Introduction personal accident insurance

Personal Accident Insurance
EXECUTIVE SUMMARY
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INTRODUCTION
Personal Accident Policy is a cover meant for compensation
in case of an accident causing injury/ death to person/ persons by
violent external means. Insurers pay compensation for death,
permanent total disablement, permanent partial disablement (like
loss of finger, etc.) and temporary total disablement (like fractures).
A personal accident policy gives financial relief to insured people if
they sustain any injury/ death due to accidents. Frost bites and snake
- bites are also treated as accidents.
A wide variety of PA policies are available in the market.
Many banks offer personal accident covers to their depositors and
credit card holders. Public transporters and the Railways insure
passengers for any accidents during the journey. More restricted
covers in the form of JPA (Janata Personal Accident) and Gramin
personal accident, PA extension under motor policies, policies for
school children, accident, cash, etc are also available. In its basic
form, there are some exclusions and conditions attached to personal
accident policies that remain the same for all insurers. However,
insurers differentiate their products in the form of various fringe
benefits and add-ons.
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The purpose of personal accident insurance is to pay fixed
compensation for death or disablement resulting from accidental
bodily injury. With effect from 1.04.1994 this insurance became a
non-tariff class of business. However, the policy forms and rating
system, used by the companies, though not uniform, follow more or
less similar approach with minor variations. The policy fom1s,
rating, underwriting etc. dealt with in this chapter are based on the
general approach.
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BASIC PRINCIPLES
1. Utmost Good Faith
• The principle of utmost good faith applies to P.A. and Mediclaim
Policies in the same manner and with the same force as it applies
to other classes of insurance. No special comments. In this behalf
are therefore necessary except that onus on the insured of
disclosing all relevant facts is stricter in this class of insurance as
compared to other classes.
• The details regarding the condition of health of the proposer are
known best to him only and may not be known to or inferred by
the insurers even after a detailed scrutiny of the proposal form.
The duty of utmost good faith is all the more important because
medical examination of the proposer is required only in limited
cases. The wording of the declaration in the different proposal
form must be carefully noted.
• The duty of disclosure also arises during the currency of the
policy. For example, personal accident policies include a
condition whereby the Insured shall give immediate notice of any
change in his occupation. Similarly, annual frequent traveler’s
policy (overseas medical) provides that the Insured shall advice
the company any material change in his health condition.
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2. Indemnity
• The policies issued in this class of insurance are not contracts of
indemnity. This is so because life is invaluable and no amount of
money can compensate the death or disablement of a human
being. However on practical consideration a measure of
indemnity does come into play. When policies 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.
• A majority of policies issued in this class are, however issued
“benefit” policies as distinct from policies of indemnity. This
means that in the event of happening of an insured event a
specified sum of money is payable irrespective of the amount of
pecuniary loss actually suffered by the insured or dependents,
which in any case can not be measured.
• This should not lead one to believe that by taking policies of this
class for larger amounts, it is easy for the insured to make profit
because the insurers seek to ensure that even under these policies
the principle of indemnity is not lost sight of. For example, if a
person earning Rs. 1000 per month were to approach an insurer
with a personal accident insurance proposal for Rs. 100000, there
is no likelihood of the proposal being accepted for that amount.
Although it is difficult to specify the exact amount for which the
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cover could be granted. (Since the practice differs with insurers),
it may be indicated that the cover is granted for, say an amount
equivalent to 60 to 72 months earnings of the insured.
• Linking the capital sum insured to the earnings of the person also
ensures that the weekly benefits provided to the insured in the
event of temporary disablement would not be disproportionate to
his weekly earnings.
• This formula is sometimes not strictly applied if the policy is
taken for Capital Sums only.
• The medical expenses extension cover however unlike the basic
Personal Accident Insurance cover, is subject to strict principle of
indemnity in all circumstances, since this relates to
reimbursement of expenses actually incurred subject to limits in
the policy.
3. Contribution
• Contribution does not apply where the contract is not one of
indemnity. An insured person may hold several personal accident
policies and is entitled to the full benefits of each.
• However the weekly compensation payable as temporary total
disablement benefit is limited to Rs. 3000 per week overall
irrespective of the total sum insured. If policies are issued by
different companies and the total sum insured exceeds Rs. 3 lacs
in respect of T.T.D. benefit liability of each company would, be
proportionate to the respective sum insured.
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• In respect of medical expenses extension too there could . arise
co-sharing of liability among the insurance policies issued by
different companies. This would happen when the expenses
incurred are for an amount less than the total cover available.
When the expenses incurred are more each policy will bear to the
extent of its own limit of liability.
• Although the insured can have more than one policy, insurers
place restrictions on additional insurances to prevent over
insurance. There is a question in the proposal form seeking
information about any other existing P.A. policies. A condition
may also be incorporated in the policy to ensure that additional
policies are not taken without the consent of the insurer.
4. Subrogation
Subrogation like contribution does not apply to
contracts, which are not of strict indemnity. However it can
apply under certain circumstances. For example, there is a
specific condition in Videsh Sanchar Yatra Mitra. Policy, which
provides that in a event of payment of claim for total loss of
baggage, any recovery from the airline in terms of Warsaw
convention shall become the property of insurers. It will be
observed that this particular section of policy covers property
(i.e. baggage) and hence the strict principle of indemnity.
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5. Insurable interest
• A person is deemed to have an unlimited interest in his own life
and as such, this principle does not pose any problem in personal
accident insurance policies.
• Since a husband has an insurable interest in the life of his wife
and vice versa it is in order for a husband to take a personal
accident insurance policy on the life of his wife and vice versa.
Insurable interest also arises for a creditor in his debtor’s life to
the extent of the debt due to the creditor.
• The employers are deemed to have an insurable interest in the
lives of their employees in so far as they would suffer in a
pecuniary sense by the death or disablement of their employees.
• Very often, group policies are taken by employer on the lives of
their employees, although there is no provision for such benefits
in their service conditions, but as a welfare measure. In such
cases claims paid to the insured employers, are passed on by
them, to the concerned employees or their dependants as the
cases may be.
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BASIC COVERAGE
If at any time during the currency of this policy, insured shall
sustain any 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 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.
Analysis of terms
1. Bodily Injury:
The use of this term excludes disease from natural causes, but
disease proximately caused by accident, is bodily injury (unless
specifically excluded by the policy). Mental shock, fright or grief,
unless causing some physical injury or disease, does not come
within the scope of bodily injury, but the modern tendency towards
the inclusion of any disablement caused by shock.
