GROUP PERSONAL ACCIDENT INSURANCE
PREAMBLE
With the advent of machines to improve speed, we all in our day to day life are exposed to risks of Accidents, though exposure to a few is more than the others. Besides the man made risks, the natural hazards, like lightning, flood, earthquake etc. are equally responsible for accidents.
Although Human Life and Sufferings can not be measured with money, but with a view to provide some relief to the injured person or members of his family in the event of an unfortunate accident, an insurance cover, known as “Personal Accident Insurance” has been designed. The policy is available to an individual or a family or group of persons.
SALIENT FEATURES OF THE POLICY
The policy has been designed to provide compensation in the event of the insured person sustaining injuries, solely and directly from an -
Accident Caused by Violent, Visible and External means, resulting into
-Death,
-Permanent Total Disablement (PTD),
-Permanent Partial Disablement (PPD) or
-Temporary Total Disablement (TTD).
CLASSIFICATION OF RISKS
Personal Accident Risk can broadly be classified into the following categories for the purpose of rating and acceptance of business:
NORMAL
Students, Housewives, Accountants, Doctors, Lawyers, Architects, Consulting Engineers, teachers, Bankers, person engaged in Administrative, Secretarial and Managerial functions, shopkeepers, Shop assistants not using machinery, Commercial Travelers and persons employed in occupations of similar nature. Builders, Contractors and Engineers engaged in superintending functions only
HEAVY
Paid drivers of Motor Cars and Light Motor Vehicles and persons engaged in occupations of similar hazard. Persons engaged in Hazardous goods, chemicals, grains elevator, shooting gallery, Motor Driving Instructor, Public Transport. Construction work, Geologists, Surveyors for Oil companies, Heavy equipment Operators, Security Guards, Forestry, Civil Engineer, Crew of Aircraft, Ocean going Vessels, Offshore works, Persons engaged in Sports Duty, Film show and shooting except as Stunt.
VERY HEAVY
Persons working in underground mines, explosives, magazines, workers involved in Electrical istallation with high-tension supply. Circus personnel, persons engaged in activities like racing on wheels or horseback, big game hunting, Mountaineering, winter sports, skiing, ice hockey, ballooning, hand gliding, river rafting, polo, Stuntman in Film and persons engaged in occupations / activities of similar hazard.
SCOPE OF COVER
I.The policy provides for payment of specified amount (benefit) on happening of specified contingency due to the accident. An Accident may include events like:
- Rail, Road, Air Accident
- Injury due to any collision / fall
- Injury due to bursting of gas cylinder
- Snake bite, Frost bite
- Burn injury, Drowning, Poisoning, etc.
This is only an illustrative list, not an exhaustive list.
II.If at any during the currency of this policy, the insured shall sustain bodily injury resulting solely and directly from accident caused by external violent and visible means, then the company shall pay to the insured or his legal personal representatives, as the case may be, the sum or sums as under:
(1)If such injury shall within twelve calendar months of its occurrence be the sole and direct cause of the death of the insured: … The Capital Sum Insured.
(2)If such injury shall within Twelve calendar months of its occurrence be the sole and direct cause of the total and irrecoverable loss of:
Sight of both eye, or of the actual loss by physical separation of two entire hands or two entire feet, or of one entire hand and one entire foot, or loss of sight of one of eye and loss of one entire foot/one hand: … The Capital Sum Insured.
Use of two hands or two feet, or of one hand one foot, or loss of sight of one eye and loss of use of one hand or one foot: The Capital Sum Insured.
(3)If such injury shall within twelve calendar months of it occurrence be the sole and direct cause of the total and irrecoverable loss of:
The sight of one eye, or of the actual loss by physical separation of one entire hand or of one entire foot: Fifty percent (50%) of the Capital Sum Insured.
Total and irrecoverable loss of use of a hand or a foot without physical separation: … … Fifty percent (50%) of the Capital Sum Insured.
NOTE: For the purpose of Clause (2) and Clause (3) above/ physical separation means “Amputation at or above the wrist and that of the foot at or above the ankle respectively”.
(4)If such injury shall, as a direct consequence thereof immediately permanently totally and absolutely, disable the insured from engaging in any employment or occupation of any description whatsoever, then a lump sum equal to: Hundred percent (100%) of the Capital Sum Insured.
