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Workmen’s Compensation Insurance

Posted on: November 8th, 2019 by shiv No Comments

Purpose

Employer shall be liable before the Court of Law to pay compensation, in accordance with the provisions of Workmen Compensation Act, 1923, for personal injury or death or disease contracted specified therein as an occupational disease peculiar to that employment in Part A Schedule III of Workmen Compensation Act 1923, caused to a workman by accident arising out of and in the course of employment.

‘Personal injury’ under the Act means physiological injury. It may be external, or it can be internal also.

Workmen:

All employees working for the employer/ insured. In case of contract labour the liability of the principal is absolute though he may not be the actual employer. e.g For The Security Gaurds provided by a security agency, the liability under WC Act also falls on the Principal.

Wages:

For purpose of calculating any claim the monthly wage taken into account are the actual wages subject to maximum of Rs.4,000/. Wages includes all allowances and cost of perks.

Legal Liability may arise due to:

Breach of, any of the, statutory regulations provided for ensuring safety to workers inside the factory premises.
Negligence of co-employees.
Injury or Accidental Injury to workers while performing their duties

Policy covers is subject to

Workmen’s Compensation Act, 1923
Fatal Accidents Act, 1855
Any other Common Law

Employer is liable to pay compensation for:

Death
Permanent total disablement
Permanent partial disablement
Temporary disablement whether total or partial

The Employer need not pay compensation – in respect of any injury caused by an accident which is directly attributable to

The workman having been at the time under the influence of drink or drugs.
Or
Willful disobedience by the workman of orders and rules expressly given to secure the safety of the workmen
Or
Willful removal or disregard by the workman of any safety devices provided for the safety of workmen

In cases of death or permanent Total Disablement of a workman, the above defences are not available to Employer.

If any disease is prescribed in the Act as “Occupational Disease”, the illness is deemed to be an injury. If the Employer defends the Claim, such expenses are also payable.

Extension of cover

Policy may be extended to cover Medical expenses incurred by the employer by payment of additional premium as per Workmen Compensation policy.

The Company shall not be liable under the policy in respect of:

Any injury by accident or disease directly attributable to war invasion act of foreign enemy hostilities (whether war be declared or not) civil war, mutiny, insurrection, rebellion, revolution or military or usurped power.
Liability towards employees of the contractor.
Liability of the insured which attaches by virtue of an agreement but which would not have attached in the absence of such agreement.
Sum which the Insured would have been entitled to recover from any party but for an agreement between the Insured and such party.

When does a claim arise under WC ACT:

The Claim under WC Act arises in case of any injury (fatal & non-fatal) / decease arising out of and in course of his employment.

IN case of an accident invoking liability under WC ACT the employer/insured needs to take following steps:

Inform the incident to WC Commissioner in whose jurisdiction the accident occurs.
Inform Police of the incident.
Inform us of the accident.

Claims Procedure

For preferring a claim he needs to submit us the following Documents to enable us to proceed with investigation of the case:

Claim Form duly filled and signed (A specimen blank copy enclosed)
Submit proof of employee/ Employer relationship.
Police FIR/ PMR (In case of fatal accidents)
Internal/ Dept Enquiry report.
Report from Labour Dept.
Copy of letter informing WC Commissioner of Accident.
Medical record / reports showing nature & extent of Disability in case of Permanent Disability cases.
Medical records/ reports evidencing the medical expenses and period of temporary disability.
Leave record of the employee in case of WC Claim.

The investigator is appointed to verify the records wage Bills/ Employment records and any shortfall in premium (i.e under-declaration of Wage Bill or No. of employees) till date plus a reasonable premium for future needs to be necessarily deposited before the claim is settled. In case of glaring difference between the initial declaration and the actual figures are detected, the claim may even be prejudiced.

In the event of claim, the Insured must inform the insurer in writing & request for a Claim Form

In Case of death of employee

Claim form
Confirmation that the accident has happened in the course of employment
Age proof for the deceased employee
Complete Medical Papers
Post Mortem Certificate
Copy of Order of the WC Commissioner for the award passed
Statement of Wages
Muster Roll of the employees

Proof of payment In case of Permanent Total Disablement and Permanent Partial Disablement

Claim form
Confirmation that the accident has happened in the course of employment
Age proof for the disabled employee
Complete Medical Papers
Disability Certificate of the attending doctor
Copy of Order of the WC Commissioner for the award passed
Statement of Wages
Muster Roll of the employee
Proof for Payment.