2. Solely and Directly:
The effect of this phrase is to require that the bodily injury
shall have been caused solely and directly by an accident; in turn,
the bodily injury must directly and independently of any other cause
result in death or disablement; hence if any other cause contributes
to the result, the insured event has not occurred.
An accident may set up a disease and result in death, but death
may still be the direct result of the accident, namely, where there is
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no break in the chain of causation, e.g. a man is thrown from his
horse while hunting and so injured that he cannot walk, he lies on
the wet ground until he is picked up, he thus catches chill which
turns to pneumonia, and dies.
However if a man breaks a leg and taken to hospital where he
contracts an infectious disease from another patient, with fatal
results, the death is not the sole and direct result of the accident; the
infectious disease constitutes a break in the chain of causation.
3. Accident:
An accident is an event, which is wholly unexpected, not
intended or designed. It does not include the' cumulative result of a
series of small incidents. Thus, a bent hand, the result of using a
pneumatic drill, is not caused by accident.
Certain voluntary acts, which result in bodily injury, are
included, where the insured’s act is the result of a chain of events
stemming from an accident. For example, an insured who is injured
whilst jumping from an upper storey of a burning building, sustains
injury by accident.
Questions often arise whether events like suicide, murder,
frostbite, snakebite; drowning etc. can be regarded as accident.
Applying the various tests, it can be stated that whilst suicide and
murder or homicide following grave provocation are not accidents,
homicide or murder without provocation, frostbite, snakebite and
drowning are accidents.
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4. External, Violent and Visible means:
The cause of accident i.e. the means must be within the
definition as a whole, but the result may not be external. For
example, injury may be internal i.e. inside the body. However the
result must be death or disablement as specified in the policy. In
other words, the means or cause of accident must be within the
definition, but the result or effect need not be external or visible, so
long as it is bodily injury.
5. 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 inability to attend to any occupation or business is
called disablement. What is referred to here is the physical inability
of the person to attend to occupation /business, and not his earning
capacity. A special note may be taken of the fact that, although there
may not be any loss of earning capacity, there still can be
disablement under the policy.
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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 inability to attend to any occupation or business is
called disablement. What is referred to here is the physical inability
of the person to attend to occupation /business, and not his earning
capacity. A special note may be taken of the fact that, although there
may not be any loss of earning capacity, there still can be
disablement under the policy.
Types of Disablement
The following are the types of disablement covered under the
policy
(i) Permanent total disablement;
(ii) Permanent partial disablement; and
(iii) Temporary total disablement;
(i) Permanent total disablement:
Disablement is of permanent and irrecoverable nature and is
absolutely total in the sense that the insured person is prevented
from engaging in gainful employment of any kind. (Example:
Paralysis). It must be noted that loss of sight of both eyes or the
actual loss by physical separation of the two entire hands or two
entire feet or one entire hand and one entire foot or loss of sight of
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one eye and such loss of one entire hand / foot are deemed as
equivalent to permanent total disablement.
The exact meaning of the phrases 'loss of sight’ and `loss of
limbs' should be understood. The loss of sight has to be total and
irrecoverable; Claims are admissible if vision has become so
impaired that it is impossible to recognise object although the
difference between darkness and light can be distinguished.
"Loss of Limbs" means loss of hand and/or foot, than is physical
separation of the hand and/or foot at or above the ankle. Loss of use
of limbs concerned, and not the limbs themselves, is also deemed to
be 'loss of limbs'.
(ii) Permanent partial disablement:
This is similar to permanent total disablement with the
difference that, the disablement is not total but is only partial. An
example is the loss of a toe or a finger. The applicable percentage of
compensation for various losses is shown in the policy by a table.
This percentage of capital sum insured will become payable. For
permanent partial disablement not specified in the table, doctor’s
assessment would be the basis.
For example, the table specifies that for loss of little finger,
compensation is 4% of capital sum insured, loss of four fingers 35%,
and loss of hearing both ears 75% and so on.
(iii) Temporary total disablement:
As the name implies, this is a disablement, which is total (i.e.
the insured person is prevented from engaging in any occupation or
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business) but for a temporary period only. This temporary period
may be days, weeks, months or even years. The position of the
person in supervisory capacity who can sign business documents.
Although confined to bed, is not easy to define, but the signing of
papers only does not usually invalidate a claim for total disablement.
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Benefit Chart
Contingency Amount of Compensation
payable
a) Death Rs. 1,00,000 (i.e. 100% of capital sum
insured)
b) Loss of two limbs
or both eyes or one
limb and one eye.
Rs. 1,00,000 (i.e. 100% of capital sum
Insured)
c) Loss of one limb
or one eye.
Rs. 50,000 (i.e. 50% of capital sum
insured)
d) Permanent total
disablement other than
the above (e.g.
Paralysis due to an
accident)
100% of capital sum insured.
e) Permanent partial
disablement
Percentage as shown in the table in the
policy
f) Temporary total
disablement
Weekly payment of Rs. 1000/- (i.e. One
percent of the capital sum insured)
subject to a maximum of 100 weeks.
The amount of weekly payment is
restricted to a maximum sum of
Rs.3000/- whatever be the capital sum
insured. This limit applies to ail
policies held by the insured
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The benefits (a), (b), (c), (d) and (e) above are referred to as capital
benefits, and benefit (f) as weekly benefit.
A specimen table of benefits showing the amounts of
Compensation payable in the event of the happening of various
Contingencies is given below for clear understanding. It is assumed
that the capital sum insured by the policy is Rs.1 00000/-. (This
amount is selected for the purpose of illustration only. the proposer
is free to choose any capital sum insured subject to the same being
commensurate with his income through gainful Occupation.).
Additional Benefits at no Extra Premium
1. Carriage of dead body
Expenses incurred for carriage of dead body of insured (death
due to accident only) to place of residence are reimbursed subject to
2% percent of Capital Sum Insured or Rs. 2500/- whichever is less.
2. Education Fund
In the event of death or permanent total disablement of the
insured person, the policy provides for Education Fund for the
dependent children, in addition to Capital Sum Insured and is
applicable to Personal Accident Individual Policy only.
3. Compensation is provided as follows:
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• If the insured person has one dependent child below the age of
25 years, l0% of the Capital Sum insured subject to maximum
of Rs.5000/-
• If the insured person has more than 1 dependent child below 25
years, 10% of the Capital Sum Insured subject to maximum of
Rs. 10,000/-
• The benefit is available only on Capital Sum Insured and not on
Cumulative Bonus. If there are existing insurances on the same
life then the total compensation payable shall be limited to
maximum of Rs.5000/- for one child and Rs.10000/- for more
than one child.
4. Cumulative Bonus
• Compensation payable for death, loss of limb(s) or sight and
Permanent Total Disablement arising out of accidental injuries
shall be increased by 5% thereof in respect of each completed
year, during which the policy shal1 have been in force, prior to
the occurrence of an accident for which capital sum becomes
payable but amount of such increase shall not exceed 50% of
the capital sum insured.
