Marketing/CRM Department, Central Office, 3rd Floor, Yogakshema, J.B. Marg, Mumbai 400 021

Phone : 22028227 Fax 22825829 Hotline : 970157 Email : [email protected]

Ref : Mktg/CRM/547/23

December 3, 2005

To All Zonal Managers, All Sr.Divisional Managers, Zonal Training Centres and Audit and Inspection

RE : PROCEDURE FOR SETTLEMENT OF CLAIMS UNDER “CRITICAL ILLNESS RIDER BENEFIT” Please refer to CO Circulars ref:Actl/1906/4 dated 08.10.03 and Actl/1918/4 dated 28.11.03 on “Critical Illness Rider”. The various features and benefits available under Critical Illness Rider (CIR) are enumerated in the aforesaid Circulars.

BENEFITS : The Critical Illness Sum Assured will be payable on the Life Assured surviving a period of 28 days from the date of occurrence of any of the following Critical Illnesses : Heart Attack (Myocardial Infarction) Stroke (Cerebro-Vascular Accident) Cancer Kidney Failure Major Organ Transplant Paralysis 3rd Degree Burns Blindness Coronary Artery By-pass Surgery 1

Heart Valve Replacement or Repair Aorta Graft Surgery CIR has following unique features as mentioned below in the area of claims :

UNIQUE FEATURES : 1)

The Sum Assured limit of Rs.5 lakhs under CIR is the overall limit under all policies taken with CIR excluding Sum Assured under Asha Deep I (Table 110), Asha Deep II (Table 121), Jeevan Asha-I (Table 129) and Jeevan Asha-II (Table 131).

2)

The definitions, exclusions, conditions, restrictions and requirements applicable to critical illnesses are as per Annexure attached to the Circular Ref:Actl/1918/4 dated 28.11.03.

3)

Critical Illness Rider will not be allowed to those already afflicted with any of the Critical Illnesses.

4)

Critical Illness Benefit equal to Critical Illness Sum Assured will be payable only once during the term of the policy.

5)

Waiting Period of six months to apply from the commencement of the risk or revival, to the first diagnosis of the Critical Illness under consideration. However, the waiting period conditions will not apply to conditions arising directly out of accidents.

6)

Critical Illness Benefit is payable when the Life Assured is diagnosed to be suffering from any one of the Critical Illnesses mentioned in the Circular i.e. if a person is diagnosed with two Critical Illnesses simultaneously, Benefit will be paid for only one Critical Illness. 2

7)

Critical Illness Benefit will be payable only after the Corporation is satisfied on the basis of available medical evidence that the specified illness has occurred. However, in some illnesses covered e.g. blindness, a specific deferment applies to establish permanence of the illness covered.

8)

The Critical Illness Sum Assured will become payable on the Life Assured surviving for a period of 28 days from the date of occurrence of any one of the Critical Illnesses. If death occurs within 28 days of the occurrence of the Critical Illness, only Death Benefit under the main Plan will be payable.

9)

The date of occurrence of Critical Illness will be reckoned for the above purpose as the date of first diagnosis of the illness/conditions. It will be the date on which the Medical examiner first examines the Life Assured and certifies the diagnosis of any of the illnesses/conditions.

10)

Within 120 days from the date on which any of the mentioned contingencies has occurred, full particulars thereof must be notified in writing to the Servicing Branch Office together with the then address and whereabouts of the Life Assured. Proof satisfactory to the Corporation of the contingency that has occurred, shall be furnished in the manner required. Any Medical examiner named by the Corporation shall be allowed to examine the Life Assured in respect of any Benefit claimed under the Benefit(S) mentioned under the policy document, in such manner and at such times, as may be required by the Corporation.

11)

Premium Waiver Benefit : A policyholder has the option to avail of a Premium Waiver Benefit. If availed, the premiums falling due on or after the date of diagnosis of Critical Illness shall be waived till the maturity date of the main Plan or earlier death of the Life Assured.

12)

Surrender Value & Loan : The Rider will not acquire any Paid-Up Value. Hence, no Surrender Value or Loan will be available. 3

13)

Revival or re-instatement of lapsed policy – Revival of CIRB will only be considered alongwith the revival of the basic Policy and not in isolation.