(5)If such injury shall within twelve calendar months of its occurrence be the sole and direct cause of the total and irrecoverable loss of use of the actual loss by physical separation of the following, then the percentage of Capital Sum Insured as indicated below shall be payable:
Nature of injuryPercentage of
Capital Sum Insured
(i) Loss of toes – all20
Great – both phalanges 5
Great – one phalanx 2
Other than great, if more than one toe lost each 1
(ii) Loss of hearing – both ears50
(iii) Loss of hearing – one ear15
(iv) Loss of speech50
(v) Loss of four fingers and thumb of one hand40
(vi) Loss of four fingers35
(vii) Loss of thumb
– both phalanges 25
-- one phalanx 10
(viii) Loss of Index finger
- three phalanges10
- two phalanges 8
- one phalanx 4
(ix) Loss of middle finger
- three phalanges 6
- two phalanges 4
- one phalanx 2
(x) Loss of Ring finger
- three phalanges 5
- two phalanges 4
- one phalanx 2
(xi) Loss of little finger
- three phalanges 4
- two phalanges 3
- one phalanx 2
(xii) Loss of metacarpals
- first or second (additional) 3
- third, fourth or fifth (additional) 2
(xiii) Any other partial disablementPercentage as assessed by Doctor
(6)If such injury shall be sole and direct cause of Temporary Total Disablement (TTD) then so long as the insured shall be totally disabled from engaging in any employment or occupation of any description whatsoever: 1% of Capital Sum Insured or Rs. 6,000/- per week whichever is less, under all policies. However, the compensation shall not be payable for more then 104 weeks in respect of any one injury calculated from the date of commencement of disablement and in no case shall exceed the Capital Sum Insured.
NOTE:
- The losses under (1, 2, 3, and 4) should occur within 12 months of occurrence of the injury. This is not applicable to (4) but the permanent total disablement (PTD) must approximately be caused by the injury.
- T.T.D. and under Table “C” above will exclude any injury which is not visible even through medical testes like sprain and similar other injuries.
- Combination of benefits other than the combination for which rates are provided should not be permitted. For eg., cover against death and temporary total disablement should not be granted unless loss of limbs or sight and permanent total/ partial disablement are also covered.
SUMMARY OF BENEFITS
Benefits DescriptionAmount of Compensation
1). Death 100% Capital Sum Insured TABLE
“A”
2). Loss of two limbs
two eyes, or oneT
limb and one eye100% Capital Sum Insured A
B
L
E
3). Loss of one limb or
One eye. 50% Capital Sum Insured “B1” T
A
B
4).Permanent total 100% Capital Sum Insured L
Disablement from T E
Injuries other than A “C”
Those named above B
(PTD). L
E
5). Permanent Partial Disablement percentage
Disablement (PPD) (as specified under (e) (i) “B”
(xii) of sum insured as
mentioned above.
6).Temporary Total 1% of Capital Sum Insured
Disablement (Max. Rs.6,000 per week)
from all policies taken together
for maximum upto 104 weeks
Table “A”Benefit 1
Table “B1”Benefit 1 to 4
Table “B”Benefit 1 to 5
Table “C”Benefit 1 to 6
SPECIAL ADDITIONAL BENEFITS (IN-BUILT)
i)CUMULATIVE BONUS
Compensation for individual policies and family package covers(ONLY)under 1 to 4 of Table of Benefits shall be increased by 5% of Capital Sum Insured in respect of each completed year subject to following:
1. Maximum accumulation:……50%.
2. Bonus is permissible on renewals of other insurers
3. Bonus is permissible only when the policy is renewed within 90 days from the date of expiry.
4. In case Capital Sum Insured is increased at the time of renewal, the bonus will be allowed only on the previous years CSI at the above rate. Cumulative Bonus on the additional sum insured will be allowed next year at 5% and such percentage that the insured has earned on the CSI of previous year policy. The bonus will accordingly be increased in subsequent years.