• This clause shal1 not in any way alter the annual character of
the Insurance nor the right of the Company to decline to renew
or to cancel this Policy.
• The earned Cumulative Bonus will not be lost if the policy is
renewed within 30 days after its expiry.
Provisos
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The following appear as provisos in the policy. The insurer is
not liable for
(a) Compensation under more than one of the sub-clauses (a to f of
benefit chart above) in respect of the same period of disablement.
Comprehensive policy provides for payment of compensation for
several contingencies like death, loss of limbs/eyes, permanent
partial disability etc. It may so happen that the insured may initially
appear as only partially disabled, but this disablement may later lead
to total disablement, loss of limbs / eyes or death.
Without restriction as stated above it may be construed that the
insured can claim under several items for the same accident It is
therefore clarified that payment can be only under one item for
the same period of disablement.
(b) Any payment after a claim under sub clauses (a), (b), (c) or (d)
of the policy has been admitted and settled. Once a claim is
settled under one of the sub-clauses referred to above the policy
becomes inoperative. No further claim can be admitted under the
policy.
(c) Any payment in case of more than one claim under the policy by
which maximum liability of the company would exceed sum
payable under sub-clause (a) (the capital sum insured) The object
of this exclusion is to clarify beyond any doubt that the
company's liability under the policy is limited to the amount of
the capital sum insured (+ cumulative bonus, if applicable).
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(d) 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 malinger. In genuine hardship cases
however 'on account' payment is made which is then adjusted
against the final payment due.
Exclusions
The exclusions commonly found in Personal Accident
policies are as follows:
Payment of compensation in respect of death, injury or disablement
of the insured
a. From intentional self-injury, suicide or attempted suicide.
b. Whilst under the influence of intoxicating liquor or drugs.
c. 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.
d. Directly or indirectly caused by venereal diseases or insanity.
e. Arising or resulting from the insured committing any breach of
law with criminal intent.
f. From service in the armed forces.
g. Resulting directly or indirectly from childbirth or pregnancy.
h. War and kindred peril and nuclear risks.
Notes:
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1. Suicide is not an accident. Besides it is an offence under the
Indian Penal Code and the insured is not allowed to benefit from
his own criminal act. But when the circumstances are such that
the evidence is equally consistent with either suicide or accident,
then the presumption of law against suicide applies and accident
will be presumed.
2. Claims arising out of liquor or drugs, venereal diseases, breach of
law with criminal intent are not payable on grounds of public
policy. The word 'criminal intent' are important. Technical
breaches of law are not excluded (e.g. Traffic offence)
3. Aviation or ballooning present abnormal risks. (Cover may be
arranged at extra premium on merits of each case).
Policy Conditions
Notice and proof of claims
• Written notice of claims with full particulars must be give to the
Company immediately
• 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,
• 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.
• Proof of claim satisfactory to the Company shall be furnished.
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• Any medical or other agent 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.
• In the event of the death, to make a post rnortem examination of
the body of the insured.
• A post mortem examination report, if necessary, be furnished
within the space of fourteen days after demand in writing.
• In the event of a loss of sight the Insured shall undergo at the
Insured's expense such operation or treatment as the company
may reasonably deem desirable.
• No sum payable under this policy shall carry interest.
No claims is payable if the claim is fraudulent or supported by
fraudulent statement.
Material Alterations
• 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.
• Change of occupation may materially alter the risk and attract a
higher rate of premium. Similarly, any disease (e.g. diabetes) or
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physical infirmity may also alter the risk. The insurers may take
appropriate underwriting decisions such as loading of premium,
restricted cover etc.
Renewal
This policy may be renewed by mutual consent every year and
in such event, the renewal premium shall be paid to the Company on
or before the date of expiry of the Policy or of the subsequent
renewal thereof. The Company shall not, however, be bound to give
notice that such renewal premium is due.
Cancellation
The Company may at any time, by notice in writing, terminate
this policy and the Company shall return to the Insured a pro-rata
part of the premium. Such notice shall be deemed sufficiently given
if posted and addressed to the insured and shall be deemed to have
been received by the Insured at the time when the same would be
delivered in the ordinary course of post.
The policy may be cancelled at any time by the Insured by a
notice in writing under a Certificate of posting or a Regd. A.D. Such
notice shall be deemed to be effective from the date of despatch of
the same by the insured.
Refund of premium at short period scale is made subject to
there being no claim under the policy.
Assignment
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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.
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.
Although the assignment of the policy is not permissible
under the Insurance Act, these policies can be assigned under the
Transfer of Property Act. It should be remembered that when these
policies are assigned, it is only the policy amount that is assigned
and not the subject matter of the policy. In other words, the
assignment involves a new creditor for the insurers and not a new
insured. This alteration has obviously no effect on the rating or
underwriting of the risk. If the assignment is effected on the policy
document itself, no stamp duty is payable. If however, it is affected
on separate paper, it attracts a stamp duty of Rs.15/-
Arbitration and Disclaimer
The following points must be noted.
(a) Differences regarding amount of loss (not question of liability)
are to be referred to arbitration.
(b) The award of arbitration is a precedent to suit in Court of Law.
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(c) If the insurers disclaim liability the insured has to file a suit in a
Court of Law within 12 month from the date of such disclaimer.
Special Features of P.A. Policy
• The cover is for 24 hours and on a worldwide basis.
• Travel as a passenger in a licensed standard type of aircraft is
automatically covered
Rating
The basic principle of fixing rates of Premium in any class of
insurance is that rates of premium should be commensurate with the
hazard involved. Thus, in fire insurance rates of premium vary
according to the type of construction, the type of occupancy, the
type of goods stored etc.
In personal accident insurance, the main factor used is the
occupation. General1y speaking exposure to personal accidents at
home, on the street etc. is the same for all persons. But the risks
associated with profession or occupations 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 being 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. The system of
classification is simple and found to be workable in practice.
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Classification of Risk
Risk Group I:
Accountants, Doctors, Lawyers, Architects, Consulting
Engineers, Teachers, Bankers, Persons engaged in administration
functions. Persons primarily engaged in occupations of similar
hazards.
Risk Group II:
Builders, Contractors and Engineers engaged in
superintending functions only, Veterinary Doctors, Paid drivers of
motor cars and light motor vehicles and persons engaged in
occupation of similar hazards and not engaged in manual labour,
All persons engaged in manual labour (Except those falling under
Group III), Cash Carrying Employees, Garage and Motor
Mechanics, Machine Operators, Drivers of trucks or lorries and
other heavy vehicles, Professional Athletes, and Sportsmen,
Woodworking Machinists and Persons engaged in occupations of
similar hazards.
Risk Group III:
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
26

