Coverage Of Personal Accident Insurance Scheme And Exclusions Of Claim
Coverage Of Personal Accident Insurance Scheme And Exclusions Of Claim.Personal accident insurance gives the policy holder coverage in cases of an accident giving rise to bodily injury, permanent disability or death. These plans make it easier for the insured and their families to be compensated during some unforseen accidents so that the costs are cut down. In this article, we shall look at the kind of coverage extended by personal accident insurance schemes especially the limitations that policyholders should lookout for.
1. Here, we’ll discuss what PAI is and how it may benefit you or your employees.
Personal accident insurance policy is a form of an insurance policy which is majorly linked to offering insurance protection to individuals in case they suffer from accidental bodily injury, disablement or even death. Personal accident insurance differs from health insurance since it covers accidents while health insurance covers treatments of illnesses. The following are some advantages provided by these policies; cash benefits, payment for hospital bills and even income compensation for those involved in an accident and need to recuperate.
This type of insurance is very useful for persons who seem to be exposed to a greater risk of accidents for different reasons including occupation or travel.
2. Key Advantage and Exposures under PAI
Personal accident insurance policies have a long list of perks based on the type of coverage that is being considered and purchased. The coverage typically includes the following:The coverage typically includes the following:
**Accidental Death Coverage**
In the unfortunate kitty that an insured event shall lead to causality’s death, the policy pays a lump sum to the nominee or beneficiary. The amount is often the total of the sum insured under the policy and assists the insured’s family in dealing with financial implications of the loss of income brought about by the mishap.
**Permanent Total Disability Coverage**
For a permanent total disability, where the injured is unable to perform any work due to human loss such as both hands, legs or eye sight, there is payment of the sum insured. This makes sure that the policy holder is provided with monitory assistance during the time of healing and in turn be able to meet basic needs without working.
**Permanent Partial Disability Coverage**
It is possible for a person to sustain irrecoverable injuries that only partially incapacitate a person; for instance, losing an arm or eye sight. In such situations the insurance company pays an amount that can be considered as corresponding to the level of disability. For instance, if a person loses one arm, he or she will receive a proportion of the sum insured with no chance to receive the full amount.
**Temporary Total Disability Coverage**
If the insured suffer from temporary total disability that results from an accident, the insurance will provide for weekly compensation where the person cannot work for a certain period. This is a proportion of the insurers’ income and is expected to help the insured during treatment period.
**Medical Expense Reimbursement**
Certain types of personal accident insurance policies provide the cost of medical treatment as one of the coverages for the accident. Hospital costs, surgical bills, costs of various tests and examinations as well as cost of drugs may fall under this category. Though, the amount of reimbursement for medical expenses depends on the policy and is not available in all the plans.
**Hospital Daily Allowance**
Some polices have provisions of a hospital daily allowance which is a prepaid limit of per day spending while admitted in a hospital for accident. This allowance can be used to cater for minor expenses such as fares, meals or other expenses incurred during the time when the patient is hospitalized.
**Ambulance Charges**
Ambulance charge is one of the costs that is normally covered in personal accident insurance thus making sure that people are transported to the hospital in the event of an emergency.
**Education Fund for Children**
Where the policyholder dies by an accident or totally disabled, some of the personal accident policies include an education fund for his children. This helps in making sure that the children’s education will not be affected or delayed any time due to lack of funds.
Coverage Of Personal Accident Insurance Scheme And Exclusions Of Claim
3. Exclusions in Personal Accident Insurance
Some general exemptions of personal accident insurance policy are as follows which policy holders should note: These are essential understand because they might lead to claim rejection and the policyholder has to understand what the policy doesn’t cover.
**Self-inflicted Injuries**
The personal accident insurance does not cater for any conceptual compensation for any disability resulting from self-harm, suicide attempts among others. It is intended that the policy be used for situations that are accidental and do not involve the people’s deliberate act.
**Participation in Hazardous Activities**
If the insured sustains further injuries while engaging in dangerous occupations like sky diving, bungee jumping, car racing and similar line of activities, the insurance company may reject the same. It is also worth noting that while some companies integrate the possibility to extend coverage of certain risky activities, the price will be more expensive.