EXCLUSIONS : No Benefit will be payable in respect of any condition arising directly or indirectly from, through or in consequence of the following exclusions : 1)

Self-inflicted injury, war/invasion, injury during criminal activity or under influence of drug, alcohol etc.

2)

Where the illness has arisen out of failure of the Life Assured to follow medical advice. Also, where the Life Assured has delayed medical treatment in order to circumvent the waiting period or other conditions and restrictions applying in the policy.

3)

If the Life Assured is infected with Human Immunodeficiency Virus (HIV) or conditions due to any Acquired Immuno Deficiency Syndrome (AIDS).

4)

As a result of accident while the Life Assured is engaged in aviation or aeronautics in any capacity other than that of a fare-paying, part-paying or non-paying passenger, in any aircraft which is authorized by the relevant regulations to carry such passengers and flying between established aerodromes.

5)

Injuries caused by such activities as hunting, mountaineering, steeplechasing or racing of any kind.

6)

Angina is specifically excluded.

7)

Transient Ischaemic Attacks are excluded.

4

8)

In case of Cancer, following are excluded : “Carcinoma in Situ”, Cervical Dysplasia, Cervix Cancer CIN-1, CIN-2 & CIN-3, and all pre-malignant conditions or non-invasive Cancers. Early Prostrate cancer TNM Classification T1 (including T1a and T1b) or equivalent classification. Melanomas of the skin of Stage 1A ( < = 1mm, level II or III, no Ulceration) – according to the new AJCC Classification of 2002. Hyperkertoses, Basal Cell and Squamous Skin Cancers. All Tumors in the presence of HIV Infections.

9)

Under Aorta Graft Surgery, Stent Grafting is excluded and Surgery on the Branches of the Aorta is not covered.

10)

Under Coronary Artery Bypass Surgery, the non-surgical techniques such as Balloon Angioplasty and all other Intra Arterial Catheter based techniques or Laser procedure treatments are excluded.

11)

Under major Organ Transplant, Stem Cell Transplants are excluded.

PROCEDURE AT BRANCH LEVEL : 1)

The LA to inform the Branch Office within 120 days from the date of occurrence of the Critical Illness.

2)

The Branch Office to call for specific requirements as per the intimation received from the LA (vide CIRB Annexure ‘A’ ) : Claimant’s Statement – Claim Form No.CIRB 1 Employer’s Certificate – Claim Form CIRB 2 Policy Bond Following Claim Forms are to be called for depending upon the nature of ailments : 5

Heart Attack (Myocardial Infarction) ) Coronary Artery By-pass Surgery ) Claim Form No.CIRB 3 & 4 Heart Valve Replacement or Repair ) Stroke (Cerebro-Vascular Accident) Cancer Kidney Failure Major Organ Transplant Paralysis 3rd Degree Burns Blindness Aorta Graft Surgery

Claim Form No.CIRB 7 & 8 Claim Form No.CIRB 5 & 6 Claim Form No.CIRB 9 & 10 Claim Form No.CIRB 17 & 18 Claim Form No.CIRB 19 & 20 Claim Form No.CIRB 15 & 16 Claim Form No.CIRB 13 & 14 Claim Form No.CIRB 11 & 12

3)

Simultaneously book liability.

4)

On receipt of the completed requirements, to arrange for early Critical Illness claim investigation as per CIRB Annexure ‘B’ where the claims are occurring within two years from the date of policy/revival. Such claim investigations are to be submitted to the Office within 15 days.

5)

To forward to the Divisional Office the following requirements, alongwith the policy file: Claim Form Claimant’s Statement Medical Attendant’s Statement. Employer’s Certificate Investigation Report Policy Bond

CLAIM INVESTIGATION : Irrespective whether claim has arisen within the Waiting Period, if the contingency occurs within 2 years from the date of commencement of risk or revival of the policy, the Branch Office has to conduct claim investigation treating it as an early claim within the waiting period and a report has to be submitted in the format captioned “Claim Investigation report under Critical Illness Benefit” (Specimen Form given in the CIRB Annexure ‘B’). 6

Where contingency has occurred after 2 years from the date of the policy : If any of the Critical Illnesses occur after 2 years from the date of issue of the

policy/revival,

investigation

need

not

be

conducted.

