Claims FAQs

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• What factors are considered by the company while asking the claimant to submit particular records / documents?

  The company considers the cause, circumstances of claimNotification to an insurance company that payment of an amount is due under the terms of the policy. and duration of the policy while asking for requirements.
  e.g. For accidental death, specific proofs such as postmortem and police report are required whereas for death due to medical reasons, the company calls for records from hospital, diagnosis / treatment reports, etc.

• Who is entitled to receive the policy monies?

  The policy monies are payable to the beneficiaryA person(s) designated by the policy owner to receive the proceeds of an insurance policy upon the death of the insured. who generally is the nomineeA person or firm into whose name the policy is transferred in order to facilitate transactions, while leaving the customer as the actual owner. / assignee / appointee (in case of a minor) as mentioned by the life assuredThe person covered by a life insurance policy. The insurance company pays out on the death of the policyholder. in the proposal form.

• What is the procedure when there is no nomination or in case of nomineeA person or firm into whose name the policy is transferred in order to facilitate transactions, while leaving the customer as the actual owner.’s death?

  In such circumstances, it is termed as “Open Title” situation. The company would require the proof of title / succession certificate issued by the competent court. The claimNotification to an insurance company that payment of an amount is due under the terms of the policy. would be paid to the person specified in the said proof. The succession certificate should specifically provide orders for disbursement of policy monies. If, however, the deceased has left a Will, a probate of the Will is required along with the copy of the Will.

• What are the circumstances under which a claimNotification to an insurance company that payment of an amount is due under the terms of the policy. is declined / repudiated by the company?

  A claimNotification to an insurance company that payment of an amount is due under the terms of the policy. will be declined if the claimNotification to an insurance company that payment of an amount is due under the terms of the policy. made does not act in accordance to

  • Declaration and authorisation agreed at the proposal stage in the proposal form
  • Terms and conditions as per the policy document

• What are the different types of riders offered by the company?

  • Personal Accident Benefit RiderAn attachment to a policy that modifies its conditions by expanding or restricting benefits or excluding certain conditions from coverage. (PAB) provides benefit in the event of accidental disability.
  • Accidental Death RiderAn attachment to a policy that modifies its conditions by expanding or restricting benefits or excluding certain conditions from coverage. Benefit (ADB) provides benefit in the event of accidental death.
  • Dreaded Disease / Critical Illness RiderAn attachment to a policy that modifies its conditions by expanding or restricting benefits or excluding certain conditions from coverage. Benefit provides benefit in case of occurrence of any of the conditions / surgeries covered in the contract.
  • Waiver Of PremiumA regular payment made to the insurance company to keep the policy in force. RiderAn attachment to a policy that modifies its conditions by expanding or restricting benefits or excluding certain conditions from coverage. Benefit (WOP) provides benefit in the form of premiumA regular payment made to the insurance company to keep the policy in force. waiver in case of accidental disability of the payer / death of the payer.

  * For details on riderAn attachment to a policy that modifies its conditions by expanding or restricting benefits or excluding certain conditions from coverage. benefit, please refer to the policy document

• What are the exclusionsSpecific conditions or circumstances listed in an insurance policy for which the policy will not provide benefit payments. under the riderAn attachment to a policy that modifies its conditions by expanding or restricting benefits or excluding certain conditions from coverage. benefits?

  ExclusionsSpecific conditions or circumstances listed in an insurance policy for which the policy will not provide benefit payments. include:

  • In case the dreaded disease / surgery occurs within waiting period (90 to 180 days) of the policy issuance, depending upon the contract terms and condition*.
  • If the condition / surgery is not covered under the policy terms and conditions*.
  • Accidental injury, which occurs due to self-inflicted injury.
  • In case, the life assuredThe person covered by a life insurance policy. The insurance company pays out on the death of the policyholder. commits suicide within 1 year of the policy issuance.
  • In case, the life assuredThe person covered by a life insurance policy. The insurance company pays out on the death of the policyholder. is involved in any unlawful activity resulting in injury.
  • In cases where the injury occurred is not as per the policy terms and conditions*.

  * For complete details on exclusion, please refer to the policy pack

• When can a claimNotification to an insurance company that payment of an amount is due under the terms of the policy. get rejected?

  Few instances when an Accidental RiderAn attachment to a policy that modifies its conditions by expanding or restricting benefits or excluding certain conditions from coverage. claimNotification to an insurance company that payment of an amount is due under the terms of the policy. can get rejected are:

  • Temporary disability such as fractures
  • Condition when the disability is not total eg: amputation of toe
  • Policy has lapsed as on date of accident
  • In case of any material non-disclosure at the time of proposal signing

  Critical illnessIncludes a range of illnesses that affect your health majorly, during a defined period of time./ Dread disease:

  • If policy has lapsed as on date of event
  • In case of any material non - disclosure at the time of proposal signing
  • If the condition/ surgery is not covered under the policy terms and conditions
  • If the criteria for the illness / surgery is not fulfilled as per the policy terms and conditions

  ** For other comprehensive details, please refer to the policy terms and conditions.

• What are the different types of Hospitalization claimNotification to an insurance company that payment of an amount is due under the terms of the policy. benefit products offered by the company?

