1. The important aspect to be noted is that Miscellaneous Accident Insurance includes a number of covers, which are in the nature of package policies. In this situation specific guidelines applicable to respective sections are to be followed. Further, in Personal Insurance sentiment and emotions play a major role. These policies have been designed as user – friendly covers and a high degree of tact and skill of persuasion is vital in handling such claims.
1.1 The guidelines given accordingly recommend a broad framework to be judiciously utilized in day-to-day operations on merits.
1.2 There are certain special features to be considered in claims under different types of covers as under.
2. WORKMEN’S COMPENSATION INSURANCE:
2.1 In addition to claim form the scrutiny of following documents is required in all W/C claims :
a) Medical Certificate
b) Wages Statement
c) Proof of age – as recorded by the employer
2.2 Temporary Disablement Claims : requires payment of fortnightly compensation to the employee directly against proper receipt.
2.3 Permanent Total Disablement Claims : The memorandum of agreement required to be submitted to W/C Commissioner while depositing compensation as per W/C act.
2.4 Fatal Claims : Perusal of death certificate and post-mortem report is important before depositing the amount with W/C Commissioner along with Form ‘A’.
a) Often Contractor’s workmen or Sub-contractor’s workmen are involved in an accident. Whether wages for this were separately specified and whether premium was collected has to be verified.
b) The company is not liable for payment of fines and penalties imposed on Insured.
3. PERSONAL ACCIDENT INSURANCE:
3.1 Generally, the scrutiny of following documents is important whilst processing all P.A. claims
a) Duly completed claim form
b) Report of attending Doctor either as a separate document or on the reverse of claim form if provision is made thereof
c) Investigation reports like laboratory test, X-rays and reports essential for confirmation of the injury,
d) Police reports, wherever necessary
e) Certificate of proof of age of dependent child in case the claim is under education grant provision
f) Medical bill corresponding to doctors prescription where medical extension is granted.
Note : the Doctor, as a part of treatment, dreams Vitamins and tonics medicines ONLY if prescribed.
3.2 In case of fatal accident cases the following documents need to be scrutinized.
a) Death certificate
b) Post-mortem report }
c) Coroner’s report }
d) Inquest report } wherever necessary / applicable
a) The original documents may be returned only if duly attested Xerox copies are retained
b) Bills/ receipts are for company’s records.
c) In respect of fatal claims the payment is to be made to the assignee named under the policy. If there is no assignee the payment is made to the legal representative as identified by Will / Probate / Letter of Administration/ Succession Certificate. Where the above documents are not available and the amount of claim is upto Rs. 5,00,000/- the following procedure may be followed :-
(i) An affidavit from the claimant(s) that he/she (they) is (are) the legal heir(s) of the deceased
(ii) An affidavit from other near relatives of the deceased that they have no objection if the claim amount is paid to the claimant(s)
(iii) Surety bond executed by persons of reasonable standing
d) In case of group policy the payment is to be made to the individual beneficiary only. However, claim payment to the employer in respect of employee is permissible. Where provision is made for writing the name of the beneficiary and if Insured organisation wants payment to be made directly to such beneficiary joint discharge should be obtained.
e) If in a particular case Doctor certifies that the claimant has lost 30% use of one limb, in such case claimant would be entitled to 30% of the compensation payable had he lost use of one entire limb.
f) The policy is to be obtained for cancellation in case of claim involving death, permanent total disablement, loss of two limbs, one limb or one eye i.e. wherever capital sum insured becomes payable.
g) In case of permanent partial disability claim the policy should be obtained for endorsement for reducing the capital Sum Insured. The weekly benefit however, should be based on original C.S.I
h) For Temporary Total Disablement claims the overall physical condition is to be considered and not any single criterion.
i) Weekly compensation should not be paid unless the total claim amount is ascertained and agreed.
j) Claims for exaggerated amount or for claims of doubtful nature the finding of panel Physician or surgeon is obtained.
The following supporting documents are required for the purpose of scrutiny.
a) Hospitalization claims:
i) Duly completed claim form
ii) Bills, receipts and discharge certificate/ card from the hospital
iii) Cash memos from the hospital
iv) Bills from chemist(s) supported by proper prescription
v) Receipt and Pathological test reports from a Pathologist supported by the note from attending medical practitioner/ surgeon prescribing such pathological tests.
vi) Nature of operation performed and surgeon’s bill and receipt.