However,

all

requirements as mentioned herein above should be called for, as the case may be. Branch Office will send the policy file alongwith premium position, claim forms duly completed and the investigation report wherever conducted, to the Claims Department, Divisional Office for consideration of the claims. The Divisional Office will decide on the admissibility of the claims in consultation with DMR and the claim file alongwith the decision will be returned by the Divisional Office to the Branch Office for implementing the decision.

PROCEDURE AT DIVISIONAL OFFICE : I)

Critical Illness during the Waiting Period : 1)

To verify whether the Critical Illness is covered under the Plan. If not, the claim to be rejected and papers returned to the Branch Office for advising the LA suitably. The terms and conditions of the main Plan remain unaltered.

2)

If the contingency is covered under the Plan, but has arisen during the Waiting Period, the claim to be rejected. Branch Office to be informed of the decision.

3)

Where on the basis of evidences and investigations placed before the Office, if the contingency dates back prior to the proposal date and suppression of material fact is established, to declare both the policies (Main + Critical Illness Rider Policy) as null and void. Issue letter to the LA for declaring the policy null and void. Fifteen days thereafter, to send a registered letter confirming the decision of declaring the policy null and void. 7

II)

Critical Illness claims after the Waiting Period : 1)

To refer the case file to DMR for his observations and recommendations.

2)

On receipt of the opinion/observations to admit the claim if it is recommended by the DMR.

3)

To call for further requirements, if the same is required by DMR.

4)

If the onset of the Critical Illness dates back prior to the date of proposal and suppression of material facts is established, to take action to declare the policy null and void as provided above.

5)

If contingency is not covered under the Plan, to reject the claim and inform the BO.

III)

Operation of Waiting Period after revival : The same procedure as mentioned at I & II will be applicable for claims occurring within six months from the date of revival.

CLAIM PROCEDURE DECISION FROM DO : 1)

AT

BRANCH

OFFICE

AFTER

THE

When the claim is admitted, to issue Discharge Form as per CIRB Annexure ‘C’. Payment to be made promptly on receipt of Discharge Voucher by debiting appropriate Heads of Accounts as mentioned hereinafter. To place an Endorsement on the Policy as per CIRB Annexure ‘D’.

2)

If claim is rejected as the same is not covered under the scope of the Policy, to inform the policyholder as per CIRB Annexure ‘E’. 8

Endorsement in the main policy as well as CIRB policy should be made as per CIRB Annexure ‘F. 3)

If the claim is rejected/repudiated, to pass entry reversing the liability raised earlier.

DATA BASE MANAGEMENT : Claim settlement in case of policies having Critical Illness Rider Benefit will be at two stages – one at the time of payment of Critical Illness Rider Benefit, secondly in case of death of the Life Assured OR maturity of the Policy whichever is earlier. Hence, suitable remarks are to be taken in the Policy Master as and when the claim arises when payments are made and finally at the time of final settlement of claims to ensure that no duplicate payment is made. The data will also be utilized to study the claim experience under the Critical Illness Rider Benefit. In case of rejection of a claim, suitable remarks on the main policy master and the CIRB policy master, rejecting that particular Critical Illness should be made.

FINANCIAL POWERS : For the purpose of determining the financial powers in respect of claim investigation and claim settlement, Sum Assured under Critical Illness Benefit and the amount of Premium Waiver Benefit should be taken.

ACCOUNTING PROCEDURE : Critical Illness Rider Benefit is available for 11 major illnesses. The following accounting codes and sub codes are provided for making various payments under these Illnesses : Account Code 112555

Head of Account Claims by Critical Illness 01 – Heart Attack (Myocardial Infarction) 02 – Stroke (Cerebro/Vascular Accident) 9

03 – Cancer 04 – Kidney Failure 05 – Major Organ Transplant 06 – Paralysis 07 – Third Degree Burns 08 – Blindness 09 – Coronary Artery By-pass Surgery 10 – Heart Valve Replacement/Repair 11 – Aorta Graft Surgery

CONDONATION OF DELAY IN INTIMATION OF BENEFIT UNDER CRITICAL ILLNESS RIDER AFTER 120 DAYS : The matter regarding condonation of delay in intimation of Benefit under Critical Illness Rider Policy after 120 days will be decided by ZM(I/C) on the merits of the case.

