Limits for all the benefits payable under the group personal accident (G.P.A.) plan are defined separately within the group plan. However, in case of multiple benefits being paid, the total of such benefits does not exceed the sum insured for the member.
In a GPA plan, medical expenses are payable for both inpatient and out-patient treatments, provided:
- The treatment is directly related to the accident covered by the plan
- The treatment occurs within the policy period
The benefit offered for medical treatment is payable in addition to the disability benefits paid under the policy. Only then these benefits will be limited to the remaining sum insured in the policy, if disability benefits have been paid.
Meaning if a permanent total disability (PTD) benefit has been paid at 100%, the GPA will not offer any reimbursement of medical expenses.
Therefore, GPA (or PA) plan is always recommended as an extension to the group health insurance plans (or health insurance).
Junaid Sheikh was working with LS. Marketing as a sales representative. He was covered under a group personal accident insurance policy obtained by his employer through Insurer X.
On 10th July 2015, Sheikh was crossing the road near his house when a truck coming at a high speed hit him and he fell on the ground. Some passersby informed the police who took him a hospital. He suffered several injuries and was hospitalized for ten days. Following discharge, he continued treatment but suffered 50% disability. Junaid lodged a claim of Rs 1 lakh with all the supporting documents like prescription slips, bills, payment receipts, etc.
Upon receiving the claim intimation from Junaid, the group personal accident insurer reviewed the claim form and supportive documents. The total coverage available under a group personal accident insurance was Rs 5 lakh. Here, the medical bill was Rs 1 lakh, which was within the total coverage limit. However, as Junaid was also suffering from disability, the insurer asked some additional documents like his salary slip, leave sanction order, etc.; to compute the disability compensation.
In this case, the insurer settled the entire medical expenses of Rs 1 lakh and also paid disability benefits of Rs 3 lakh. It means, Junaid got the total amount of Rs 4 lakh (1 lakh-medical expenses + 3 lakh-disability benefit).
Kavita Kaushik was working as a marketing executive with ZEX Solutions from the past four years. Last year, she was travelling to Chennai when her car hit the tree while saving a child who accidently came on the road to pick his ball while playing. Though, there was no injury to child, Kavita suffered some serious head injuries and was taken to a nearby private hospital.
The doctors performed some MRI tests whose reports showed swelling on a right side of the brain. Though, the doctors saved her life, she became disabled.
As Kavita’s company was offering her group personal accident insurance policy, her father reached out to the insurer for the compensation. Kavita was still in the hospital when the insurer paid out a lump sum amount to her father on the basis of her salary.
Read More: What is group personal accident insurance?
When Kavita was discharged from the hospital, her father again approached the insurer for the settlement of medical expenses this time. The insurer asked for medical bills and reports, and on the basis of that, agreed to settle the claim.
The group personal accident insurance company was offering the coverage of Rs 5 lakh. In this case, the insurer had already paid the disability benefit of Rs 5 lakh to Kavita on the basis of her salary, and therefore, did not pay anything for medical expenses.
The entire coverage under group personal accident insurance available to Kavita got exhausted in paying disability benefits. Therefore, the insurer did not settle medical expenses.
In any case, the insurer will not pay anything more than its sum insured.
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