gliding, river rafting, polo and persons engaged in occupations /
activities of similar hazard.
Age Limits
• The minimum age limit is 5 years and maximum 70.
• In case of persons who already have a cover, policies may be
renewed after they complete 70 years but up to the age of 80
subject to a loading 5% of the renewal premium.
• In case of fresh proposals from persons above 70 years but
below 80 years cover may be granted at normal rates plus
loading of 10%.
• No medical examination is required for renewal or fresh
cover.
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POLICIES OF PERSONAL ACCIDENT INSURANCE
1. Family Package Cover
2. War and allied risks
3. Flight Insurance Coupons
4. Janta Personal Accident Insurance
5. Gramin Personal Accident Insurance
6. Student Safety Insurance
7. Group Personal Accident Policies
8. New Schemes
• Raj Rajeshwari Mahila Kalyan Yojna
• Bhagyashree Child Welfare Policy
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Family Package Cover
A Family package covers the all the members of the family to
protect from any accident occurs in the future. Family Package cover
may be granted on the following pattern:
(a) Earning Member
(Persons Insured) and
Spouse, if earning
100% of the Capital Sum
Insured for each.
(b) Spouse (if not earning
member)
50% of the Capital Sum Insured
or Rs.l1akh whichever is lower.
(c) Children (between the
age of 5 years and 25
years)
25% of the Capital Sum Insured
or RS. 50000/- whichever is
lower per child.
Notes:
1. For children the cover is limited to Death and Permanent
Disablement (total or partial)
2. Premium payable for husband and wife will be on the tota1 sum
insured for husband and wife.
3. A discount of 5% may be granted on the gross premium.
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Extensions of the policy
Medical Expenses
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. These
benefits are in addition to the other benefits under the policies.
War and allied risks
War and allied policy of personal accident insurance is
provided to the Indian individual / experts working in foreign
countries. In short War risk cover can be granted to Indian personnel
/ experts working in foreign countries on civilian duties at the
following additional premium.
(a) P.A. Policies issued during
peace time normal period
50% extra over the normal
rate (i.e. 150% of the normal
rate.)
(b) P.A. Policies during abnor-
mal/apprehensive period (i.e.
during the period when
warlike conditions have alre-
ady occurred or are imminent
in foreign country / ies where
150 % extra over the normal
rate (i.e. 250% of the normal
rate)
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the Indian Personnel are
working on civilian duties)
The Proposal Form
The form elicits information on the following
1) Personal details
2) Physical condition
3) Habits and pastimes
4) Other or previous insurances
5) Previous accidents or illness
6) Selection of benefits and sum insured
7) Declaration
• Personal details relate to, inter alia, age, height and weight, full
description of occupation and average monthly income.
• Age will show whether the proposer is within the limits of age
for entrants for the policy desired. Weight and height should be
compared with a table of average weight for sex, height and age
and further investigation would be made if the proposer is 15
percent or more over or under the average.
• Physical condition details relate to any physical infirmity or de-
fect, chronic diseases etc.
• Proposers who have lost a limb or the sight of any eye may only
be accepted on special terms in approved cases. They constitute
abnormal risks because they are "less able to avoid certain types
of accidents and in view of the fact that if the remaining arm or
leg is injured or the sight or the remaining eye is affected, the
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degree and length of disablement is likely to be much greater
than normal.
• Diabetes may retard recovery as the wound may not heal
quickly and the disablement may be unduly prolonged. The
medical history of the proposer must be examined in order to
determine whether and to what extent injuries or illnesses may
affect the future accident risks. There are many complaints of
such an obviously serious nature as to make the risk
uninsurable, e.g. valvular disease of the heart.
• Hazardous pastimes like mountaineering, polo, motor racing,
aerobatics etc, require extra premium.
Sum Insured
• 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. A policy for Rs.1lac may not be
granted to a person earning Rs. 1000/- per month, because in
the event of temporary disablement, his benefit per week is Rs.
1000/-, (Rs. 4000/-) per month) which is disproportionate to his
monthly salary. The sum insured could be up to 24 months
income.
• Although it is difficult to specify the exact amount for which
the cover could be granted (since the practice differs with
insurers), where no weekly benefit cover is allowed it mav be
indicated that the cover may be granted for say an amount
32

