Health Assurance Personal Accident

Eligibility Criteria & Options

• Entry Age : Coverage available for adults and children. Entry age for adults is 18 years to 65 years and entry age for children is 2 years to 21 years (dependent children).
• Specifically for the Policyholder's sum insured of ₹100 lacs and above, on the insured person attaining age 70 years, the coverage would get reduced to a flat sum insured of ₹100 lacs from the date of next renewal of the policy, irrespective of the original sum insured.
• Health Assurance AccidentCare can be issued to an individual customer or family. The family policy offers following combinations:
  • 1 Adult + 1 Child
  • 1 Adult + 2 Children
  • 2 Adults
  • 2 Adults + 1 Child
  • 2 Adults + 2 Children

Features of AccidentCare

• Coverage AccidentCare : The Sum Insured options are
  • 5/10/15/20/30/35/40/45/50/60/75/100/125/150/175/200/225/250/275/300/350/400/450/ 500 lacs
• AccidentCare Temporary Total Disability (TTD)
  • 1 lac to 20 lacs (in multiple of 50,000)
• Policy Renewal: We offer lifetime renewability for all the three benefits under Health Assurance.
• The default policy term for all plans is one year. A two year or three year policy term option is also available for Health Assurance Individual and Family options.
• As with all health insurance policies, you may save tax under Section 80D of the Income Tax Act when you buy a Niva Bupa Health Assurance policy. Tax benefits are subject to changes in the tax laws, please consult your tax advisor for more details.
• Health Assurance AccidentCare is available only for Risk Class 1 & 2 occupations and occupations falling under Risk Class 3 are declined category as mentioned in the coverage section.

Benefit Descriptions

AccidentCare Sum Insured Cover (Individual or Family option) AccidentCare coverage may be availed by an individual or families. The sum insured cannot exceed 12 times of the annual income in case of salaried persons or 15 times of annual income in case of self employed persons. In case of family option, the sum insured shall get assigned for all the insured persons in the following manner:

• Self (Insured 1) - 100% of Sum Insured;
• Spouse - 50% of Sum Insured or Rs 10 lacs (whichever is lower);
• Children - 20% of Sum Insured or Rs 5 lacs (whichever is lower);

Accident Death (AD) If an Insured Person dies solely and directly due to an Accidental injury within 365 days from the date of occurrence of such accident, the sum insured as chosen will be paid to the nominee.
Funeral Expenses If the claim has been accepted for the accident death of an Insured Person, then in addition to any amount payable under Accident Death benefit, the insurer will make a one-time payment towards the funeral expenses of that Insured Person.
Accident Permanent Total Disability (PTD) * If an Insured Person suffers Permanent Total Disability solely and directly due to an accident and within 365 days from the occurrence of such accident, the insurance company will pay the sum insured as specified in the Product Benefit Table provided in the product prospectus. This is subject to:

• Permanent Total Disability is proved to the satisfaction of the insurer; and a disability certificate is presented to them, and such disability certificate shall be issued by a Medical Board duly constituted by the Central or the State Government; and
• The insurer will admit a claim under PTD only if the disability continues for a period of at least 6 continuous calendar months from the commencement of the Permanent Total Disability unless there are no chances of variation, over time, in the degree of disability as in amputation/Loss of limbs etc; and
• If the Insured Person dies before a claim has been admitted, no amount under this benefit will be payable, however the claim will be considered as under Accident Death; and
• The insurer will not make payment under PTD in respect of an Insured Person and for any and all policy periods more than once in the Insured Person's lifetime.

* Permanent Total Disability means disablement of the Insured Person such that at least one of the following conditions is satisfied :

• Unable to Work The Insured Person suffers an injury and due to such injury the Insured Person is unlikely to ever be able to engage in any occupation or employment or business for remuneration or profit.
• Loss of use of limbs or sight The Insured Person suffers from total and irrecoverable loss of: i. The use of two limbs (including paraplegia and hemiplegia) OR ii. The sight of both eyes OR iii. The use of one limb and the sight of one eye
• Loss of independent living The Insured Person is permanently unable to perform independently three or more of the following six activities of daily living.
  • Washing / Dressing / Feeding / Toileting / Mobility / Transferring