In case of death and Permanent disablement claims, the claim would be processed only after the full compensation is deposited before the Commissioner

In case of Temporary Total Disablement

Claim form
Confirmation that the accident has happened in the course of employment
Complete Medical Papers
Fitness Certificate from the attending doctor
Statement of Wages
Muster Roll of the employee
Complete list of workers employed as on Date of Accident under all categories
The Company reserves the right for appointing of an investigator for the claim.
On receipt of the above documents by the Insured, the claim will be processed.
Earnings, Wages and Salaries

Shall mean the employees total remuneration paid or fallen due for payment including overtime, value of board and/or lodging, housing accommodation bonuses and all other perquisite privileges or benefits in kind or money, received by the employees from the employer in connection with their employment.

As specified under Workmen Compensation Act, 1923.

The Sum insured available under the policy. Whichever is less.

Quantum of Claim:

The amount of claim payable under WC Policy is strictly governed by the WC ACT and depends upon two factors:

Monthly wages of the employee.
Age of the Employee. Based upon the age the WC ACT specifies a Factor Multiplier Table which is appended with this note.

When Death results from the injury:

An amount equal to 50% of the monthly wages of the deceased workman multiplied by the relevant factor.

An amount of Rupees eighty thousand whichever is more.

When permanent total Disablement results from the Injury:

An amount equal to 60% of the monthly wages of the injured workman multiplied by the relevant factor.

An amount of Rupees Ninety Thousand whichever is more.

When permanent Partial Disablement results from the injury:

In case of an injury specified in the ACT, such percentage of the compensation which would have been payable in case of Permanent Total Disablement as is specified therein as being the percentage of the loss of earning capacity caused by that injury.

And

In case the injury is not specified in ACT, such percentage of the compensation payable in case of permanent total disability as is proportionate to the loss of earning capacity(as assessed by the qualified medical practitioner) permanently caused by the injury.

(where more injuries than one are caused by the same accident, the amount of compensation under this head shall be aggregate but not so in any case as to exceed the amount which would have been payable if permanent total disablement had resulted from the injuries.)

Where Temporary Disablement whether total or partial results from the Injury:

A half monthly payment of the sum equivalent to 25% of the monthly wages of the workmen, if the disablement is for more than 3days. This will continue during the period of disablement or 5yrs. whichever is shorter.

THE WC Claim needs to be deposited necessarily with WC Commissioner of the Area, unless order to the contrary are obtained from him. The discharge of WC Commissioner is sufficient discharge for us.

Claiming Health Insurance Can Be Harrowing. You Can Make it Hassle Free

Posted on: November 7th, 2019 by shiv No Comments

Do not make false declarations while taking the policy. The proposal form is the basis of the contract with the insurer. Obviously, insurance companies can’t be expected to honor a claim if the claim is not made in accordance with agreed terms.
5 POINTS TO REMEMBER

Proposal Form is Sacrosanct

Do not make false declarations while taking the policy. The proposal form is the basis of the contract with the insurer.
Obviously, insurance companies can’t be expected to honor a claim if the claim is not made in accordance with agreed
terms.

Fill the complete form yourself and sign it yourself. Do not leave it upon your agent

Read the Policy Document

It is important to read and understand the terms and conditions of a policy well. Ask your insurance broker to explain any term that you do not understand. Be clear about the policy you plan to take to avoid any hassle or heartburn in the future. Insurance companies will honor a claim if the claim is.

Check for Co-Payment Clause

Many policies impose co-payment if treatment is taken in a hospital outside the insurer’s network. It is, therefore, important to know the existence of this clause and to check whether the hospital of your choice is in the network or not. This payment should not come as surprise and a disappointment to you.

Submit All Documents

The documentation checklist required for health insurance claims usually includes first prescription of the doctor, any treatment related documents, investigation reports (X-rays, ECG, lab reports etc.), original medical bills and receipts of the hospital, labs, doctors etc., besides an admission and discharge summary form from the hospital. In case of an accident-related hospitalization a copy of the FIR will also be typically required. Original documents have to be submitted. Insurers will not reimburse bills that are photocopies.