STUDY OF CLAIMS : Each Divisional Office will properly maintain all relevant data in a separate register with appropriate columns as and when claim is decided under Critical Illness Rider Benefit. The data will be used for the purpose of study of claim experience under the Benefit by DO/ZO/CO. The Central Office will send the format for the purpose separately and will call for the data which is relevant for the study at Corporate level.

EXECUTIVE DIRECTOR (CRM) PS :

Necessary Program for Settlement of Claims under CIRB will be provided shortly.

Claims-sriticalilnessrider/aag

10

CIRB ANNEXURE ‘A’ LETTER TO THE LIFE ASSURED FOR REQUIREMENTS FOR SETTLING THE BENEFITS OF CRITICAL ILLNESS RIDER Dear Sir/Madam,

Re : Requirements needed for processing the claim under Critical Illness Benefits of Pol.No.___________________ This has reference to your letter dated ____________ informing us of the Critical Illness suffered by you. In order to enable us to process the claim, we request you to forward the following Claim Forms alongwith Original Discharge Summary furnished by the Hospital if discharge obtained in support of your claim. Besides these evidences, kindly send us the Policy Document with completed Claim Forms. 1)

Claimant’s Statement (Claim Form No.CIRB 1)

2) 3) 4) 5) 6) Kindly arrange to send us the requirements at the earliest. Assuring you of our best services, Thanking you,

Yours faithfully,

p.Sr./BRANCH MANAGER Claims-sriticalilnessrider/aag

11

CIRB ANNEXURE ‘B’ CLAIM INVESTIGATION REPORT OF CRITICAL ILLNESS RIDER BENEFIT (CONFIDENTIAL) Report should be submitted Latest by _____________ Policy No.

:

Name of Life Assured

:

Occupation

:

Age

:

Date of FPR

:

Date of Revival

:

Agent

:

Dev.Officer

:

The Investigator has to ensure that i)

There is no non-disclosure as per details given below : a) The Life Assured having suffered from the reported critical illness before the date of proposal/date of risk or date of revival. b) The critical illness having occurred during the period of six months from the date of risk/revival. c) The Life Assured having suffered from illness/complaints before the date of commencement of risk/date of revival which led to the present critical illness. d) Due to past history, before the date of commencement/date of revival, of any illness, or any physical deformity or for reasons of build, the Life Assured would not have been eligible to obtain Critical Illness Rider Benefit.

ii)

Claims are made for critical illness which are covered under the policy and that the Life Assured has suffered from the specified critical illness. At the time of investigation, it may also be ascertained whether the LA was suffering from any other disease/ailment, prior to taking the policy; if so, details thereof may be obtained. 12

iii)

As the claim under the above critical illness is made during the life time of the Life Assured, the identity of the Life Assured is to be established by ensuring that the Reports submitted pertained to him only, by making enquiries with the usual Medical Attendant/Specialists.

iv)

In respect of hospital reports received from the Life Assured that authenticity of the reports including the existence of the Hospital/Medical Centre should be ascertained.

PART – I (To be completed by Branch Office) 1)

Critical illness for which claim is preferred

:

2)

Date from which treatment taken

:

3)

Name & Address of Doctors/Specialist from whom treatment taken

:

4)

Name & Address of Hospitals/Medical Centre/s where treatment taken

:

5)

Any other instructions, if any, for lines of enquiry :

PART – II (To be completed by the Investigating Officer) 1 (a) State the details of enquiry made with the Assured with respect to the critical illness for which claim has been preferred.

:

(b) Are you satisfied that the person who is reported to have suffered from critical illness which resulted into the claim is the Life Assured under the above policy?