Child Education Benefit (available only in Family option with children) If a claim has been accepted for the Accident Death (AD) or Accident Permanent Total Disability (PTD) of the proposer, then in addition to any amount payable under AD or PTD, the insurer will make an onetime payment as an education benefit for each of that Proposer's dependent children, provided that each child is an insured person under the Policy. Such benefit shall be payable for a maximum of up to 2 dependent children.
Accident Permanent Partial Disability (PPD) If an Insured Person suffers Permanent Partial Disability solely and directly due to an accident and within 365 days from the date of occurrence of such accident, the insurance company will pay the amount which is a percentage of the chosen sum insured, provided that:

• The Permanent Partial Disability is proved to satisfaction of the insurer; and a disability certificate is presented to Us, and such disability certificate shall be issued by a Medical Board duly constituted by the Central or the State Government: and
• They will admit a claim only if the Permanent Partial Disability continues for a period of at least 6 continuous calendar months from the commencement of the Permanent Partial Disability unless there are no chances of variation, over time, in the degree of disability as in amputation/Loss of limbs etc;; and
• If the Insured Person dies before a claim has been admitted under PPD, no amount will be payable, however they will consider the claim under Accident Death
• If a claim has been admitted under PPD, then no further claim in respect of the same condition will be admitted

Accident Temporary Total Disability (TTD) (Optional Benefit) If the Proposer suffers an injury solely and directly due to an accident occurring during the policy period which solely and directly results in the Proposer's Temporary Total Disability within 365 days from the date of occurrence of such accident, the insurer will pay an amount equal to 1% of TTD sum insured per week for each week that the Temporary Total Disability continues subject always to the availability of the TTD sum insured. It is agreed and understood that:

• The insurer will make payment under TTD for only a part of the week if the Proposer has suffered Temporary Total Disability for that part of the week.
• They shall not be liable to make any payment under TTD in respect of more than 100 weeks in a lifetime and once this limit is attained, the benefit cannot be renewed any further.
• The amount payable under TTD is calculated on a per day basis and shall be payable from the first day of onset of the Temporary Total Disability provided that the Temporary Total Disability continues for at least 3 continuous days.

Accident Hospitalization (Optional Benefit) If the insured person is hospitalised during the policy period solely and directly due to an Injury sustained arising from an accident occurring during the policy period, the insurance company will pay the medical expenses incurred subject to the maximum amount as specified in the Schedule of Insurance Certificate. The Accident Hospitalization benefit shall be available for hospitalization in India only following the accident.

Specific Exclusions for AccidentCare Cover

The insurance company shall not be liable to make any payment under any benefits under the AccidentCare Cover if the claim is attributable to, or based on, or arise out of, or are directly or indirectly connected to any of the following:

• Suicide or self inflicted injury, whether the Insured Person is medically sane or insane.
• Treatment for any injury or illness resulting directly or indirectly from nuclear, radiological emissions, war or war like situations (whether war is declared or not), rebellion (act of armed resistance to an established government or leader), acts of terrorism.
• Service in the armed forces, or any police organization, of any country at war or at peace or service in any force of an international body or participation in any of the naval, military or air force operation during peace time.
• Any change of profession after inception of the Policy which results in the enhancement of Our risk, if not accepted and endorsed by Us on the Schedule of Insurance Certificate.
• Committing an assault, a criminal offence or any breach of law with criminal intent.
• Taking or absorbing, accidentally or otherwise, any intoxicating liquor, drug, narcotic, medicine, sedative or poison, except as prescribed by a Medical Practitioner other than the Policyholder or an Insured Person.
• Participation in aviation/marine including crew other than as a passenger in an aircraft/water craft that is authorized by the relevant regulations to carry such passengers between established airports or ports.
• Including but not limited to engaging in or taking part in professional/adventure sports or any hazardous pursuits, such as speed contest or racing of any kind (other than on foot), bungee jumping, parasailing, ballooning, parachuting, skydiving, paragliding, hang gliding, mountain or rock climbing necessitating the use of guides or ropes, potholing, abseiling, deep sea diving using hard helmet and breathing apparatus, polo, snow and ice sports, hunting etc.
• Body or mental infirmity or any disease except where such condition arises directly as a correspondence of an accident during the policy period. However this exclusion is not applicable to claims made under the PPD benefit.
• Any costs or expenses specified in the List of Expenses Generally Excluded at Annexure II of policy document. This is applicable only for Accident Hospitalization benefit.