5. The bonus is allowed only in respect of individual policies and family package policies.
ii). CHILDREN EDUCATION FUND:
In the event of death or permanent total disablement of the insured person due to an accident and provided the claim under the policy is admissible, compensation towards Education Fund for the dependant children shall be paid as under:
If the Insured person has one dependent child, below the age of 23 years, amount payable is equal to 10% of C.S.I subject to a maximum of Rs.5,000/-.
If the insured person has more than one dependent child below the age of 23 years, amount payable is equal to 10% of the CSI subject to a maximum of Rs.10,000/-
The payment as above will be made along with the CSI to the same person/s who is/are entitled to receive the CSI.
The benefit under this extension will be available on the basis of the Original CSI only and not on the cumulative Bonus.
The age of 23 years shall apply on the date of accident only.
This benefit is available in case of individual P.A. only. However, Zonal Head will have discretion to provide this benefit in Group policy also.
Provided that if there be any other PA Insurance(s) in the name of the insured and benefits under this Regulation becoming payable under all such policies the total amount so payable under all such policies, the total amount so payable shall be limited to a maximum of Rs.5,000/- in case there is one dependent child and Rs.10,000/- in case there are more than one dependent child. The amount so payable shall be borne by all the policies in proportion in the original sum insured.
iii)EXPENSES FOR CARRIAGE OF DEAD BODY
The policy covers reimbursement of actual expenses, including funeral charges incurred for transportation of the dead body of the insured to the place of his residence in the event of death claim being admissible under the Policy subject to maximum liability under all the policies being restricted to Rs.2,500/- This compensation for carriage of dead body will be paid along with the claim amount on the basis of declaration by the claimant.
iv)AMBULANCE CHARGES
Ambulance charges for transportation of Insured person to Hospital following accident, which results in liability having been admitted by the Company as per 1 to 6 of the Table of Benefits is payable upto Rs. 1,000 (Rs.one Thousand) per insured person any one accident or actual expenses whichever is lower in addition to CSI
v)DAMAGE TO CLOTHES
The cost of clothing damaged in accident as described under the Table of Benefits is payable at Rs. 1000 per insured person any one accident or actual expenses whichever is lower in addition to CSI. However, in the event of death, this amount is payable on basis of declaration by the claimant.
vi)LOSS OF EMPLOYMENT
In the event of, permanent total disablement i.e. 2,3, 4 of Table of Benefits of insured person, leading to loss of employment of Insured Person, the Company will pay 1% of the CSI subject to a maximum of Rs. 15,000 in addition to CSI
EXTENSIONS OF THE POLICY(at additional premium )
(I) Temporary Total Disablement Benefit: The maximum benefit is limited to Rs.10,000 per week or 1% of C.S.I. for the period of Disablement. However in consultation with Corporate Office of ITGI, this limit can be increased for high net worth individual who are valuable clients of ITGI.
(II) Medical Benefit Extension: A policy can be extended on payment of extra premium to cover medical expenses necessarily incurred by the insured in connection with the injury, provided the claim otherwise is admissible under the policy. The extension is available under all the Tables i.e. Benefit (1), Benefits (1) to (4), benefits (1) to (5) and benefits (1) to (6) by loading the basic premium either by 10% or by 25% or by 50% or by 100% and the benefit available is reimbursement of Medical expense (in case of first two options i.e. loading by 10% or by 25%) and reimbursement of Hospitalization expenses and limited medical expenses (in case of other two options i.e. loading by 50% or 100%) as under: -
a) If loaded by 10% b) If loaded by 25%
1. Actual expenses incurred, or1. Actual expenses incurred, or
2. 10% of the C.S.I. or2. 20% of the C.S.I. or
3. 25% of the admissible P.A. claims3. 50% of the admissible P.A. claim amount,
whichever shall be less. whichever shall be less.
c) If loaded by 50% d)If loaded by 100%
1. Actual Expenses or1. Actual Expenses or
2. 35% of capital sum insured or2. 50% of capital sum insured or
3. 75% of the admissible PA claim3. 100% of the admissible PA claim amount
whichever shall be less. whichever shall be less.
Note: The Medical benefit under Option c and Option d above will be restricted to the maximum benefit prescribed under Option b unless the Insured Person has been hospitalised.