In case of mediclaim claims the receipts and bills need to be original but copies of treatment papers, diagnostic reports etc. have to be retained after verification with one original if the Insured wishes to keep the originals provided the originals
b) The following issues may be specially looked into:
(i) In case, previous medical history is not shown on discharge card/narrative summary of the hospital/admission papers of the hospital should be called for.
(ii) That admission to hospital is not for routine check up.
(iii) That figures and/or dates of purchase in the cash memos are not altered by way of erasure superimposition of writing or added writing with different ink.
(iv) That treatment taken is in line with nature of disease
c) Domiciliary Hospitalisation Claims:
In the case of domiciliary hospitalisation claims, compliance of the coverage as explained under definition 2.4 of the policy should be verified.
d) In the case of death of insured after having incurred medical expenses the amount of admissible claim should be reimbursed to legal representative of the deceased or any other insured family member submitting original bills, cash memos etc. after obtaining proper declaration by that person to the effect that the person claiming reimbursement of expenses actually incurred such expenses for the treatment of the insured person.
e) On Account payment in medi-claim policy
In exceptional circumstances where the treatment involves high expenses, on account payment may be considered if dealing office is satisfied about the admissibility of the claim.
f) Panel doctors
Only such claims where suspicions are aroused in relation to disease allegedly suffered, linked to pre-existing condition, and may be referred to the doctor for investigation. Reference to panel doctor/ referee for investigations should not be made as routine but selectively on merits.
5. OVERSEAS MEDICLAIM INSURANCE
Mercury international Assistance and Claims Ltd., London are claims settling agents for Overseas Mediclaim Insurance.
5.1 To avoid delay claim form is attached to the policy so that Indian citizens visiting any part of the World may write to claim settling agency directly.
5.2 In case any claimant has returned to India without submitting their claims to Mercury, they should be advised to lodge their claims directly to Mercury or ‘Tower’ in India.
5.3 Mercury should be informed of specific exclusions under the policy.
5.4 In case any premium cheque is dishonored information should be sent to Mercury immediately either by fax or e-mail.
6. BHAVISHYA AROGYA POLICY
6.1 The guidelines for mediclaim insurance will generally hold good for this type of insurance also. However the following aspects are important :
1) Pre-existing condition is not applicable
2) Pre and post hospitalization expenses are not payable
For any one illness the payment of claim is limited to 40% of original Sum Insured. The settlement of any claim will reduce the limit available.
7. HORSE INSURANCE
The following supporting documents are required for processing of claims
i) Duly completed claim form
ii) Veterinary certificate
iii) Valuation of the animal
iv) Post mortem report
v) Pathological tests involving tissue sample
vi) Treatment chart
7.1 On intimation of any accident or illness, which is likely to result in a claim, deployment of veterinary doctor should be considered.
7.2 If animal is killed, whether circumstances necessitated such killing is to be verified.
7.3 Mercy killing is considered subject to advance notice
If death is due to operation whether company’s approval was obtained and additional premium was charged.
8. ALL RISK INSURANCE
Claims may be settled on the basis of completed claim form, if settling authority is satisfied about genuineness of the claim. Surveyor/investigator may be appointed only if considered necessary.
9. THEFT CLAIM
In case of personal effects the invoice/ bill should not be insisted upon but market value should be the basis of claim settlement.
While final police report should be called for, where it is not forthcoming within a period of six months of the loss, the claim may be settled on the basis of First investigation Report lodged provided other documents are in order. Indemnity bond is to be obtained before settlement.
10. BAGGAGE INSURANCE
The above provisions are applicable to claims under this class of insurance also.
11. BURGLARY INSURANCE
The following documents are considered important while processing claims
i) Duly completed claim form
ii) Final Investigation Report from the police
iii) Survey report
11.1 In case of small losses upto a specified amount the dealing office can arrange for settlement of claim on the basis of completed claim form, G D entry / First information report registered with the police provided they are satisfied about the genuineness of the claim.
