental death-An accidental death policy is a less expensive alternative to life insurance, but it
will only cover deaths from an accident. This is a good option for those who are otherwise in good
health and are not at any risk of dying from any medical condition in the near future.
Disability insurance-In the event that you get severely injured and could no longer work, a disability
coverage will pay you a monthly stipend to survive on.
Accidents can happen to anyone at any time, which could lead to minor inconveniences to major
losses, especially if you incurred a disability that prevents you from working. You may also end up
using your entire life savings getting treatment since it’s no secret how expensive quality healthcare
is in the Philippines.
No one can predict when an accident might occur, but you can make all necessary preparations for it
so that you and your family won’t suffer if it does happen. A personal accident insurance will help
cover your hospital bills without affecting your lifestyle and burdening your family.
Sum assured for dependents and spouses are limited to 20% and 50% respectively.
Get renewal bonus if you renew the policy within 30 days from its date of expire.
6. POLICY COVERAGE-The policy offers multiple options to choose from. You can choose
among the following options:
8. DISCOUNT- Family discount of 10% on the premiums paid for Family Package cover and
Individual cover.
9. EXCLUSION- The policy does not cover any existing disability, claims for more than one
categories mentioned in the policy document. It also does not cover death and disablement caused
due to self-injury, suicide or attempted suicide, consumption of alcohol or drugs, childbirth,
pregnancy etc.
Individual: This policy can be taken by any individual. The benefits usually enclose partners
and children. Since several activities are excluded from this policy, it is not as useful for
people who love adventurous sports, like mountaineering and rock climbing.
Children: The purpose of this policy is to provide financial help to parents if they are unable
to work or if they incur expenses as a result of an accident.
Group: This policy is used by companies to cover employees for expenses related to
accidents.
Self-employed: Since self employed individuals are not eligible for employee benefits, they
are worse off when injured in an accident.
Team: Through a team accident insurance policy, organizers can seek cover for all the
members of a sports team.
Over 50: This policy targets people over 50 years of age, as accidents can cause more
grievous injuries to them.
Travel accidents: This policy offers benefits in case the policyholder meets with an accident
while traveling.
There are varied accident insurance policies to suit different needs. One should understand and
choose the policy with utmost care.
Think for a moment , what all can happen if one meets an accident , what can happen , what are
different kind of end results of it ? An Accidental Insurance policy covers almost all of them. Below
is table which given you an idea on what kind of situations are covered by accidental policies.
In case of a death due to accident, the policy would pay 100% Sum
1. Death Assured to the nominee. Some companies also pay a “Children?s
Education Bonus” of 5000 or 10000 for maximum of 2 children.
Permanent
1. Loss of Index Finger or thumb
Partial
2. Loss of hearing in 1 ear
Disablement
3. Loss of 1 eye sight
4. Loss of 1 hand
4. This means that for some weeks or months a person is totally disabled and
Temporary will not be able to work and earn money. In this case most of the
Other Features:-
Accident insurance is the cheapest and smartest way of filling the insurance gap especially for the
young who are aware of the importance of insurance and whose salaries are still not very high .
1. ACCIDENTAL DEATH
If an insured died due to an accident his nominees will get 100% sum insured. So it’s very
important to have right nominee in any kind of insurance policy whether accidental or life.
Some time a person met with an accident & loses his body parts – may not be able to work in
future. In case of Permanent total disability 100% sum insured is given to the insured person.
It covers:
Loss of both hands or both feet or one hand and one foot
Loss of a Limb (hand/foot) and an eye
Complete and irrecoverable loss of sight of both eyes
Complete and irrecoverable loss of speech & hearing of both ears
As the name suggest this benefit is given if someone losses one hand or one leg or even small
body part like finger/toe. For this every insurance company have their own tables – what they
will cover & how much they will pay depends upon the age limit of the person as per policy
documents.
Sometime it can happen that anyone met with some serious accident but there is no permanent
loss. But doctor suggested a complete bed rest of 5 weeks or a complete checkup of any part
of the body. This will impact an earning for a small period so in such case accidental
insurance can compensate for this income loss. Weekly benefit is normally 1% of your sum
assured for maximum 100 weeks. There is also a maximum limit according to your income.
1. CAUSE OF DEATH
Accident life insurance coverage only pays out if your death can be directly attributed to an
accident. If you were to suffer a heart attack when driving, the policy won't pay out.
Some policies don't cover accidents that occur due to the participation in high risk activities,
such as bungee jumping, hang gliding and rock climbing. Always check the terms and
conditions if you intend to participate in these activities.