equivalent to 60 to 72 months' earning of the insured. This
restriction is not very strictly applied if the policy is for Capital
Sum only.
• While giving cover to persons who are not gainfully employed
e.g. housewives, students etc. the insurers make sure that they
provide for capital benefits only and that no weekly
compensation is provided for.
Flight Insurance Coupons
Passenger fight Coupon provides cover for accidental bodily
injury (as defined in the personal accident policy), whilst in or
entering into or descending from any aircraft owned and/ or operated
by a regular airline over a scheduled route by which the insured is
travelling as a passenger during the flight specified.
The benefit chart is as under:
Contingency Benefit
• Death Capital Sum Insured
(100%)
• Loss of two limbs -,,-
• Loss of one limb and one
eye
-,,-
• Loss of two eyes -,,-
• Loss of one limb or one
eye
50 % of Capital Sum
Insured
• Temporary total 1 % of Capital Sum
33

disablement Insured per week
• Up to 104 weeks Not to exceed Rs.3000/-
• The rate of premium is Rs. One per Rs. 10000/- capital sum
insured for flight not exceeding 24 hours duration.
• There are two methods of issuing these covers (a) The cover may
be issued for specific flight(s) only or (b) The cover may be
issued for a certain specific period of time and the company will
be on risk in respect of all the flights undertaken by the insured
within that period.
• Under (a) flat premium is charged based on the sum insured and
the duration of flight(s). Under (b) a deposit premium is collected
from the insured, equal to number of flights, expected to be
undertaken during the policy period. At the end of the policy
period the insured is expected to declare all the flights actually
undertaken by him. On the basis of this information the premium
earned is calculated and the deposit premium is adjusted.
• These declaration policies can be given not only to individuals
but also to companies in respect of their employees, who travel
by air frequently.
• Arranging covers on specific flights basis is time consuming and
cumbersome for both the insurer as well as the insured. The
insurer has to issue a document each time a flight is undertaken.
Often people may have to fly at short notice and may not have
34

sufficient time to obtain a flight insurance coupon. Declaration
policies are therefore popular. Since however, the insurer is fully
dependent upon the insured for accounting of each and every
flight undertaken (basis for calculating premium) moral hazard of
the proposer should be beyond reproach. Such covers are
therefore given only to reputed concerns and clients of long
standing.
Janta Personal Accident Insurance
The salient features of the revised market agreement for Janta
Personal Accident policy effective 1-11-1999 are as follows:
• Any person, irrespective of sex and occupation in the age
group 10 to 70 years may be covered.
• The minimum sum insured is Rs.25,000/- and maximum Rs,
1,00,000/- per person per annum. The rate of premium is
Rs.15/- per sum insured of Rs.25,000/- which can be
increased in multiplies of Rs.25,000/- and rate applicable
accordingly
• The insurance pays specified benefits if the insurance sustains
bodily injury resulting solely and directly from accident
caused by outward violent, and visible means and such bodily
injury within 12 calender months of its occurrence be the sole
and direct cause or specified contingencies.
The contingencies are:
35

Contingencies Sum Insured Payable
1.Death 100% of Sum Insured
2.Total and irrevocable loss of sight
of both eyes or losses of use of two
hands or feet or loss of sight of one
eye and loss of use of one hand or
foot.
50% of Sum Insured
3.Total and irrevocable loss of sight
of one eye or loss of use of one
hand or foot.
50% of Sum Insured
4.Permanent total disablement due to
accident
100% of Sum Insured
Group Discount
Group Size Discount (%)
101 to 1,000 5
1,001 to 10,000 7.5
10,001 to 50,000 10
50,001 to 1,00,000 12.5
1,00,001 to 2,00,000 15
2,00,001 to 5,00,000 20
5,00,001 to 10,00,000 25
Above 10,00,000 30
Group insurance policy should be issued only in respect of the
named Groups. For the purpose of availing of Group Discount and
other benefits the proposed "Group" should fall clearly under anyone
of the following categories:
36

 Employer-employee relationship including dependents of the
employee.
 Pre identified segments / groups where the premium is to be paid
by the State / Central Governments.
 Members of a registered co-operative society.
 Members of Registered Service Clubs.
 Holders of credit card of Banks / Diners / Master / Visa.
 Holders of Deposit Certificates issued by Banks / NBFC's.
 Shareholders of Banks / Public Limited Companies.
 In case of proposals relating to any further category different
from the seven notified categories, they may be deliberated and
decided upon by a Central Committee comprising a nominated
HO Technical Manager each from the Companies and GIC.
 No Group Discount can be offered on the 'anticipated' group size.
Group Discount is to be considered and worked out only on the
actual number of members registered in the 'Group' at the time of
taking out the policy.
 Claims under such policies cannot be paid to anyone other than
the individual insured.
 Wherever group policies for higher Sum Insured are needed, the
same shall be covered under Personal accident policy.
Long Term Discount
Term of the Policy
(years)
Discount
(%)
37

1 Nil
2 5
3 10
4 15
5 20
The exclusions are the same as under individual personal
accident policy.
Underwriting instructions
a) The policy in respect of individual or Group JPA should be
issued for a maximum period of 3-5 years.
b) In case of long-term policy, the premium is to be collected in one
lump sum amount in advance.
c) No refund of premium will be allowed even if the claim arises in
the earlier years under long-term policy.
d) No renewal of group policy should be encouraged where loss
ratio is 60% and above.
e) PTD should be covered as per existing JPA policy and only
Death cover should not be given.
Claims Procedure
a) Immediate notice to be given to the policy issuing office.
b) Claim Form to be submitted with medical certificate and bills.
c) For death claim, Nominees should submit:
(i) Death Certificate
(ii) Original Policy
38