  ExclusionsSpecific conditions or circumstances listed in an insurance policy for which the policy will not provide benefit payments. include:

  • Medicash Plus provides fixed Hospital cash benefit and Surgical benefit.
  • Healthy Family Floater and Healthy Family Floater plus provides Hospital/Surgical cash benefit and critical illnessIncludes a range of illnesses that affect your health majorly, during a defined period of time. benefit on event of any dread disease.

  * For details on MA/HFF benefit, please refer to the policy document

• What are the exclusionsSpecific conditions or circumstances listed in an insurance policy for which the policy will not provide benefit payments. under the Medicash Plus and Health Family Floater benefits?

  ExclusionsSpecific conditions or circumstances listed in an insurance policy for which the policy will not provide benefit payments. include:

  • In case the hospitalization occurs within waiting period (90) of the policy issuance, depending upon the contract terms and condition*.(refer list I)
  • In case the surgery occurs with in 24 months of the policy issuance (refer list II)
  • Accidental injury, which occurs due to self-inflicted injury.
  • In case, the life assuredThe person covered by a life insurance policy. The insurance company pays out on the death of the policyholder. commits suicide within 1 year of the policy issuance.
  • In case, the life assuredThe person covered by a life insurance policy. The insurance company pays out on the death of the policyholder. is involved in any unlawful activity resulting in injury.
  • In cases where the injury occurred is not as per the policy terms and conditions*.
  • If the condition / surgery is not covered under the policy terms and conditions*.

  * For complete details on exclusion, please refer to the policy pack

• When can a claimNotification to an insurance company that payment of an amount is due under the terms of the policy. get rejected?

  ExclusionsSpecific conditions or circumstances listed in an insurance policy for which the policy will not provide benefit payments. include:

  • When the Hospitalization period is less than 48hrs.
  • Hospital is not registered or not fulfilling the criteria as per contract.
  • Policy has lapsed as on date of hospitalization
  • In case of any material non-disclosure at the time of proposal signing

• What expenses will be reimbursed?

  ExclusionsSpecific conditions or circumstances listed in an insurance policy for which the policy will not provide benefit payments. include:

  • Based on the number of units purchased, per day hospitalization cash benefit will be settled apart from fixed surgical benefit if any.
  • ClaimNotification to an insurance company that payment of an amount is due under the terms of the policy. settlement is based on the eligibility calculation and is independent of actual expenses incurred on the hospitalization.

  ** For other comprehensive details, please refer to the policy terms and conditions.

• Who is entitled to receive the claimNotification to an insurance company that payment of an amount is due under the terms of the policy. benefit?

  • GTL in lieu of EDLI Policy – NomineeA person or firm into whose name the policy is transferred in order to facilitate transactions, while leaving the customer as the actual owner. mentioned as per the Provident Fund nomination form
  • GTL – Max New York Life Super Life (Employer-Employee) Policy – Policyholder / company
  • GTL – Gratuity Policy – Policyholder trust
  • GTL Affinity – Life Shield – NomineeA person or firm into whose name the policy is transferred in order to facilitate transactions, while leaving the customer as the actual owner. registered at the time of coverage commencement
  • GTL Affinity – Credit life – Policyholder

  *** The nomination may vary depending upon the policy terms and conditions

• What is the procedure if nobody has been nominated on the PF nomination form or in case the nomineeA person or firm into whose name the policy is transferred in order to facilitate transactions, while leaving the customer as the actual owner. dies before the life assuredThe person covered by a life insurance policy. The insurance company pays out on the death of the policyholder. does, in case of EDLI policy?

  Such circumstances are termed as “Open Title” situation. The company would require the proof of title / succession certificate issued by the competent court. The claimNotification to an insurance company that payment of an amount is due under the terms of the policy. would be paid to the person specified in the said proof and our liability as an insurer will be discharged. If the company has accepted the claimNotification to an insurance company that payment of an amount is due under the terms of the policy. but is waiting for such proof, then the company holds the money till the proof is submitted and pays the interest as directed by the IRDA from time to time.

• What do you mean by the ‘Actively At Work’ clause?

  ‘Actively At Work’ shall mean that when the coverage date commences, the member should be performing all his / her regular duties at work in the usual way and on a full time basis. If the member is absent on the coverage commencement date, due to illness, injury or maternity, the coverage shall not commence until he resumes work and performs all the regular duties of his / her job on a full time basis. Also, he / she needs to sign a health declaration, which has to be countersigned by the employer.

• How do we differentiate between addition / deletion request and death claimNotification to an insurance company that payment of an amount is due under the terms of the policy.?

  Addition / deletion list should include the members who either have joined the company or have been terminated / resigned from the company. Any member who has died should not be included in the addition / deletion list. The same should have a mention in the ’no death declaration” in the addition / deletion list.

• What do you mean by free cover limit and how is it determined?

  Free cover limit is the maximum limit available on sum assuredThe sum assured is the minimum amount payable to the assured or his/her dependants on the death of the life assured. where the evidence of good health is not taken by the insurer. It is determined after taking into account the size of the group and accordingly graded cover is offered.

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