:

(c)

2)

Describe any peculiarities in the physique : deformity, etc, health or habits discovered during the enquiry indicating the date of onset. Whether age stated in the proposal is in : order or whether there is any understatement of age keeping in view the maximum age at entry allowed under Critical Illness Rider which is 50 years 13

3)

What is the Assured’s average monthly : income? Whether in your opinion he/she could afford the total insurance looking to the members of his family to be supported by him/her?

4)

Whether the Life Assured has any relationship : with Agent or Development Officer and whether any of them has got a pecuniary interest in the claim amount?

5)

State whether any of the parent of the assured died of Heart Attack, Kidney failure, cancer, stroke, etc.

6) (a) What was the general state of health of the Assured at the time of commencement or before the date of revival?

:

(b) If not in good health, whether you have got any proof to that effect. Give details.

:

7)

Whether his/her habits are sober and temperate?

8)

Give a short history of last illness including the date when symptoms were first observed, actual cause of illness and the Doctors who attended with respective dates.

:

9)

Ascertain the name and address of the Assured’s usual Medical Attendant and enquire of him whether he had occasion to treat the Assured for illness which resulted into the present critical illness or for any other ailment prior to the date of commencement or revival of the policy and if so, for what ailment and how long?

:

10)

Give a short history of last illness which led to the present critical illness, with the date of

:

:

14

symptoms first observed, actual cause of the illness and Doctors who attended. 11)

Whether the Life Assured had been treated for any illness (other than those resulting into present critical illness) in a Hospital before the date of commencement or revival? If so, please give details such as name of hospital, date of admission, case No, etc.

12)

Whether the Assured is undergoing or undergoes treatment in a Hospital concerning : the present critical illness? Please state name of hospital, date of first admission, present position of treatment, etc.

13)

Are you satisfied that all the Doctors whom you contacted were frank and gave full facts? If not, do you suspect any of them is concealing something? If so, give name of the Doctor and his address and whether he/she is an appointed Doctor of LIC?

14)

Whether any x-ray, blood or urine test, or : ECG or any other Special Medical Reports were taken before the date of commencement/ revival of policy, If so, give details.

15)

If the Life Assured was employed, make : careful enquiry of the Employer (s). Whether the Assured had availed of any sick leave on grounds of health any time during the period of three years before the date of commencement or revival of the policy and six months from effecting the policy? If so, ascertain the exact dates of such leave and obtain from Employers certified copies of the Medical Certificates submitted by him/her in support of such leave.

15

:

:

16)

Ascertain from Assured’s Employers, the nature of his/her duties if the LA was eligible for any reimbursement of medical expenses incurred by him/her and if so, the details of reimbursement availed by him/her for his/her own sickness prior to the date of commencement/revival of the policy.

:

17)

If the Assured is in business, please ascertain :

:

i)

How long he/she is in business?

ii)

Nature of his/her business

iii)

Address of his/her business premises

iv)

Please enquire from neighbouring Businessman the usual state of health and habits of the Assured.

18)

Whether the Agent, Development Officer, Medical Examiner have conspired with the Assured in perpetrating a fraud on the Corporation? If so, how?

:

19)

On the basis of enquiries made, have you got any reasonable suspicion regarding the bonafides of the claim?

:

20)

Any other information that you desire to give and your conclusions on the result of investigation.

:

Signature Name

:

Designation : Place

:

Date

:

sk/CIRB

16

CIRB ANNEXURE ‘C’ DISCHARGE UNDER CRITICAL ILLNESS RIDER BENEFIT Ref : Pol.No.______________________ I, Shri/Smt._________________________________________________ the Life Assured do hereby acknowledge receipt from the Life Insurance corporation of India the sum of Rs._______________________ in full satisfaction of all my claims and demands in respect of the following payment under the above Policy in terms of the Policy Contract, for which the Policy is hereby delivered for cancellation. i)

Payment towards Critical Illness Rs._______________________ Amount payable Rs._______________________ Less : Unpaid premium Other deductions

Rs._______________________ Rs._______________________

(*strike out which are not applicable) Net amount payable

Rs._______________________

I hereby declare that I have not served on any Office of the Life Insurance Corporation of India any notice of assignment or re-assignment in respect of the above Policy not shall I serve on any Office of the said corporation any notice of assignment or re-assignment before payment of the Critical Illness benefit claim under the Policy. I have not dealt with Policy in any other way. Dated at _____________ this_________________day of ___________200 WITNESS : Signature :

___________________

Full Name

:

___________________

Designation :

___________________

Address

___________________

:

___________________ ___________________

Re 1 Revenue Stamp

Signature in full/short in English/Vernacular Claims-sriticalilnessrider/aag

17

NOTE: 1)

Payment will be made by ‘Not Negotiable – Account Payee Cheque’ on the Corporation’s Bankers.