**Injuries Under the Influence of Alcohol or Drugs**
Criminals who fight their case based on an accident while under the influence of alcohol or drugs normally have their claims rejected. That is why such actions are qualified by the insurers as reckless behaviour and the claims related to such actions are usually denied.
**Pregnancy and Childbirth**
Pregnancy or childbirth or any sickness or medical expenses in connection therewith, or even accidents during the confinement period and any illness or accident arising therefrom is also excluded from personal accident insurance. This is usuallyีช OVER AND ABOVE the normal health insurance policies but not included in.
**Mental or Nervous Disorders**
Pre-existing mental or nervous disorders in this context include but are not limited to depression, anxiety, stress, amongst others, these pre-existing conditions which are a result of mental or nervous disorder are not covered in personal accident insurance.
**War and Terrorism**
Personal accident insurance usually does not cover losses arising from war, invasion, civil commotion or terrorism, accidents or injuries resulting in death. This is because such situations entails risk that are usually beyond the normal accident cover that is accorded to an individual.
**Pre-existing Disabilities**
In case the insured person has been suffering from a disability at the time of purchasing this policy, any injury that worsens his or her condition is not an aspect covered under the policy. For instance, suppose a person has a partial disability before he or she sustains another injury in the same part of the body; the insurer will not compensate for the medical expenses or pay for it.
**Engaging in Criminal Activities**
Any mishap or loss that takes place when the life of the insured involves in unlawful or unlawful acts like robbery or violence is deemed to be non compensated. It is a norm, that the insurance does not bear liability for the compensation of the damages that stem from the unlawful conduct.
**Injuries Due to Nuclear Radiation**
Nuclear risks; Nuclear radiation, radioactive contamination and mishaps, including injuries resulting from such exposure are not covered. These are regarded as the exceptional risks that are not in the realm of the normal accidental risk insurance policies.
**Cosmetic and Plastic Surgery**
Treatments that are cosmetically or plastically related are not allowable with the exception of those that are accidental. If the surgery is an optional one and not essential after the accident the insurer will not pay for it.
4. The following is the step by step of how Personal Accident Insurance claim process would look like:
It is rather easy to file a claim under an insurance scheme of personal accident scenario. The insured or their nominee must follow these steps to ensure a smooth claims process:The insured or their nominee must follow these steps to ensure a smooth claims process:
1. **Inform the Insurer Immediately:** If an insured has incurred an accident, the insured or his/her authorized person shall inform the insurer immediately. Typically, there’s a time limit (which is within 24-48 hours) when an incident is to be reported if one is interested in claiming it.
2. **Submit Necessary Documents:** The insured must also enclose important papers that are the claim form, medical reports if any, FIR if any (in case of accidental demise or grievous injury) and any other papers which the insurer may require. In particular, adequate special attention should be paid to the completeness and accuracy of all the necessary documents because it is essential not to have any difficulties during the claims settlement.
3. **Undergo Medical Examination (If Required):** Most insurance companies may wish to make a determination on whether a claimant is entitled to disability or otherwise the consequences of a particular disabling injury. For this evaluation, the insured has to spend time with the doctor appointed by the insurer.
4. **Claim Settlement:** Therefore, if the insurer has reviewed the claim and accepted it they will make the payment to the claimant as per the insurance policy. If the insured dies due to an accident, the payment goes to one who is nominated while for disability the payment goes to the insured.
5. Conclusion
Personal accident insurance is one of the most vital financial remedies against the risks that may be incurred in the course of an accident or injury. It offers the much-needed cash during such times of disasters so that the holder and his/her family can be well protected against the financial consequences of accidents.
But the same policy comes with its exclusions which if not well understood may lead to disagreements or denial of a certain claim. Some of the common categories of exclusions are accidents resulting from self-inflicted harm, engaging in illicit business, taking drugs and substances, engaging in risky activities among others.
In order to avoid some common pitfalls when purchasing a personal accident insurance policy, one needs to go through a policy document, research various plans and choose a policy that would suit the individual. In so doing, they can protect an aspect of their financial security and feel relieved in case of the occurrence of an accident.