Page 269 - IC38 GENERAL INSURANCE

F. Claims management – personal accident

1. Personal accident

Definition

Personal accident is a benefit policy and covers accidental death, accidental
disability (permanent / partial), Temporary total disability and may also have
add-on coverage of accidental medical expenses, funeral expenses, educational
expenses etc. depending on particular product.

The peril covered under the PA policy is “Accident”.

Definition

Accident is defined as anything sudden, unforeseen, unintentional, external,
violent and by visible means.

Claims manager should mark caution and check following areas on receipt of the
notification of the claim:

a) Person in respect of whom the claim is made is covered under the policy

b) Policy is valid as on date of loss and premium is received

c) Loss is within the policy period

d) Loss has arisen out of “Accident” and not sickness

e) Check for any fraud triggers and assign investigation if need be

f) Register the claim and create reserve for the same

g) Maintain the turnaround time (claim servicing time) and keep the
customer informed of the development of the claim.

2. Claims investigation

If any red alert is noticed in the claim intimation or on receipt of the claim
documents, claim may be assigned to a professional investigator for verification
simultaneously.

Example

Examples of red alerts for personal accident claims (for purpose of further
investigation, but does not indicate positive indication of fraud or claim being
fraudulent):

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