Accident Trauma Care


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Accident Trauma Care

  1. 1. Presentation On Accident Trauma Care
  2. 2. Accident Means <ul><li>Not only Road/Rail or Travel accidents but also includes </li></ul><ul><li>Accidental Fall </li></ul><ul><li>Electric Shock </li></ul><ul><li>Snake Bite </li></ul><ul><li>Drowning in Water </li></ul><ul><li>Any thing other than Natural Death or Death due to Disease. </li></ul>
  3. 3. Family <ul><li>Family shall mean </li></ul><ul><li>Insured Person </li></ul><ul><li>Spouse </li></ul><ul><li>Dependent Children upto 18 years of age </li></ul><ul><li>Dependent Parents. </li></ul>
  4. 4. Age Limits <ul><li>Available for Persons aged between 18 years and 70 years. </li></ul><ul><li>Children from 3 years can be covered under family package when atleast any one of the parents are covered. </li></ul>
  5. 5. <ul><li>Section I </li></ul>
  6. 6. Covers <ul><li>Accidental Death </li></ul><ul><li>Permanent Total Disablement </li></ul><ul><li>The coverage is applicable only in respect of loss occurring within India. </li></ul>
  7. 7. Accidental Death <ul><li>Covers Death of the Insured Person </li></ul><ul><li>Death occurring within 12 Months from the date of Accident </li></ul><ul><li>Compensation payable is 100% of Capital Sum Insured </li></ul>
  8. 8. Permanent Total Disablement <ul><li>Disablement cover </li></ul><ul><li>The disablement should occur within 12 Calendar months from the date of the Accident </li></ul><ul><li>The disablement is confirmed and claimed for, prior to the expiry of a period of 60 days since occurrence of the disablement </li></ul>
  9. 9. <ul><li>Section II </li></ul>
  10. 10. Covers <ul><li>Covers hospitalisation expenses incurred for grevious injury following an accident, other than work-place accidents and incurred as inpatient for treatment in any nursing home / hospital in India. </li></ul>
  11. 11. Add On Covers <ul><li>Work-place accidents </li></ul>
  12. 12. Allowable Expenses <ul><li>Room, Boarding Expenses as provided by the Hospital / Nursing Home not exceeding 2% of the Sum Insured </li></ul><ul><li>Nursing expenses </li></ul><ul><li>Surgeon, Anaesthetist, Medical Practitioner, Consultants, Specialist Fees </li></ul><ul><li>Anaesthesia, Blood, Oxygen, Operation Theatre charges, Surgical Appliances, Medicines and Drugs, Diagnostic Materials and X-ray, diagnostic imaging modalities, cost of Pacemaker and similar expenses </li></ul>
  13. 13. <ul><li>Common features to Section I and II </li></ul>
  14. 14. Risk Groups that can be covered Risk Group I Persons engaged primarily in administrative functions Risk Group II Persons engaged in manual work other than what is specifically provided under Group III Note: Risk Group III cannot be covered under this policy.
  15. 15. Sum Insured <ul><li>Section I : </li></ul><ul><li>Sum Insured in Multiples of Rs. 5,000/- upto a maximum of Rs. 1,00,000/-. </li></ul><ul><li>Section II* : </li></ul><ul><li>Sum Insured in Multiples of Rs. 5,000/- upto a maximum of Rs. 1,00,000/-. </li></ul><ul><li>* Sum Insured under Section II can be equal to or less than Sum Insured under Section I. </li></ul>
  16. 16. Premium Rating Note: Rate provided is “Per Mille” i.e., Per Thousand Minimum Premium: Rs. 100/- Section Coverage Rate I PA Re. 1 per mille II (a) Basic cover i.e., Hospitalisation for Grevious Injuries Rs. 2 per mille II (b) Additional coverage for workplace accidents Re. 1 per mille
  17. 17. Group Discount Group Discount Applicable to Accident Trauma Care (Group) Policies Number of persons Discount on the final premium 101-1000 5% 1001-10000 7.5% 10001-50000 10% 50001-100000 12.5% 100001- 200000 15% 200001-500000 20% 500001-1000000 25% Above 1000000 30%
  18. 18. Major Exclusions <ul><li>Any Claim, </li></ul><ul><li>In Respect of Pre Existing Conditions. </li></ul><ul><li>If the Insured acts against the advice of the Physician. </li></ul><ul><li>Whilst under the influence of intoxicating liquor or drugs. </li></ul><ul><li>Arising out of mental diseases, suicide or attempted suicide, self inflicted injuries or sexually transmitted conditions, anxiety, etc. </li></ul><ul><li>Due to participation in hazardous sport / activities. </li></ul><ul><li>By persons who are physically and mentally challenged unless specifically agreed and endorsed in the policy. </li></ul><ul><li>Cost of spectacles, contact lens, hearing aids, walkers, crutches, wheel chairs, artificial limbs and such other aids. </li></ul><ul><li>Note: For a detailed list kindly refer the policy conditions. </li></ul>
  19. 19. Claims Procedure - Accident Claims <ul><li>Document to be submitted in case of Death Claims </li></ul><ul><li>Completed Claim form </li></ul><ul><li>Death certificate, Panchanama </li></ul><ul><li>FIR, wherever applicable </li></ul><ul><li>Postmortem report </li></ul><ul><li>In the absence of assignment, Legal Heir ship Certificate/Succession Certificate / Will duly probated </li></ul><ul><li>Original Policy, if issued for Individual </li></ul><ul><li>Coroner’s Report/Police Inquest Report </li></ul>
  20. 20. Claims Procedure - Accident Claims (Contd.) <ul><li>Document to be submitted in case of Disablement Claims </li></ul><ul><li>Original Policy </li></ul><ul><li>Disability Certificate from the attending Doctor confirming the %age of disability. </li></ul><ul><li>Photo of the person indicating the disability. </li></ul><ul><li>Completed claim form </li></ul><ul><li>FIR, Wherever applicable </li></ul>
  21. 21. <ul><li>Immediate intimation to the Call Centre (1800 425 2255) </li></ul><ul><li>Claim form will be sent to the Insured. </li></ul><ul><li>Based on the intimation a field visit will be done by the Star Doctor </li></ul><ul><li>Bills has to be settled by the Insured and will be reimbursed by Star on submitting the following documents </li></ul><ul><li>Original Discharge Summary </li></ul><ul><li>Main Hospital Bill with Break Up </li></ul><ul><li>Investigation Reports with X-Ray Film </li></ul><ul><li>Medical Bills with Prescriptions </li></ul><ul><li>Cashless facility will be provided on a case to case basis if treatment is taken in a Network Hospital. </li></ul>Claim Procedure – Medical Claims
  22. 22. Thank You