11.2 It is preferable in cases of burglary / theft which involves assessment of losses involving checking books of accounts to appoint an investigator with surveyors license and knowledge of accounts.
11.3 Waiver of Final Investigation Report of the police can be considered at the discretion of the Competent Authority so long as the investigator cum surveyors’ report does not raise any doubt in regard to the cause and quantum of loss. Subrogation/ indemnity letter from the Insured is a must.
12. MONEY POLICY
The following documents are considered important while processing claims :
1) Duly completed claim form
2) Final Investigation Report from the police
3) Survey report
12.1 In case of losses reported from the premises, the procedure to be followed for settlement of claims is on similar lines as that of burglary policy.
12.2 However, if infidelity of the employee is involved, departmental proceedings and/or criminal action to be initiated against the erring employee wherever applicable and such reports to be obtained.
12.3 The limit per sending declared will be the maximum indemnity and average will not apply if the cash carried is more than the limit intimated.
12.4 Since the policy is on adjustment basis, the annual estimate of carrying does not have any bearing on the claim.
13. BANKER’S INDEMNITY INSURANCE
13.1 The following documents are considered important while processing claims :
i) Duly completed claim form
ii) First Information Report to the police
iii) Survey report
13.2 The Banker’s Indemnity cover being wide in nature legal opinion may be sought before settlement of any major and/or doubtful claim in nature.
13.3 Reinstatement of the sum insured : additional premium to be either collected or deducted from the claim amount.
13.4 Policy is subject to single reinstatement clause by which the company’s liability under the policy is restricted to double the sum insured shown in the policy schedule. Care has to be taken if there are number of claims under the same policy. Although, forgery of documents is covered under the policy, it is to be noted that this relates to the specified documents only issued by the bank and none-other. Policy does not cover claim-involving losses prior to retroactive date. In case of change in Insurer, fresh retroactive date is applied or effected.
14. JEWELLERS BLOCK INSURANCE
The following documents are considered important for processing claims :
i) Duly completed claim form
ii) First Information Report from police
iii) Survey report
14.1 Most of the losses reported under this class of business relate to hold-up, robbery, theft etc. and hence on receipt of intimation of loss, claim form may be obtained and also contents of First Information Report verified and a competent surveyor conversant with the trade deputed.
14.2 For recovery of insured property when it is in the custody of police or court authorities, attempt should be made to approach the concerned authorities by appointing a lawyer. This matter is required to be pursued with regular intervals particularly in view of nature of commodity involved.
14.3 Furthermore, claim settling authority may consider availing of services of expert valuer/ advocate/ surveyor of diamond and/ or jewellery while taking delivery of property.
15. FIDELITY GUARANTEE INSURANCE
Processing of claim shall be considered based on the completed claim form, survey report and/or investigator’s report and Final Investigation Report. It is necessary to verify with the employer whether any amount is due to the defaulting employee, which can be withheld by the employer and adjusted against the claim. However, final investigation report may be waived where the surveyor and/or investigator have not raised any doubt as to the cause and quantum of loss. Settlement of claim to be effected after obtaining letter of indemnity/ subrogation from the Insured. Where departmental inquiry by the employer has established guilt of the employee and assessment report is clean, settlement may be effected after suitable indemnity/ subrogation letter is received from the Insured without waiting for the outcome of any criminal action pending in any court of law.
16. SHOPKEEPER’S INSURANCE POLICY
This is a package policy providing various covers such as Fire, Burglary, Cash-in-transit. PA and/or liability. Depending on the section under which the claim is lodged the procedure for settlement of claims for that specified class of risk as given in the guidelines might be followed.
17. HOUSEHOLDER’S COMPREHENSIVE POLICY
17.1 The procedure for settlement of claims in respect in respect of each specified class of risk like Fire, Burglary, Cash-in transit etc. under the policy would be the same for that specified class of risk given in the guidelines.
17.2 Where claims under Personal insurance involving articles of daily use liable to depreciation are involved, it would be in order to accept the present day replacement value with reasonable depreciation for a period of use and it may be taken as a fair measure of indemnity subject to adequacy of the sum insured individually and collectively as the case may be. For such items, purchase vouchers/ cash memo need not be insisted upon.