If it Still Happens

If an insurer repudiates a claim, insist on a repudiation letter that explains the basis on which the claim is repudiated. If you do not agree you can represent the claim again as per the escalation matrix in the grievance redressal machinery. If you are still not satisfied, you may approach the insurance Ombudsman, whose decision is binding.

Download pdf

10 Questions About Health Insurance

Posted on: November 7th, 2019 by shiv No Comments

It is the standard practice in all mediclaim policies to release the payment against the original bills only. This prevents duplicacy of payments and even frauds. However certain medical records can be returned to the claimant on request.
You Always Wanted to Ask, But Didn’t Know Whom To

1. Do we need to submit all the claim documents in original?

2. Why pre-post hospitalization expenses are not covered for maternity?

Child birth is not a disease, illness or ailment and is therefore not covered under any standard medical insurance policy. However a maternity cover is granted in corporate policies as a value added benefit. But it is not treated at par with usual diseases treatment reimbursement parameters. Therefore insurers do not cover pre & post hospitalization expenses in the maternity cover.

3. What is the time limit for settlement of a reimbursement claim?

The standard time limit for settlement of any claim is 15 days from the date of submission of the documents to the approving authority or reply to last query raised whichever is later.

4. The insurance company deducted some amount from my reimbursement because a couple of reports
were not submitted. Can this amount be recovered by submitting the reports now?

Yes, you can submit these reports and get the reimbursement for them but if they are submitted immediately after the settlement. The insurer will not reimburse if there is a delay of more than 15 days in submitting such reports from the day of the settlement of the claim.

5. Why has the insurer not reimbursed the bills for non medical items?

They were prescribed by the doctor.

In a health insurance policy, the focus is on actual expenses made strictly towards treatment and other expenses are excluded under a written stipulation mentioned in the policy document. Expenses on non-medical items like Disposable Pads, Cotton, Baby Oil, Soap, Glucose, Foot Pad, Tissue Paper, Sanitary Paper etc. are not reimbursed by the insurers.

6. Certain tests were prescribed by the doctor before the operation. However I was not hospitalized because of favorable test reports. Why were the tests disallowed as ‘Observation & Investigation’ and not paid?

Expenses are generally made under following 3 categories:

OPD Expenditure
Tests for evaluation
Hospitalization

The medical policy is mainly designed to cover 24 hour hospitalization and not those covered under point 1 & 2 above. However the tests for evaluation done within 30 days prior to hospitalization and within 60 days after discharge from the hospital are paid as pre & post hospitalization part of the claim. Tests which do not lead to hospitalization are not paid. This is a universal feature of the medical policy.

7. Why has the insurer not reimbursed the bills for medical instruments? They were a part of the treatment.

To keep the premium of the policy affordable insurers do not include medical instruments like thermometers, disposable syringes, insulin pump etc. for reimbursement. Accommodation of the cost of such items will increase the cost of the policy phenomenally and will make it beyond the reach of the common man.

8. Is it possible to re-claim a rejected cashless through reimbursement?

During a cashless approval the insurance company’s (or TPA’s) doctor has to evaluate the merits of the claim within an hour and send a response to the hospital. Sometimes the doctors are not able to decide in favour of the claimant due to lack of information or clarity of information. In such cases the cashless approval is not granted. However it does not mean
a rejection of the claim. Such claims should be sent for reimbursement. When all the documents reach the insurer after hospitalization, they are able to take a well informed decision and such claims are generally paid on merits.

9. The insurer deducted some amount from the claim. The reason mentioned was ‘Limit Exhaustion’. However there was sufficient balance in my sum insured. Why was the entire amount not reimbursed?

In addition to the overall limit of Sum Insured there are sublimits in the policy under different heads like room rent, doctor’s fees, and medicines. Sub limits on sum insured are also enforced by the insurer on treatment of certain diseases like cataract, hernia etc. The insurer will not reimburse more than the sub-limited sum insured for such treatments. This is done to control the claims and also to ensure that the balance sum insured can be utilized for another treatment if required.

10. Why acknowledgement of payment on the letter pad of the hospital is not acceptable in absence of proper numbered bills or a receipt?

All financial transactions are governed by standard accounting practices which require numbered stationary in standard format. Such procedures also help the insurers in controlling frauds.