(iii) Claim Form
(iv) Postmortem Report
(v) Police Report if complaint is loaded.
d) Claims of person presumed to be dead due to drowning, may be
settled after two years of the submission of the following
documents:
(i) Police report and final investigation report.
(ii) Report of findings by Customs / Port Authorities.
(iii)Affidavit duly notarised.
f) Subject to above, claims of persons of a fishing vessel which is
missing or a total loss will be presumed dead and claim settled
accordingly.
Gramin Personal Accident Insurance
The Gramin Personal Accident Insurance was introduced to
provide security against risk to the people who are living in rural
39

areas. The cover is mainly for the benefit of the people living in the
rural areas of the country.
The sum insured is fixed at Rs. 10,000 @ a premium of Rs. 5
only. The following benefits are covered :
Contingencies Benefits
 Death Rs. 10,000
 Loss of both eyes or Loss of two
limbs or Loss of one limb or one eye
Rs. 10,000
 Loss of one limb Rs. 5,000
 Permanent total disability Rs. 10,000
The other features of the scheme are:
1. Age limits are minimum 10 years and maximum 70 years.
2. A policy-cum-proposal form is devised.
3. Claims procedure is simplified. There is a provision for nomina-
tion so that death claims are settled expeditiously. Post mortem
report is not insisted upon where evidence of accident is clearly
available.
4. Group discounts and long-term discounts are available.
Student Safety Insurance
40

This insurance is available to schools, colleges or other
educational institutions. The policy provides personal accident
benefits to registered students. The benefits are:
Rs.
1) Death 10000
2) Loss of two limbs / eyes 10000
3) Loss of one limb/eye 5000
4) Permanent total disablement
other than under (ii) above
10000
5) Permanent Partial Disablement Percentage of Capital Sum
Insured
Medical expenses incurred by the student for treatment in a
hospital/ nursing home as inpatient for injuries sustained in an
accident. Limit up to Rs. 500/- (any one student, any one year)
Compensation limits under the policy
a) Per student Rs. 10,000
b) Per Accident Rs. 5,00,000
c) Per Policy Period Rs. 10,00,000
(Note: Limits under (b) & (c) can be amended to suit the
requirement of the insured institution at suitable extra premium)
Premium is charged as a percentage on the limit any one year
plus a per capital charge on the number of students. Rate is reduced
if the number of students covered is large.
Features of the scheme
a) Policy is issued in the name of the Institution. The students are
insured persons.
41

b) Claim amount is payable to the Parent/ Guardian as recorded in
the School Register.
c) Claim papers are to be routed through the institution for proper
processing.
d) Maintenance of Attendance Register and declaration from
institution to that effect.
e) A1l Students are to be covered.
f) Additional students are covered during policy period at extra
premium. But no deletions are allowed.
Claims
Claim form
The onus of substantiating a claim under the policy rests on
the insured. It is also necessary for him to comply with the condition
of the policy concerning claim procedure. The usual relevant
conditions are:
(a) That notice of the occurrence be given immediately, to be
followed by full details.
(b) That the insured shall furnish satisfactory proof of all matters
upon which a claim is based.
In practice, insurers have found it best to supply claimants
with a printed claim form.
The essential features of an accident claim form are:
(a) Personal details, such as age and occupation, so that these may
be checked against the policy records.
(b) Number of the policy and date of issue.
42

(c) Details of the accident (date and time, where and how) for the
purposes of proof and to test whether the occurrence comes
within, the definition of
(d)"Accident" in the policy.
(e) The nature of the injuries, nature and extent of disability (capital
sum or weekly benefit). This is necessary for assessment of
amount of loss.
(f) Whether a similar injury has been sustained before, in order to
check the proposal form or previous advices.
(g)Other insurances, to see whether they have been disclosed
previously or have been effected subsequently in order to keep in
mind the principle of indemnity.
(h)Name and address of the attending doctor. (To consult him, if
necessary).
(i) Time at which and place where the insurers' doctor could visit the
claimant. This visit may not be necessary in all cases but it is
desirable to have this information ready. Besides, this could
prove as a deterrent to a claimant who is inclined to malinger.
(j) The declaration, whereby the insured warrants that all his answer
is true.
(k)A medical certificate (sometimes issued as a separate form) in
order to obtain a doctor's opinion of the injuries and of the
alleged disability.
Processing of claims also involves considerations relating to
change of risk.
Occupation
43

• The insurance is based on the insured following a certain
occupation. The insurance does not apply because of the
express basic condition of the policy that only a certain
occupation is followed and the insured has to give notice of
change.
• A1though legally claim can be repudiated on grounds of
change of occupation, it is not done unless the accident
occurred during the course of following the changed
occupation. The insurers need not admit the claim, but where
it is clear that the omission is due to a genuine oversight, the
claim is usually paid, provided the new occupation is one,
which the insurers would have accepted, had they known of it.
• Where the new occupation is an acceptab1c 0ne, but require a
higher rate of premium than that charged, the position is
usually met by a payment, usua1ly a percentage of the other
wise admissible claim amount against a comp1ete discharge
from the insured.
Physical Defects
• Non-disclosure of any such defect means that the claim can be
repudiated, whether or not the defect concerns the injury for,
which the claim is being made. It is unlikely, however, that
any reputable insurers would take advantage of such a
technicality, but that is the law.
44

• If the physical defect brought to light by the claim is one,
which would have rendered the risk unacceptable had it been
known at the time of acceptance or last renewal, then the
claim is refused. If, notwithstanding the physical defect, the
risk would still have been acceptable, although on different
terms, the claim may be settled ex-gratia on the basis of the
terms, which would have applied.
Proximate Cause
The doctrine of proximate cause is also relevant to processing of
claims. The following are illustrations based on case law.
(a) An accident and a disease may be in operation both at the same
time and it has to be decided whether the result is caused by
disease. If the disease is present before the accident and the
accident causes a condition which is in no way contributed to
by the disease, then the condition is proximately caused by the
accident, e.g. if a sufferer from asthma is able to travel to and
from his business and in the course of a journey falls into a
street excavation and breaks his leg, this is an accidental injury.
(b) If either accident or disease could have produced the result,
then a claim for the accident cannot be admitted unless there is
proof of the accident being the proximate cause of death. e.g. a
man with a heart disease was thrown from a cart and found
dead nobody could tell what was the cause of death; it might
have been the disease or it might have been the accident.
45

