miscellaneous insurance

Personal Accident Insurance

 Common Exclusions :
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• Disablement arising from:

• i. Self injury or suicide;
• ii. Accident while under influence of alcohol or
drugs;
• iii. War and allied perils
• iv. Whilst committing any breach of law with
criminal intent

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 Sum insured
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• The liability of the insurer is to pay the capital sum

insured. The sum insured is selected by the insured but
insurers exercise some control by comparing the sum
insured with the average monthly income of the
insured.
• The sum insured offered by a company can be a
fixed amount or the basis of insured’s income.
• In personal accident insurance the main factor used
for fixation of premium is occupation as the risks
associated with profession or occupation vary
according to the nature of work performed

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miscellaneous insurance Occupations are classified into 3 groups

• Risk Group 1 : Accountants, Doctors,

Architects, Engineers, Teachers, Bankers etc
• Risk Group 2 : Builders, Contractors,
Veterinary Doctors, Paid drivers of motor
cars etc
• Risk Group 3 : Persons engaged in manual
labour, Cash carrying employees, Garage and
Motor Mecahnics, Drivers of truck and
lorries, Professional Sports men etc

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 Personal Accident Policies
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• Personal Accident are issued

Policies as
benefit policies
indemnity policies.which
Since Personal accident
distinct
Insuranceare
is a benefit plan and from
hence do not
attract contribution.
• Thus, if a person has more than one
policy with different insurer, in the
event of accidental death, PTD, PPD,
claims would be paid under all the policies.

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 Subrogation does not apply to
personal accident policy
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• The weekly compensation payable as

temporary total disablement benefit is
limited to a predetermined amount per
week overall irrespective of the total sum
insured.
• Although the insured can have more than
one policy, insurers place restrictions on
additional insurance to prevent over
insurance. Subrogation like contribution
does not apply to personal accident policy.
 Company’s total liability is restricted
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• If an accident causes a Temporary Total

Disablement (TTD) as well as a Permanent
Partial Disablement (PPD), the insurer will pay for
the higher of the two benefits and not for both.
Even if payment of compensation is possible
under more than one claim involving different
accidents under the same policy, the company’s
total liability is restricted to the sum insured.

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 In case of any event leading to a claim
under the policy
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• The insurer should be informed

immediately with a written notice along
with the claim form relevant to the nature of
loss needs to be submitted to the insurer.
• In case 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.

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 Documents required For Accidental
Death Claims
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• Claim Form
• Police FIR or Police Panchnama
• Post-mortem Report or Coroner’s
Report
For payment
• Death Certificate to beneficiary – succession
certificate or notarized affidavit certifying
legal heir status
• Where payment to beneficiary is
notarized affidavit, a through
adequate stamp paper letter of indemnity on
 Documents required For Accidental
Injury Claims
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• Claim form
• Police FIR, if accident is reported to Police
• Medical papers, pathology reports, X-ray
reports, as applicable
• For Permanent Disability Claims – disability
certificate from reputed surgeon or
Municipal Hospital
• For Temporary Total Disability Claims-sick
leave
certificate from Employer
• Attending Physician’s statement.
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 Pradhan Mantri Suraksha Bima Yojana
(for Accidental Death and Disability)
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• 1. All savings bank account holders in the age

18 to 70 years in participating banks will be
entitled to join. In case of multiple saving bank
accounts held by an individual in one or
different banks, the person would be eligible to
join the scheme through one savings bank
account only.
• 2. The cover shall be for the one year
period stretching from 1st June to 31st May.
• 4. Premium: Rs.12/- per annum per member.
• 5. Participating Bank will be the Master
policy 11
holder on behalf of the participating subscribers
miscellaneous insurance Benefits
Table of Benefits Sum Insured

a Death Rs. 2 Lakh

b Total and irrecoverable loss of both Rs. 2 Lakh
eyes or loss of use of both hands or
feet or loss of sight of one eye and
loss of use of hand or foot

c Total and irrecoverable loss of sight Rs. 1 Lakh

of one eye or loss of use of one hand
or foot

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 Termination of cover on any of the following events
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1) On attaining age 70 years (age nearest birth day).

2) Closure of account with the Bank or insufficiency of balance to keep the
insurance in force.
3) In case a member is covered through more than one account and
premium is received by the Insurance Company inadvertently, insurance
cover will be restricted to one only and the premium shall be liable to be
forfeited.
4) If the insurance cover is ceased due to any technical reasons such as
insufficient balance on due date or due to any administrative issues, the
same can be reinstated on receipt of full annual premium, subject to
conditions that may be laid down. During this period, the risk cover will be
suspended and reinstatement of risk cover will be at the sole discretion of
Insurance Company.
5) Participating banks will deduct the premium amount in the same month
when the auto debit option is given, preferably in May of every year, and
remit the amount due to the Insurance Company in that month itself
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 Miscellaneous features i) Family Package Cover
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• (i) For children the cover is limited to Death and