(III) Indian Personnel working abroad: In respect of Indian personnel Corporate/Professionals working in a foreign country on civilian duties, the cover may be granted for personal accident on payment of additional premium as under:-
Circumstances / Chargeable Additional Premiuma)During Normal Times / 50% of Premium
b)During apprehensive or Disturbance times / 200% of premium
However the coverage for circumstance ‘b’ should be underwritten only in consultation with Corporate Office of ITGI.
(IV) Cost of Travel: The Policy can be extended to cover the cost of travel for one of relation of Insured person, friend, or colleague to meet the insured person who has been injured due to accident and the claim has been admitted under the Table of Benefit and also for return travel expenses for injured insured person. The scheme is as under:-
a)Cost of travel for any relation, friend, colleague or any other nominated person by the Insured person or his/her spouse:- In the event of insured person meeting with an accident outside the city/town, where his/her principle place of residence is located and claim having been admitted under ‘Table of Benefits’ ‘1 to 6’ and becomes payable; the Company would reimburse the cost of travel expenses for one of the relation, friend, colleague of insured person or a nominated person by a insured person or his/her spouse to join him/her for both outward/return journey . This extension is available only if the Insured Person is hospitalized in consequence of Accident. The maximum liability of the Company would be limited to 2% (two percent) of the Capital Sum Insured or Rs. 10,000 or actual expenses whichever is lower within the period of insurance. The prescribed rates would be Rs. 7.50 per insured person.
b)Cost of travel for insured person. In the event of insured person meeting with an accident outside the city/town, where his/her principle place of residence is located and claim having been admitted under ‘Table of Benefits’ ‘1 to 6’ and becomes payable; the Company would reimburse the cost of travel expenses for insured person to his / her principle place of residence or any other location for emergency treatment. The extension is available only if the Insured Person is hospitalized as a consequence of Accident. The maximum liability of the company would be limited to 1.00% of the Capital Sum Insured or Rs. 5,000 or actual expenses, whichever is lower. The Prescribed Rate would be Rs.4.00 per Insured Person.
(V) COST OF SUPPORTING ITEMS:- In the event of Insured person meeting with an accident and liability having been admitted under Table of Benefits, 2 to 5, the Company would reimburse the cost of purchase of supporting items such as artificial limb, crutches, stretcher,
tricycle, wheelchairs, intra-ocular lenses, spectacles or any other items which in the opinion of Medical Practitioner is necessary for insured person. The Company’s maximum liability would be limited to Rs. 10,000 (Ten thousand) or 2% of sum insured or actual expenses, whichever is lower in addition to CSI in any one period of Insurance. The Prescribed Rate would be Rs.10.00 per Insured Person.
EXCLUSIONS
a)Intentional self injury, suicide or attempted suicide, Venereal Disease or Insanity
b)The insured being under the influence of intoxicating liquor or drugs
c)Death or disablement resulting from pregnancy or child birth. (in case of female insured)
d)The Insured committing any breach of law with criminal intent
e)Engaging in Aviation or Balloning or Whilst mounting into or dismounting from or travelling in any a ballon or aircraft other than as passenger (fare paying or otherwise) in any duly licensed standard type of aircraft.
f)Contracting any illness directly or indirectly arising from or attributable to HIV or any HIV related illness including AIDS and/or any mutant derivative or variation of HIV or AIDS.
g)War and allied perils
h)Nuclear perils
i)On duty with any armed forces.
RATE OF PREMIUM
Although this class of business is non-tariff and the rate of premium depends on the discretion of the underwriter, who decides the same on the basis of his experience and other material facts such as:
Age of the person
Profession and nature of job
Earning
Size of group in case of Group Policies etc
ITGI has decided to charge following rate of basic premium:
Sr.No. / Table & Benefits / Rate of premium
Normal Heavy Very Heavy Risk Risk Risk
1. / “A” Benefit (1) / 0.40 0.60 0.75
2. / “B1” Benefits (1) to (4) / 0.70 1.00 1.25
3. / “B” Benefits (1) to (5) / 0.85 1.25 1.60
4. / “C” Benefits (1) to (6) / 1.40 2.00 2.50
Note: Unless to certain exceptional circumstances prevail very heavy risk should not be covered and it should be done in consultation with Corporate Office of ITGI with full details.
AGE LIMIT
Normal age limit is 5 to 70 years.