(c) The disease, which produces the ultimate result, follows the
accident and was not there beforehand. In such case, the
accident remains the proximate cause so long as the events,
which follow it, are the natural ones in such circumstances. e.g.
the sequence may be accident, shock, weakness, chill, which in
weakened condition leads to pneumonia and death. Death is
caused by accident. On the other hand, a person, who is
hospitalised for accidental injuries, contracts on infectious;
disease in the hospital and dies, the disease, which is a new
intervening cause, is regarded as the proximate cause.
(d) The disease promotes the accident but the injuries are due to the
accident. For example, fit - fall into river drowned - death.
Here, the disease is the remote cause and the accident the
proximate cause.
Documents
The following documents are necessary:
(a) Claim form: to supply particulars of the occurrence.
(b) Medical Certificate: to obtain medical opinion on the cause or
extent of incapacity or progress towards recovery.
46

(c) Medical examiner's Report: To corroborate medical certificate in
doubtful cases, or if other causes are in operations.
(d) Receipt /Discharge form: to acknowledge the money and to
confirm the finality of the settlement.
(e) Death Certificate: To give the date and cause of death. Post
mortem reports where a post-mortem has been done.
(f) 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, interalia required are:
- Medical certificate, diagnostic reports etc.
- Prescription bills and receipts.
- Leave of absence certificate from the employer.
- Medical fitness certificate.
Group Personal Accident Policies
Group policies have become popular because progressive
employers have appreciated the importance of welfare benefit for
their employees. These policies are also available to associations,
47

clubs etc who find it administratively convenient to arrange a group
policy to cover their members. The essential requisites for a group
policy are: Some common relationship among the persons to be
insured and a central point for administration of the policy scheme.
Under the group policy, the term 'insured' is applied to the
employer, association, etc. and the term 'insured persons' to those for
whose benefit the insurance is effected.
Claims are payable to the insured, the employer, association
etc. whose discharge shall be complete to the insurers and no insured
person has an independent right of action against the insurers.
Types of Policies
A. The Employer and Employee Relationship
These policies are granted to firms, association etc. to cover
(i) Named employees
(ii) Unnamed employees
B. No Employer – Employee Relationship
These policies are granted to Associations, Societies, Clubs, etc., to
cover
(i) Named members
(ii) Members not identified by name
(Note: Employees may be covered separately)
48

Coverage
The coverage is the same as under individual policy except
that cumulative bonus and education grant do not apply. Medical
expenses and war risk extensions are available.
Sum Insured
The sum insured may be fixed separately for each insured
person or it may be linked to emoluments payable to the insured
person. In the latter case, the following endorsement in incorporated
in the policy.
The premium for this insurance is calculated on the wages or
salaries paid by the employer to the insured persons during the
period of insurance and employer shall keep an accurate record of all
such payments and shall at all times allow the Company to inspect
such record. The employer shall within one month of the expiry of
each period of insurance furnish to the Company a statement of the
payments, and the premium for such policy shall thereupon be
adjusted by a further payment to or refund by the Company as the
case may be.
Premium
Rates of premium are applicable to named employees as per
the classification of risks and the benefits selected. Thus rates will
vary according to the occupation of persons covered. For example,
49

the same rate will apply to well-defined groups of employee all of
whom, broadly speaking follow the same type of occupation.
In respect of unnamed employees the employer is required to
declare the number of employees in each classification based on
authentic records maintained by him. Rates of premium for named
member of an Association, Clubs etc. apply according to the
classification of risk.
Where the membership is of a general nature not restricted to
a particular occupation, Underwriters use their discretion in applying
the rates.
On Duty Covers
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 the employees arising out of and in the course
of employment only.
Off Duty Covers
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 can be charged.
Exclusion of Death Cover
It is possible to issue Group P.A. policies excluding the Death
benefit, subject to following conditions:
50

a) A group life policy covering Death benefit for the same group of
persons is in existence.
b) A discount in the premium applicable to death cover is allowed
from the total premium.
Proposal Form
It is customary to dispense with forms for completion by the
members and to have one document only, completed by the insured.
He is required to make a declaration that no member suffers from a
physical infirmity or defect, which would render his participation
unacceptable. Sometimes even this precaution is waived, it being
understood and / or made clear by endorsement that disability prior
to the commencement of cover and also any cumulative effect as a
result of such disability stand excluded.
New Schemes
Raj Rajeshwari Mahila Kalyan Yojna
51

This is a personal accident insurance scheme designed for
women in the age group of 10-75 years irrespective of their income,
occupation or vocation.
Coverage
The Insurance cover would be available on 24 hour risk basis.
If the insured shall sustain any bodily injury resulting solely and
directly from Accident caused by outward, violent and visible
means, and if such injury shall within 6 calendar months (unless
otherwise specified) of its occurrence lead to disablement, then the
company shall pay to the Insured the sum specified below:
a) Permanent Total Disablement Rs. 25,000/-
b) Loss of one limb and one eye or loss
of both eyes and / or loss of both limbs Rs. 25,000/-
c) Loss of one limb / sight in one eye Rs.12,500/-
Death due to accident as defined is also covered. In the case
of unmarried woman the compensation of Rs.25,000/- is payable to
the nominee or legal heir.
In the case of married woman, compensation of Rs.25,000/- in
the event of the insured's husband's death due to accident, is payable
to the wife only. In the event of wife pre-deceasing the husband or
simultaneous death of both husband and insured wife, no
Compensation shall arise under this extension.
Definition / Explanation
52