2)

This discharge must be signed by the Life Assured and witnessed in English by any English knowing person provided he knows the Life Assured.

3)

In case you so desire, we can prepare the cheque mentioning your Name, Bank Account No. and Name of the Bank. Kindly indicate your choice and the details of the Bank Account.

3)

Illiterate persons who affix their thumb impression must have it identified by and attested by an Agent of the Corporation who is a Member of the Club at the level of Divisional Managers’ Club and above, a Block Development Officer, a Gazetted Officer, Magistrate or an Officer or Development Officer with atleast 3 years standing or a confirmed Development Officer recruited from the Agents who were DM/BM Club Members before joining, Bank Manager of the Branches of State Bank of India or of one of the Nationalized Banks (provided the attesting Bank Manager signs after affixing an Official Rubber Stamp giving his name and address of the Bank where is he working) or the principal/Head Master of a local High School or Higher Secondary School run by the Government. The attesting Official must make the following Declaration under his signature.

Shri/Smt.___________________________________ wife/widow/son/daughter of Shri ____________________________________ has affixed his/her thumb impression in my presence after understanding the contents thereof. __________________________ Signature of the Attesting Official Seal of the Office

Claims-sriticalilnessrider/aag

18

CIRB ANNEXURE ‘D’

FORM OF ENDORSEMENT TO BE PLACED ON THE MAIN POLICY BOND AFTER PAYMENT OF THE CLAIM FOR BENEFIT OF CRITICAL ILLNESS

Ref : Pol.No.______________________ Notice having been given to the Corporation of the occurrence of the Critical Illness __________________________________________(mention the Critical Illness)

Rs.___________________________________ being payable towards Critical Illness Rider Benefit under the Policy is paid on _________________. No further Critical Illness Rider Benefit is payable under the Policy in future.

Date :

p.Sr./BRANCH MANAGER

Claims-sriticalilnessrider/aag

19

CIRB ANNEXURE ‘E’

LETTER TO THE CLAIMANT WHERE THE CRITICAL ILLNESS BENEFIT CLAIM IS OUTSIDE THE PURVIEW OF THE RIDER

Dear Sir/Madam

Re : Critical Illness Benefit Claim under Pol.No._______________________ This has reference to the claim made under the Critical Illness Benefits of your above Policy vide your letter dated ____________. On scrutiny of the evidences submitted, in support of your claim, we find that the ailment suffered was ____________________. We wish to point out that the above ailment is not covered under the Provisions of the Rider. Hence, we regret that the claim made by you for the benefits of Critical Illness is inadmissible. However, the policy continues to offer besides the insurance protection, the Critical Illness Benefit other than – (mention the Critical Illness inadmissible) as mentioned in the Policy conditions. Therefore, we request you to keep the Policy in force by payment of regular premium. Thanking you, Yours faithfully,

p.Sr./BRANCH MANAGER Claims-sriticalilnessrider/aag

20

CIRB ANNEXURE ‘F’ FORM OF ENDORSEMENT TO BE PLACED ON THE MAIN POLICY BOND AFTER REJECTION OF THE CLAIM FOR BENEFIT OF CRITICAL ILLNESS

Ref : Pol.No.______________________ Notice having been given to the Corporation of the occurrence of the Critical Illness __________________________________________(mention the Critical Illness) The claim under the said Benefit is hereby rejected on the grounds : 1)

The above said illness for which the Benefit is claimed is not covered under the Plan.

2)

The said illness though covered under the Plan, has arisen during the Waiting Period.

Date :

p.Sr./BRANCH MANAGER

Claims-sriticalilnessrider/aag

21