• Permanent Disablement (total or partial)
• (ii) Premium payable for husband and wife will be on the
• total sum insured for husband and wife.
• (iii) A discount of 5% is granted on the gross premium.
 ii) Extensions
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• A personal accident policy can be extended by

endorsement, on payment of extra premium to cover
medical expenses incurred by the insured in connection
with the accidental bodily injury, subject to specified limits.
 CLAIM PROCEDURE
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a) Intimation: Immediately the intimation to be sent to the insurance company

in writing mentioning the nature of loss and the policy number.
b) Claim form: The claim form is designed to elicit information, among other
things, on the following :
Personal details such as age, occupation, etc.
Details of accident, nature of injuries, etc.
Name and address of the attending doctor.
Medical certificate of the attending doctor (sometimes this is issued as a
separate form).
Details of other insurances to apply contribution, if applicable and to check
whether they had been disclosed in the proposal form.
miscellaneous insurance

• 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)
 Disablement claims the documents
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• For disablement claims the documents, inter-alia, required

are Medical Certificate, diagnostic reports etc.
• Prescription, bills and receipts.
• Leave of absence certificate from the employer.
• Medical fitness certificate.
 GROUP PERSONAL ACCIDENT POLICY
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• In the above paras we have studied about eh individual personal

• accident insurance policy but the said policy can be issued
• where there is some common relationship among the persons
• to be insured and a central point for the administration of the
• insurance scheme. Accordingly, these policies can be granted
• only to groups clearly following under any one of the following
• categories:
 GROUP POLICIES GRANTED TO
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Employer - employee relationship including dependants 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.
miscellaneous insurance Salient Features of Group Policy

The coverage is the same as under individual P.A. policy except that
a. cumulative bonus and education grant do not apply.
However, medical expenses and war risks extensions are available.
b. The sum insured is fixed separately for each insured person.
c. Rates of premium applicable to named employees as per the
classification of risks. Where it is not possible to obtain details of
occupation for each insured person, insurers use their discretion in
applying the rates.
miscellaneous insurance

• If P.A. cover is required only for the restricted hours of duty (and not for all
the 24 hours of the day), a reduced premium equivalent to 75% of the
appropriate premium is charged. The cover applies to accident to employees
• arising out of and in the course of employment only. If cover is required only
for the restricted hours, when the employee is not at work and / or not on
official duty, the reduced premium of 50% of the appropriate premium is
charged.
• e. It is possible to exclude the Death benefit, subject to following conditions;
• (i) A group life policy covering Death benefit for the same group of persons is
in existence.
• (ii) Group P.A. Policy covers a group of 100 persons or more
 1. Special feature of normal PA policy
miscellaneous insurance

• a. Cover is for office hours & on a world wide basis

• b. Cover is for 24 hours & within India only
• c. Cover is for office hours & within India only
• d. Cover is for 24 hours & on a world wide basis
 2. Which of the following contingencies is not’ covered
under personal accident policy?
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a. Permanent total disablement

b. Temporary total disablement
c. Permanent partial disablement
d. Temporary partial disablement
 3. Under Personal Accident Policy, weekly benefits are
paid subject to a maximum period of
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a. 100 b. 52
c. 104 d. 75
 4. Which of the following Statements are true?
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Statement A: Once a claim for permanent total

disablement is paid, the personal accident policy becomes
inoperative.
Statement B: Weekly compensation is paid only when
the total amount is arrived at and agreed
a. Both Statements
b. Neither of the Statements
c. Only Statement A
d. Only Statement B
 5. Claim under P.A. policy cover is not payable if the
death is occasion by
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a. Murder b. Drowning
c. Snake bite d. Suicide
 6. The Principle of Contribution does not apply to the
following policy
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a. Standard Fire Policy b. Machinery Breakdown

c. Personal Accident d. Burglary Policy
 7. On duty PA policy covers
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a. Accident in course of employment

b. Accident while coming to workplace
c. Accident while returning to house from workplace
d. Accident occurring during holidaying
 8. A owner of two wheeler is covered under motor package
policy. He has a separate PA cover also. A dies in a accident
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a. Death Claim to the legal heir in a PA policy only is payable

b. Death claim in the PA cover in the two-wheeler policy only
is payable
c. Both the claims under both the policies are payable
d. Claim under none of the policy is payable
 9. Which of the following differentiates GPA policy from
individual PA POLICY?
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a. Death b. Disablement
c. Medical expenses d. Cumulative bonus
 10. Which of the following benefits can be granted only
on payment of extra premium under PA POLICY?
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a. Medical expenses
b. Loss of limb
c. Carriage of dead body
d. Education fund
 ANSWER TO OBJECTIVE TYPE QUESTIONS
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1. d 2. d 3.c 4. a
5. d 6. c 7. a 8. c
9. d 10. a