Permanent Total Disablement means such disablement of a
permanent nature as incapacitates an insured for all work, which she
was capable of performing at the time of the accident resulting in
such disablement.
Death or disability by accident caused by external, violent and
visible means would include Death and or Permanent total
Disablement arising out of or traceable to slipping and / or falling
from the mountainous terrain, biting by insects, snakes and / or
animals; drowning, washing away in floods, landslides, rock slides,
earthquake, cyclone and other convulsions of nature and / or
calamities, murder and terrorist activities.
In the case of woman it also includes Death and Permanent
Total Disablement caused by surgical operations such as
sterilisation, cesarean, hysterectomy, i.e. removal of uterus and
removal of breasts due to cancer operations, death at the time of
child birth provided that such deaths occur during the surgical
operation in hospital/nursing home or whilst being in the hospital /
nursing home after such surgery convalescence, however not beyond
a period of seven days from the date of surgical operations.
Extended Coverage
On payment of additional premium, the policy is extended to
cover the following:
53

Sr
.
Risk Covered Compensation
Payable
i. Temporary total disablement arising out of an
accident defined here above and· resulting in
hospitalisation as an in patient resulting in
total disability to engage in any occupation or
work or employment
Rs.500/- per
month subject to
max. of
Rs.l,500/-
ii. Legal Divorce: Actual legal expenses
necessarily incurred for legal divorce
proceedings initiated during the currency of
the policy and incurred during the currency of
the policy or during renewal of the policy but
once in lifetime of the insured and provided
the expenses shall be reimbursed only on
obtaining divorce decree.
Actuals not
Exceeding
Rs.2,000/-
iii. Loss and or damage to household goods /
personal effects whilst contained in house /
dwelling arising out of fire, lightning, riots,
terrorism, storm, typhoon, flood, cyclone and
earthquake.
Rs. 2,000/-
The exclusions and policy conditions are more or less the
same as under individual personal accident policy. However there is
a special condition, which provides that if a similar policy is taken
with one or more insurers, the maximum liability of insurers is
limited to a sum of Rs. 25,000/- only.
Premium
54

• Basic cover - Rs.15/- per woman per year.
• Basic cover with extended cover - Rs.23/- per woman per year.
Group Discount
This discount is allowed on the basis of number of persons
covered under the policy.
Long Term Discounts
Term Of The Policy
(Years)
Discount
(%)
1
2
3
4
5
Nil
5
10
15
20
Proposal Form
The form elicits details such as name, address, age,
occupation, name and age of husband, if married, nomination etc.
The form includes a declaration that the answers are true and the
proposer does not suffer from any disablement or incapacity.
Bhagyashree Child Welfare Policy
This scheme is applicable to girl children in the age group 0 to
18 years, whose parents' age does not exceed 60 years. The scheme
55

is intended to provide insurance cover to ONE girl child in a family
who loses either the father or the mother due to accidental death.
Coverage
The Insurance cover would be available on 24 hour risk basis.
In case of death of either or both parents resulting solely and directly
from Accident caused by outward, violent and visible means, and if
such accident shall within 6 calendar months (unless otherwise
specified) of is occurrence lead to death then the company shall
deposit a sum of Rs.25,000/- in the name of the gir1 child mentioned
in the schedule of the policy with a financial institution named in the
schedule.
The financial institution shall make following disbursements
from Corpus created out of the deposit amount for the benefit of the
girl child to the living parent or to the nominated guardian or the girl
child as the case may be, in the following manner.
Age of the
Girl
Child
Amount of
Compensation
Payable to
1 – 5 years Rs. 1,200 P.A Surviving parent or guardian
for looking after the needs of
56

the child.
6 – 11
years
Rs. 1,200 P.A Surviving parent or guardian
provided the girl child is
admitted in a school and
expenditure is incurred on her
education.
12 – 17
years
Rs. 2,400 P.A Surviving parent or guardian
provided the girl child is
admitted in a school and
expenditure is incurred on her
education.
18 years Balance amount to
the credit of the girl
child
To the girl child.
In case of discontinuation of studies by the child the
scholarship will not be paid but on completion of 18 years balance
amount to her credit will be paid as a lump sum.
In case of death of the girl child before attaining the age of 18
years balance amount standing to the credit of the girl child would
be paid to the surviving parent or guardian.
The definition / explanation of death by accident, exclusions,
policy conditions are more or less the same as under Raj Rageshwari
Mahila Kalyan Yojana.
Premium
57

The premium is Rs.15/- per girl child Per Year. Group
discount is provided as follows:
No. Of Persons Discount (in %)
250 - 1,000
1,001 - 10,000
10,001 - 1 LAC
ABOVE 1 LAC - 2.5 LACS
ABOVE 2.5 LACS - 5 LACS
ABOVE 5 LACS - 10 LACS
ABOVE 10 LACS
5
10
15
30
35
40
45
Proposal Form
The form elicits details of name, date of birth and address of
the girl child to be insured and the parents and name and address of
the nominated guardian, etc.
Claims Procedure
A uniform claims procedure has been prescribed.
According to this procedure the functions of the policy issuing office
are to:
(a) Process claims and send intimation of approval of claim to the
insured girl / surviving parent/ guardian.
(b) Submit monthly summary statement of all claims approved with
supporting documents along with a consolidated amount for all
58

claims @ Rs.25, 000/- per claim, to the GIC Asset Management
Co. Ltd.
(c) Enrol the insured girl child as a member of the GIC Bhagyashree
Child Welfare Plan, which managed by the GICAMC on behalf
of GIC Mutual Fund.
(d) Confirm schooling details of the insured girl child and make
disbursements to the concerned party on receipt of periodic
payments from ‘GICAMC’
(e) Monitor each claim account and advice GICAMC of changes, if
any.
The functions of the GICAMC are to ensure that, within 30
days of the receipt of the monthly summary statement, that
membership advice is mailed to the beneficiary and to the policy
issuing office and to issue payment warrants to the policy issuing
office.
Conclusion
59

Introduction personal accident insurance

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