Personal Accident Insurance

We all in our day-to-day life are exposed to risk of accidents. It is a known fact that despite all possible precautions accidents do occur. Accident may occur while walking, driving or even in the house due to fall from stairs or in the bathroom etc. This may result into disablement or loss of limbs or sometimes-even death. Knowing the fact one’s endeavor that he/she or his/her dependents get adequate compensation in the events of disablement or death.

To cater the need the general insurance industry has devised an insurance cover known as the Personal Accident insurance. The policy covers the risks of accidental death and/or disablement and the cover is worldwide. The policy provides compensation in the event of insured sustaining injuries, solely and directly from an accident caused by violence, visible and permanent total disablement, permanent partial disablement or temporary total disablement. 

Risks under Personal Accident can be classified as under:

1. Normal Risk

Accountants, Doctors, Lawyers, Architects, Consulting Engineers, Teachers, Bankers, Persons engaged in Administrative, Secretarial and managerial functions, Shopkeepers, Shop Assistants not using machinery, Commercial travelers and persons engaged in occupations of similar hazards

2.  Heavy Risks

Persons working in underground mines, explosives, workers involved in electrical installation with high intensity power supply. Jockeys, Circus personnel, Persons engaged in activities like racing on wheels or horsebacks, mountaineering, winter sports, Skiing, ice hockey etc persons engaged in occupations of similar hazards.

Being insured against death is not sufficient: a disability caused by accidents sometimes doesn’t allow you to work. Even if the disability is temporary, you still need a cover to meet financial obligation during hospitalization. It is here that personal accident policies come in handy.

These accident policies provide cover for groups too. In case of group accidental policies, the insurer gives marginal discounts on premiums.

Scope of the cover

Permanent total disability: Defined as permanent loss of use of any two limbs, or permanent and complete loss of sight in both eyes or injuries that render the insured incapable of earning an income from the date of the accident onwards from any work, occupation or profession (commensurate with his educational qualifications, training and experience).

Permanent partial disability: Defined as permanent loss of any body part, one eye, one limb or one finger or a toe or injuries that render the insured incapable of earning an income. While the loss may be permanent, its effects on the insured and on his life are partial.

Temporary total disability: Defined as temporary loss in any form that may render a person immobile or affect his earning capacity from the time of the accident. In other words, a fracture in the arm or leg that keeps you from work qualifies: you may be mobile but the injury may not support your ability to work.

Permanent Partial Disablement: 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 stated in the schedule
Total and irrecoverable loss of use of a hand or a foot without physical separation, fifty percent (50%) of the Capital Sum Insured cited in the Schedule
‘Physical Separation’ means amputation at or above the wrist and/that of the foot at or above the ankle respectively.

Permanent Total Disablement: At any time during the currency of the policy, the insured sustains any bodily injury resulting solely and directly from accident caused by external violent and visible means. 

1. If such injury, within 12 months of its occurrence, be the sole and direct cause of the death of the insured, the capital sum insured as stated in the schedule.
2. If such injury within 12 months of its occurrence be the sole and direct cause of the total and irrecoverable loss of:

• Sight in either eyes or actual loss by physical separation of both hands or feet or one entire hand and one entire foot, loss of sight in one eye and loss of one entire foot or one entire hand-the capital sum insured, stated in the schedule of the policy.
• Loss of both hands or feet or one hand and one foot, or of loss of sight in one eye and loss of use of one hand or one foot, the capital sum insured stated in the schedule of the policy.

    3.   If such injury within 12 months of its occurrence be the sole and direct cause of the total and irrecoverable loss of:

• Sight in one eye or actual loss by physical separation of one entire hand or one entire foot- 50% of the capital sum insured stated in the schedule of the policy.
• Total and irrecoverable loss of use of a hand or a foot without physical separation - 50 per cent of the capital sum insured.

    4.   If such injury shall as a direct consequence permanently, totally and absolutely disable the insured from engaging in any employment or occupation of any description whatsoever- lumpsum equal to 100% of the capital sum insured. 

    5.   If such injury shall within 12 months of its occurrence be the sole and direct cause of the total and irrecoverable loss of use of or the actual loss by physical separation of the following, then the percentage of the capital sum insured as indicated below, shall be payable. This benefit is called permanent partial disablement benefit.    

     6 . If such injury shall be the sole and direct cause of temporary total disablement, then so long as the insured shall be totally disabled from engaging in any employment or occupation of any description whatsoever- a sum at the rate of one per cent of capital sum insured per week but not exceeding Rs 3,000/- per week. This benefit is known as temporary total disablement benefit.

Compensation payable under sub-clause (f) shall not be payable for more than 100 weeks in respect to a person’s injury calculated from the date of commencement of disablement and shall not exceed the capital sum insured.

Payment under this sub-clause (f) shall not be made until the total amount of compensation is ascertained and agreed upon.

Note: If any such injury as mentioned above shall result in the inability to remain gainfully employed, then the Capital Sum Insured payable will be 100%.

Terrorism and Acts of Terrorism

 In case of the death of the insured arising out of terrorism or acts of terrorism within the policy period, the nominee (mentioned in the policy) is compensated with the sum Insured. The Company shall also pay compensation against permanent and total loss of limbs, sight etc. (of the insured) arising out of terrorism or acts of terrorism.

Exclusions:

There is some exclusion in the Personal Accident Policy:

• Intentional self-injury, suicide or attempted suicide, general disease or instantly.
• The Insured being under the influence of intoxicating liquor or drugs.
• Death or disablement resulting from pregnancy or child birth (in case of female insured)
• The insured committing any breach of law with criminal intent.
• Engaging in aviation activities other than traveling as bonafide passengers (in a duly licensed standard type of aircraft) any where in the world.
• War and Allied risks.
• Nuclear Perils.
• Service on duty with any armed forces.

Pregnancy Exclusion Clause

Insurance under this policy shall not extend to cover death or disablement resulting directly or indirectly caused by, contributed to/or aggravated or prolonged by child birth or pregnancy or any consequence thereof. Insurers broadly put disability into three categories.

Territorial Limits

The cover provided under Personal Accident Policy is worldwide. However the claims are payable only in Indian Rupees (If the policy is taken in India)

What should the Insured age be?

Normally the cover is restricted to persons between the age of 5 to 70 years for both male and female. Cover beyond these age limits can be had at higher rates of premium as under.

Renewal of the policy above 70years of age but up to 80years is subject to loading of 5%on the premium. Fresh proposal above 70years but below 80years is subject to a loading of 10% on the premium. No medical examination is to be insisted for a and b.

Extensions of the policy:

 1.   Medical Benefits Extension

A policy can be extended on payment of extra premium to cover medical expenses incurred by the insured in connection with injury, provided the claim for the injury is admissible under the policy. The extension is available by loading the premium either by 10% or by 25% and the benefit available is reimbursement of Medical expenses

 2.   War and Allied Risks

War and allied risks are exceptions under the policy. But in respect of Indian personnel/Experts working in foreign countries on Civilian duties ‘this exception may be deleted on payment of additional premium.

 3.   Special Additional Benefits

Effective from April 10, 1989, a new clause called Children’s’ Education Fund has been incorporated under the PA policy. Under this clause:

• If the insured person has one dependent child below the age of 23 years, an amount equal to 10% of the CSI subject to a maximum of Rs 5,000.
• If the insured person has more than one dependent child below the age of 23 years, an amount equal to 10 per cent of the CSI subject to a maximum of Rs l0,000.