Coverage for accidental medical expenses is one of the key add-on benefits in the Group Personal Accident policy. Most accidents lead to medical expenses incurred by the employee on first aid or treatment. Coverage of accidental medical expenses in the GPA policy provides reimbursement for the above expenses.
It is important to note that this benefit is an add-on benefit and not a prime benefit. Hence this benefit is not triggered on a stand-alone basis.
It is triggered only if one of the below four prime benefits are triggered –
- Accidental Death (AD)
- Permanent Total Disability (PTD)
- Permanent Partial Disability (PPD)
- Temporary Total Disability (TTD)
Insurers allow clients to choose multiple limits for accidental medical expenses add-on in the Group Personal Accident policy. So, the defaults coverage limit offered by insurers is –
10% of Sum Insured or 40% of Admissible Claim Amount or Actual Medical Expenses whichever is lower.
The admissible claim amount is the amount payable under any of the 4 prime policy benefits – AD, PTD, PPD, or TTD.
Let us illustrate the claim payable under accidental medical expenses benefit through an example. Suppose an employee meets with an accident and is in a hospital for 3 days for treatment. He/she incurs hospitalization expenses of INR 1,00,000. Upon discharge from the hospital, advised him 2-week bed rest by the doctor. He follows the doctor’s advice and takes a rest for 2 weeks. His absence of work due to accidental injury triggers TTD’s claim. Suppose that his TTD claim amount is INR 50,000. Then as per the condition for coverage mentioned above claim payable under the accidental medical expenses section will be INR 20,000 i.e. 40% of the admissible claim amount which is the TTD claim amount in this example.
The default medical expenses extension covers IPD i.e. hospitalization claims only. Insurers do give coverage for OPD claims upon clients’ request but they regulate claim out-go by restricting each OPD claim with an upper limit, typically under INR 25K limit per OPD claim.
So, below are the few limits the insurers offer on accidental medical expenses –
- 10% of Sum Insured or 40% of Admissible Claim Amount or Actual Medical Expenses whichever is lower (Default)
- 20% of Sum Insured or 40% of Admissible Claim Amount or Actual Medical Expenses whichever is lower (Higher)
- 10% of Sum Insured or 25% of Admissible Claim Amount or Actual Medical Expenses whichever is lower (Lower)
Few insurers offer fixed benefit limits for accidental medical expenses (For Example – INR 2,00,000 per claim) wherein they do not link the medical expenses benefit with AD, PTD, PPD, or TTD.
You can choose from the above options to design your group’s personal accident policy so as to cover medical expenses.