3. PERSONAL ACCOUNTABILITY :
If you die in an accident when intoxicated, on drugs or breaking the law, your accidental death
life insurance policy won't pay out.
4. TIME FRAME :
Most policies specifically state that your death or dismemberment must occur within 3 months
of the accident taking place.
ESTABLISHMENT
The Oriental Insurance Company Ltd. is a public sector general insurance company of India. The
Oriental Insurance Company Ltd was incorporated at Bombay on 12th September 1947. The
Company was a wholly owned subsidiary of the Oriental Government Security Life Assurance
Company Ltd and was formed to carry out General Insurance business. The Company was a
subsidiary of Life Insurance Corporation of India from 1956 to 1973 ( till the General Insurance
Business was nationalized in the country). In 2003 all shares of our company held by the General
Insurance Corporation of India have been transferred to Central Government.
CASE STUDY
Insurance company wants accident victim to submit irrelevant documents, faces heat
By Jehangir B Gai, | Updated: Jul 21, 2014, 08.37 AM
There were five occupants in the car. Police identified one of the deceased as Syed Abu, 23, a native
of Alwarthirunagar in Chennai.
BACKGROUND
Insurance companies often delay payment of a claim and harass a consumer by demanding
Case study
Harpreet Singh Oberoi was working with Mirasu Marketing as a sales representative. He was covered
under a personal accident policy obtained by his employer through Oriental Insurance Company.
On June 7 2004, Oberoi met with an accident, for which an FIR was registered at the Jalandhar police
station. Oberoi suffered several injuries and was hospitalized for a week. Following discharge, he
continued treatment, but suffered 50% disability. Oberoi lodged a claim of Rs 1,85,000 with
supporting documents such as bills, prescription slips, payment receipts etc. But the claim was
neither settled nor rejected, prompting Oberai to file a complaint before the Jalandhar district forum
against the insurance company and his employer.
The employer refuted its liability as the policy was a contract between Oberoi and Oriental Insurance
Co.
The employer also questioned the jurisdiction of the Jalandar forum as Oberoi was working in
Mumbai when the accident occurred. The insurance company stated that it could not decide on the
claim as Oberoi had not submitted all necessary documents. The Forum held the insurance company
liable to pay Rs 1,85,000, while the employer was asked to pay 9% interest, Rs 5,000 in
compensation and Rs 3,000 toward costs.
The insurance company appealed to the Punjab State Commission; the employer did not. The state
commission observed that the employer had failed to furnish relevant documents. It held the insurer
and employer jointly and severally liable to pay Rs 1,85,000.
Meanwhile, Mirasu Marketing amalgamated with Femcare Pharma, and later with Dabur. The state
commission's order was challenged by Dabur before the national commission. The national
commission
observed that two documents not supplied: Oberoi's salary certificate and leave sanction order.
While these may have been relevant to compute disability, they were irrelevant for for reimbursement
of medical expenses. All supporting documents had been submitted to substantiate the claim.
)
The state commission's order holding the employer liable for payment of the claim amount was
set aside, and this liability was fastened on the insurance firm alone. The commission said the order
of the District Forum directing the employer to pay interest, compensation and costs had not been
challenged in appeal. Since the employer had not appealed, this order had attained finality and could
not be challenged. Dabur was held liable for interest payment, compensation and costs. (Judgment
dated May12, 2014.)
IMPACT
Insurance firms must focus on documents relevant to decide the claim, and not harass consumers by
asking for irrelevant documents and piecemeal information.
(The author is a consumer activist and has won the Govt of India's National Youth Award for
Consumer Protection. His email is: jehangir.gai.articles@hotmail.com)
DOCUMENTS REQUIRED
ISSUING OFFICE
CLAIM FORM
This form is issued without admission of liability and must be completed and returned within 7
days after its receipt. No claim can be admitted unless a medical overleaf be furnished at the
expense of the claimant.
Wt. st lbs
I HEREBY DECLARE that I have received the injuries above described and warrant the truth of
the foregoing particulars in every respect, and I agree that if I have made, or if shall make false
or untrue statement, suppression or concealment, my right to compensate shall be absolutely
forfeited.
I claim to be paid sum of………………..per week, or the total sum of …………which I agree to
accept in full settlement of my claim on the company.
Dated Signature
Accident Insurance should taken by every person or individual who possess a vehicle so that he can
be insured form the risk raises by accident taken place .Accident insurance provides a cash cover to a
policyholder when he/she suffers injuries as a result of an accident. While insurance helps a
policyholder pay off hospital and medical bills in case of accident injuries, it provides cash benefits
to family members if the policyholder dies in the accident. This insurance applicable 24 hours a day,
365 days a year, is also commonly referred to as personal accident insurance.